Microsurgical approaches to the cerebellar interpeduncular region: qualitative and quantitative analysis

Serrato-Ávila, Juan Leonardo; Archila, Juan Alberto Paz; Costa, Marcos Devanir Silva da; Rocha, Paulo Ricardo; Marques, Sérgio Ricardo; Moraes, Luís Otávio Carvalho de; Cavalheiro, Sérgio; Yağmurlu, Kaan; Lawton, Michael T.; Chaddad-Neto, Feres

doi:10.3171/2021.6.jns204457

Cited by 4 publications

(5 citation statements)

References 49 publications

(88 reference statements)

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“…In the latter, a “Rule of 3” for the posterior fossa intricately correlates three portions of the brainstem, three fissures, three cerebellar peduncles, three cerebellar cortical surfaces, and three cranial nerve groups. These are all supported by three respective arteries and accompanying veins, forming three complexes (upper, middle, and lower c.), with distinct segments and collateral branches intricately woven into the posterior circulation’s intricate tapestry which will be thoroughly elucidated later on [ 3 , 38 – 40 , 52 ].…”

Section: Introductionmentioning

confidence: 99%

Posterior vascular anatomy of the encephalon: a comprehensive review

Morales-Roccuzzo,

Sabahi,

Obrzut

et al. 2024

Surg Radiol Anat

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Purpose This article presents a comprehensive exploration of neurovascular anatomy of the encephalon, focusing specifically on the intricate network within the posterior circulation and the posterior fossa anatomy; enhancing understanding of its dynamics, essential for practitioners in neurosurgery and neurology areas. Method A profound literature review was conducted by searching the PubMed and Google Scholar databases using main keywords related to neurovascular anatomy. The selected literature was meticulously scrutinized. Throughout the screening of pertinent papers, further articles or book chapters were obtained through additional assessment of the reference lists. Furthermore, four formalin-fixed, color latex–injected cadaveric specimens preserved in 70% ethanol solution were dissected under surgical microscope (Leica Microsystems Inc, 1700 Leider Ln, Buffalo Grove, IL 60089, USA), using microneurosurgical as well as standard instruments, and a high-speed surgical drill (Stryker Instruments 1941 Stryker Way Portage, MI 49002, USA). Ulterior anatomical dissection was performed. Results Detailed examination of the basilar artery (BA), a common trunk formed by the union of the left and right vertebral arteries, denoted a tortuous course across the basilar sulcus. Emphasis is then placed on the Posterior Inferior Cerebellar Artery (PICA), Anterior Inferior Cerebellar Artery (AICA) and Superior Cerebellar Artery (SCA). Each artery’s complex course through the posterior fossa, its divisions, and potential stroke-related syndromes are explored in detail. The Posterior Cerebral Artery (PCA) is subsequently unveiled. The posterior fossa venous system is explained, categorizing its channels. A retrograde exploration traces the venous drainage back to the internal jugular vein, unraveling its pathways. Conclusion This work serves as a succinct yet comprehensive guide, offering fundamental insights into neurovascular anatomy within the encephalon’s posterior circulation. Intended for both novice physicians and seasoned neuroanatomists, the article aims to facilitate a more efficient clinical decision-making in neurosurgical and neurological practices.

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Section: Introductionmentioning

confidence: 99%

Posterior vascular anatomy of the encephalon: a comprehensive review

Morales-Roccuzzo,

Sabahi,

Obrzut

et al. 2024

Surg Radiol Anat

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confidence: 99%

“…Although the supracerebellar approach and its variations have been compared with the occipital transtentorial approach by several qualitative and quantitative studies, none have described the comparative efficacy of the PCIT and the midline SCIT for lesions of the dorsal brainstem and cerebellomesencephalic fissure. 2,[15][16][17][18][19][20][21] In this study, we describe the different exposures afforded by the SCIT and PCIT from a practical standpoint and better identify their anatomic and surgical indications.…”

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confidence: 99%

Comparison Between the Supracerebellar Infratentorial and Precuneal Interhemispheric, Transtentorial Approaches to the Cerebellomesencephalic Fissure: An Anatomoradiological Study and Illustrative Cases

Alexander

Agosti

Leonel

et al. 2023

Operative Neurosurgery

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BACKGROUND:The dorsal brainstem and cerebellomesencephalic fissure are challenging surgical targets. To afford a preferentially craniocaudal trajectory to this region, the precuneal interhemispheric transtentorial approach (PCIT) has been proposed.OBJECTIVE:To didactically describe and compare exposures and anatomic indications of the supracerebellar infratentorial approach (SCIT) and PCIT to the cerebellomesencephalic fissure.METHODS:Nine formalin-fixed, latex-injected cadaveric head specimens were used to perform a midline SCIT and bilateral PCITs and measure the distance of each approach. Twenty-four formalin-fixed specimens were used to measure the distance from the most posterior cortical bridging vein entering the superior sagittal sinus to the calcarine sulcus and the torcula. Fifty-one magnetic resonance images were reviewed to calculate the angle of each approach. Three illustrative surgical cases were described.RESULTS:Mean distances from the brain or cerebellar surface to the operative target of the PCIT and SCIT were 7.1 cm (range: 5-7.7 cm) and 5.5 cm (range: 3.8-6.2 cm), respectively. The SCIT provided direct access to structures of the quadrigeminal cistern bilaterally. The PCIT provided access from the ipsilateral inferior colliculus to the ipsilateral infratrochlear zone. The PCIT's benefit was the direct access it provided to the cerebellomesencephalic fissure because of its superior to inferior trajectory.CONCLUSION:The PCIT is indicated for unilateral lesions of the cerebellomesencephalic fissure and dorsal brainstem that harbor a craniocaudal long axis and do not have a superior extension beyond the superior colliculi. The SCIT is beneficial for lesions that extend bilaterally, have an anteroposterior long axis, or involve the Galenic complex.

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“…7 Surgery is favored in the symptomatic patient when concerns over the latency from radiosurgery to obliteration and overshooting the shunting zone during embolization predominate. 4,11…”

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“…7 Surgery is favored in the symptomatic patient when concerns over the latency from radiosurgery to obliteration and overshooting the shunting zone during embolization predominate. 4,11 For small AVM with high-flow shunts localization of the nidus and fistulous connection is the main challenge. Sinus skeletonization in complex dural arteriovenous fistula is a reported technique.…”

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confidence: 99%

The Microsurgical Management of a Cerebellar Vermian Arteriovenous Malformations Associated With High-Flow Fistulae: 2-Dimensional Operative Video

Dória-Neto

Agyemang

Rodríguez

et al. 2023

Operative Neurosurgery

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Arteriovenous malformations (AVM) in the posterior fossa represent 2% to 15% of all brain AVMs, are often smaller, and have a higher risk of hemorrhage. [1][2][3][4] The presence of a single draining vein, venous stenosis, and high-flow fistulae increases hemorrhage risk but also venous congestion. [3][4][5][6] AVM associated with high-flow fistula can be managed surgically, radiosurgically, or endovascularly. 7-10 Embolization of the associated fistula is reported to be safer than embolization of the nidus. 7 Surgery is favored in the symptomatic patient when concerns over the latency from radiosurgery to obliteration and overshooting the shunting zone during embolization predominate. 4,11 For small AVM with high-flow shunts localization of the nidus and fistulous connection is the main challenge. Sinus skeletonization in complex dural arteriovenous fistula is a reported technique. 12 We adapt this technique to delineate and disconnect a subpial posterior fossa AVM with high-flow fistula. We present a video case of an obese male in his 50s with hypertension and end-stage renal disease who presented with a 9-month history of progressive spastic quadriparesis. The patient consented to the procedure. Examination revealed grade 2 power on the left and grade 4 on the right with brisk reflexes. MRI showed T2 signal hyperintensity in the pons, and digital subtraction angiography confirmed an AVM overlying the culmen of the vermis with feeders from the S3 segment of the superior cerebellar artery, draining into the precentral vein. We demonstrated that surgical management of micro-AVMs with associated high-flow fistulae can be safely achieved in experienced hands using technique of vein skeletonization guided by indocyanine green angiography. The patient signed the Institutional Consent Form, which states that he accepts the procedure and allows the use his images and videos for any type of medical publications in conferences and/or scientific articles.

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Microsurgical approaches to the cerebellar interpeduncular region: qualitative and quantitative analysis

Cited by 4 publications

References 49 publications

Posterior vascular anatomy of the encephalon: a comprehensive review

Posterior vascular anatomy of the encephalon: a comprehensive review

Comparison Between the Supracerebellar Infratentorial and Precuneal Interhemispheric, Transtentorial Approaches to the Cerebellomesencephalic Fissure: An Anatomoradiological Study and Illustrative Cases

The Microsurgical Management of a Cerebellar Vermian Arteriovenous Malformations Associated With High-Flow Fistulae: 2-Dimensional Operative Video

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