Transsylvian-Transinsular Approach for an Insular Cavernous Malformation Resection: 3-Dimensional Operative Video

2018 ◽  
Vol 16 (2) ◽  
pp. E50-E50
Author(s):  
Justin Mascitelli ◽  
Sirin Gandhi ◽  
Ernest Wright ◽  
Michael T Lawton
Keyword(s):  
Cavernous Malformation ◽  
Cerebral Arteries ◽  
Internal Capsule ◽  
Acute Onset ◽  
Sylvian Fissure ◽  
Posterior Limb ◽  
Postoperative Mri ◽  
Patient Consent ◽  
Transinsular Approach ◽  
Surgical Corridor

Abstract Surgical resection of insular lesions is challenging due to their proximity to critical neurovascular structures such as the middle cerebral arteries (MCA), Sylvian veins, thalamus, internal capsule (IC), and lenticulostriate arteries. A surgical series using the transsylvian-transinsular approach to treat cerebrovascular pathologies reported ∼5% permanent neurological morbidity.1,2 This case demonstrates the utility of this approach for resecting an insular cavernous malformation (CM). A 25-yr-old female presented with an acute-onset right homonymous hemianopsia. Neuroimaging revealed a large left insular CM, adjacent to the posterior limb of IC. After obtaining IRB approval and patient consent, a left pterional craniotomy with a wide distal Sylvian fissure split was completed. Using neuronavigation, an insular entry point was chosen for corticectomy. The CM was opened with subsequent hematoma evacuation and intracapsular resection technique. Inspection of the cavity revealed remnants anteromedially near the IC, which were removed meticulously, mobilizing the CM away from the IC. Postoperative MRI demonstrated gross total resection of the CM. The patient was discharged home on postoperative day 5 with persistent homonymous hemianopia. This case describes the use of a transsylvian-transinsular approach to access deep lesions with the shortest surgical distance and minimal cortical transgression. A wide Sylvian fissure split exposes the M2 MCA and accesses a safe insular zone, keeping the most eloquent structures deep to the lesion in the surgical corridor. This approach can safely expose vascular pathologies in the insular region without the risk of injury to overlying eloquent frontal and temporal lobes, even in the dominant hemisphere.

Image-guided Transsylvian, Transinsular Approach for Insular Cavernous Angiomas

Neurosurgery ◽  
2003 ◽  
Vol 53 (6) ◽  
pp. 1299-1305 ◽  
Author(s):  
Wuttipong Tirakotai ◽  
Ulrich Sure ◽  
Ludwig Benes ◽  
Boris Krischek ◽  
Siegfried Bien ◽  
...  
Keyword(s):  
Image Guidance ◽  
Internal Capsule ◽  
Sylvian Fissure ◽  
Image Guided ◽  
Neurosurgical Patients ◽  
Stereotactic System ◽  
Microsurgical Techniques ◽  
Transinsular Approach ◽  
The Ideal

Abstract OBJECTIVE Surgical treatment of cavernomas arising in the insula is especially challenging because of the proximity to the internal capsule and lenticulostriate arteries. We present our technique of image guidance for operations on insular cavernomas and assess its clinical usefulness. METHODS Between 1997 and 2003, with the guidance of a frameless stereotactic system (BrainLab AG, Munich, Germany), we operated on eight patients who harbored an insular cavernoma. Neuronavigation was used for 1) accurate planning of the craniotomy, 2) identification of the distal sylvian fissure, and, finally, 3) finding the exact site for insular corticotomy. Postoperative clinical and neuroradiological evaluations were performed in each patient. RESULTS The navigation system worked properly in all eight neurosurgical patients. Exact planning of the approach and determination of the ideal trajectory of dissection toward the cavernoma was possible in every patient. All cavernomas were readily identified and completely removed by use of microsurgical techniques. No surgical complications occurred, and the postoperative course was uneventful in all patients. CONCLUSION Image guidance during surgery for insular cavernomas provides high accuracy for lesion targeting and permits excellent anatomic orientation. Accordingly, safe exposure can be obtained because of a tailored dissection of the sylvian fissure and minimal insular corticotomy.

Origin of the Perforating Arteries of the Interpeduncular Fossa in Relation to the Termination of the Basilar Artery

1998 ◽  
Vol 4 (2) ◽  
pp. 109-120 ◽  
Author(s):  
G. Brassier ◽  
X. Morandi ◽  
D. Fournier ◽  
S. Velut ◽  
P. Mercier
Keyword(s):  
Basilar Artery ◽  
Cerebral Arteries ◽  
Internal Capsule ◽  
Great Majority ◽  
Medial Thalamus ◽  
Posterior Limb ◽  
Early Stages ◽  
Human Brains ◽  
Oculomotor Nerves ◽  
Perforating Arteries

We studied the perforating arteries of the interpeduncular fossa in 100 human brains which had previously been embalmed and injected with coloured intravascular neoprene latex. Three groups of perforating arteries were observed: the short interpeduncular arteries, a group of very fine arteries which can originate on every artery in the interpeduncular fossa and are destined to the cerebral peduncles and the oculomotor nerves (III); the diencephalic arteries, larger in diameter, most of which supply the mamillary bodies; only a few of them (one or two) penetrate the diencephalic floor and reach the posterior limb of the internal capsule and the anterior and medial thalamus; the diencephalic arteries are either individual branches of the P1 segment of the posterior cerebral arteries (PCA) or stem from the same segment of the PCA via a trunk common to the mesencephalic arteries; the latter supply the mesencephalic area medial to the pars reticularis of the black substance. Our study focusses on where the diencephalic and mesencephalic arteries originate, based on how both anterior longitudinal neural arteries merged into a basilar artery in the embryo. When merging was symmetrical, whether in the early stages or later, the origins are more or less equally distributed; however, when merging was asymmetrical, the great majority of the perforating diencephalic and mesencephalic arteries stem from the P1 segment on the side that merged earliest (cranially).

Left Transsylvian-Transinsular Approach for Radiation-Induced Cavernous Malformation: 3-Dimensional Operative Video

2018 ◽  
Vol 17 (2) ◽  
pp. E62-E63
Author(s):  
Jan-Karl Burkhardt ◽  
Sirin Gandhi ◽  
Halima Tabani ◽  
Arnau Benet ◽  
Michael T Lawton
Keyword(s):  
De Novo ◽  
Cavernous Malformation ◽  
Insular Cortex ◽  
High Grade ◽  
En Bloc ◽  
Bifurcation Aneurysm ◽  
Patient Consent ◽  
Radiation Induced ◽  
Transinsular Approach ◽  
Mca Aneurysm

Abstract De novo cavernous malformation (CM) formation after radiation therapy for brain tumors is well known, but CM formation adjacent to a radiosurgically treated arteriovenous malformation (AVM) is rare.1 This video demonstrates the microsurgical resection of a de novo CM adjacent to a previously treated high-grade AVM and clipping of a middle cerebral artery (MCA) aneurysm. A 70-yr-old male with history of radiosurgery for AVM presented with aphasia and confusion. Preoperative angiography showed complete occlusion of the AVM. MRI showed multiple cystic lesions suspicious for radiation-induced necrosis and CM. IRB approval and patient consent was obtained. A pterional craniotomy was performed with transsylvian exposure of the insula. The radiated feeding arteries were followed to the occluded AVM nidus. A CM was noted deep to this candelabra of the MCA vessels, which were mobilized to access and resect the CM. A small incision was made in this insular cortex underneath the malformation circumferentially freeing it of adhesions. The sclerotic AVM nidus was circumferentially dissected and removed en bloc. Thorough exploration of the resection cavity revealed no residual CM or AVM nidus. Attention was then turned to the M2-MCA bifurcation aneurysm, which was occluded with a straight clip. Postoperative imaging confirmed complete CM resection. The patient recovered from his aphasia. This case demonstrates the management of a radiation-induced de novo CM following treatment of a high-grade AVM. Radiographic follow-up for radiosurgically treated AVM is needed to rule out long-term complications. Bleeding from a de novo CM mimics bleeding from residual AVM nidus, requiring careful angiographic evaluation.

Transsylvian, Carotid-Oculomotor Triangle Approach for Resection of a Rapidly Enlarging Midbrain-Pontine Cavernous Malformation: 3-Dimensional Operative Video

2019 ◽  
Vol 17 (3) ◽  
pp. E112-E112
Author(s):  
Thomas J Sorenson ◽  
Joshua D Hughes ◽  
Giuseppe Lanzino ◽  
Leonardo Rangel Castilla
Keyword(s):  
Surgical Planning ◽  
Cavernous Malformation ◽  
Mass Effect ◽  
Sylvian Fissure ◽  
Cavernous Malformations ◽  
3 Dimensional ◽  
Postoperative Mri ◽  
Leg Weakness ◽  
Magnetic Resonance Imaging Mri ◽  
Orbital Rim

Abstract Cavernous malformations (CM) of the anterior midbrain are best reached through an orbitozygomatic (OZ) approach with removal of the orbital rim and wide Sylvian fissure dissection. Our surgical video demonstrates this approach to resect a ruptured CM in a 36-yr-old woman who presented with headaches, left face and left arm paresthesias/weakness, and right-sided partial oculomotor nerve (CN III) palsy. Initial magnetic resonance imaging (MRI) showed a midbrain CM, and the patient was managed conservatively. However, 1 wk later, she presented again with worsened left arm and leg weakness and complete CN III palsy. Seven Tesla MRI demonstrated a larger hematoma, and the CM with new mass effect and upper pons extension. The patient underwent a right modified OZ craniotomy and Sylvian fissure split under guidance of intraoperative neuronavigation and with neuromonitoring. The carotid-oculomotor triangle and the Liliequist membrane were dissected to access the midbrain, and CN III was identified and followed posteriorly to the midbrain. Confirmed with neuronavigation, a longitudinal incision of the midbrain was performed, and the CM was encountered. The hematoma and CM were debulked and removed in a piece-meal fashion, leaving hemosiderin-stained brain intact to prevent unnecessary additional damage to the midbrain. Postoperative MRI confirmed gross-total resection, and the patient's weakness recovered substantially. In this video, we demonstrate that the brainstem is no longer forbidden surgical territory, and show how the use of neuronavigation for surgical planning, positioning, and approach, in addition to the understanding of safe entry zones and meticulous microsurgical technique have made safe and effective surgery on the brainstem possible.

Surgical anatomy of the proximal anterior cerebral artery

1976 ◽  
Vol 44 (3) ◽  
pp. 359-367 ◽  
Author(s):  
Ralph O. Dunker ◽  
A. Basil Harris
Keyword(s):  
Cerebral Artery ◽  
Anterior Cerebral Artery ◽  
Anterior Commissure ◽  
Cerebral Arteries ◽  
Internal Capsule ◽  
Carotid Bifurcation ◽  
Surgical Anatomy ◽  
Anterior Communicating Artery ◽  
Content Type ◽  
Posterior Limb

✓ The authors present this study of proximal anterior cerebral arteries in the normal human to provide a clearer basis for strategy in aneurysm surgery. They describe patterns of origin of branches, their subarachnoid course, and parenchymal distribution. Branches that originate from the anterior cerebral artery at the internal carotid bifurcation perfuse the genu and contiguous posterior limb of the internal capsule and the rostral thalamus. Proximal 4-mm branches supply the anterior limb of the internal capsule, the neighboring hypothalamus, anteroventral putamen, and pallidum. The remaining anterior cerebral artery proximal to the communicating artery sends branches to the optic chiasm, the adjacent hypothalamus, and the anterior commissure. Heubner's artery arises directly opposite the anterior communicating artery to supply much of the striatum and internal capsule rostral to the anterior commissure. The anterior communicating artery branches supply the fornix, corpus callosum, septal region, and anterior cingulum. The parenchymal distribution of these end arteries may be surmised from the site of origin of named vessels. With this anatomical information one can avoid interruption of blood supply to vital structures when dealing with the anterior cerebral artery and its branches.

Medulla oblongata cavernoma removal through a lazy far lateral approach: operative video and technical nuances

2019 ◽  
Vol 1 (2) ◽  
pp. V21
Author(s):  
Carlos Candanedo ◽  
Samuel Moscovici ◽  
Sergey Spektor
Keyword(s):  
Medulla Oblongata ◽  
Cavernous Malformation ◽  
Complete Removal ◽  
Lateral Approach ◽  
Neurological Deficits ◽  
Total Resection ◽  
Postoperative Mri ◽  
Far Lateral Approach ◽  
Far Lateral ◽  
Brainstem Cavernous Malformation

Removal of brainstem cavernous malformation remains a surgical challenge. We present a case of a 63-year-old female who was diagnosed with a large cavernoma located in the medulla oblongata. The patient suffered three episodes of brainstem bleeding resulting in significant neurological deficits (hemiparesis, dysphagia, and dysarthria). It was decided to remove the cavernoma through a left-sided modified far lateral approach.3The operative video demonstrates the surgical steps and nuances of a complete removal of this complex medulla oblongata cavernous malformation. Total resection was achieved without complications. Postoperative MRI revealed no signs of residual cavernoma with clinical improvement.The video can be found here: https://youtu.be/BTtMvvLMOFM.

Deep brain stimulation of the posterior limb of the internal capsule in the treatment of central poststroke neuropathic pain of the lower limb: case series with long-term follow-up and literature review

2020 ◽  
Vol 133 (3) ◽  
pp. 830-838 ◽  
Author(s):  
Andrea Franzini ◽  
Giuseppe Messina ◽  
Vincenzo Levi ◽  
Antonio D’Ammando ◽  
Roberto Cordella ◽  
...  
Keyword(s):  
Neuropathic Pain ◽  
Lower Limb ◽  
Internal Capsule ◽  
Posterior Limb ◽  
Vas Score ◽  
The Mean ◽  
Deep Brain ◽  
Stimulation Of

OBJECTIVECentral poststroke neuropathic pain is a debilitating syndrome that is often resistant to medical therapies. Surgical measures include motor cortex stimulation and deep brain stimulation (DBS), which have been used to relieve pain. The aim of this study was to retrospectively assess the safety and long-term efficacy of DBS of the posterior limb of the internal capsule for relieving central poststroke neuropathic pain and associated spasticity affecting the lower limb.METHODSClinical and surgical data were retrospectively collected and analyzed in all patients who had undergone DBS of the posterior limb of the internal capsule to address central poststroke neuropathic pain refractory to conservative measures. In addition, long-term pain intensity and level of satisfaction gained from stimulation were assessed. Pain was evaluated using the visual analog scale (VAS). Information on gait improvement was obtained from medical records, neurological examination, and interview.RESULTSFour patients have undergone the procedure since 2001. No mortality or morbidity related to the surgery was recorded. In three patients, stimulation of the posterior limb of the internal capsule resulted in long-term pain relief; in a fourth patient, the procedure failed to produce any long-lasting positive effect. Two patients obtained a reduction in spasticity and improved motor capability. Before surgery, the mean VAS score was 9 (range 8–10). In the immediate postoperative period and within 1 week after the DBS system had been turned on, the mean VAS score was significantly lower at a mean of 3 (range 0–6). After a mean follow-up of 5.88 years, the mean VAS score was still reduced at 5.5 (range 3–8). The mean percentage of long-term pain reduction was 38.13%.CONCLUSIONSThis series suggests that stimulation of the posterior limb of the internal capsule is safe and effective in treating patients with chronic neuropathic pain affecting the lower limb. The procedure may be a more targeted treatment method than motor cortex stimulation or other neuromodulation techniques in the subset of patients whose pain and spasticity are referred to the lower limbs.

scholarly journals How I do it: parietal trans-sulcal para-fascicular approach to lateral thalamic/internal capsule cavernous malformation

2021 ◽  
Author(s):  
Michael Amoo ◽  
Kieron J. Sweeney ◽  
Ronan Kilbride ◽  
Mohsen Javadpour
Keyword(s):  
White Matter ◽  
Cavernous Malformation ◽  
Internal Capsule ◽  
Complete Resection ◽  
Brain Lesions ◽  
Tubular Retractor ◽  
Surgical Technology ◽  
Feasible Alternative ◽  
Traditional Approaches ◽  
Deep Brain

Abstract Background The surgical management of deep brain lesions is challenging, with significant morbidity. Advances in surgical technology have presented the opportunity to tackle these lesions. Methods We performed a complete resection of a thalamic/internal capsule CM using a tubular retractor system via a parietal trans-sulcal para-fascicular (PTPF) approach without collateral injury to the nearby white matter tracts. Conclusion PTPF approach to lateral thalamic/internal capsule lesions can be safely performed without injury to eloquent white matter fibres. The paucity of major vessels along this trajectory and the preservation of lateral ventricle integrity make this approach a feasible alternative to traditional approaches.

scholarly journals A Case of Anterior Choroidal Artery Occlusion and Stroke Secondary to External Compression

2021 ◽  
pp. 369-374
Author(s):  
Satya Narayana Patro ◽  
Khawaja Hassan Haroon ◽  
Khansabegum Tamboli ◽  
Abdulaziz Zafar ◽  
Suhail Hussain ◽  
...  
Keyword(s):  
Medial Temporal Lobe ◽  
Optic Tract ◽  
Internal Capsule ◽  
Cerebral Peduncle ◽  
Anterior Choroidal Artery ◽  
Vessel Occlusion ◽  
External Compression ◽  
Posterior Limb ◽  
Anterior Choroidal ◽  
Choroidal Artery

The anterior choroidal artery (AChA) is a small artery commonly arising from the supraclinoid segment of the internal carotid artery (ICA). The significance of the AChA is related to its strategic supply to various important structures of the brain, such as the optic tract, the posterior limb of the internal capsule, the cerebral peduncle, the lateral geniculate body, medial temporal lobe, medial area of pallidum, and the choroid plexus [<i>J Neurol</i>. 1988;235:387–91]. The AChA syndrome in its complete form consists of the triad of hemiplegia, hemisensory loss, and hemianopia. However, incomplete forms are more frequent in clinical practice [<i>Stroke</i>. 1994;25:837–42]. Isolated infarction in the AChA territory is relatively rare. The presumed pathogenic mechanisms of AChA infarction are cardiac emboli, large-vessel atherosclerosis, dissection of the ICA, small-vessel occlusion, or other determined or undetermined causes [<i>Stroke</i>. 1994;25:837–42 and <i>J Neurol Sci</i>. 2009;281:80–4].

scholarly journals Asymmetrical Myelination of the Posterior Limb of the Internal Capsule (PLIC):Aan Early Predictor of Hemiplegia

1999 ◽  
Vol 45 (4, Part 2 of 2) ◽  
pp. 340A-340A
Author(s):  
Linda S de Vries ◽  
Floris Groenendaal ◽  
Karin J Rademaker ◽  
Linda C Meiners
Keyword(s):  
Internal Capsule ◽  
Posterior Limb ◽  
Early Predictor
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