Inferior is Superior—Transtentorial Transcollateral Sulcus Approach to the Ventricular Atrium: 2-Dimensional Operative Video

Abstract

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.

Preserving the cerebellar hemispheric tentorial bridging veins through a novel tentorial cut technique for supracerebellar approaches

“…Although many complications caused by venous sacrifice are transient and infrequent, 30 sacrificing even a limited number of bridging veins may cause severe complications such as infarction, hemorrhage, or even death. 11,16,17,21,36,37 In a study with 13 case series and 578 patients operated on via supracerebellar infratentorial approaches, a venous infarction rate of only 0.345% caused by sacrifice was reported; however, case reports were not included in that study. 11 Furthermore, case series with transient or subclinical complications related to venous sacrifice may be underreported.…”

“…Some case reports describe severe complications related to venous sacrifice. 11,[16][17][18][19][20][21] Therefore, the consequences of sacrificing the CHTB veins should be considered for patients undergoing perimedian or paramedian supracerebellar approaches during which CHTB veins present common obstacles. 22 To prevent complications related to sacrificing CHTB veins, our surgical techniques have evolved over time to protect all bridging veins.…”