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Benet A, Spetzler RF. Cavernous Malformations: What They Have Taught Us. Neurosurgery 2023; 69:9-21. [PMID: 36924486 DOI: 10.1227/neu.0000000000002400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 01/13/2023] [Indexed: 03/18/2023] Open
Affiliation(s)
- Arnau Benet
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
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Catapano JS, Rumalla K, Srinivasan VM, Lawrence PM, Larson Keil K, Lawton MT. A taxonomy for brainstem cavernous malformations: subtypes of pontine lesions. Part 2: inferior peduncular, rhomboid, and supraolivary. J Neurosurg 2022; 137:1477-1490. [PMID: 35334460 DOI: 10.3171/2022.1.jns212691] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 01/13/2022] [Indexed: 12/26/2022]
Abstract
OBJECTIVE Part 2 of this 2-part series on pontine cavernomas presents the taxonomy for subtypes 4-6: inferior peduncular (IP) (subtype 4), rhomboid (5), and supraolivary (6). (Subtypes 1-3 are presented in Part 1.) The authors have proposed a novel taxonomy for pontine cavernous malformations based on clinical presentation (syndromes) and anatomical location (MRI findings). METHODS The details of taxonomy development are described fully in Part 1 of this series. In brief, pontine lesions (323 of 601 [53.7%] total lesions) were subtyped on the basis of predominant surface presentation identified on preoperative MRI. Neurological outcomes were assessed according to the modified Rankin Scale, with score ≤ 2 defined as favorable. RESULTS The 323 pontine brainstem cavernous malformations were classified into 6 distinct subtypes: basilar (6 [1.9%]), peritrigeminal (53 [16.4%]), middle peduncular (100 [31.0%]), IP (47 [14.6%]), rhomboid (80 [24.8%]), and supraolivary (37 [11.5%]). Subtypes 4-6 are the subject of the current report. IP lesions are located in the inferolateral pons and are associated with acute vestibular syndrome. Rhomboid lesions present to the fourth ventricle floor and are associated with disconjugate eye movements. Larger lesions may cause ipsilateral facial weakness. Supraolivary lesions present to the surface at the ventral pontine underbelly. Ipsilateral abducens palsy is a strong localizing sign for this subtype. A single surgical approach and strategy were preferred for subtypes 4-6: for IP cavernomas, the suboccipital craniotomy and telovelar approach predominated; for rhomboid lesions, the suboccipital craniotomy and transventricular approach were preferred; and for supraolivary malformations, the far lateral craniotomy and transpontomedullary sulcus approach were preferred. Favorable outcomes were observed in 132 of 150 (88%) patients with follow-up. There were no significant differences in outcomes between subtypes. CONCLUSIONS The neurological symptoms and signs associated with a hemorrhagic pontine subtype can help define that subtype clinically with key localizing signs. The proposed taxonomy for pontine cavernous malformation subtypes 4-6 meaningfully guides surgical strategy and may improve patient outcomes.
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Tsunoda S, Inoue T, Segawa M, Akabane A. Anterior transpetrosal resection of the lower ventral pontine cavernous malformation: A technical case report with operative video. Surg Neurol Int 2021; 12:261. [PMID: 34221592 PMCID: PMC8248077 DOI: 10.25259/sni_102_2021] [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: 02/03/2021] [Accepted: 04/29/2021] [Indexed: 11/04/2022] Open
Abstract
Background Surgical treatment of pontine cavernous malformations (CMs) is challenging due to the anatomical difficulties and potential risks involved. We successfully applied an anterior transpetrosal approach (ATPA) to remove a lower ventral pontine CM, and herein we discuss the outline of our procedure accompanied by a surgical video. Case Description A 50-year-old woman presenting with progressively worsening diplopia was urgently admitted to our hospital. Preoperative images showed a lower ventral pontine CM compressing the corticospinal tract posteriorly. Considering the location of the CM, we determined that an ATPA was the appropriate approach to achieve a more anterolateral trajectory. We performed extradural anteromedial petrosectomy and penetrated the brainstem from the point just below the anterior inferior cerebellar artery and above the root exit zone of the abducens nerve, which might be located in the somewhat lowest border of actual maneuverability in the ATPA. Maneuverability through this corridor was sufficient without hindering and darkening the high magnification microscopic view, as demonstrated in our surgical video. Conclusion This report demonstrates surgical treatment of a lower ventral pontine CM using the ATPA. The surgical video we present provides information that is useful for understanding this technique's maneuverability and working window.
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Affiliation(s)
- Sho Tsunoda
- Department of Neurosurgery, NTT Medical Center Tokyo, Tokyo, Japan
| | - Tomohiro Inoue
- Department of Neurosurgery, NTT Medical Center Tokyo, Tokyo, Japan
| | - Masafumi Segawa
- Department of Neurosurgery, NTT Medical Center Tokyo, Tokyo, Japan
| | - Atsuya Akabane
- Department of Neurosurgery, NTT Medical Center Tokyo, Tokyo, Japan
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Rutledge C, Raper DMS, Rodriguez Rubio R, Winkler EA, Abla AA. Supracerebellar Infratentorial Infratrochlear Trans-Quadrangular Lobule Approach to Pontine Cavernous Malformations. Oper Neurosurg (Hagerstown) 2021; 20:268-275. [PMID: 33432968 DOI: 10.1093/ons/opaa373] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 09/06/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Brainstem cavernous malformations with symptomatic hemorrhage have a poor natural history. Those without a pial or ependymal presentation are often observed given the morbidity of resection. Surgical removal is considered only in patients with accessible lesions that have repeated symptomatic hemorrhagic. OBJECTIVE To describe a novel supracerebellar infratentorial infratrochlear trans-quadrangular lobule approach to safely resect lesions in the upper pons. METHODS We use a hybrid paramedian/lateral suboccipital craniotomy in the gravity-dependent supine position. Opening the cerebellomesencephalic fissure over the tentorial surface of the cerebellum brings the trochlear nerve, branches of the superior cerebellar artery, and the quadrangular lobule of the cerebellum into view. Removal of small a portion of the quadrangular lobule defines an entry point on the superomedial aspect of the middle cerebellar peduncle, and a surgical trajectory aimed superior to inferior. RESULTS A total of 6 patients underwent this approach. All presented with symptomatic hemorrhage and all cavernous malformations were completely resected. Five patients were improved or unchanged with modified Rankin scale scores of 1 or 2. CONCLUSION The trans-quadrangular lobule approach allows safe resection of upper pontine cavernous malformations along a superior to inferior trajectory.
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Affiliation(s)
- Caleb Rutledge
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Daniel M S Raper
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Roberto Rodriguez Rubio
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Ethan A Winkler
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Adib A Abla
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
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The brainstem and its neurosurgical history. Neurosurg Rev 2021; 44:3001-3022. [PMID: 33580370 DOI: 10.1007/s10143-021-01496-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 02/01/2021] [Accepted: 02/04/2021] [Indexed: 10/22/2022]
Abstract
Brainstem is one of the most complex structures of the human body, and has the most complex intracranial anatomy, which makes surgery at this level the most difficult. Due to its hidden position, the brainstem became known later by anatomists, and moreover, brainstem surgery cannot be understood without knowing the evolution of ideas in neuroanatomy, neuropathology, and neuroscience. Starting from the first attempts at identifying brainstem anatomy in prehistory and antiquity, the history of brainstem discoveries and approach may be divided into four periods: macroscopic anatomy, microscopic anatomy and neurophysiology, posterior fossa surgery, and brainstem surgery. From the first trepanning of the posterior fossa and later finger surgery, to the occurrence of safe entry zones, this paper aims to review how neuroanatomy and brainstem surgery were understood historically, and how the surgical technique evolved from Galen of Pergamon up to the twenty-first century.
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Kalani MYS, Yağmurlu K, Martirosyan NL, Spetzler RF. The lateral supracerebellar infratentorial, translateral mesencephalic sulcus approach to the mesencephalopontine junction. NEUROSURGICAL FOCUS: VIDEO 2019; 1:V14. [PMID: 36284868 PMCID: PMC9541774 DOI: 10.3171/2019.10.focusvid.19454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 07/29/2019] [Indexed: 11/07/2022]
Abstract
The lateral supracerebellar infratentorial (SCIT) approach provides advantageous access to lesions located in the lateral mesencephalon and mesencephalopontine junction. For lesions that abut the pial surface, a direct approach is ideal and well tolerated. For deep-seated lesions, the lateral mesencephalic sulcus (LMS) can be used to access lesions with minimal morbidity to the patient. This video demonstrates the use of the SCIT approach via the LMS to remove a cavernous malformation at the level of the mesencephalopontine junction. The use of somatosensory and motor evoked potential monitoring and intraoperative neuronavigation is essential for optimizing patient outcomes. Meticulous, multilayered closure is critical for optimal results in the posterior fossa. For optimal patient outcomes, approach selection for deep-seated lesions should combine the two-point method with safe entry zones. At follow-up, the patient had persistent sensory changes but was otherwise neurologically intact. The video can be found here: https://youtu.be/bHFEZhG8dHw.
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Kalani MYS, Yağmurlu K, Martirosyan NL, Spetzler RF. The suboccipital, telovelar, transsuperior fovea approach to dorsal pontine lesions. NEUROSURGICAL FOCUS: VIDEO 2019; 1:V19. [PMID: 36285055 PMCID: PMC9541755 DOI: 10.3171/2019.7.focusvid.1927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 05/16/2019] [Indexed: 11/06/2022]
Abstract
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.
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Yang Y, van Niftrik B, Ma X, Velz J, Wang S, Regli L, Bozinov O. Analysis of safe entry zones into the brainstem. Neurosurg Rev 2019; 42:721-729. [PMID: 30726522 DOI: 10.1007/s10143-019-01081-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 12/09/2018] [Accepted: 01/21/2019] [Indexed: 01/02/2023]
Abstract
Intra-axial brainstem surgeries are challenging. Many experience-based "safe entry zones (SEZs)" into brainstem lesions have been proposed in the existing literature. The evidence for each one seems limited. English-language publications were retrieved using PubMed/MEDLINE. Studies that focused only on cadaveric anatomy were also included, but the clinical case number was treated as zero. The clinical evidence level was defined as "case report" when the surgical case number was ≤ 5, "limited evidence" when there were more than 5 but less than 25 cases, and "credible evidence" when a publication presented more than 25 cases. Twenty-five out of 32 publications were included, and 21 different SEZs were found for the brainstem: six SEZs were located in the midbrain, 9 SEZs in the pons, and 6 SEZs in the medulla. Case report evidence was found for 10 SEZs, and limited evidence for 7 SEZs. Four SEZs were determined to be backed by credible evidence. The proposed SEZs came from initial cadaveric anatomy studies, followed by some published clinical experience. Only a few SEZs have elevated clinical evidence. The choice of the right approach into the brainstem remains a challenge in each case.
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Affiliation(s)
- Yang Yang
- Department of Neurosurgery, University Hospital of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
| | - Bas van Niftrik
- Department of Neurosurgery, University Hospital of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
| | - Xiangke Ma
- Department of Neurosurgery, University Hospital of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
| | - Julia Velz
- Department of Neurosurgery, University Hospital of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
| | - Sophie Wang
- Department of Neurosurgery, University Hospital of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
| | - Luca Regli
- Department of Neurosurgery, University Hospital of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
| | - Oliver Bozinov
- Department of Neurosurgery, University Hospital of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland.
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Mercier P, Bernard F, Delion M. Microsurgical anatomy of the fourth ventricle. Neurochirurgie 2018; 67:14-22. [PMID: 29875069 DOI: 10.1016/j.neuchi.2018.04.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2017] [Revised: 02/28/2018] [Accepted: 04/08/2018] [Indexed: 11/18/2022]
Abstract
Anatomical description of the fourth ventricle is essential for an accurate understanding of its related tumoral pathologies and surgical approach respecting cerebellar and brainstem structures. Numerous cadaver pictures illustrate this chapter which contains V4 floor and roof description and its vascularization.
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Affiliation(s)
- P Mercier
- Laboratoire d'anatomie, faculté desanté, 28, rue Roger-Amsler, CS 74521, 49045 Angers cedex 1, France.
| | - F Bernard
- Laboratoire d'anatomie, faculté desanté, 28, rue Roger-Amsler, CS 74521, 49045 Angers cedex 1, France
| | - M Delion
- Laboratoire d'anatomie, faculté desanté, 28, rue Roger-Amsler, CS 74521, 49045 Angers cedex 1, France
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