Microsurgical and endoscopic approaches to the pulvinar

Abstract

OBJECTIVEApproaches to the pulvinar remain challenging because of the depth of the target, surrounding critical neural structures, and complicated arterial and venous relationships. The purpose of this study was to compare the surgical approaches to different parts of the pulvinar and to examine the efficacy of the endoscope as an adjunct to the operating microscope in this area.METHODSThe pulvinar was examined in 6 formalin-fixed human cadaveric heads through 5 approaches: 4 above and 1 below the tentorium. Each approach was performed using both the surgical microscope and 0° or 45° rigid endoscopes.RESULTSThe pulvinar has a lateral ventricular and a medial cisternal surface that are separated by the fornix and the choroidal fissure, which wrap around the posterior surface of the pulvinar. The medial cisternal part of the pulvinar can be further divided into upper and lower parts. The superior parietal lobule approach is suitable for lesions in the upper ventricular and cisternal parts. Interhemispheric precuneus and posterior transcallosal approaches are suitable for lesions in the part of the pulvinar forming the anterior wall of the atrium and adjacent cisternal part. The posterior interhemispheric transtentorial approach is suitable for lesions in the lower cisternal part and the supracerebellar infratentorial approach is suitable for lesions in the inferior and medial cisternal parts.The microscope provided satisfactory views of the ventricular and cisternal surfaces of the pulvinar and adjacent neural and vascular structures. The endoscope provided multi-angled and wider views of the pulvinar and adjacent structures.CONCLUSIONSA combination of endoscopic and microsurgical techniques allows optimal exposure of the pulvinar.

Endoscopic far-lateral supracerebellar infratentorial approach for resection of posterior clinoid meningioma: Case report and literature review

“…With the rapid development of neuroendoscopy, the infratentorial space has been recognized as another optimal endoscopic operating area. Earlier anatomic studies have addressed the possibility of endoscope-assisted or purely endoscopic ELSI for accessing the posterior and posterolateral incisural space ( 17 – 19 ). Clinically, endoscope-assisted or purely endoscopic ELSI has been used for removal of supratentorial lesions, such as cavernous malformation in the posteromedial temporal lobe and petroclival meningiomas extending into the middle fossa, with the aid of tentorium incision ( 10 , 20 ).…”

“…endoscopic ELSI for accessing the posterior and posterolateral incisural space (17)(18)(19). Clinically, endoscope-assisted or purely endoscopic ELSI has been used for removal of supratentorial lesions, such as cavernous malformation in the posteromedial temporal lobe and petroclival meningiomas extending into the middle fossa, with the aid of tentorium incision (10, 20).…”

An endoscopic-assisted contralateral paramedian supracerebellar infratentorial approach in the treatment of thalamic hemorrhage with hematoma extension into the brainstem: a case report

“…The superior parietal approach can provide access to the posterior hypothalamus and a part of the adjacent brainstem but requires incisions of the superior longitudinal fasciculus and the carpet fibers ( 11 , 12 ), which interrupt vital functions such as optic radiations and speech pathways. The same issue arises with the transprecuneus approach, which involves interhemispheric ( 13 ) access to the posterior upper thalamus, but requires removal of the corpus callosum tongs, medial cingulate gyrus, upper longitudinal fasciculus I, and precuneus ( 14 ), which are involved in higher mental functioning, memory, and other neurocognitive functions ( 15 ). The posterior interhemispheric transcallosal approach also needs to cut and pull the pressure part of the corpus callosum, which can cause disconnection syndrome ( 16 ).…”

Neurosurgery for brain metastasis from breast cancer

“…During the past two decades, endoscopic surgery has dramatically increased, especially in surgery for intraventricular lesions and in transsphenoidal surgery. Additionally, the visualization of deep structures is often better with an angled endoscope than a microscope ( 78 ). An endoscope has several characteristics that complement those of a microscope, making an endoscope a useful adjunct to microsurgery with a microscope ( 79 , 80 ).…”