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Wang L, Zhang SB, Guo YF, Ren ST. From forbidden territory to feasible pursuit: Surgical management of primary pontine hemorrhage. Asian J Surg 2024:S1015-9584(24)00846-7. [PMID: 38735827 DOI: 10.1016/j.asjsur.2024.04.164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 04/18/2024] [Accepted: 04/25/2024] [Indexed: 05/14/2024] Open
Affiliation(s)
- Li Wang
- Biomedical Laboratory, Department of Neurosurgery, Liaocheng People's Hospital, School of Medicine, Liaocheng University, China
| | - Shu-Bao Zhang
- Department of Neurosurgery, Liaocheng People's Hospital, China
| | - Yun-Fa Guo
- Department of Neurosurgery, Liaocheng People's Hospital, China
| | - Song-Tao Ren
- Department of Neurosurgery, Liaocheng People's Hospital, China.
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Xiao X, Yang N, Gu G, Wang X, Jiang Z, Li T, Zhang X, Ma L, Zhang P, Liao H, Zhang L. Diffusion MRI is valuable in brainstem glioma genotyping with quantitative measurements of white matter tracts. Eur Radiol 2024; 34:2921-2933. [PMID: 37926739 DOI: 10.1007/s00330-023-10377-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 08/03/2023] [Accepted: 09/05/2023] [Indexed: 11/07/2023]
Abstract
OBJECTIVES To investigate the value of diffusion MRI (dMRI) in H3K27M genotyping of brainstem glioma (BSG). METHODS A primary cohort of BSG patients with dMRI data (b = 0, 1000 and 2000 s/mm2) and H3K27M mutation information were included. A total of 13 diffusion tensor and kurtosis imaging (DTI; DKI) metrics were calculated, then 17 whole-tumor histogram features and 29 along-tract white matter (WM) microstructural measurements were extracted from each metric and assessed within genotypes. After feature selection through univariate analysis and the least absolute shrinkage and selection operator method, multivariate logistic regression was used to build dMRI-derived genotyping models based on retained tumor and WM features separately and jointly. Model performances were tested using ROC curves and compared by the DeLong approach. A nomogram incorporating the best-performing dMRI model and clinical variables was generated by multivariate logistic regression and validated in an independent cohort of 27 BSG patients. RESULTS At total of 117 patients (80 H3K27M-mutant) were included in the primary cohort. In total, 29 tumor histogram features and 41 WM tract measurements were selected for subsequent genotyping model construction. Incorporating WM tract measurements significantly improved diagnostic performances (p < 0.05). The model incorporating tumor and WM features from both DKI and DTI metrics showed the best performance (AUC = 0.9311). The nomogram combining this dMRI model and clinical variables achieved AUCs of 0.9321 and 0.8951 in the primary and validation cohort respectively. CONCLUSIONS dMRI is valuable in BSG genotyping. Tumor diffusion histogram features are useful in genotyping, and WM tract measurements are more valuable in improving genotyping performance. CLINICAL RELEVANCE STATEMENT This study found that diffusion MRI is valuable in predicting H3K27M mutation in brainstem gliomas, which is helpful to realize the noninvasive detection of brainstem glioma genotypes and improve the diagnosis of brainstem glioma. KEY POINTS • Diffusion MRI has significant value in brainstem glioma H3K27M genotyping, and models with satisfactory performances were built. • Whole-tumor diffusion histogram features are useful in H3K27M genotyping, and quantitative measurements of white matter tracts are valuable as they have the potential to improve model performance. • The model combining the most discriminative diffusion MRI model and clinical variables can help make clinical decision.
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Affiliation(s)
- Xiong Xiao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, 119#, Nan Si Huan Xi Lu, Fengtai District, Beijing, 100070, China
| | - Ne Yang
- Department of Biomedical Engineering, School of Medicine, Tsinghua University, Beijing, China
| | - Guocan Gu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, 119#, Nan Si Huan Xi Lu, Fengtai District, Beijing, 100070, China
| | - Xianyu Wang
- Department of Biomedical Engineering, School of Medicine, Tsinghua University, Beijing, China
| | - Zhuang Jiang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, 119#, Nan Si Huan Xi Lu, Fengtai District, Beijing, 100070, China
| | - Tian Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, 119#, Nan Si Huan Xi Lu, Fengtai District, Beijing, 100070, China
| | - Xinran Zhang
- Department of Biomedical Engineering, School of Medicine, Tsinghua University, Beijing, China
| | - Longfei Ma
- Department of Biomedical Engineering, School of Medicine, Tsinghua University, Beijing, China
| | - Peng Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, 119#, Nan Si Huan Xi Lu, Fengtai District, Beijing, 100070, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hongen Liao
- Department of Biomedical Engineering, School of Medicine, Tsinghua University, Beijing, China.
| | - Liwei Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, 119#, Nan Si Huan Xi Lu, Fengtai District, Beijing, 100070, China.
- China National Clinical Research Center for Neurological Diseases, Beijing, China.
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
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Inci S, Baylarov B. Axial Sections of Brainstem Safe Entry Zones and Clinical Importance of Intrinsic Structures: A Review. World Neurosurg 2024; 185:171-180. [PMID: 38401754 DOI: 10.1016/j.wneu.2024.02.088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Revised: 02/14/2024] [Accepted: 02/15/2024] [Indexed: 02/26/2024]
Abstract
Brainstem surgery is more difficult and riskier than surgeries in other parts of the brain due to the high density of critical tracts and cranial nerves nuclei in this region. For this reason, some safe entry zones into the brainstem have been described. The main purpose of this article is to bring on the agenda the significance of the intrinsic structures of the safe entry zones to the brainstem. Having detailed information about anatomic localization of these sensitive structures is important to predict and avoid possible surgical complications. In order to better understand this complex anatomy, we schematically drew the axial sections of the brainstem showing the intrinsic structures at the level of 9 safe entry zones that we used, taking into account basic neuroanatomy books and atlases. Some illustrations are also supported with intraoperative pictures to provide better surgical orientation. The second purpose is to remind surgeons of clinical syndromes that may occur in case of surgical injury to these delicate structures. Advanced techniques such as tractography, neuronavigation, and neuromonitorization should be used in brainstem surgery, but detailed neuroanatomic knowledge about safe entry zones and a meticulous surgery are more important. The axial brainstem sections we have drawn can help young neurosurgeons better understand this complex anatomy.
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Affiliation(s)
- Servet Inci
- Department of Neurosurgery, Medical Faculty, Hacettepe University, Ankara, Turkey.
| | - Baylar Baylarov
- Department of Neurosurgery, Medical Faculty, Hacettepe University, Ankara, Turkey
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4
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Goto Y, Inoue T. Intercollicular Approach for Midbrain Cavernous Malformation: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01088. [PMID: 38451078 DOI: 10.1227/ons.0000000000001124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 01/22/2024] [Indexed: 03/08/2024] Open
Abstract
Previously reported midbrain cavernous malformations often exhibit lateral expansion, making their excision through the nearest brain surface incision easier.1-5 Nevertheless, excising a midbrain cavernous malformation that lacks lateral extension can be particularly challenging because of limited access.5 The anterior midline approach is typically conducted through the interpeduncular fossa zone.3,5 Still, it restricts surgical maneuverability because of the presence of the posterior communicating artery, the posterior cerebral artery, and the oculomotor nerve. On the other hand, the posterior midline approach through the intercollicular region, although reported in only a single case, lacks technical details and postoperative neurological status.3,5 In this report, we elaborate on the feasibility of surgical manipulations for midline-located midbrain cavernous angiomas through the intercollicular region and discuss the resulting postoperative neurological outcomes.
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Affiliation(s)
- Yukihiro Goto
- Department of Neurosurgery, Koto Memorial Hospital, Higashiohmi-City, Shiga-Prefecture, Japan
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5
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Weiß L, Roth F, Rea-Ludmann P, Rosenstock T, Picht T, Vajkoczy P, Zdunczyk A. NTMS based tractography and segmental diffusion analysis in patients with brainstem gliomas: Risk stratification and clinical potential. BRAIN & SPINE 2024; 4:102753. [PMID: 38510608 PMCID: PMC10951762 DOI: 10.1016/j.bas.2024.102753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Revised: 01/17/2024] [Accepted: 01/21/2024] [Indexed: 03/22/2024]
Abstract
Introduction Surgery on the brainstem level is associated with a high-risk of postoperative morbidity. Recently, we have introduced the combination of navigated transcranial magnetic stimulation (nTMS) and diffusion tensor imaging (DTI) tractography to define functionally relevant motor fibers tracts on the brainstem level to support operative planning and risk stratification in brainstem cavernomas. Research question Evaluate this method and assess it's clinical impact for the surgery of brainstem gliomas. Material and methods Patients with brainstem gliomas were examined preoperatively with motor nTMS and DTI tractography. A fractional anisotropy (FA) value of 75% of the individual FA threshold (FAT) was used to track descending corticospinal (CST) and -bulbar tracts (CBT). The distance between the tumor and the somatotopic tracts (hand, leg, face) was measured and diffusion parameters were correlated to the patients' outcome. Results 12 patients were enrolled in this study, of which 6 underwent surgical resection, 5 received a stereotactic biopsy and 1 patient received conservative treatment. In all patients nTMS mapping and somatotopic tractography were performed successfully. Low FA values correlated with clinical symptoms revealing tract alteration by the tumor (p = 0.049). A tumor-tract distance (TTD) above 2 mm was the critical limit to achieve a safe complete tumor resection. Discussion and conclusion nTMS based DTI tractography combined with local diffusion analysis is a valuable tool for preoperative visualization and functional assessment of relevant motor fiber tracts, improving planning of safe entry corridors and perioperative risk stratification in brainstem gliomas tumors. This technique allows for customized treatment strategy to maximize patients' safety.
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Affiliation(s)
- Lion Weiß
- Charité – Universitätsmedizin Berlin, Department of Neurosurgery, Germany
| | - Fabia Roth
- Charité – Universitätsmedizin Berlin, Department of Neurosurgery, Germany
| | - Pierre Rea-Ludmann
- Charité – Universitätsmedizin Berlin, Department of Neurosurgery, Germany
| | - Tizian Rosenstock
- Charité – Universitätsmedizin Berlin, Department of Neurosurgery, Germany
- Berlin Institute of Health at Charité – Universitätsmedizin Berlin, Germany
| | - Thomas Picht
- Charité – Universitätsmedizin Berlin, Department of Neurosurgery, Germany
- Cluster of Excellence Matters of Activity. Image Space Material, Humboldt Universität zu Berlin, Germany
| | - Peter Vajkoczy
- Charité – Universitätsmedizin Berlin, Department of Neurosurgery, Germany
| | - Anna Zdunczyk
- Charité – Universitätsmedizin Berlin, Department of Neurosurgery, Germany
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Deletis V, Seidel K, Fernández-Conejero I. Intraoperative Neurophysiologic Monitoring and Mapping in Children Undergoing Brainstem Surgery. J Clin Neurophysiol 2024; 41:108-115. [PMID: 38306218 DOI: 10.1097/wnp.0000000000001037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2024] Open
Abstract
SUMMARY Intraoperative neurophysiologic monitoring during surgery for brainstem lesions is a challenge for intraoperative neurophysiologists and surgeons. The brainstem is a small structure packed with vital neuroanatomic networks of long and short pathways passing through the brainstem or originating from it. Many central pattern generators exist within the brainstem for breathing, swallowing, chewing, cardiovascular regulation, and eye movement. During surgery around the brainstem, these generators need to be preserved to maintain their function postoperatively. This short review presents neurophysiologic and neurosurgical experiences of brainstem surgery in children.
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Affiliation(s)
- Vedran Deletis
- Department of Neurosurgery, University Hospital Dubrava, Zagreb, Croatia
- Albert Einstein College of Medicine, New York, New York, U.S.A
| | - Kathleen Seidel
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; and
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Lin BJ, Ju DT, Tseng KY, Liu WH, Tang CT, Hueng DY, Chen YH, Hsia CC, Chen GJ, Ma HI, Liu MY, Chung TT. Endoscopically assisted presigmoid retrolabyrinthine approach to the lateral mesencephalic sulcus: a cadaveric study with comparison to the variant supracerebellar infratentorial approaches. Neurosurg Rev 2023; 46:73. [PMID: 36944828 DOI: 10.1007/s10143-023-01979-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 03/08/2023] [Accepted: 03/12/2023] [Indexed: 03/23/2023]
Abstract
The supracerebellar infratentorial (SCIT) approach is commonly used to gain access to the lateral mesencephalic sulcus (LMS), which has been established as a safe entry point into the posterolateral midbrain. This study describes a lateral variant of the SCIT approach, the supreme-lateral SCIT approach, for accessing the LMS through the presigmoid retrolabyrinthine craniectomy and quantitatively compares this approach with the paramedian and extreme-lateral SCIT approaches. Anatomical dissections were performed in four cadaveric heads. In each head, the supreme-lateral SCIT approach was established on one side, following a detailed description of each step, whereas the paramedian and supreme-lateral SCIT approaches were established on the other side. Quantitative measurements of the exposed posterolateral midbrain, the angles of LMS entry, and the depth of surgical corridors were recorded and compared between the three SCIT approach variants. The supreme-lateral (67.70 ± 23.14 mm2) and extreme-lateral (70.83 ± 24.99 mm2) SCIT approaches resulted in larger areas of exposure anterior to the LMS than the paramedian SCIT approach (38.61 ± 9.84 mm2); the supreme-lateral SCIT approach resulted in a significantly smaller area of exposure posterior to the LMS (65.24 ± 6.81 mm2) than the other two variants (paramedian = 162.75 ± 31.98 mm2; extreme-lateral = 143.10 ± 23.26 mm2; both P < .001). Moreover, the supreme-lateral SCIT approach resulted in a surgical corridor with a shallower depth and a smaller angle relative to the horizontal plane than the other two variants. The supreme-lateral SCIT approach is a more lateral approach than the extreme-lateral SCIT approach, providing a subtemporal approach with direct LMS visualization. The supreme-lateral SCIT offers the benefits of both subtemporal and SCIT approaches and represents a suitable option for the management of selected midbrain pathologies.
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Affiliation(s)
- Bon-Jour Lin
- Department of Neurological Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan.
- Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan.
| | - Da-Tong Ju
- Department of Neurological Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Kuan-Yin Tseng
- Department of Neurological Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Wei-Hsiu Liu
- Department of Neurological Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chi-Tun Tang
- Department of Neurological Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Dueng-Yuan Hueng
- Department of Neurological Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Yuan-Hao Chen
- Department of Neurological Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chung-Ching Hsia
- Department of Neurological Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Guann-Juh Chen
- Department of Neurological Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Hsin-I Ma
- Department of Neurological Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Ming-Ying Liu
- Department of Neurological Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Tzu-Tsao Chung
- Department of Neurological Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan.
- Department of Surgery, Cheng-Hsin General Hospital, Taipei, Taiwan.
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Zhou J, Ping A, Mao J, Gu Y, Liu F, Shao A. ZJUSAH Classification: A New Classification for Primary Brainstem Hemorrhage. Life (Basel) 2023; 13:life13030846. [PMID: 36984002 PMCID: PMC10059730 DOI: 10.3390/life13030846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 03/14/2023] [Accepted: 03/16/2023] [Indexed: 03/30/2023] Open
Abstract
To analyze and improve ZJUSAH classification for primary brainstem hematoma, we retrospectively reviewed 211 patients with primary brainstem hemorrhage who were admitted to our institution between January 2014 and October 2020. The primary clinical outcomes were the 30-day survival rate and 90-day consciousness recovery rate, which were evaluated using the National Institutes of Health Stroke Scale score. Univariate logistic regression and multivariate Cox regression analyses were performed to evaluate the prognostic model. The overall 30-day survival rate of the 211 patients was 69.7%. The 30-day survival rate was 95% among Type 1 patients, 77.8% among Type 2 patients, and 63.2% among Type 3 patients. The 90-day consciousness recovery rate was 63.2% among Type 1 patients, 61.9% among Type 2 patients, and 30.2% among Type 3 patients. Our findings suggest that ZJUSAH classification can be optimized according to hematoma volume, with Type 3 patients with a hematoma larger than 12.4 mL tending to have a worse state of consciousness. Additionally, we discovered that ZJUSAH classification is valuable in predicting 30-day survival rates in conservative treatment patients. In conclusion, our study established and optimized a new CT-based hematoma classification system for primary brainstem hematoma, which facilitates treatment selection and prognostic prediction.
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Affiliation(s)
- Jingyi Zhou
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310009, China
| | - An Ping
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310009, China
| | - Jizhong Mao
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310009, China
| | - Yichen Gu
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310009, China
| | - Fengqiang Liu
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310009, China
- Brain Research Institute, Zhejiang University, Hangzhou 310058, China
- Collaborative Innovation Center for Brain Science, Zhejiang University, Hangzhou 310058, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou 310009, China
| | - Anwen Shao
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310009, China
- Brain Research Institute, Zhejiang University, Hangzhou 310058, China
- Collaborative Innovation Center for Brain Science, Zhejiang University, Hangzhou 310058, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou 310009, China
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Cheok SK, Zada G. Commentary: Transmiddle Cerebellar Peduncle Approach to a Large Pontine Tumor: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2023; 24:e114-e115. [PMID: 36537817 DOI: 10.1227/ons.0000000000000551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Accepted: 09/29/2022] [Indexed: 01/14/2023] Open
Affiliation(s)
- Stephanie Kim Cheok
- Department of Neurological Surgery, Keck School of Medicine at University of Southern California, Los Angeles, California, USA
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Catapano JS, Benner D, Rhodenhiser EG, Rumalla K, Graffeo CS, Srinivasan VM, Winkler EA, Lawton MT. Safety of brainstem safe entry zones: comparison of microsurgical outcomes associated with superficial, exophytic, and deep brainstem cavernous malformations. J Neurosurg 2022:1-11. [PMID: 36681989 DOI: 10.3171/2022.9.jns222012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 09/08/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Safe entry zones (SEZs) enable safe tissue transgression to lesions beneath the brainstem surface. However, evidence for the safety of SEZs is scarce and is based on anatomical studies, case reports, and small series. METHODS A cohort of 154 patients who underwent microsurgical brainstem cavernous malformation (BSCM) treatment during a 23-year period and who had preoperative MR images and intraoperative photographs or videos was retrospectively examined. This study assessed the safety of SEZs for access to deep BSCMs, preoperative MRI to predict BSCM surface proximity, and the relationships between BSCM subtype, surgical approach, and SEZs. Lesions were characterized as exophytic, superficial, or deep on the basis of preoperative MRI and intraoperative inspection. Outcomes were scored as good (modified Rankin Scale [mRS] score ≤ 2) or poor (mRS score > 2) and relative outcomes as stable/improved or worse relative to baseline (± 1 point). RESULTS Resections included 34 (22%) in the midbrain, 102 (66%) in the pons, and 18 (12%) in the medulla. Of those, 23 (15%) were exophytic, 57 (37%) were superficial, and 74 (48%) were deep. Established SEZs were used for 97% (n = 72) of deep lesions; the preferred SEZ associated with its subtype was used for 91% (n = 67). MR images accurately depicted exophytic BSCMs that did not require SEZ approaches (sensitivity, 96%) but overestimated the proximity of lesions superficial to brainstem surfaces (specificity, 67%), resulting in unanticipated SEZ use. Final neurological outcomes were good in 80% of patients with follow-up data (119/149), and relative outcomes were stable/improved in 93% (139/149). Outcomes for patients with brainstem transgression through an SEZ did not differ from outcomes for patients with superficial or exophytic lesions that did not require SEZ use (final mRS score ≤ 2 in 72% of all patients with deep lesions vs 82% of all patients with superficial or exophytic lesions [p = 0.10]). Among patients with follow-up, the rates of permanent new cranial nerve deficits in patients with deep BSCMs and superficial or exophytic BSCMs were 21% and 20%, respectively (p = 0.81), with no significant change in overall cranial nerve deficit (0 and -1, p = 0.65). CONCLUSIONS Neurological outcomes for patients with deep BSCMs were equivalent to those for superficial or exophytic BSCMs, validating the safety of SEZs for deep BSCMs. Preoperative T1-weighted MR images overestimated the lesion's surface proximity, necessitating detailed knowledge of SEZs and readiness to use them in cases of radiological-microsurgical discordance. Most patients achieved favorable outcomes despite the transgression of eloquent brainstem tissue in and around SEZs.
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Affiliation(s)
- Joshua S. Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona
| | - Dimitri Benner
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona
| | - Emmajane G. Rhodenhiser
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona
| | - Kavelin Rumalla
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona
| | - Christopher S. Graffeo
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona
| | - Visish M. Srinivasan
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona
| | - Ethan A. Winkler
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona
| | - Michael T. Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona
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Guberinic A, van den Elshout R, Kozicz T, Laan MT, Henssen D. Overview of the microanatomy of the human brainstem in relation to the safe entry zones. J Neurosurg 2022; 137:1524-1534. [PMID: 35395628 DOI: 10.3171/2022.2.jns211997] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Accepted: 02/07/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The primary objective of this anatomical study was to apply innovative imaging techniques to increase understanding of the microanatomical structures of the brainstem related to safe entry zones. The authors hypothesized that such a high-detail overview would enhance neurosurgeons' abilities to approach and define anatomical safe entry zones for use with microsurgical resection techniques for intrinsic brainstem lesions. METHODS The brainstems of 13 cadavers were studied with polarized light imaging (PLI) and 11.7-T MRI. The brainstem was divided into 3 compartments-mesencephalon, pons, and medulla-for evaluation with MRI. Tissue was further sectioned to 100 μm with a microtome. MATLAB was used for further data processing. Segmentation of the internal structures of the brainstem was performed with the BigBrain database. RESULTS Thirteen entry zones were reported and assessed for their safety, including the anterior mesencephalic zone, lateral mesencephalic sulcus, interpeduncular zone, intercollicular region, supratrigeminal zone, peritrigeminal zone, lateral pontine zone, median sulcus, infracollicular zone, supracollicular zone, olivary zone, lateral medullary zone, and anterolateral sulcus. The microanatomy, safety, and approaches are discussed. CONCLUSIONS PLI and 11.7-T MRI data show that a neurosurgeon possibly does not need to consider the microanatomical structures that would not be visible on conventional MRI and tractography when entering the mentioned safe entry zones. However, the detailed anatomical images may help neurosurgeons increase their understanding of the internal architecture of the human brainstem, which in turn could lead to safer neurosurgical intervention.
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Affiliation(s)
- Alis Guberinic
- 1Department of Neurosurgery, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Rik van den Elshout
- 2Department of Radiology, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Tamas Kozicz
- 3Department of Biochemistry and Molecular Biology, Mayo Clinic, Rochester, Minnesota; and
- 4Department of Clinical Genomics, Mayo Clinic, Rochester, Minnesota
| | - Mark Ter Laan
- 1Department of Neurosurgery, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Dylan Henssen
- 2Department of Radiology, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
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Gurses ME, Gungor A, Rahmanov S, Gökalp E, Hanalioglu S, Berker M, Cohen-Gadol AA, Türe U. Three-Dimensional Modeling and Augmented Reality and Virtual Reality Simulation of Fiber Dissection of the Cerebellum and Brainstem. Oper Neurosurg (Hagerstown) 2022; 23:345-354. [DOI: 10.1227/ons.0000000000000358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 05/24/2022] [Indexed: 11/07/2022] Open
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Prognosis and Influencing Factors of Early Microsurgery for Severe Hypertensive Brainstem Hemorrhage. DISEASE MARKERS 2022; 2022:5062591. [PMID: 36193500 PMCID: PMC9526571 DOI: 10.1155/2022/5062591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 09/03/2022] [Indexed: 11/24/2022]
Abstract
Objective To investigate the prognosis and influencing factors of early microsurgery for severe hypertensive brainstem hemorrhage. Methods The clinical data of 19 patients with severe hypertensive brainstem hemorrhage treated in the Department of Neurosurgery of the Second Affiliated Hospital of Shandong First Medical University between January 2018 and December 2021 were retrospectively analyzed. The clinical efficacy and risk factors affecting the prognosis were analyzed by chi-square test and multivariate logistic regression. Results A total of 19 patients with severe hypertensive brainstem hemorrhage were treated by early microsurgery, including 14 cases by subtemporal approach and 5 cases by retrosigmoid approach. After 3 months of follow-up, 6 patients died and 13 patients survived. The 30-day and 90-day mortality rates were 21.1% and 31.6%, respectively, and the good prognosis rate was 15.4%. Univariate analysis showed that hematoma volume and hematoma clearance rate might be the factors affecting the prognosis of patients with severe hypertensive brainstem hemorrhage; the observed difference was statistically significant (P < 0.05). Multivariate logistic regression analysis further confirmed that hematoma volume was an independent factor affecting the death of patients with brainstem hemorrhage (P < 0.05), while hematoma volume (B: 2.909, OR: 18.332, 95% CI: 1.020–329.458, P: 0.048) was a risk factor. Conclusion Hematoma volume resulted as an independent factor affecting the death of patients with severe hypertensive brainstem hemorrhage. Early microsurgical clearance of brainstem hematoma contributed to reducing the 30-day and 90-day mortality and improving the prognosis of patients.
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Yang Y, Neidert MC, Velz J, Kälin V, Sarnthein J, Regli L, Bozinov O. Mapping and Monitoring of the Corticospinal Tract by Direct Brainstem Stimulation. Neurosurgery 2022; 91:496-504. [DOI: 10.1227/neu.0000000000002065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 04/28/2022] [Indexed: 11/19/2022] Open
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15
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Management of Primary Brainstem Hemorrhage: A Review of Outcome Prediction, Surgical Treatment, and Animal Model. DISEASE MARKERS 2022; 2022:4293590. [PMID: 35864996 PMCID: PMC9296309 DOI: 10.1155/2022/4293590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 05/04/2022] [Indexed: 11/17/2022]
Abstract
Primary brainstem hemorrhage (PBH) has the worst prognosis of all types of intracerebral hemorrhage. Currently, the management of PBH is controversial. Hematoma classification, scoring systems, and electrophysiological monitoring are critical for predicting the outcome of PBH. Surgery may be an effective treatment for PBH. Clinical studies have emphasized the importance of animal models for understanding the pathogenesis and pathological mechanisms of PBH. In this study, combined with recent studies, the outcome prediction, surgical treatment, and animal models of PBH were reviewed.
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Velz J, Özkaratufan S, Krayenbühl N, Beccaria K, Akeret K, Attieh C, Ghannam B, Guida L, Benichi S, Bozinov O, Puget S, Blauwblomme T, Regli L. Pediatric brainstem cavernous malformations: 2-center experience in 40 children. J Neurosurg Pediatr 2022; 29:612-623. [PMID: 35303707 DOI: 10.3171/2022.1.peds21538] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 01/13/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Brainstem cavernous malformations (BSCMs) are relatively uncommon, low-flow vascular lesions in children. Given the paucity of data, guidelines regarding the clinical management of BSCMs in children are lacking and the surgical indication is most commonly based on an individual surgeon's judgment and experience. The goal in this study was to evaluate the clinical behavior of BSCMs in childhood and the long-term outcome in children managed conservatively and surgically. METHODS This was an observational, retrospective study including all children with BSCMs who were followed at 2 institutions between 2008 and 2020. RESULTS The study population consisted of 40 children (27 boys, 67.5%) with a mean age of 11.4 years. Twenty-three children (57.5%) were managed conservatively, whereas 17 children (42.5%) underwent resection of BSCMs. An aggressive clinical course was observed in 13 children (32.5%), who experienced multiple hemorrhages with a progressive pattern of neurological decline. Multiple BSCMs were observed in 8 patients, of whom 3 patients presented with a complex of multiple tightly attached BSCMs and posed a significant therapeutic challenge. The overall long-term outcome was favorable (modified Rankin Scale [mRS] scores 0-2) in 36 patients (90%), whereas an unfavorable outcome (mRS scores 3 and 4) was seen in 4 children (10%). An mRS score of 5 or 6 was not observed. The mean (± SD) follow-up was 88.0 (± 92.6) months. CONCLUSIONS The clinical course of BSCMs in children is highly variable, with benign lesions on the one hand and highly aggressive lesions with repetitive hemorrhages on the other. Given the greater life expectancy and the known higher functional recovery in children, surgical treatment should be considered early in young patients presenting with surgically accessible lesions and an aggressive clinical course, and it should be performed in a high-volume center.
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Affiliation(s)
- Julia Velz
- 1Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, Switzerland
- 2University of Zurich, Switzerland
- 3Division of Pediatric Neurosurgery, University Children's Hospital Zurich, Switzerland
- 4Department of Pediatric Neurosurgery, APHP, Hôpital Necker, Paris, France
| | - Sena Özkaratufan
- 1Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, Switzerland
- 2University of Zurich, Switzerland
| | - Niklaus Krayenbühl
- 1Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, Switzerland
- 2University of Zurich, Switzerland
- 3Division of Pediatric Neurosurgery, University Children's Hospital Zurich, Switzerland
| | - Kevin Beccaria
- 4Department of Pediatric Neurosurgery, APHP, Hôpital Necker, Paris, France
- 5Université de Paris, France
| | - Kevin Akeret
- 1Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, Switzerland
- 2University of Zurich, Switzerland
| | - Christian Attieh
- 4Department of Pediatric Neurosurgery, APHP, Hôpital Necker, Paris, France
| | - Boulos Ghannam
- 4Department of Pediatric Neurosurgery, APHP, Hôpital Necker, Paris, France
| | - Lelio Guida
- 4Department of Pediatric Neurosurgery, APHP, Hôpital Necker, Paris, France
- 5Université de Paris, France
| | - Sandro Benichi
- 4Department of Pediatric Neurosurgery, APHP, Hôpital Necker, Paris, France
- 5Université de Paris, France
| | - Oliver Bozinov
- 1Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, Switzerland
- 6Department of Neurosurgery, Kantonsspital St. Gallen, Switzerland; and
| | - Stephanie Puget
- 4Department of Pediatric Neurosurgery, APHP, Hôpital Necker, Paris, France
- 7Department of Neurosurgery, Hôpital Pierre Zobda Quitman, CHU de Fort de France, Université des Antilles, Fort de France, Martinique
| | - Thomas Blauwblomme
- 4Department of Pediatric Neurosurgery, APHP, Hôpital Necker, Paris, France
- 5Université de Paris, France
| | - Luca Regli
- 1Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, Switzerland
- 2University of Zurich, Switzerland
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Yang Y, Velz J, Neidert MC, Lang W, Regli L, Bozinov O. The BSCM score: a guideline for surgical decision-making for brainstem cavernous malformations. Neurosurg Rev 2021; 45:1579-1587. [PMID: 34713352 PMCID: PMC8976795 DOI: 10.1007/s10143-021-01679-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 10/12/2021] [Accepted: 10/20/2021] [Indexed: 11/07/2022]
Abstract
Microsurgical resection of brainstem cavernous malformations (BSCMs) can be performed today with acceptable morbidity and mortality. However, in this highly eloquent location, the indication for surgery remains challenging. We aimed to elaborate a score system that may help clinicians with their choice of treatment in patients with BSCMs in this study. A single-center series of 88 consecutive BSCMs patients with 272 follow-up visits were included in this study. Univariable and multivariable generalized estimating equations (GEE) were constructed to identify the association of variables with treatment decisions. A score scale assigned points for variables that significantly contributed to surgical decision-making. Surgical treatment was recommended in 37 instances, while conservative treatment was proposed in 235 instances. The mean follow-up duration was 50.4 months, and the mean age at decision-making was 45.9 years. The mean BSCMs size was 14.3 ml. In the multivariable GEE model, patient age, lesion size, hemorrhagic event(s), mRS, and axial location were identified as significant factors for determining treatment options. With this proposed score scale (grades 0–XII), non-surgery was the first option at grades 0–III. The crossover point between surgery and non-surgery recommendations lay between grades V and VI while surgical treatment was found in favor at grades VII–X. In conclusion, the proposed BSCM operating score is a clinician-friendly tool, which may help neurosurgeons decide on the treatment for patients with BSCMs.
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Affiliation(s)
- Yang Yang
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital of Zurich, University of Zurich, Ramistrasse 100, CH-8091, Zurich, Switzerland. .,Department of Neurosurgery, Kantonsspital St. Gallen, Rorschacher Strasse 95, CH-9007, St. Gallen, Switzerland.
| | - Julia Velz
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital of Zurich, University of Zurich, Ramistrasse 100, CH-8091, Zurich, Switzerland
| | - Marian C Neidert
- Department of Neurosurgery, Kantonsspital St. Gallen, Rorschacher Strasse 95, CH-9007, St. Gallen, Switzerland
| | - Wei Lang
- Department of Geriatric Medicine, University Hospital Zurich, City Hospital Waid Zurich, Tiechestrasse 99, CH-8037, Zurich, Switzerland
| | - Luca Regli
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital of Zurich, University of Zurich, Ramistrasse 100, CH-8091, Zurich, Switzerland
| | - Oliver Bozinov
- Department of Neurosurgery, Kantonsspital St. Gallen, Rorschacher Strasse 95, CH-9007, St. Gallen, Switzerland
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Serrato-Avila JL, Paz Archila JA, Silva da Costa MD, Riechelmann GS, Rocha PR, Marques SR, Carvalho de Moraes LO, Cavalheiro S, Yağmurlu K, Lawton MT, Chaddad-Neto F. Three-Dimensional Quantitative Analysis of the Brainstem Safe Entry Zones Based on Internal Structures. World Neurosurg 2021; 158:e64-e74. [PMID: 34715371 DOI: 10.1016/j.wneu.2021.10.100] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Revised: 10/10/2021] [Accepted: 10/11/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Brainstem safe entry zones (EZs) are gates to access the intrinsic pathology of the brainstem. We performed a quantitative analysis of the intrinsic surgical corridor limits of the most commonly used EZs and illustrated these through an inside perspective using 2-dimensional photographs, 3-dimensional photographs, and interactive 3-dimensional model reconstructions. METHODS A total of 26 human brainstems (52 sides) with the cerebellum attached were prepared using the Klingler method and dissected. The safe working areas and distances for each EZ were defined according to the eloquent fiber tracts and nuclei. RESULTS The largest safe distance corresponded to the depth for the lateral mesencephalic sulcus (4.8 mm), supratrigeminal (10 mm), epitrigeminal (13.2 mm), peritrigeminal (13.3 mm), lateral transpeduncular (22.3 mm), and infracollicular (4.6 mm); the rostrocaudal axis for the perioculomotor (11.7 mm), suprafacial (12.6 mm), and transolivary (12.8 mm); and the mediolateral axis for the supracollicular (9.1 mm) and infracollicular (7 mm) EZs. The safe working areas were 46.7 mm2 for the perioculomotor, 21.3 mm2 for the supracollicular, 14.8 mm2 for the infracollicular, 33.1 mm2 for the supratrigeminal, 34.3 mm2 for the suprafacial, 21.9 mm2 for the infrafacial, and 51.7 mm2 for the transolivary EZs. CONCLUSIONS The largest safe distance in most EZs corresponded to the depth, followed by the rostrocaudal axis and, finally, the mediolateral axis. The transolivary had the largest safe working area of all EZs. The supracollicular EZ had the largest safe area to access the midbrain tectum and the suprafacial EZ for the floor of the fourth ventricle.
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Affiliation(s)
- Juan Leonardo Serrato-Avila
- Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, São Paulo, Brazil; Laboratory of Microneurosurgery Anatomy, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Juan Alberto Paz Archila
- Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, São Paulo, Brazil; Laboratory of Microneurosurgery Anatomy, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Marcos Devanir Silva da Costa
- Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, São Paulo, Brazil; Laboratory of Microneurosurgery Anatomy, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Guilherme Salemi Riechelmann
- Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, São Paulo, Brazil; Laboratory of Microneurosurgery Anatomy, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Paulo Ricardo Rocha
- Laboratory of Microneurosurgery Anatomy, Universidade Federal de São Paulo, São Paulo, Brazil; Department of Morphology and Genetics, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Sergio Ricardo Marques
- Department of Morphology and Genetics, Universidade Federal de São Paulo, São Paulo, Brazil
| | | | - Sergio Cavalheiro
- Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, São Paulo, Brazil; Laboratory of Microneurosurgery Anatomy, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Kaan Yağmurlu
- Department of Neurosurgery, University of Virginia, Health System, Charlottesville, Virginia, USA; Department of Neuroscience, University of Virginia, Health System, Charlottesville, Virginia, USA
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Feres Chaddad-Neto
- Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, São Paulo, Brazil; Laboratory of Microneurosurgery Anatomy, Universidade Federal de São Paulo, São Paulo, Brazil; Department of Neurosurgery, Hospital Beneficência Portuguesa de São Paulo, São Paulo, Brazil.
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Chen D, Tang Y, Nie H, Zhang P, Wang W, Dong Q, Wu G, Xue M, Tang Y, Liu W, Pan C, Tang Z. Primary Brainstem Hemorrhage: A Review of Prognostic Factors and Surgical Management. Front Neurol 2021; 12:727962. [PMID: 34566872 PMCID: PMC8460873 DOI: 10.3389/fneur.2021.727962] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Accepted: 08/19/2021] [Indexed: 01/04/2023] Open
Abstract
Primary brainstem hemorrhage (PBSH) is the most fatal subtype of intracerebral hemorrhage and is invariably associated with poor prognosis. Several prognostic factors are involved, of which the two most predominant and consistent are the initial level of consciousness and hemorrhage size. Other predictors, such as age, hyperthermia, and hydrocephalus, are generally not dependable indicators for making prognoses. Scoring systems have now been developed that can predict mortality and functional outcomes in patients suffering from PBSH, which can thus guide treatment decision-making. A novel grading scale, entitled “the new primary pontine hemorrhage (PPH) score,” represents the latest approach in scoring systems. In this system, patients with a score of 2–3 points appear to benefit from surgical management, although this claim requires further verification. The four main surgical options for the treatment of PBSH are craniotomy, stereotactic hematoma puncture and drainage, endoscopic hematoma removal, and external ventricular drainage. Nevertheless, the management of PBSH still primarily involves conservative treatment methods and surgery is generally not recommended, according to current practice. However, the ongoing clinical trial, entitled Safety and Efficacy of Surgical Treatment in Severe Primary Pontine Hemorrhage Evacuation (STIPE), should provide additional evidence to support the surgical treatment of PBSH. Therefore, we advocate the update of epidemiological data and re-evaluation of PBSH treatment in a contemporary context.
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Affiliation(s)
- Danyang Chen
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yingxin Tang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hao Nie
- Department of Geriatrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ping Zhang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wenzhi Wang
- Department of Neuroepidemiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Qiang Dong
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Guofeng Wu
- Department of Emergency, Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Mengzhou Xue
- The Department of Cerebrovascular Diseases, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yuping Tang
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Wenjie Liu
- Beijing WanTeFu Medical Apparatus Co., Ltd., Beijing, China
| | - Chao Pan
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhouping Tang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Microsurgical anatomy of safe entry zones on the ventrolateral brainstem: a morphometric study. Neurosurg Rev 2021; 45:1363-1370. [PMID: 34546449 DOI: 10.1007/s10143-021-01644-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 08/14/2021] [Accepted: 09/08/2021] [Indexed: 11/27/2022]
Abstract
Surgery of the brainstem is challenging due to the complexity of the area with cranial nerve nuclei, reticular formation, and ascending and descending fibers. Safe entry zones are required to reach the intrinsic lesions of the brainstem. The aim of this study was to provide detailed measurements for anatomical landmark zones of the ventrolateral surface of the human brainstem related to previously described safe entry zones. In this study, 53 complete and 34 midsagittal brainstems were measured using a stainless caliper with an accuracy of 0.01 mm. The distance between the pontomesencephalic and bulbopontine sulci was measured as 26.94 mm. Basilar sulcus-lateral side of pons (origin of the fibers of the trigeminal nerve) distance was 17.23 mm, transverse length of the pyramid 5.42 mm, and vertical length of the pyramid 21.36 mm. Lateral mesencephalic sulcus was 12.73 mm, distance of the lateral mesencephalic sulcus to the oculomotor nerve 13.85 mm, and distance of trigeminal nerve to the upper tip of pyramid 17.58 mm. The transverse length for the inferior olive at midpoint and vertical length were measured as 5.21 mm and 14.77 mm, consequently. The thickness of the superior colliculus was 4.36 mm, and the inferior colliculus 5.06 mm; length of the tectum was 14.5 mm and interpeduncular fossa 11.26 mm. Profound anatomical knowledge and careful analysis of preoperative imaging are mandatory before surgery of the brainstem lesions. The results presented in this study will serve neurosurgeons operating in the brainstem region.
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21
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Velz J, Neidert MC, Yang Y, Akeret K, Nakaji P, Regli L, Bozinov O. Mortality in Patients with Brainstem Cavernous Malformations. Cerebrovasc Dis 2021; 50:574-580. [PMID: 34134124 DOI: 10.1159/000516909] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 04/09/2021] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Brainstem cavernous malformations (BSCM)-associated mortality has been reported up to 20% in patients managed conservatively, whereas postoperative mortality rates range from 0 to 1.9%. Our aim was to analyze the actual risk and causes of BSCM-associated mortality in patients managed conservatively and surgically based on our own patient cohort and a systematic literature review. METHODS Observational, retrospective single-center study encompassing all patients with BSCM that presented to our institution between 2006 and 2018. In addition, a systematic review was performed on all studies encompassing patients with BSCM managed conservatively and surgically. RESULTS Of 118 patients, 54 were treated conservatively (961.0 person years follow-up in total). No BSCM-associated mortality was observed in our conservatively as well as surgically managed patient cohort. Our systematic literature review and analysis revealed an overall BSCM-associated mortality rate of 2.3% (95% CI: 1.6-3.3) in 22 studies comprising 1,251 patients managed conservatively and of 1.3% (95% CI: 0.9-1.7) in 99 studies comprising 3,275 patients with BSCM treated surgically. CONCLUSION The BSCM-associated mortality rate in patients managed conservatively is almost as low as in patients treated surgically and much lower than in frequently cited reports, most probably due to the good selection nowadays in regard to surgery.
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Affiliation(s)
- Julia Velz
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland
| | - Marian Christoph Neidert
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland.,Department of Neurosurgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Yang Yang
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland.,Department of Neurosurgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Kevin Akeret
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland
| | - Peter Nakaji
- Department of Neurosurgery at Banner, University Medical Center Phoenix, Phoenix, Arizona, USA
| | - Luca Regli
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland
| | - Oliver Bozinov
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland.,Department of Neurosurgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
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Shah A, Jhawar SS, Goel A. The lateral cerebral peduncle approach to ventrally placed intra-axial midbrain tumors: A technical note. J Clin Neurosci 2021; 89:226-231. [PMID: 34119272 DOI: 10.1016/j.jocn.2021.04.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Accepted: 04/26/2021] [Indexed: 10/21/2022]
Abstract
We describe the anatomical landmarks and surgical feasibility of a novel 'safe' brainstem entry zone to approach ventrally placed intra-axial midbrain tumors. The anatomy of the brainstem was specifically studied to evaluate safe surgical entry zone in the midbrain on two formalin fixed silicon injected cadaver head specimens. A novel entry point through the lateral one - fifth of the cerebral peduncle was identified to be 'safe' to approach lesions of the ventral midbrain. Three patients, having oculomotor schwannoma, peduncular glioma and a peduncular cavernoma were operated using this safe entry zone. To approach the midbrain, retrosigmoid lateral supracerebellar route was used in two patients and a basal subtemporal avenue was deployed in one patient. On the basis of fine microanatomical dissection on cadavers, a novel entry point through the lateral one-fifth of the cerebral peduncle, 5 mm anterior to the lateral mesencephalic sulcus and approximately 5 mm superior to the fourth nerve was identified. The proposed brainstem entry point traverses the parieto-temporo-occipital pontine fibers and the trajectory is between the corticospinal tracts ventrally and the substantia nigra dorsally. Three patients were operated successfully using the approach. There were no post-operative motor, sensory or extra-pyramidal deficits. The corridor through the lateral one-fifth of the cerebral peduncle presents a safe and relative 'easy' surgical route to approach ventrally placed intra-axial midbrain tumors.
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Affiliation(s)
- Abhidha Shah
- Department of Neurosurgery, K.E.M. Hospital and Seth, G.S. Medical College, Parel, Mumbai, India
| | - Sukhdeep Singh Jhawar
- Department of Neurosurgery, K.E.M. Hospital and Seth, G.S. Medical College, Parel, Mumbai, India
| | - Atul Goel
- Department of Neurosurgery, K.E.M. Hospital and Seth, G.S. Medical College, Parel, Mumbai, India; Lilavati Hospital and Research Centre, Bandra (E), Mumbai, India.
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Kong L, Xiao X, Pan C, Zhang L. Trans-lamina terminalis suprategmental approach for ventral midbrain lesions: Technical note. J Clin Neurosci 2020; 83:25-30. [PMID: 33342626 DOI: 10.1016/j.jocn.2020.11.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 06/16/2020] [Accepted: 11/23/2020] [Indexed: 11/16/2022]
Abstract
Surgical resection of lesions located in the ventral midbrain is challenging. Few approaches and safe entry zones (SEZs) have been proposed and used to remove this type of lesion, and each has its limitations. Using two illustrating cases, the authors describe a trans-lamina terminalis suprategmental approach for removing ventral midbrain lesions. This approach provides a straight surgical trajectory with sparse neurovascular structures and can be performed with a standard pterional or subfrontal craniotomy. It may be the ideal approach for ventromedial midbrain lesions extending towards the third ventricle.
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Affiliation(s)
- Lu Kong
- Department of Neurosurgery, Qingdao Municipal Hospital, 266071 Qingdao, China
| | - Xiong Xiao
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, 100070 Beijing, China
| | - Changcun Pan
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, 100070 Beijing, China
| | - Liwei Zhang
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, 100070 Beijing, China.
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25
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Tayebi Meybodi A, Hendricks BK, Witten AJ, Hartman J, Tomlinson SB, Cohen-Gadol AA. Virtual Exploration of Safe Entry Zones in the Brainstem: Comprehensive Definition and Analysis of the Operative Approach. World Neurosurg 2020; 140:499-508. [PMID: 32474103 DOI: 10.1016/j.wneu.2020.05.207] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Accepted: 04/28/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND A detailed and accurate understanding of the intrinsic brainstem anatomy and the interrelationship between its internal tracts and nuclei and external landmarks is of paramount importance for safe and effective brainstem surgery. Using anatomical models can be an important step in increasing such understanding. In the present study, we have shown the applicability of our developed virtual 3-dimensional (3D) model in depicting the safe entry zones (SEZs) to the brainstem. METHODS Accurate 3D virtual models of brainstem elements were created using high-resolution magnetic resonance imaging and computed tomography to depict the brainstem SEZs. RESULTS All the described SEZs to different parts of the brainstem were successfully depicted using our 3D virtual models. CONCLUSIONS The virtual models provide an immersive experience of brainstem anatomy, allowing users to understand the intricacies of the microdissection that is necessary to appropriately work through the brainstem nuclei and tracts toward a particular target. The models provide an unparalleled learning environment to understand the SEZs into the brainstem that can be used for training and research.
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Affiliation(s)
- Ali Tayebi Meybodi
- The Neurosurgical Atlas, Indianapolis, Indiana, USA; Department of Neurosurgery, Rutgers University Medical School, Newark, New Jersey, USA
| | | | - Andrew J Witten
- Department of Neurosurgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | | | | | - Aaron A Cohen-Gadol
- The Neurosurgical Atlas, Indianapolis, Indiana, USA; Department of Neurosurgery, Indiana University School of Medicine, Indianapolis, Indiana, USA.
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Matsushima T, Rutka J, Matsushima K. Evolution of cerebellomedullary fissure opening: its effects on posterior fossa surgeries from the fourth ventricle to the brainstem. Neurosurg Rev 2020; 44:699-708. [PMID: 32281017 DOI: 10.1007/s10143-020-01295-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 03/10/2020] [Accepted: 03/30/2020] [Indexed: 11/27/2022]
Abstract
Surgical approaches to the fourth ventricle and its surrounding brainstem regions have changed significantly in the previous 30 years, after the establishment of cerebellomedullary fissure (CMF) opening. With the development of CMF opening techniques, CMF opening surgeries have become widely used for the treatment of various pathologies and have contributed to the improvement of surgical results in posterior fossa surgeries. We here review the historical progress of CMF opening surgeries to help the future progression of neurosurgical treatments. The authors studied the available literature to clarify how CMF opening surgeries have developed and progressed, and how much the idea and development of CMF opening techniques have affected the advancement of posterior fossa surgeries. With the establishment of angiography, anatomical studies on CMF in the 1960s were performed mainly to clarify vascular anatomy on radiological images. After reporting the microsurgical anatomy of CMF in a cadaveric study in 1982, one of the authors (T.M.) first proposed the clinical usefulness of CMF opening in 1992. This new method enabled wide exposure of the fourth ventricle without causing vermian splitting syndrome, and it took the place of the standard approach instead of the conventional transvermian approach. Several authors reported their experiences using this method from the end of the twentieth century to the early twenty-first century, and the naming of the approach, "telovelar approach" by Mussi and Rhoton in 2000 contributed to the global spread of CMF opening surgeries. The approach has become widely applied not only for tumors but also for vascular and brainstem lesions, and has assisted in the development of their surgical treatments, and brought up the idea of various fissure dissection in the posterior fossa. Studies of microsurgical anatomy of the fourth ventricle, including the CMF, has led to new surgical approaches represented by the transCMF/telovelar approach. The CMF opening method caused a revolution in posterior fossa surgeries. The idea was developed based on the experience gained while dissecting the CMF (the roof of the fourth ventricle) in the laboratory. Anatomical studies using cadaveric specimens, particularly their dissection by surgeons themselves, together with a deep understanding of brain anatomy are essential for further advancements in neurosurgical treatments.
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Affiliation(s)
- Toshio Matsushima
- International University of Health and Welfare, Fukuoka, Japan. .,Neuroscience Center, Fukuoka Sanno Hospital, 3-6-45 Momochihama, Sawara-ku, Fukuoka, 814-0001, Japan.
| | - James Rutka
- Department of Neurosurgery, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ken Matsushima
- Department of Neurosurgery, Tokyo Medical University, Tokyo, Japan
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Cavalheiro S, Serrato-Avila JL, Párraga RG, Da Costa MDS, Nicácio JM, Rocha PR, Chaddad-Neto F. Interpeduncular Sulcus Approach to the Posterolateral Pons. World Neurosurg 2020; 138:e795-e805. [PMID: 32217179 DOI: 10.1016/j.wneu.2020.03.084] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Accepted: 03/15/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE In this article, we describe a new safe entry point for the posterolateral pons. METHODS To show the adjacent anatomy and measure the part of the interpeduncular sulcus that can be safely accessed, we first performed a review of the literature regarding the pons anatomy and its surgical approaches. Thereafter, 1 human cadaveric head and 15 (30 sides) human brainstems with attached cerebellums were bilaterally dissected with the fiber microdissection technique. A clinical correlation was made with an illustrative case of a dorsolateral pontine World Health Organization grade I astrocytoma. RESULTS The safe distance for accessing the interpeduncular sulcus was found to extend from the caudal end of the lateral mesencephalic sulcus to the point at which the intrapontine segment of the trigeminal nerve crosses the interpeduncular sulcus. The mean distance was 8.2 mm (range, 7.15-8.85 mm). Our interpeduncular sulcus safe entry zone can be exposed through a paramedian infratentorial supracerebellar approach. When additional exposure is required, the superior portion of the quadrangular lobule of the cerebellar hemispheric tentorial surface can be removed. In the presented case, surgical resection of the tumor was performed achieving a gross total resection, and the patient was discharged without neurologic deficit. CONCLUSIONS The interpeduncular sulcus safe entry zone provides an alternative direct route for treating intrinsic pathologic entities situated in the posterolateral tegmen of the pons between the superior and middle cerebellar peduncles. The surgical corridor provided by this entry point avoids most eloquent neural structures, thereby preventing surgical complications.
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Affiliation(s)
- Sergio Cavalheiro
- Department of Neurosurgery, Pediatric Oncology Institute, Federal University of São Paulo, São Paulo, Brazil
| | | | - Richard Gonzalo Párraga
- Department of Neurosurgery, Neurosurgery Institute of Bolivia (INEB), Cochabamba, Bolivia; Department of Neurological Surgery, Hospital UNIVALLE, Cochabamba, Bolivia
| | - M D S Da Costa
- Department of Neurosurgery, Pediatric Oncology Institute, Federal University of São Paulo, São Paulo, Brazil
| | - Jardel Mendoça Nicácio
- Department of Neurosurgery, Pediatric Oncology Institute, Federal University of São Paulo, São Paulo, Brazil
| | - Paulo Ricardo Rocha
- Department of Morphology and Genetics, Federal University of São Paulo, São Paulo, Brazil
| | - Feres Chaddad-Neto
- Department of Neurosurgery, Vascular Division, Federal University of São Paulo, São Paulo, Brazil; Department of Neurosurgery, Hospital Beneficência Portuguesa de São Paulo, São Paulo, Brazil
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Abou-Al-Shaar H, White TG, Peto I, Dehdashti AR. Left suboccipital supracerebellar transtentorial approach for resection of tectal cavernous malformation. NEUROSURGICAL FOCUS: VIDEO 2019; 1:V19. [PMID: 36284869 PMCID: PMC9541817 DOI: 10.3171/2019.10.focusvid.19394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 07/30/2019] [Indexed: 11/10/2022]
Abstract
A 64-year-old man with a midbrain cavernoma and prior bleeding presented with a 1-week history of diplopia, partial left oculomotor nerve palsy, and worsening dysmetria and right-sided weakness. MRI revealed a hemorrhagic left tectal plate and midbrain cavernoma. A left suboccipital supracerebellar transtentorial approach in the sitting position was performed for resection of his lesion utilizing the lateral mesencephalic sulcus safe entry zone. Postoperatively, he developed a partial right oculomotor nerve palsy; imaging depicted complete resection of the cavernoma. He recovered from the right third nerve palsy, weakness, and dysmetria, with significant improvement of his partial left third nerve palsy. The video can be found here: https://youtu.be/ofj8zFWNUGU.
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Affiliation(s)
- Hussam Abou-Al-Shaar
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; and
| | - Timothy G. White
- Department of Neurosurgery, Hofstra Northwell School of Medicine, Manhasset, New York
| | - Ivo Peto
- Department of Neurosurgery, Hofstra Northwell School of Medicine, Manhasset, New York
| | - Amir R. Dehdashti
- Department of Neurosurgery, Hofstra Northwell School of Medicine, Manhasset, New York
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Zenonos GA, Sur S, Nuñez M, Fernandes-Cabral DT, Morcos JJ. Far lateral approach for resection of lower pontine cavernous malformation. NEUROSURGICAL FOCUS: VIDEO 2019; 1:V27. [PMID: 36285058 PMCID: PMC9541832 DOI: 10.3171/2019.7.focusvid.19172] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 05/16/2019] [Indexed: 06/16/2023]
Abstract
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.
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Affiliation(s)
- Georgios A. Zenonos
- Department of Neurological Surgery, University of Miami, Miami, Florida; and
| | - Samir Sur
- Department of Neurological Surgery, University of Miami, Miami, Florida; and
| | - Maximiliano Nuñez
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - David T. Fernandes-Cabral
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jacques J. Morcos
- Department of Neurological Surgery, University of Miami, Miami, Florida; and
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