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.

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 Intracranial cavernous malformation in children: a single-centered experience with 30 consecutive cases

2013 ◽  
Vol 71 (4) ◽  
pp. 220-228 ◽  
Author(s):  
Marcelo Campos Moraes Amato ◽  
João Flávio Gurjão Madureira ◽  
Ricardo Santos de Oliveira
Keyword(s):  
Clinical Presentation ◽  
Cavernous Malformation ◽  
Neurological Deficits ◽  
Treatment Modalities ◽  
Study Group ◽  
Functional Evaluation ◽  
Cavernous Malformations ◽  
Asymptomatic Patients ◽  
The Mean

Objectives: To determine the clinical presentation and treatment outcome of pediatric intracranial cavernous malformation (CM) in a single-centered institution. Methods: Clinical data review of 30 patients under 18 years-old who had undergone surgery for cavernous malformation from January 1993 to December 2011. Results: The Study Group included 18 males and 12 females (mean age: 8.7 years-old). Symptoms at presentation were seizures (16/30, 53.3%), headache (15/30, 50.0%), and focal neurological deficits (11/30, 36.6%). Multiple cavernous malformations were found in 5/30 (16.6%). According to location, patients were classified in groups: (G1) brain-steam in 5/30 (16.6%), (G2) cerebellum in 2/30 (6.6%), (G3) supratentorial associated with seizures in 16/30 (53.3%), and (G4) supratentorial without seizures in 7/30 (23.3%). Surgical resection was performed in 26 out of 30 (86.6%) patients. The mean follow-up period was 4.1 years. Of 15 children followed-up with preoperative seizures, all were rendered seizure-free after surgery. Conclusions: For symptomatic solitary cavernous malformation, the treatment of choice is complete microsurgical excision preceded by careful anatomical and functional evaluation. For multiple cavernous malformation or asymptomatic patients, the treatment modalities must be cautiously considered.

scholarly journals Usefulness of the anterior transpetrosal approach for pontine cavernous malformations

2019 ◽  
Vol 1 (1) ◽  
pp. V4
Author(s):  
Hiroki Morisako ◽  
Takeo Goto ◽  
Christian A. Bohoun ◽  
Hironori Arima ◽  
Tsutomu Ichinose ◽  
...  
Keyword(s):  
Nerve Palsy ◽  
Facial Nerve Palsy ◽  
Cavernous Malformation ◽  
Neurological Deficits ◽  
Total Removal ◽  
Cavernous Malformations ◽  
Small Incision ◽  
Anterior Transpetrosal Approach ◽  
Formidable Challenge ◽  
Ocular Movement

Surgical resection of pontine cavernous malformation remains a particularly formidable challenge. We report the surgical outcome of eight cases with pontine cavernous malformations operated using the anterior transpetrosal approach. All cases presented with neurological deficits caused by hemorrhage before surgery. Gross-total removal was achieved in all cases without any postoperative complication such as worsening of facial nerve palsy, ocular movement disorder, or hemiplegia. A small incision of the pons with multidirectional dissection is the most important factor for minimizing postoperative neurological deficits, so resection of a pontine cavernous malformation via this approach can be an alternative better option.The video can be found here: https://youtu.be/2Q2CUhBbo28.

The Supracarotid-infrafrontal Approach: Surgical Technique and Clinical Application to Cavernous Malformations in the Anteroinferior Basal Ganglia

2009 ◽  
Vol 64 (suppl_1) ◽  
pp. ONS86-ONS95 ◽  
Author(s):  
James S. Waldron ◽  
Michael T. Lawton
Keyword(s):  
Basal Ganglia ◽  
Posterior Part ◽  
Internal Capsule ◽  
Neurological Deficits ◽  
Cavernous Malformations ◽  
Working Space ◽  
Brain Surface ◽  
Careful Handling ◽  
Surgical Corridor ◽  
Perforating Arteries

Abstract Objective: Many symptomatic cavernous malformations deep in the anteroinferior basal ganglia are deemed to be inoperable and managed conservatively because transcortical, transsylvian-transinsular, and transcallosal approaches are unsuitable. We present an approach to these lesions through the supracarotid triangle, between ascending perforators, and through the basomedial frontal lobe. Methods: The supracarotid-infrafrontal approach incorporates an orbitozygomatic craniotomy, wide microsurgical exposure of the supracarotid triangle, dissection of perforating arteries, and image-guided resection through the posterior part of the medial orbital gyrus and anterior perforated substance. Results: During 10 years of surgical experience with 269 patients with cavernous malformations, 5 patients were identified with lesions in the basal ganglia that were resected completely using the supracarotid-infrafrontal approach. Transient neurological deficits were observed postoperatively in 2 patients, and all patients had excellent outcomes (modified Rankin Scale score of 0 or 1; mean duration of follow-up, 1.4 years). Conclusion: Cavernous malformations in the anteroinferior basal ganglia come to the brain surface directly behind the internal carotid artery bifurcation, and the supracarotid-infrafrontal trajectory best matches the lesions' axes. The surgical corridor runs between perforating arteries, but entrance into these lesions opens additional working space that is not normally present when the approach is used with aneurysms. Careful handling of crossing and ascending perforating arteries is critical, as is delicate dissection of the lesion's superior pole where it abuts the internal capsule.

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.

scholarly journals Supracerebellar Infratentorial Approach for Complex Thalamic Cavernous Malformation: 2-Dimensional Operative Video

2019 ◽  
Vol 17 (4) ◽  
pp. E147-E148
Author(s):  
Benjamin K Hendricks ◽  
Robert F Spetzler
Keyword(s):  
Cavernous Malformation ◽  
Video Recording ◽  
Large Mass ◽  
Complete Excision ◽  
Foramen Of Monro ◽  
Institutional Review ◽  
Key Points ◽  
Stereotactic Navigation ◽  
Supracerebellar Infratentorial Approach ◽  
Ambient Cistern

Abstract Key points for the approach include the use of a supracerebellar infratentorial craniotomy, dynamic and gravity retraction, lighted bipolar forceps and suction, and stereotactic navigation. This patient has a large cavernous malformation extending from the midbrain to the thalamus in craniocaudal extent. The cavernous malformation extends to the midbrain surface along the interface with the ambient cistern, making it appropriate for the supracerebellar infratentorial approach. By cutting the tentorium access to the superior extension becomes feasible. The cavernous malformation is excised in a piecemeal manner utilizing a CO2 laser. Because removal of the large mass allowed the partial collapse of the cavity, a small segment of the cavernous malformation obscured by the collapse is retained cranially along the foramen of Monro. This situation required a return to the operating room for complete excision. The patient tolerated both procedures well and remained at her neurological baseline postoperatively. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. The surgical video has been used with permission from the Barrow Neurological Institute.

Cavernous malformations of the brain stem

1991 ◽  
Vol 75 (1) ◽  
pp. 32-39 ◽  
Author(s):  
Richard S. Zimmerman ◽  
Robert F. Spetzler ◽  
K. Stuart Lee ◽  
Joseph M. Zabramski ◽  
Ronald W. Hargraves
Keyword(s):  
Brain Stem ◽  
Cavernous Malformation ◽  
Venous Malformation ◽  
Neurological Status ◽  
Shunt Infection ◽  
Neurological Deficits ◽  
Cavernous Malformations ◽  
Content Type ◽  
The Brain ◽  
Fine Print

✓ Once they become symptomatic, cavernous malformations of the brain stem appear to cause progressive morbidity from repetitive hemorrhage, and can even be fatal. Twenty-four patients with long-tract and/or cranial nerve findings from their cavernous malformations of the brain stem were seen for initial evaluation or surgical consultation and thereafter received either surgical or continued conservative treatment. The decision to operate was based on the proximity of the cavernous malformation to the pial surface of the brain stem, the patient's neurological status, and the number of symptomatic episodes. Sixteen patients were treated by definitive surgery directed at excision of their malformation. In four patients, associated venous malformations influenced the surgical approach and their recognition avoided the risk of inappropriate excision of the venous malformation. Although some of the 16 patients had transient, immediate, postoperative worsening of their neurological deficits, the outcome of all except one was the same or improved. Only one patient developed recurrent symptoms: a new deficit 2½ years after surgery required reoperation after regrowth of the cavernous malformation. She has been neurologically stable since the second surgery. One patient died 6 months postoperatively from a shunt infection and sepsis. The eight conservatively treated patients are followed with annual magnetic resonance imaging studies. One has a dramatic associated venous malformation. Seven patients have either minor intermittent or no symptoms, and the eighth died from a hemorrhage 1 year after his initial presentation. Based on these results, surgical extirpation of symptomatic cavernous malformations of the brain stem appears to be the treatment of choice when a patient is symptomatic, the lesion is located superficially, and an operative approach can spare eloquent tissue. When cavernous malformations of the brain stem are completely excised, cure appears permanent.

scholarly journals Posterolateral route for a midbrain cavernous malformation reaching the anterior surface of the brainstem

2019 ◽  
Vol 1 (1) ◽  
pp. V13
Author(s):  
Michel W. Bojanowski ◽  
Gunness V. R. Nitish ◽  
Gilles El Hage ◽  
Kim Lalonde ◽  
Chiraz Chaalala ◽  
...  
Keyword(s):  
Brain Tissue ◽  
Cavernous Malformation ◽  
Normal Brain ◽  
Anterior Surface ◽  
Normal Brain Tissue ◽  
Cavernous Malformations ◽  
Entry Zone ◽  
Supracerebellar Infratentorial Approach ◽  
Pass Through ◽  
Safe Entry Zone

Cavernous malformations in the midbrain can be accessed via several safe entry zones. The accepted rule of thumb is to enter at the point where the lesion is visible at the surface of the brainstem to pass through as little normal brain tissue as possible. However, in some cases, in order to avoid critical neural structures, this rule may not apply. A different safe entry zone can be chosen. Our video presents a case of a ruptured cavernous malformation in the midbrain reaching its anterior surface which was successfully resected via a posterolateral route using the supracerebellar infratentorial approach.The video can be found here: https://youtu.be/7kt-OQuBmz0.

scholarly journals Paramedian contralateral supracerebellar infratentorial approach to thalamic cavernous malformation

2019 ◽  
Vol 1 (1) ◽  
pp. V11
Author(s):  
André Bortolon Bissoli ◽  
Aderaldo Costa Alves Junior ◽  
Pedro Tadao Hamamoto Filho ◽  
Marco Antonio Zanini
Keyword(s):  
Cavernous Malformation ◽  
Cerebral Peduncle ◽  
Cavernous Malformations ◽  
Eloquent Areas ◽  
Close Proximity ◽  
History Of ◽  
Supracerebellar Infratentorial Approach ◽  
Vascular Structures ◽  
Left Thalamus ◽  
The Brain

Cavernous malformations (CVMs) located in the thalamus are uncommon. However, they pose difficulties for resection because of their close proximity to eloquent areas of the brain and vascular structures, and all surgical corridors to access them are narrow. In this video, we report the case of a 19-year-old woman who presented with a long-standing history of right hemiparesis with recent deterioration. MRI revealed a large CVM located in the left thalamus, with signs of recent hemorrhage extending to the left cerebral peduncle. Resection was achieved with a paramedian contralateral supracerebellar infratentorial approach in a semisitting position, with an uneventful postoperative course.The video can be found here: https://youtu.be/Arvu52FkHOE.

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