The lateral infratrigeminal transpontine window to deep pontine lesions

Ferroli, Paolo; Schiariti, Marco; Cordella, Roberto; Boffano, Carlo; Nava, Simone; Corte, Emanuele La; Cavallo, Claudio; Bauer, Dario; Castiglione, Melina; Broggi, Morgan; Acerbi, Francesco; Broggi, Giovanni

doi:10.3171/2014.11.jns141116

Cited by 13 publications

(9 citation statements)

References 42 publications

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“…This regular approach is used more often by neurosurgeons than more bulky, complex, or exceptional approaches to the skull base. [8][9][10][11][12][13] The presigmoid approach has been proposed as an alternative to allow a flatter approach to the most anterior lesions in the brainstem, thus avoiding the retraction of the pons. In our opinion, this approach is more limited and increases the risk of postoperative CSF fistula and infection.…”

Section: Discussionmentioning

confidence: 99%

Retrosigmoid Approach: A Simple and Safe Way to Resect Intrinsic Pontomedullary Lesions

González-Darder

Capilla-Guasch

Real-Peña

2019

J Neurol Surg B Skull Base

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Objectives The main objective of this article is to describe a simple and safe protocol for the microsurgical management of ventrally located intrinsic pontomedullary lesions based on the retrosigmoid approach, cortectomy performed utilizing safe entry zones of the pons and medulla, and a delicate microsurgical resection. The intraoperative protocol includes redundant procedures that provide security in decision-making during surgery. Design A prospective series of 11 cases is presented. All patients were studied following the same clinical and imaging workup. A regular retrosigmoid craniotomy surgical approach was utilized. The peritrigeminal area in the pons and the olivary area in the medulla were considered as the safe entry zones. Neuronavigation of the white fiber tracts and electrophysiological monitoring were used as intraoperative aids to locate the lesions, the safe entry zones, and the placement of the cortectomy. Results Six lesions were pontine, two medullary, and the remaining six pontomedullary. Eight lesions were cavernomas, while the remaining three tumors. Overall, we obtained a postoperative functional improvement in the affected cranial nerves in 90.1% of the patients and a total or partial recovery of long ascending or descending pathway symptoms in 72.3% of the patients. All the patients were satisfied with the procedure and the results. Conclusions Radical resection of ventral intrinsic pontomedullary lesions displays a high degree of intraoperative reliability, and a good clinical result is possible using simple surgical procedures. The anatomical references are the first element in the decision-making process during surgery.

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Section: Discussionmentioning

confidence: 99%

Retrosigmoid Approach: A Simple and Safe Way to Resect Intrinsic Pontomedullary Lesions

González-Darder

Capilla-Guasch

Real-Peña

2019

J Neurol Surg B Skull Base

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“…Surgical approaches are potentially guided by the location of the lesion within the brainstem [2,6-8,16]. Abla et al [2] have recommended the retro-sigmoid, sub-occipital±telovelar, or retro-sigmoid/lateral supra cerebellar infra-tentorial approaches for a pontine cavernoma and the retro-sigmoid or far-lateral approach for cavernoma located at the pontomedullary junction.…”

Section: Discussionmentioning

confidence: 99%

“…Recurrent hemorrhage from BC can be lethal if not managed by an experienced neurosurgeon at an experienced center [1-3]. Various surgical approaches, such as retrosigmoid, suboccipital, far lateral, infratentorial supracerebellar, orbitozygomatic, and translabyrinthine, have been described to approach these lesions with varying success [2,6-8]. There is a paucity of literature focusing on surgical approaches in patients who present with recurrent hemorrhage.…”

Section: Introductionmentioning

confidence: 99%

Trans-labyrinthine Infra-trigeminal Approach for Recurrent Pontomedullary Cavernoma: A Step-wise Technical Note

Sharma¹,

Lin²,

Andaluz³

et al. 2019

Cureus

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Recurrent brainstem cavernoma is a challenging lesion due to the neurological risks associated with different surgical approaches. In this technical report, we present a 35-year-old female with a history of multiple brain cavernomas. She underwent midline suboccipital craniotomy and trans-fourth ventricle approach for resection of the brain stem cavernoma following two major bleeding episodes, one year prior to the presentation. Following the trans-labyrinthine infra-trigeminal approach, the patient recovered well postoperatively with a baseline neuro exam and was discharged to acute rehab on postoperative day 5 (POD5). The translabyrinthine approach is a safe and effective corridor for pontine or pontomedullary lesions in carefully selected patients. Appropriate selection of surgical approach (based on location), meticulous surgical technique, and intraoperative neuromonitoring help in maximizing surgical resection while minimizing neurological deficits.

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“…The peritrigeminal or infratrigeminal safe entry zone runs along the vertical transtrigeminal line from the axilla of the trigeminal root to the shoulder of the vestibulocochlear nerve. 24 Entry at this lateral border of the peritrigeminal region exposes medially placed lesions because of the anterior protuberance of the pons. 24 Entry should parallel the fascicles of the trigeminal nerve as the incision deepens and moves obliquely posteriorly, which positions the incision almost perpendicular to the approach's trajectory and away from the anterolateral pons.…”

Section: Peritrigeminal Cmsmentioning

confidence: 99%

“…24 Entry at this lateral border of the peritrigeminal region exposes medially placed lesions because of the anterior protuberance of the pons. 24 Entry should parallel the fascicles of the trigeminal nerve as the incision deepens and moves obliquely posteriorly, which positions the incision almost perpendicular to the approach's trajectory and away from the anterolateral pons. A supratrigeminal safe entry zone from the shoulder of the trigeminal nerve to the pontomesencephalic sulcus has also been described for more superior peritrigeminal pontine lesions.…”

Section: Peritrigeminal Cmsmentioning

confidence: 99%

A taxonomy for brainstem cavernous malformations: subtypes of pontine lesions. Part 1: basilar, peritrigeminal, and middle peduncular

Catapano

Rumalla

Srinivasan

et al. 2022

Journal of Neurosurgery

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OBJECTIVE Brainstem cavernous malformations (BSCMs) are complex, difficult to access, and highly variable in size, shape, and position. The authors have proposed a novel taxonomy for pontine cavernous malformations (CMs) based upon clinical presentation (syndromes) and anatomical location (findings on MRI). METHODS The proposed taxonomy was applied to a 30-year (1990–2019), 2-surgeon experience. Of 601 patients who underwent microsurgical resection of BSCMs, 551 with appropriate data were classified on the basis of BSCM location: midbrain (151 [27%]), pons (323 [59%]), and medulla (77 [14%]). Pontine lesions were then subtyped on the basis of their predominant surface presentation identified on preoperative MRI. Neurological outcomes were assessed according to the modified Rankin Scale, with a score ≤ 2 defined as favorable. RESULTS The 323 pontine BSCMs were classified into 6 distinct subtypes: basilar (6 [1.9%]), peritrigeminal (53 [16.4%]), middle peduncular (MP) (100 [31.0%]), inferior peduncular (47 [14.6%]), rhomboid (80 [24.8%]), and supraolivary (37 [11.5%]). Part 1 of this 2-part series describes the taxonomic basis for the first 3 of these 6 subtypes of pontine CM. Basilar lesions are located in the anteromedial pons and associated with contralateral hemiparesis. Peritrigeminal lesions are located in the anterolateral pons and are associated with hemiparesis and sensory changes. Patients with MP lesions presented with mild anterior inferior cerebellar artery syndrome with contralateral hemisensory loss, ipsilateral ataxia, and ipsilateral facial numbness without cranial neuropathies. A single surgical approach and strategy were preferred for each subtype: for basilar lesions, the pterional craniotomy and anterior transpetrous approach was preferred; for peritrigeminal lesions, extended retrosigmoid craniotomy and transcerebellopontine angle approach; and for MP lesions, extended retrosigmoid craniotomy and trans–middle cerebellar peduncle approach. Favorable outcomes were observed in 123 of 143 (86%) patients with follow-up data. There were no significant differences in outcomes between the 3 subtypes or any other subtypes. CONCLUSIONS The neurological symptoms and key localizing signs associated with a hemorrhagic pontine subtype can help to define that subtype clinically. The proposed taxonomy for pontine CMs meaningfully guides surgical strategy and may improve patient outcomes.

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The lateral infratrigeminal transpontine window to deep pontine lesions

Cited by 13 publications

References 42 publications

Retrosigmoid Approach: A Simple and Safe Way to Resect Intrinsic Pontomedullary Lesions

Retrosigmoid Approach: A Simple and Safe Way to Resect Intrinsic Pontomedullary Lesions

Trans-labyrinthine Infra-trigeminal Approach for Recurrent Pontomedullary Cavernoma: A Step-wise Technical Note

A taxonomy for brainstem cavernous malformations: subtypes of pontine lesions. Part 1: basilar, peritrigeminal, and middle peduncular

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