Lateral inferior cerebellar peduncle approach to dorsolateral medullary cavernous malformation

Deshmukh, Vivek R.; Rangel-Castilla, Leonardo; Spetzler, Robert F.

doi:10.3171/2014.5.jns132276

Cited by 24 publications

(14 citation statements)

References 16 publications

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“…We can observe that I have a The extended retrosigmoid approach provides an excellent corridor to the lateral aspect of the pontomedullary junction (PMJ). 1,2 This video demonstrates a microsurgical resection of a progressive enlarging cavernous malformation (CM) of the PMJ. The patient is a 33-year-old woman with progressive symptoms, including right facial droop, left hemianesthesia, diplopia, and nystagmus.…”

Section: Transcriptmentioning

confidence: 99%

Microsurgical resection of an enlarging lateral pontomedullary cavernous malformation

Cohen-Cohen¹,

Lanzino²,

Rangel-Castilla³

2019

Neurosurgical Focus: Video

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The extended retrosigmoid approach provides an excellent corridor to the lateral aspect of the pontomedullary junction (PMJ).1,2 This video demonstrates a microsurgical resection of a progressive enlarging cavernous malformation (CM) of the PMJ. The patient is a 33-year-old woman with progressive symptoms, including right facial droop, left hemianesthesia, diplopia, and nystagmus. The patient underwent a right extended retrosigmoid approach with intraoperative neuronavigation and neuromonitoring. Lower cranial nerve dissection allowed access to the lateral PMJ. A longitudinal corticotomy was performed above the glossopharyngeal. The CM was removed in a piecemeal fashion. Postoperative MRI confirmed gross-total resection and the patient remained neurologically stable.The video can be found here: https://youtu.be/K_TtiTo1RsQ.

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Section: Transcriptmentioning

confidence: 99%

Microsurgical resection of an enlarging lateral pontomedullary cavernous malformation

Cohen-Cohen¹,

Lanzino²,

Rangel-Castilla³

2019

Neurosurgical Focus: Video

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“…Thirteen zones were selected: 1) anterior mesencephalic zone, 2) lateral mesencephalic sulcus, 3) intercollicular region, 4) peritrigeminal zone, 5) supratrigeminal zone, 6) lateral pontine zone, 7) supracollicular zone, 8) infracollicular zone, 9) median sulcus of the fourth ventricle, 10) anterolateral and 11) posterior median sulci of the medulla, 12) olivary zone, and 13) lateral medullary zone. 5,9,14,20,23,35 Five human cadaveric heads, formalin-fixed and injected with colored silicone rubber, were carefully dissected in a simulated surgical environment at the Skull Base Laboratory of the Barrow Neurological Institute in Phoenix, Arizona. With the heads fixed with Mayfield clamps, 10 surgical approaches were performed on each head: 1) orbitozygomatic, 2) subtemporal, 3) subtemporal transtentorial, 4) anterior petrosectomy, 5) suboccipital telovelar, 6) median supracerebellar infratentorial, 7) extreme lateral supracerebellar infratentorial, 8) retrosigmoid, 9) far lateral, and 10) retrolabyrinthine.…”

Section: Methodsmentioning

confidence: 99%

Microsurgical anatomy of safe entry zones to the brainstem

Cavalcanti

Preul

Kalani

et al. 2016

JNS

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143

118

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H istorically, the surgical management of intrinsic brainstem lesions has been controversial. The surgical extirpation of focal gliomas, cavernous malformations, or hemangioblastomas within the brainstem has caused heated discussions in scientific meetings and the literature. In 1939, Bailey et al. 3 declared this subject to be a pessimistic chapter in neurosurgery; 30 years later, Matson and Ingraham 26 would still claim such lesions were inoperable. However, in 1971, Lassiter et al. 25 were among the first to advocate surgical intervention. By 1986, Epstein and McCleary reported that surgery was feasible with reasonable morbidity and mortality.15 Concurrent with Epstein and McCleary's report, Raimondi would rationally state that to have the child merely survive (i.e., with severe neurological deficits) is no justification for surgery. 33 The development and improvement of complex skull base surgical approaches and incremental advances in neuroimaging, parallel to image-guided surgery, allowed a few authors to safely and effectively resect lesions in the brainstem. 5,23,32Knowledge of different skull base exposures, gained through laboratory dissections, allows neurosurgeons to approach lesions in the brainstem. Nevertheless, the brainstem, roughly the size of the human thumb, contains a rich concentration of nuclei and fibers in a small sectional area, resulting in a high likelihood of morbidity after manipulation. Awareness of the main safe entry zones on the brainstem is key to reducing morbidity for any lesion that does not emerge to the pial or ependymal surface. Such zones represent entry points and trajectories where eloquent structures and perforators are sparse and where a neurotomy would cause the least possible damage.abbreviatioNs CN = cranial nerve; mini-OZ = mini-modified orbitozygomatic approach; PCA = posterior cerebral artery; P 2 P = posterior P 2 ; SCA = superior cerebellar artery; TAPS = transanterior perforating substance. obJective The aim of this study was to enhance the planning and use of microsurgical resection techniques for intrinsic brainstem lesions by better defining anatomical safe entry zones. methods Five cadaveric heads were dissected using 10 surgical approaches per head. Stepwise dissections focused on the actual areas of brainstem surface that were exposed through each approach and an analysis of the structures found, as well as which safe entry zones were accessible via each of the 10 surgical windows. results Thirteen safe entry zones have been reported and validated for approaching lesions in the brainstem, including the anterior mesencephalic zone, lateral mesencephalic sulcus, intercollicular region, peritrigeminal zone, supratrigeminal zone, lateral pontine zone, supracollicular zone, infracollicular zone, median sulcus of the fourth ventricle, anterolateral and posterior median sulci of the medulla, olivary zone, and lateral medullary zone. A discussion of the approaches, anatomy, and limitations of these entry zones is included. coNclusioNs A detailed understanding...

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“…This route can also be used to access the area around the lateral part of the pontomedullary sulcus or lateral surface of the inferior cerebellar peduncle, which has been recently reported as a potential safe entry zone. 1,2,9,18 The rhomboid lip can be elevated with the flocculus or incised to enter the foramen of Luschka. Opening the lateral edge of the cerebellomedullary fissure also facilitates the superomedial elevation of the biventral lobule, and exposes the dorsolateral medulla and posterior intermediate or lateral sulci, which have been reported as safe medullary entry zones.…”

Section: Cerebellopontine Fissurementioning

confidence: 99%

Anatomy and approaches along the cerebellar-brainstem fissures

Matsushima

Yağmurlu

Kohno

et al. 2016

JNS

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R ecent advances in microsurgical and endoscopic techniques, imaging, and electrophysiological monitoring have facilitated safe resection of brainstem lesions that were previously considered inoperable. [3][4][5]9,11,12,[14][15][16]19,21,[23][24][25][26]37,38,40,44,62,64,65,70,73,75,79,86 The brainstem surface, when near to or accessed by the lesion, is the shortest and most direct path for surgical treatment. 3,5,9,14,21,64,75,79 Several safe entry zones have been proposed and used for lesions inside the brainstem. 3,5,9,12,13,23,24,40,65,86 To maximize the chances of safe and precise removal of these lesions, sufficient exposure of the brainstem surface is critical, as is selection of an appropriate entry corridor into the brainstem.Cerebral fissures, such as the sylvian fissure, are routinely opened in the supratentorial region to access deeply situated pathology without dividing any neural tissue. Fissure dissection has also been used in the infratentorial region. 22,49,53,60,61 Opening the arachnoid membranes and trabeculae along the cerebellar-brainstem fissures, as in the telovelar or transcerebellomedullary fissure approaches, was originally proposed to access the pineal region, cranial nerve (CN) V, and the fourth ventricle. 22,49,60 However, brainstem surgery frequently requires the opening of the 3 cerebellar-brainstem fissures and/or adjacent cerebellar fissures to expose the cerebellar peduncles and brainstem surface hidden by the parts of the cerebellum forming the walls of the 3 cerebellar-brainstem fissures.61,71 Most of the major cerebellar arteries, veins, and vital neural structures, including a majority of the CNs and all 3 cerebellar peduncles, are located inside or close to these fissures. 27,43,45,56,66,68,85 Detailed knowledge of these fissures is abbreviatioNs AICA = anterior inferior cerebellar artery; CN = cranial nerve; PCA = posterior cerebral artery; PICA = posterior inferior cerebellar artery; SCA = superior cerebellar artery. obJective Fissure dissection is routinely used in the supratentorial region to access deeply situated pathology while minimizing division of neural tissue. Use of fissure dissection is also practical in the posterior fossa. In this study, the microsurgical anatomy of the 3 cerebellar-brainstem fissures (cerebellomesencephalic, cerebellopontine, and cerebellomedullary) and the various procedures exposing these fissures in brainstem surgery were examined. methods Seven cadaveric heads were examined with a microsurgical technique and 3 with fiber dissection to clarify the anatomy of the cerebellar-brainstem and adjacent cerebellar fissures, in which the major vessels and neural structures are located. Several approaches directed along the cerebellar surfaces and fissures, including the supracerebellar infratentorial, occipital transtentorial, retrosigmoid, and midline suboccipital approaches, were examined. The 3 heads examined using fiber dissection defined the anatomy of the cerebellar peduncles coursing in the depths of these fissures. results Dissections dir...

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Lateral inferior cerebellar peduncle approach to dorsolateral medullary cavernous malformation

Abstract: key WoRDs • cavernous malformation • inferior cerebellar peduncle • dorsolateral medulla • surgical techniqueAbbreviations used in this paper: BSCM = brainstem cavernous malformation; CN = cranial nerve; ICP = inferior cerebellar peduncle.

Cited by 24 publications

References 16 publications

Microsurgical resection of an enlarging lateral pontomedullary cavernous malformation

Microsurgical resection of an enlarging lateral pontomedullary cavernous malformation

Microsurgical anatomy of safe entry zones to the brainstem

Anatomy and approaches along the cerebellar-brainstem fissures

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