Posterior interhemispheric transfalcine transprecuneus approach for microsurgical resection of periatrial lesions: indications, technique, and outcomes

Bohnstedt, Bradley N.; Kulwin, Charles; Shah, Mitesh V.; Cohen-Gadol, Aaron

doi:10.3171/2015.3.jns14847

Cited by 21 publications

(17 citation statements)

References 33 publications

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“…9,16,41,45,48,55,57,59,75,84,94,125 Understanding the periventricular white matter tracts is helpful not only in defining more precise surgical strategies, but also in clarifying the symptoms of and appropriate treatment for patients with hydrocephalus and periventricular lesions. 11,18,36,38,40,47,50,52,58,65,66,76,80,101 This study examines the tracts at risk in the 3 surgical routes-anterior, posterior, and lateral-to the lateral ventricle.…”

Section: Discussionmentioning

confidence: 99%

The white matter tracts of the cerebrum in ventricular surgery and hydrocephalus

Güngör¹,

Baydın²,

Middlebrooks

et al. 2017

JNS

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S urgical approaches to the lateral ventricle always require passage through one and often multiple fiber tracts to reach their target. These approaches remain a challenge because of the deep location and variable shape and size of the ventricles, their covering mantle of tracts, and relationships to important neural structures such as the thalamus and internal capsule. 55,75,84 In addition, a number of tracts course in the walls of the ventricle where they are separated from the cerebrospinal fluid by only a thin layer of ependyma and would likely be exposed to the greatest possibility of damage by hydrocephalus.84,124 Recent studies have focused on the relationships of the fiber tracts to eloquent cortical areas and avoiding the optic radiations in approaches to the lateral ventricle. 16,41,48,59,63,75,89,92,94,125 The aim of the present study was to explore the relationships of the tracts to the lateral ventricles and the various surgical approaches to the ventricles and to examine the anatomy and syndromes related to ventricular enlargement. MethodsForty adult human formalin-fixed cadaveric hemispheres (20 brains) were examined under magnification that ranged from ×6 to ×40. The dura, pia, arachnoid, and surface vessels were gently removed. All specimens were frozen in water for at least 2 weeks at -16°C, as described by Klingler, to separate the tracts and facilitate dissection. 51 After freezing, the specimens were thawed and rinsed of formalin under tap water for at least 1 hour. Prior OBJECTIVEThe relationship of the white matter tracts to the lateral ventricles is important when planning surgical approaches to the ventricles and in understanding the symptoms of hydrocephalus. The authors' aim was to explore the relationship of the white matter tracts of the cerebrum to the lateral ventricles using fiber dissection technique and MR tractography and to discuss these findings in relation to approaches to ventricular lesions. METHODS Forty adult human formalin-fixed cadaveric hemispheres (20 brains) and 3 whole heads were examined using fiber dissection technique. The dissections were performed from lateral to medial, medial to lateral, superior to inferior, and inferior to superior. MR tractography showing the lateral ventricles aided in the understanding of the 3D relationships of the white matter tracts with the lateral ventricles. RESULTS The relationship between the lateral ventricles and the superior longitudinal I, II, and III, arcuate, vertical occipital, middle longitudinal, inferior longitudinal, inferior frontooccipital, uncinate, sledge runner, and lingular amygdaloidal fasciculi; and the anterior commissure fibers, optic radiations, internal capsule, corona radiata, thalamic radiations, cingulum, corpus callosum, fornix, caudate nucleus, thalamus, stria terminalis, and stria medullaris thalami were defined anatomically and radiologically. These fibers and structures have a consistent relationship to the lateral ventricles. CONCLUSIONS Knowledge of the relationship of the white matter tracts o...

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Section: Discussionmentioning

confidence: 99%

The white matter tracts of the cerebrum in ventricular surgery and hydrocephalus

Güngör¹,

Baydın²,

Middlebrooks

et al. 2017

JNS

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“…The surgeon, therefore, must weigh the advantages and disadvantages of this approach against his or her technical expertise. In the senior author's experience, 3 the PITTA is superior to conventional ipsilateral approaches (eg, anterior transsylvian, posterior transcortical or transcallosal, lateral transtemporal or subtemporal) for the majority of periatrial lesions, particularly those that involve the lateral regions of the trigone.…”

Section: A N U S C R I P Tmentioning

confidence: 99%

“…Standard ipsilateral interhemispheric and transcortical approaches to the periatrial region suffer limitations related to the need for extensive brain retraction and parenchymal transgression and the inaccessibility of lesions with significant lateral extension. [2][3][4] In the 1990s, Atul Goel published the first description of the contralateral transfalcine approach for resection of deep-…”

Section: Contralateral Pittamentioning

confidence: 99%

“…That group published their favorable experience with this operative route in a series of 10 patients with periatrial lesions. 2 Details of the PITTA technique can be found in the report on a 14-patient series by Bohnstedt et al 3 The evolution of the PITTA for periatrial lesions demonstrates key principles of microneurosurgical innovation (Figure 1). The approach capitalizes on a natural plane to access the surgical target, thus avoiding risks associated with cortical transgression.…”

Section: A N U S C R I P Tmentioning

confidence: 99%

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Innovations in the Art of Microneurosurgery for Reaching Deep-Seated Cerebral Lesions

Tomlinson

Hendricks²,

Torregrossa

et al. 2019

World Neurosurgery

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Deep-seated cerebral lesions have fascinated and frustrated countless surgical innovators since the dawn of the microneurosurgical era. To determine the optimal approach, the microneurosurgeon must take into account the characteristics and location of the pathological lesion as well as the operator's range of technical expertise. Increasingly, microneurosurgeons must select between multiple operative corridors that can access to the surgical target. Innovative trajectories have emerged for many indications that provide more flexible operative angles and superior exposure but result in longer working distances and more technically demanding maneuvers. In this article, we highlight 4 innovative surgical corridors and compare their strengths and weaknesses against those of more conventional approaches. Our goal is to use these examples to illustrate the following principles of microneurosurgical innovation: (1) discover more efficient and flexible exposures with superior working angles; (2) ensure maximal early protection of critical neurovascular structures; and (3) effectively handle target pathology with minimal disruption of normal tissues.

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“…More posteriorly, the parietooccipital interhemispheric approach (PIA) enables the resection of pathologies in the peritrigonal or periatrial region. This is challenging due to the depth of the region and due to strategically important structures [12,37,65].…”

Section: Introductionmentioning

confidence: 99%

The interhemispheric fissure—surgical outcome of interhemispheric approaches

et al. 2020

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Exposure of the anterior skull base is challenging due to strategic structures. The interhemispheric approach (IHA) has turned out to be a feasible technique. We report our experience with IHAs in patients with extraaxial lesions (EAL). We performed a retrospective chart review at a tertiary neurosurgical center between April 2009 and March 2020. We included patients with resection of EAL through IHAs concentrating on surgical technique, complete resection rate, postoperative outcome, and complications. Seventy-four patients resected by an IHA were included: 49 (66.2%) frontal (FIA), nine (12.1%) parietooccipital (PIA), and 16 (21.6%) frontobasal IHAs (FBIAs). Median age at time of surgery was 59 years (range 16-88 years), 47 (63.5%) female and 27 (36.5%) male. Complete resection rate was 83.8% (FIA 89.8%, PIA 55.6%, FBIA 81.3%). Rate of new minor deficits was 17.6%, rate of major deficits 5.4%, total rate 23.0%. 51 (68.9%) WHO°I meningiomas, ten (13.5%) WHO°II meningiomas, two (2.7%) WHO°III meningiomas, nine (12.2%) metastases, one (1.4%) sarcoma, and one (1.4%) local adenocarcinoma were resected. Total complication rate was 27.0%. Rate of major complications requiring intervention was 9.6%. Mean follow-up was 34.2 (± 33.2) months. In patients with lesions of the interhemispheric fissure, overall morbidity and complications are comparatively high. Extensions of IHAs with potential even higher morbidity are not necessary though; we support the use of standardized IHAs. Our findings suggest regular usage of relatively feasible IHAs for a satisfying outcome. Invasive, complicated, or contralateral trajectories were not needed.

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Posterior interhemispheric transfalcine transprecuneus approach for microsurgical resection of periatrial lesions: indications, technique, and outcomes

Cited by 21 publications

References 33 publications

The white matter tracts of the cerebrum in ventricular surgery and hydrocephalus

The white matter tracts of the cerebrum in ventricular surgery and hydrocephalus

Innovations in the Art of Microneurosurgery for Reaching Deep-Seated Cerebral Lesions

The interhemispheric fissure—surgical outcome of interhemispheric approaches

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