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.

Subtemporal transtentorial approach for resection of a pontomesencephalic cavernous malformation

2019 ◽  
Vol 1 (2) ◽  
pp. V10
Author(s):  
Georgios A. Zenonos ◽  
Samir Sur ◽  
Maximiliano Nuñez ◽  
David T. Fernandes-Cabral ◽  
Jacques J. Morcos
Keyword(s):  
Cavernous Malformation ◽  
3D Video ◽  
Fiber Tractography ◽  
High Definition ◽  
Entry Zone ◽  
Link Type ◽  
Transtentorial Approach

In this 3D video we review the case of a pontomesencephalic cavernous malformation in a 27-year-old woman who presented with hemiparesis and diplopia. The cavernous malformation was completely resected through a subtemporal transtentorial approach and an epitrigeminal brainstem entry zone, with a significant improvement in the patient’s hemiparesis. The relevant anatomy is reviewed in detail through multiple anatomical brainstem dissection specimens, as well as high-definition fiber tractography images. The rationale for the approach is analyzed relative to other possible options, and a number of technical pearls are provided.The video can be found here: https://youtu.be/8EoIWL7XqAc.

scholarly journals Far lateral approach for resection of lower pontine cavernous malformation

2019 ◽  
Vol 1 (1) ◽  
pp. V27
Author(s):  
Georgios A. Zenonos ◽  
Samir Sur ◽  
Maximiliano Nuñez ◽  
David T. Fernandes-Cabral ◽  
Jacques J. Morcos
Keyword(s):  
Cavernous Malformation ◽  
Lateral Approach ◽  
3D Video ◽  
Fiber Tractography ◽  
Abducens Palsy ◽  
High Definition ◽  
Entry Zone ◽  
Link Type ◽  
Far Lateral Approach ◽  
Far Lateral

In this 3D video we review the case of a lower pontine cavernous malformation in a 31-year-old man who presented with hemiparesis and an abducens palsy. The cavernous malformation was completely resected through a far lateral approach and a peritrigeminal brainstem entry zone, with a significant improvement in the patient’s hemiparesis. The relevant anatomy is reviewed in detail through multiple anatomical brainstem dissection specimens, as well as high-definition fiber tractography images. The rationale for the approach is analyzed relative to other possible options, and a number of technical pearls are provided.The video can be found here: https://youtu.be/fH2Q7RjlBKQ.

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.

scholarly journals Pontine cavernous malformation: microsurgery evading the floor of the fourth ventricle

2019 ◽  
Vol 1 (1) ◽  
pp. V15
Author(s):  
Abdullah Keleş ◽  
Mehmet Volkan Harput ◽  
Uğur Türe
Keyword(s):  
Fourth Ventricle ◽  
Cavernous Malformation ◽  
Total Resection ◽  
Middle Cerebellar Peduncle ◽  
Link Type ◽  
Postoperative Mri ◽  
First Choice ◽  
Cerebellar Peduncle ◽  
Neurologically Intact

This video demonstrates resection of a left pontine cavernous malformation that is abutting the floor of the fourth ventricle (f4V). Even though accessing the lesion through the f4V seems to be reasonable, we used a lateral supracerebellar approach through the middle cerebellar peduncle to preserve especially the abducens and facial nuclei. After total resection the patient was neurologically intact at the 3-month follow-up. Postoperative MRI revealed 3.5-mm pontine tissue between the cavity and f4V that appeared to be absent in preoperative MRI. Approaching pontine lesions through the f4V is not the first choice. In our opinion, the philosophy of safe entry zones is a concept to be reassessed.The video can be found here: https://youtu.be/1Jh6giZc-48.

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.

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 The superior fovea triangle approach: a novel safe entry zone to the brainstem

2017 ◽  
Vol 127 (5) ◽  
pp. 1134-1138 ◽  
Author(s):  
Kaan Yagmurlu ◽  
M. Yashar S. Kalani ◽  
Mark C. Preul ◽  
Robert F. Spetzler
Keyword(s):  
Fourth Ventricle ◽  
Motor Nucleus ◽  
Entry Zone ◽  
Adult Human ◽  
Facial Nerves ◽  
Important Landmark ◽  
Fiber Dissection ◽  
Dissection Technique ◽  
Formalin Fixed ◽  
Safe Entry Zone

The authors describe a safe entry zone, the superior fovea triangle, on the floor of the fourth ventricle for resection of deep dorsal pontine lesions at the level of the facial colliculus. Clinical data from a patient undergoing a suboccipital telovelar transsuperior fovea triangle approach to a deep pontine cavernous malformation were reviewed and supplemented with 6 formalin-fixed adult human brainstem and 2 silicone-injected adult human cadaveric heads using the fiber dissection technique to illustrate the utility of this novel safe entry zone. The superior fovea has a triangular shape that is an important landmark for the motor nucleus of the trigeminal, abducens, and facial nerves. The inferior half of the superior fovea triangle may be incised to remove deep dorsal pontine lesions through the floor of the fourth ventricle. The superior fovea triangle may be used as a safe entry zone for dorsally located lesions at the level of the facial colliculus.

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.

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