Foramen magnum meningiomas are a formidable disease entity whose resection requires intimate knowledge of the relevant neurovascular anatomy. Due attention is given to the anterior spinal artery and the importance of its preservation to avoid devastating deficits from anterior spinal artery syndrome. There is an underappreciated but clinically significant set of perforating arteries arising from the distal vertebral arteries at the vertebrobasilar junction that supply the medial and anterior medulla through the ventrolateral sulcus. [1][2][3] Injury to or occlusion of these arteries causes a brainstem infarction known as medial medullary syndrome, or Dejerine syndrome, which mainly involves the pyramidal tracts, hypoglossal nucleus, and medial lemniscus. 4 Here, we describe an incomplete variant of Dejerine syndrome exclusively involving the pyramids, occurring during surgical resection of a foramen magnum meningioma. These arteries are analogous to the perforators of the distal basilar artery whose importance was highlighted by Drake's seminal work. 5,6 The patient underwent resection of a ventral foramen magnum meningioma, complicated by the need for vertebral artery stenting. The patient promptly lost motor-evoked potentials while somatosensory-evoked potentials remained perfectly at baseline. The patient was initially densely quadriplegic postoperatively, without sensory or cranial nerve deficits. MRI demonstrated T2 hyperintensity limited exclusively to the pyramids. After a long convalescence, she fortunately made a full recovery. We highlight the knowledge and preservation of the perforators at the vertebrobasilar junction during resection of foramen magnum tumors. The patient consented to surgery and publication of her images.
Lesions of the ventricular atrium are difficult to access given their deep location and surrounding critical structures, particularly in the dominant hemisphere. The supracerebellar transtentorial approach has gained popularity for lesions of the mesial temporal lobe and thalamus since its first description by Voigt and Yasargil. [1][2][3] This approach to the ventricular atrium through the collateral sulcus has been investigated in cadaveric studies and reported in 2 clinical cases. [4][5][6][7] The collateral sulcus is a consistently identifiable landmark and relatively shallow, providing a reliable and short route to the atrium. 8,9 Navigation is extremely helpful in determining the entry and trajectory. When traversing the supracerebellar corridor, one must be aware of tentorial venous anatomy. A remnant of the medial or lateral tentorial sinus can be associated with venous complications if sacrificed, particularly when a supracerebellar vein drains into the remnant. 10 Here, we present a case of a 39-year-old woman with speech and vision deficits because of a hemorrhagic tumor in the left atrium originating from the temporal lobe with trapping of the temporal horn. Functional MRI demonstrated language function in the left superior temporal gyrus lateral to the lesion. A supracerebellar transtentorial transcollateral approach was used to maximize preservation of vision and language. Sacrifice of a bridging vein draining into the medial tentorial sinus led to ipsilateral cerebellar edema that was managed with hypertonic saline. The patient otherwise tolerated the procedure well with no worsening of language or vision. The patient consented to surgery and publication of images.
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