scholarly journals Subtemporal approach for the resection of a midbrain cavernous malformation: evaluation of safe surgical corridors

2019 ◽  
Vol 1 (1) ◽  
pp. V1 ◽  
Author(s):  
Thalia Estefania Sanchez Correa ◽  
David Gallardo Ceja ◽  
Diego Mendez-Rosito
Keyword(s):  
Female Patient ◽  
Deleterious Effect ◽  
Cavernous Malformation ◽  
Clinical Analysis ◽  
Anatomical Landmarks ◽  
Entry Zone ◽  
Subtemporal Approach ◽  
Critical Location ◽  
Brainstem Cavernous Malformation ◽  
Safe Entry Zone

Brainstem cavernous malformation management is complex due to its critical location and deleterious effect when bleeding. Therefore, every case should be thoroughly analyzed preoperatively. We present the case of a female patient with a midbrain cavernous malformation. A comprehensive anatomical and clinical analysis of the surgical corridors is done to decide the safest route. A subtemporal approach was done and the lateral mesencephalic sulcus and vein were important anatomical landmarks to guide the safe entry zone. Nuances of technique and surgical pearls related to the safe entry zones of the midbrain are discussed and illustrated in this operative video.The video can be found here: https://youtu.be/vYA-IgiT2lU.

Retrosigmoid transhorizontal fissure approach to lateral pontine cavernous malformation: comparison to transpetrosal presigmoid retrolabyrinthine approach

2021 ◽  
pp. 1-10
Author(s):  
Julia R. Schneider ◽  
Amrit K. Chiluwal ◽  
Mohsen Nouri ◽  
Giyarpuram N. Prashant ◽  
Amir R. Dehdashti
Keyword(s):  
Operative Time ◽  
Cavernous Malformation ◽  
Similar Efficacy ◽  
Middle Cerebellar Peduncle ◽  
Entry Zone ◽  
Cadaveric Dissection ◽  
Cerebellar Peduncle ◽  
Retrolabyrinthine Approach ◽  
Brainstem Cavernous Malformation

OBJECTIVE The retrosigmoid (RS) approach is a classic route used to access deep-seated brainstem cavernous malformation (CM). The angle of access is limited, so alternatives such as the transpetrosal presigmoid retrolabyrinthine (TPPR) approach have been used to overcome this limitation. Here, the authors evaluated a modification to the RS approach, horizontal fissure dissection by using the RS transhorizontal (RSTH) approach. METHODS Relevant clinical parameters were evaluated in 9 patients who underwent resection of lateral pontine CM. Cadaveric dissection was performed to compare the TPPR approach and the RSTH approach. RESULTS Five patients underwent the TPPR approach, and 4 underwent the RSTH approach. Dissection of the horizontal fissure allowed for access to the infratrigeminal safe entry zone, with a direct trajectory to the middle cerebellar peduncle similar to that used in TPPR exposure. Operative time was longer in the TPPR group. All patients had a modified Rankin Scale score ≤ 2 at the last follow-up. Cadaveric dissection confirmed increased anteroposterior working angle and middle cerebellar peduncle exposure with the addition of horizontal fissure dissection. CONCLUSIONS The RSTH approach leads to a direct lateral path to lateral pontine CM, with similar efficacy and shorter operative time compared with more extensive skull base exposure. The RSTH approach could be considered a valid alternative for resection of selected pontine CM.

scholarly journals The suboccipital, telovelar, transsuperior fovea approach to dorsal pontine lesions

2019 ◽  
Vol 1 (1) ◽  
pp. V19
Author(s):  
M. Yashar S. Kalani ◽  
Kaan Yağmurlu ◽  
Nikolay L. Martirosyan ◽  
Robert F. Spetzler
Keyword(s):  
Fourth Ventricle ◽  
Cavernous Malformation ◽  
Venous Anomaly ◽  
Entry Zone ◽  
Lateral Entry ◽  
Link Type ◽  
Safe Entry Zone

Dorsal pons lesions at the facial colliculus level can be accessed with a suboccipital telovelar (SOTV) approach using the superior fovea safe entry zone. Opening the telovelar junction allows visualization of the dorsal pons and lateral entry at the level of the fourth ventricle floor. Typically, a lateral entry into the floor of the fourth ventricle is better tolerated than a midline opening. This video demonstrates the use of the SOTV approach to remove a cavernous malformation at the level of the facial colliculus. This case is particularly interesting because of a large venous anomaly and several telangiectasias in the pons. Dissections in the video are reproduced with permission from the Rhoton Collection (http://rhoton.ineurodb.org).The video can be found here: https://youtu.be/LqzCfN2J3lY.

Using the Lateral Pontine Safe Entry Zone for Resection of Deep-Seated Cavernous Malformations in the Lateral Pons: 2-Dimensional Operative Video

2020 ◽  
Vol 19 (5) ◽  
pp. E518-E519
Author(s):  
Daniel D Cavalcanti ◽  
Joshua S Catapano ◽  
Paulo Niemeyer Filho
Keyword(s):  
Trigeminal Nerve ◽  
Cranial Nerve ◽  
Cavernous Malformation ◽  
Vascular Malformations ◽  
Cranial Nerves ◽  
Cavernous Malformations ◽  
Entry Zone ◽  
History Of ◽  
Tumor Biopsies ◽  
Safe Entry Zone

Abstract The retrosigmoid approach is one of the main approaches used in the surgical management of pontine cavernous malformations. It definitely provides a lateral route to large central lesions but also makes possible resection of some ventral lesions as an alternative to the petrosal approaches. However, when these vascular malformations do not emerge on surface, one of the safe corridors delimited by the origin of the trigeminal nerve and the seventh-eight cranial nerve complex can be used.1-5  Baghai et al2 described the lateral pontine safe entry zone in 1982, as an alternative to approaches through the floor of the fourth ventricle when performing tumor biopsies. They advocated a small neurotomy performed right between the emergence of the trigeminal nerve and the facial-vestibulocochlear cranial nerves complex. Accurate image guidance, intraoperative cranial nerve monitoring, and comprehensive anatomical knowledge are critical for this approach.4,5  Knowing the natural history of a brainstem cavernous malformation after bleeding,6 we sought to demonstrate in this video: (1) the use of the retrosigmoid craniotomy in lateral decubitus for resection of deep-seated pontine cavernous malformations; (2) the wide opening of arachnoid membranes and dissection of the superior petrosal vein complex to improve surgical freedom and prevent use of fixed cerebellar retraction; and (3) the opening of the petrosal fissure and exposure of the lateral pontine zone for gross total resection of a cavernous malformation in a 19-yr-old female with a classical crossed brainstem syndrome. She had full neurological recovery after 3 mo of follow-up.  The patient consented in full to the surgical procedure and publication of the video and manuscript.

Posterior petrosectomy for resection of pontine cavernous malformation

2019 ◽  
Vol 1 (2) ◽  
pp. V18
Author(s):  
Avital Perry ◽  
Thomas J. Sorenson ◽  
Christopher S. Graffeo ◽  
Colin L. Driscoll ◽  
Michael J. Link
Keyword(s):  
Real Time ◽  
Surgical Resection ◽  
Cavernous Malformation ◽  
Low Pressure ◽  
Vascular Lesions ◽  
Cavernous Malformations ◽  
Entry Zone ◽  
Microsurgical Techniques ◽  
Safe Entry Zone ◽  
Ultrasound Probes

Cavernous malformations (CMs) are low-pressure, focal, vascular lesions that may occur within the brainstem and require treatment, which can be a substantial challenge. Herein, we demonstrate the surgical resection of a hemorrhaged brainstem CM through a posterior petrosectomy approach. After dissection of the overlying vascular and meningeal structures, a safe entry zone into the brainstem is identified based on local anatomy and intraoperative neuronavigation. Small ultrasound probes can also be useful for obtaining real-time intraoperative feedback. The CM is internally debulked and resected in a piecemeal fashion through an opening smaller than the CM itself. As brainstem CMs are challenging lesions, knowledge of several surgical nuances and adoption of careful microsurgical techniques are requisite for success.The video can be found here: https://youtu.be/szB6YpzkuCo.

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 Median suboccipital craniotomy and telovelar approach for posterior pontine cavernous malformations

2019 ◽  
Vol 1 (1) ◽  
pp. V8
Author(s):  
Daniel D. Cavalcanti ◽  
Paulo Niemeyer Filho
Keyword(s):  
Cavernous Malformation ◽  
Resonance Imaging ◽  
Cavernous Malformations ◽  
Entry Zone ◽  
Suboccipital Craniotomy ◽  
Telovelar Approach ◽  
Lateral Decubitus ◽  
Neurologically Intact ◽  
Safe Entry Zone

The pons is the preferred location for cavernous malformations in the brainstem. When these lesions do not surface, it is critical to select the optimal safe entry zone to reduce morbidity.1–3 In this video, we demonstrate in a stepwise manner the medial suboccipital craniotomy and the telovelar approach performed in a lateral decubitus position. They were used to successfully resect a pontine cavernous malformation in a centroposterior location in a 19-year-old patient with diplopia, right-sided numbness, and imbalance. The paramedian supracollicular safe entry zone was used once the lesion did not reach the ependymal surface.2,3 Late magnetic resonance imaging demonstrated total resection and the patient was neurologically intact after 3 months of follow-up. The approach is also demonstrated in a cadaveric dissection to better illustrate all steps.The video can be found here: https://youtu.be/ChArkxA8kig.

scholarly journals Fully endoscopic access and resection of hemorrhaged cavernous malformation of the posterior midbrain

2019 ◽  
Vol 1 (1) ◽  
pp. V14
Author(s):  
Giulio Cecchini ◽  
Giovanni Vitale ◽  
Thomas J. Sorenson ◽  
Francesco Di Biase
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/j7VTqRO7qd4.

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.

scholarly journals The epitrigeminal approach to the brainstem

2018 ◽  
Vol 128 (5) ◽  
pp. 1512-1521 ◽  
Author(s):  
Georgios Andrea Zenonos ◽  
David Fernandes-Cabral ◽  
Maximiliano Nunez ◽  
Stefan Lieber ◽  
Juan Carlos Fernandez-Miranda ◽  
...  
Keyword(s):  
Cavernous Malformation ◽  
Anatomical Study ◽  
Normal Subjects ◽  
Surgical Approaches ◽  
Illustrative Case ◽  
Fiber Tractography ◽  
High Definition ◽  
Entry Zone ◽  
Corticospinal Tracts ◽  
Direct Distance

OBJECTIVESurgical approaches to the ventrolateral pons pose a significant challenge. In this report, the authors describe a safe entry zone to the brainstem located just above the trigeminal entry zone which they refer to as the “epitrigeminal entry zone.”METHODSThe approach is presented in the context of an illustrative case of a cavernous malformation and is compared with the other commonly described approaches to the ventrolateral pons. The anatomical nuances were analyzed in detail with the aid of surgical images and video, anatomical dissections, and high-definition fiber tractography (HDFT). In addition, using the HDFT maps obtained in 77 normal subjects (154 sides), the authors performed a detailed anatomical study of the surgically relevant distances between the trigeminal entry zone and the corticospinal tracts.RESULTSThe patient treated with this approach had a complete resection of his cavernous malformation, and improvement of his symptoms. With regard to the HDFT anatomical study, the average direct distance of the corticospinal tracts from the trigeminal entry zone was 12.6 mm (range 8.7–17 mm). The average vertical distance was 3.6 mm (range −2.3 to 8.7 mm). The mean distances did not differ significantly from side to side, or across any of the groups studied (right-handed, left-handed, and ambidextrous).CONCLUSIONSThe epitrigeminal entry zone to the brainstem appears to be safe and effective for treating intrinsic ventrolateral pontine pathological entities. A possible advantage of this approach is increased versatility in the rostrocaudal axis, providing access both above and below the trigeminal nerve. Familiarity with the subtemporal transtentorial approach, and the reliable surgical landmark of the trigeminal entry zone, should make this a straightforward approach.

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