The paramedian supracerebellar-transtentorial approach to the entire length of the mediobasal temporal region: an anatomical and clinical study

Türe, Uğur; Harput, Mehmet Volkan; Kaya, Ahmet Hilmi; Baimedi, Praveen; Fırat, Zeynep; Türe, Hatice; Bingöl, Canan Aykut

doi:10.3171/2011.12.jns11791

Cited by 108 publications

(91 citation statements)

References 51 publications

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“…1,4, 14,15,20,32,36,41 However, these approaches have some risk of damaging neocortical structures and white matter pathways or involve an extremely narrow operating field, excessive brain retraction, and potential injury to the vein of Labbé. The transsylvian approach was proposed to reduce these risks.…”

Section: 45mentioning

confidence: 99%

Microsurgical anatomy of the inferior limiting insular sulcus and the temporal stem

Ribas

Yağmurlu

Wen

et al. 2015

JNS

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T he temporal stem is a widely used term, but is still a controversial concept. Definitions of the stem range from its being as small as the fiber bundles passing between the limen insula and the anterior end of the temporal horn, to its being as large as including all the fibers passing beneath the length of the inferior limiting insular sulcus (ILS). 13,42,45,46 The transsylvian approach to the medial temporal lobe is commonly directed through or adjacent to the ILS and temporal stem, where opening of the temporal horn and exposure of the amygdala and the hippocampus are key steps. Unfortunately, the temporal lobe is the site of important brain functions, and complications involving visual and language deficits are not rare. 12,34,38 In this study, based on the larger definition of the stem, the location of each white matter pathway between the ILS and temporal horn was described, with special attention to their relation to the limen insula. The meeting point of the ILS with the limen insula can be identified during surgery and used as a landmark to estimate the position of each set of fibers beneath the ILS. MethodsFourteen adult cadaveric cerebral hemispheres were examined using ×3 to ×40 magnification. The specimens were fixed with formalin and preserved in a 70% alcohol abbreviatioNs DTI = diffusion tensor imaging; ILS = inferior limiting insular sulcus; LGB = lateral geniculate body; TLP = temporal limen point. obJect The purpose of this study was to describe the location of each white matter pathway in the area between the inferior limiting insular sulcus (ILS) and temporal horn that may be crossed in approaches through the temporal stem to the medial temporal lobe. Methods The fiber tracts in 14 adult cadaveric cerebral hemispheres were examined using the Klingler technique. The fiber dissections were completed in a stepwise manner, identifying each white matter pathway in different planes and describing its position in relation to the anterior end of the ILS. results The short-association fibers from the extreme capsule, which continue toward the operculae, are the most superficial subcortical layer deep to the ILS. The external capsule fibers are found deeper at an intermediate layer and are formed by the uncinate fasciculus, inferior frontooccipital fasciculus, and claustrocortical fibers in a sequential anteroposterior disposition. The anterior commissure forms the next deeper layer, and the optic radiations in the sublenticular part of the internal capsule represent the deepest layer. The uncinate fasciculus is found deep to the anterior third of the ILS, whereas the inferior frontooccipital fasciculus and optic radiations are found superficial and deep, respectively, at the posterior two-thirds of this length. coNclusioNs The authors' findings suggest that in the transsylvian approach, a 6-mm incision beginning just posterior to the limen insula through the ILS will cross the uncinate fasciculus but not the inferior frontooccipital fasciculus or optic radiations, but that longer incisions carry a...

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Section: 45mentioning

confidence: 99%

Microsurgical anatomy of the inferior limiting insular sulcus and the temporal stem

Ribas

Yağmurlu

Wen

et al. 2015

JNS

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“…16; Table 3). 104,107 This approach requires a parahippocampal gyrus incision to reach the hippocampus and amygdala, which can damage the cingulum, fornix, and Li-Am fasciculus and may cause limbic system dysfunction with behavioral and cognitive changes (Table 3). 53,54,72,88 …”

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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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“…[1][2][3]9,15,19,21 Exposure of the PMT region through these traditional approaches increases the risk of eloquent visual, language, and limbic temporal lobe pathway damage due to vascular injury or tissue transgression or retraction. 3,9,19,21,24 The subtemporal approach offers access to the PMT region at the expense of retraction of the temporal lobe.aBBreviatiONS ECoG = electrocorticography; PHG = parahippocampal gyrus; PMT = posteromedial temporal; SCTT = supracerebellar-transtentorial. …”

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confidence: 99%

The supracerebellar-transtentorial approach to posteromedial temporal lesions in children with refractory epilepsy

Weil¹,

Middleton²,

Niazi³

et al. 2015

PED

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OBJECT Operations on tumors of the posteromedial temporal (PMT) region, that is, on those arising from the posterior parahippocampal, fusiform, and lingual gyri, are challenging to perform because of the deep-seated location of these tumors between critical cisternal neurovascular structures and the adjacent temporal and occipital cortexes. Traditional surgical approaches require temporal or occipital transgression, retraction, or venous sacrifice. These approaches may result in unintended complications that should be avoided. To avoid these complications, the supracerebellar-transtentorial (SCTT) approach to this region has been used as an effective alternative treatment in adult patients. The SCTT approach uses a sitting position that offers a direct route to the posterior fusiform and lingual gyri of the temporal lobe. The authors report the feasibility, safety, and efficacy of this approach, using a modified lateral park-bench position in a small cohort of pediatric patients. METHODS The authors carried out a retrospective case review of 5 consecutive patients undergoing a paramedian SCTT approach between 2009 and 2014 at the authors' institution. RESULTS The SCTT approach in the park-bench position was used in 3 boys and 2 girls with a mean age of 7.8 years (range 13 months to 16 years). All patients presented with a seizure disorder related to a tumor in a PMT region involving the parahippocampal and fusiform gyri of the left (n = 3) or right (n = 2) temporal lobe. No procedure-related complications were observed. Gross-total resection and control of seizures were achieved in all cases. Tumor classes and types included 1 Grade II astrocytoma, 1 pleomorphic xanthoastrocytoma, 1 ganglioglioma, and 2 glioneural tumors. None of the tumors had recurred by the mean follow-up of 22 months (range 1–48 months). Outcomes of epileptic seizures were excellent, with seizure symptoms in all 5 patients scoring in Engel Class IA. CONCLUSIONS The SCTT approach represents a viable option when resecting tumors in this region, providing a reasonable working corridor and low morbidity. The authors' experience in a cohort of pediatric patients demonstrates that complete resection of the lesions in this location is feasible and is safe when involving an approach that involves using a park-bench lateral positioning.

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The paramedian supracerebellar-transtentorial approach to the entire length of the mediobasal temporal region: an anatomical and clinical study

Cited by 108 publications

References 51 publications

Microsurgical anatomy of the inferior limiting insular sulcus and the temporal stem

Microsurgical anatomy of the inferior limiting insular sulcus and the temporal stem

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

The supracerebellar-transtentorial approach to posteromedial temporal lesions in children with refractory epilepsy

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