Contralateral Supracerebellar-Infratentorial Approach for Resection of Thalamic Cavernous Malformations

2018 ◽  
Vol 15 (4) ◽  
pp. 404-411 ◽  
Author(s):  
Justin Mascitelli ◽  
Jan-Karl Burkhardt ◽  
Sirin Gandhi ◽  
Michael T Lawton
Keyword(s):  
Intraoperative Complications ◽  
Occipital Lobe ◽  
Senior Author ◽  
Pineal Region ◽  
Neurological Deficits ◽  
Cavernous Malformations ◽  
Posterior Thalamus ◽  
Neurological Outcomes ◽  
The Right ◽  
Brain Retraction

Abstract BACKGROUND Surgical resection of cavernous malformations (CM) in the posterior thalamus, pineal region, and midbrain tectum is technically challenging owing to the presence of adjacent eloquent cortex and critical neurovascular structures. Various supracerebellar infratentorial (SCIT) approaches have been used in the surgical armamentarium targeting lesions in this region, including the median, paramedian, and extreme lateral variants. Surgical view of a posterior thalamic CM from the traditional ipsilateral vantage point may be obscured by occipital lobe and tentorium. OBJECTIVE To describe a novel surgical approach via a contralateral SCIT (cSCIT) trajectory for resecting posterior thalamic CMs. METHODS From 1997 to 2017, 75 patients underwent the SCIT approach for cerebrovascular/oncologic pathology by the senior author. Of these, 30 patients underwent the SCIT approach for CM resection, and 3 patients underwent the cSCIT approach. Historical patient data, radiographic features, surgical technique, and postoperative neurological outcomes were evaluated in each patient. RESULTS All 3 patients presented with symptomatic CMs within the right posterior thalamus with radiographic evidence of hemorrhage. All surgeries were performed in the sitting position. There were no intraoperative complications. Neuroimaging demonstrated complete CM resection in all cases. There were no new or worsening neurological deficits or evidence of rebleeding/recurrence noted postoperatively. CONCLUSION This study establishes the surgical feasibility of a contralateral SCIT approach in resection of symptomatic thalamic CMs It demonstrates the application for this procedure in extending the surgical trajectory superiorly and laterally and maximizing safe resectability of these deep CMs with gravity-assisted brain retraction.

scholarly journals Combined supra/infratentorial-transsinus approach to large pineal region tumors

1998 ◽  
Vol 4 (4) ◽  
pp. E2
Author(s):  
Ibrahim M. Ziyal ◽  
Laligam N. Sekhar ◽  
Eduardo Salas ◽  
Wayne J. Olan
Keyword(s):  
Venous Pressure ◽  
Tumor Resection ◽  
Occipital Lobe ◽  
Transverse Sinus ◽  
Pineal Region ◽  
Combined Approach ◽  
Pineal Region Tumors ◽  
Before And After ◽  
Nerve Paresis ◽  
Brain Retraction

Object The authors sought to confirm that the combined supra/infratentorial-transsinus approach offers a safer means of resecting large pineal region tumors than other approaches currently being used. The aforementioned method provides a wider exposure of the pineal region with less brain retraction than the infratentorial-supracerebellar or the occipital-transtentorial approach alone and is applicable to some large and giant tumors of this area. This combined approach was used in six patients to remove large pineal region tumors including four tentorial meningiomas, one pineocytoma, and one epidermoid cyst. Methods The transverse sinus and tentorium were sectioned after review of preoperative angiographic studies, after taking intraoperative measurements of the venous pressure in the nondominant transverse sinus before and after clipping and while monitoring the somatosensory evoked potentials. The occipital lobe cortex and cerebellum were retracted slightly along the tentorium. Deep veins of the galenic system, the quadrigeminal area, and the tumor were well exposed. Before it was used for tumor resection the approach was studied in five cadaveric head specimens, and the projection of different approaches was compared radiologically. The tumors were removed in a gross-total manner in all patients, and none of the major veins of the galenic system was injured. Resuturing of the nondominant transverse sinus was performed postoperatively in one patient. One of the six patients experienced transient visual loss, and another suffered mild right sixth cranial nerve paresis; however, both recovered in 3 weeks. The wide exposure of the combined approach was also confirmed on radiological and anatomical studies. Conclusions The combined supra/infratentorial-transsinus approach is preferred for the resection of certain large pineal region tumors.

Posterior Interhemispheric Approach: Surgical Technique, Application to Vascular Lesions, and Benefits of Gravity Retraction

2006 ◽  
Vol 59 (suppl_1) ◽  
pp. ONS-41-ONS-49 ◽  
Author(s):  
John H. Chi ◽  
Michael T. Lawton
Keyword(s):  
Arteriovenous Malformations ◽  
Artery Aneurysm ◽  
Occipital Lobe ◽  
Vascular Lesions ◽  
Arteriovenous Fistulae ◽  
Cavernous Malformations ◽  
Neurological Outcomes ◽  
Interhemispheric Approach ◽  
Occipital Lobes ◽  
Posterior Midline

Abstract OBJECTIVE: To review an experience with the posterior interhemispheric approach applied to vascular lesions in the posterior midline, to examine the effects of patient position and gravity retraction of the occipital lobe, and to identify circumstances requiring increased exposure by sectioning the falx and tentorium. METHODS: During a 6.5-year period, 46 posterior interhemispheric approaches were performed to treat 28 arteriovenous malformations, 10 dural arteriovenous fistulae, seven cavernous malformations, and one posterior cerebral artery aneurysm. Twenty-three patients were positioned prone and 23 patient were positioned laterally. RESULTS: A standard posterior interhemispheric approach was used in 38 patients, and the occipital bitranstentorial/falcine approach was used in seven patients. A contralateral occipital transfalcine approach was used with one thalamic cavernous malformation. All lesions were resected completely and/or obliterated angiographically, with good neurological outcomes in 83% of patients and no operative mortality. Blood loss was lower, operative durations were shorter, postoperative cerebral edema was decreased, and visual outcomes were improved in patients positioned laterally. CONCLUSION: The posterior interhemispheric approach, without additional dural cuts, is appropriate for most vascular lesions in the posterior midline. Gravity retracts the occipital lobes when patients are positioned laterally, enhancing operative exposure and reducing morbidity. Extension of the posterior interhemispheric approach to a transtentorial or transfalcine approach is required for falcotentorial dural arteriovenous fistulae and vein of Galen arteriovenous malformations, but is not usually necessary with cavernous malformations or other arteriovenous malformations.

scholarly journals Neurological outcomes of untreated brainstem cavernous malformations in a prospective observational cohort and literature review

2021 ◽  
pp. svn-2020-000608
Author(s):  
Da Li ◽  
Jing-Jie Zheng ◽  
Jian-Cong Weng ◽  
Pan-Pan Liu ◽  
Ze-Yu Wu ◽  
...  
Keyword(s):  
Neurological Status ◽  
Neurological Deficits ◽  
Developmental Venous Anomaly ◽  
Cavernous Malformations ◽  
Neurological Outcomes ◽  
Scale Scores ◽  
Risk Patients ◽  
History Of ◽  
Lost To Follow Up

BackgroundHaemorrhages of brainstem cavernous malformations (CMs) can lead to neurological deficits, the natural history of which is uncertain. The study aimed to evaluate the neurological outcomes of untreated brainstem CMs and to identify the adverse factors associated with worsened outcomes.MethodsFrom 2009 to 2015, 698 patients (321 women) with brainstem CMs were entered into the prospective cohort after excluding patients lost to follow-up (n=43). All patients were registered, clinical data were collected and scheduled follow-up was performed.ResultsAfter a median follow-up of 60.9 months, prospective haemorrhages occurred in 167 patients (23.9%). The mean modified Rankin Scale scores at enrolment and at censoring time were 1.6 and 1.2. Neurological status was improved, unchanged and worsened in 334 (47.9%), 293 (42.0%) and 71 (10.2%) patients, respectively; 233 (33.4%) recovered to normal levels. Lesions crossing the axial midpoint (relative risk (RR) 2.325, p=0.003) and developmental venous anomaly (DVA) (RR 1.776, p=0.036) were independently significantly related to worsened outcomes. The percentage of worsened outcomes was 5.3% (18 of 337) in low-risk patients (neither DVA nor crossing the axial point) and increased to 26.0% (13 of 50) in high-risk patients (with both DVA and crossing the axial point). The percentage of worsened outcomes significantly increased as the number of prospective haemorrhages increased (from 1.5% (8 of 531, if 0 prospective ictus) to 37.5% (48 of 128, if 1 ictus) and 38.5% (15 of 39, if >1 ictus)).ConclusionsThe neurological outcomes of untreated brainstem CMs were improved/unchanged in majority of patients (89.8%) with a fatality rate of 1.7% in our cohort, which seemed to be favourable. Radiological features significantly predicted worsened outcomes. Our results provide evidence for clinical consultation and individualised treatment. The referral bias of our cohort was underlined.

scholarly journals Resection of brainstem cavernous malformation via perifacial zone through retrosigmoid supracondylar approach

2019 ◽  
Vol 1 (1) ◽  
pp. V16 ◽  
Author(s):  
Ken Matsushima ◽  
Michihiro Kohno ◽  
Helmut Bertalanffy
Keyword(s):  
Cavernous Malformation ◽  
Senior Author ◽  
Neurological Deficits ◽  
Cavernous Malformations ◽  
Inferior Surface ◽  
Complete Surgical Resection ◽  
Brainstem Cavernoma ◽  
Dissection Techniques ◽  
Pontomedullary Junction

Hemorrhagic brainstem cavernous malformations carry a high risk of progressive neurological deficits owing to recurrent hemorrhages and hence require complete surgical resection while minimizing damage to the dense concentration of nuclei and fibers inside the brainstem. To access lesions inside the lower pons, the senior author (H.B.) has preferred to approach the lesions via the “perifacial zone” through the pontomedullary sulcus from the inferior surface of the pontine bulge for more than 20 years.1,2 This video demonstrates a case of a cavernous malformation inside the lower pons, which was surgically treated via the pontomedullary junction through the retrosigmoid supracondylar approach in a half-sitting position. The lesion was completely removed in piecemeal fashion through a tiny incision on the sulcus, which did not cause any new neurological deficits. The modified Rankin Scale improved from 4 before the surgery to 1, and the patient had no recurrence during the 2 years of follow-up. The advantage of this access and the dissection techniques for this challenging lesion are introduced, based on our experience with more than 230 surgeries of brainstem cavernoma.The video can be found here: https://youtu.be/0H_XqkQgQ9I.

Improvement of visual field defects after focal resection for occipital lobe epilepsy: case report

2018 ◽  
Vol 128 (3) ◽  
pp. 862-866 ◽  
Author(s):  
Takahiro Yamamoto ◽  
Tadashi Hamasaki ◽  
Hideo Nakamura ◽  
Kazumichi Yamada
Keyword(s):  
Visual Cortex ◽  
Visual Field ◽  
Occipital Lobe ◽  
Neurological Deficits ◽  
Visual Field Defects ◽  
Epileptic Focus ◽  
Visual Aura ◽  
Occipital Lobe Epilepsy ◽  
The Right ◽  
Field Defects

Improvement of visual field defects after surgical treatment for occipital lobe epilepsy is rare. Here, the authors report on a 24-year-old man with a 15-year history of refractory epilepsy that developed after he had undergone an occipital craniotomy to remove a cerebellar astrocytoma at the age of 4. His seizures started with an elementary visual aura, followed by secondary generalized tonic-clonic convulsion. Perimetry revealed left-sided incomplete hemianopia, and MRI showed an old contusion in the right occipital lobe. After evaluation with ictal video-electroencephalography, electrocorticography, and mapping of the visual cortex with subdural electrodes, the patient underwent resection of the scarred tissue, including the epileptic focus at the occipital lobe. After surgery, he became seizure free and his visual field defect improved gradually. In addition, postoperative 123I-iomazenil (IMZ) SPECT showed partly normalized IMZ uptake in the visual cortex. This case is a practical example suggesting that neurological deficits attributable to the functional deficit zone can be remedied by successful focal resection.

scholarly journals Surgical removal of a spinal intrathecal projectile led to a significant improvement of cauda equina syndrome

2020 ◽  
Vol 11 ◽  
pp. 227
Author(s):  
Zaid Aljuboori
Keyword(s):  
Cauda Equina Syndrome ◽  
Cauda Equina ◽  
Gunshot Wounds ◽  
Foot Drop ◽  
Neurological Deficits ◽  
Neurological Injury ◽  
Surgical Removal ◽  
Neurological Outcomes ◽  
Burning Pain ◽  
The Right

Background: Penetrating gunshot wounds of the spine are common and can cause severe neurological deficits. However, there are no guidelines as to their optimal treatment. Here, we present a penetrating injury to the lower thoracic spine at the T12 level that lodged within the canal at L1, resulting in a cauda equina syndrome. Notably, the patient’s deficit resolved following bullet removal. Case Description: A 29-year-old male sustained a gunshot injury. The bullet entered the right lower chest, went through the liver, entered the spinal canal at T12, fractured the right T12/L1 facet, and settled within the canal at the L1 level. The patient presented with severe burning pain in the right leg, and perineum. On exam, he had right-sided moderate weakness of the iliopsoas and quadriceps femoris muscles, a right-sided foot drop, decreased sensation throughout the right leg, and urinary retention. Computed tomography myelography showed the bullet located intrathecally at the L1 level causing compression of the cauda equina. The patient underwent an L1 laminectomy with durotomy for bullet removal. Immediately postoperatively, the patient improved; motor power returned to normal, the sensory exam significantly improved; and he was left with only mild residual numbness and burning pain in the right leg. Conclusion: With gunshot injuries, there is a direct correlation between the location/severity of the neurological injury and the potential for recovery. In patients with incomplete cauda equina syndromes, bullet extraction may prove beneficial to neurological outcomes.

Giant Frontotemporal Cavernous Malformation in a 2-Month-Old Infant: A Case Report and Review of the Literature

2021 ◽  
pp. 1-7
Author(s):  
Olivia E. Gilbert ◽  
John M. Wilson ◽  
Jerome M. Volk
Keyword(s):  
Pediatric Population ◽  
Surgical Excision ◽  
Vascular Lesion ◽  
Neurological Deficits ◽  
Seizure Freedom ◽  
Cavernous Malformations ◽  
Large Size ◽  
Complete Surgical Excision ◽  
Successful Removal ◽  
The Right

<b><i>Introduction:</i></b> Cavernous malformations in the pediatric population are exceedingly rare, especially in infants. Giant cavernous malformations (GCM) are even more rare and have a diameter &#x3e;4 cm. The onset of symptoms predominantly occurs in adulthood, but the rate of hemorrhage is significantly higher in the pediatric population. Similar to non-GCM, GCM can be misidentified as tumors on imaging due to their tumefactive pattern with edema. Here, we present a rare case of a right frontotemporal GCM in a 2-month-old girl, the youngest recorded case in the existing literature. <b><i>Case Presentation:</i></b> A previously healthy 2-month-old girl presented to the emergency department following an increasing frequency of seizure-like activity that began 3 days prior to presentation. Magnetic resonance imaging of the brain with and without contrast characterized a large (5.8 × 4.3 × 4.2 cm) heterogeneous lesion of the right temporal lobe with diffuse scattered blood products of various ages seen throughout the lesion. She underwent a right-sided craniotomy where a gross total excision was achieved. Pathology confirmed the diagnoses of a GCM. The patient’s seizures subsequently resolved, and she continues to do well postoperatively. <b><i>Discussion/Conclusion:</i></b> GCM can be mistaken for tumors due to their large size, cystic nature, and surrounding edema, but a vascular lesion should always remain in the differential diagnosis before operating, even in infants. Surgery is generally recommended in patients that present with a symptomatic hemorrhage, recurrent hemorrhages, persistent seizures despite medical management, or progressively worsening neurological deficits if the GCM is in a safe location. It has been shown that 70–99% of patients undergoing surgery with successful removal of the GCM can achieve seizure freedom 2 years postoperatively. Complete surgical excision of this infant’s GCM was successful in treating her neurologic symptoms; therefore, pathological confirmation of this lesion is critical and should prompt a complete surgical excision.

Supracerebellar-Supratrochlear and Infratentorial-Infratrochlear Approaches

2010 ◽  
Vol 66 (suppl_2) ◽  
pp. ons264-ons274 ◽  
Author(s):  
Nader Sanai ◽  
Zaman Mirzadeh ◽  
Michael T. Lawton
Keyword(s):  
Cavernous Malformation ◽  
Neurological Deficits ◽  
Viewing Angle ◽  
Surgical Experience ◽  
Cavernous Malformations ◽  
Neurological Outcomes ◽  
Supracerebellar Infratentorial Approach ◽  
Ambient Cistern ◽  
Thalamic Lesions ◽  
Surgical Corridor

Abstract OBJECTIVE Lateral supracerebellar-infratentorial approaches are established for lesions in ambient cistern and posterolateral midbrain, but published surgical experiences do not describe results with this approach in the sitting position. Gravity retraction of the cerebellum opens this surgical corridor and dramatically alters exposure, creating 2 variations of the lateral supracerebellar-infratentorial approach: the supracerebellar-supratrochlear approach and the infratentorial-infratrochlear approach. METHODS We reviewed our experience treating cavernous malformations and arteriovenous malformations (AVMs) of the posteroinferior thalamus and posterolateral midbrain by use of supracerebellar-supratrochlear and infratentorial-infratrochlear approaches. Microsurgical technique, clinical data, radiographic features, and neurological outcomes were evaluated. RESULTS During an 11-year surgical experience with 341 cavernous malformation patients and 402 AVM patients, 8 patients were identified, 6 with cavernous malformations and 2 with AVMs. Infratentorial-infratrochlear approaches were used in 4 patients (50%), including 3 with inferolateral midbrain cavernous malformations. Supracerebellar-supratrochlear approaches were used in 4 patients (50%), including 2 with posterior thalamic lesions surfacing on pulvinar. Resections were radiographically complete in all cases. There were no new, permanent neurological deficits, nor were there any medical or surgical complications. There has been no evidence of rebleeding or recurrence. CONCLUSIONS Gravity retraction of the cerebellum transforms the lateral supracerebellar-infratentorial approach, enhancing exposure and approach trajectories that can be achieved with patients in prone or lateral positions. The increased upward viewing angle of the supracerebellar-supratrochlear approach accesses the posteroinferior thalamus. The increased downward-viewing angle of the infratentorial-infratrochlear approach accesses cerebellomesencephalic fissure and posterolateral midbrain. These approaches open wide corridors for safe surgical resection of symptomatic cavernous malformations and AVMs.

Emotional Reactivity to Visual Content as Revealed by ERP Component Clustering

2015 ◽  
Vol 29 (4) ◽  
pp. 135-146 ◽  
Author(s):  
Miroslaw Wyczesany ◽  
Szczepan J. Grzybowski ◽  
Jan Kaiser
Keyword(s):  
Emotional Reactivity ◽  
Brain Activity ◽  
Affective State ◽  
Occipital Lobe ◽  
Stimulus Onset ◽  
Emotional States ◽  
Neural Basis ◽  
Temporoparietal Junction ◽  
The Right ◽  
The Impact

Abstract. In the study, the neural basis of emotional reactivity was investigated. Reactivity was operationalized as the impact of emotional pictures on the self-reported ongoing affective state. It was used to divide the subjects into high- and low-responders groups. Independent sources of brain activity were identified, localized with the DIPFIT method, and clustered across subjects to analyse the visual evoked potentials to affective pictures. Four of the identified clusters revealed effects of reactivity. The earliest two started about 120 ms from the stimulus onset and were located in the occipital lobe and the right temporoparietal junction. Another two with a latency of 200 ms were found in the orbitofrontal and the right dorsolateral cortices. Additionally, differences in pre-stimulus alpha level over the visual cortex were observed between the groups. The attentional modulation of perceptual processes is proposed as an early source of emotional reactivity, which forms an automatic mechanism of affective control. The role of top-down processes in affective appraisal and, finally, the experience of ongoing emotional states is also discussed.

Microsurgical resection of medullary cavernoma via the olivary zone by the retrosigmoid supracondylar approach

2019 ◽  
Vol 1 (2) ◽  
pp. V7
Author(s):  
Ken Matsushima ◽  
Michihiro Kohno ◽  
Helmut Bertalanffy
Keyword(s):  
Cavernous Malformation ◽  
Cleavage Plane ◽  
Foramen Magnum ◽  
Senior Author ◽  
Neurological Deficits ◽  
Lateral Part ◽  
Sitting Position ◽  
Brainstem Cavernoma ◽  
Microsurgical Resection

Microsurgical resection of the medullary cavernoma is rare, comprising less than 15% of more than 250 surgeries of brainstem cavernoma performed by the senior author (H.B.).1 This video demonstrates a case of a cavernous malformation inside the lateral part of the medulla, which was surgically treated via the olivary zone by the retrosigmoid supracondylar approach in a half-sitting position. Osseous drilling of the lateral foramen magnum provided wide exposure of the cerebellomedullary cistern around the olive.2,3 The lesion was completely dissected at the appropriate cleavage plane from the normal parenchyma. The patient developed no new neurological deficits and had no recurrence during 3 years of follow-up after the operation.The video can be found here: https://youtu.be/7i7SccS5HmU.

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