The Transsylvian Approach Is “Minimally Invasive” but Not “Atraumatic”

Letter to the Editor. Neuritis ossificans

“…[1][2][3][4] Furthermore, our results have been confirmed by others who have used both similar and different methodologies. [5][6][7]12,16,17,21,22,29,30,33,36 In summary, it was precisely because of the potential (and certainly avoidable) consequences associated with the use the maneuvers proposed by the authors of the Letter to the Editor that we have been conducting our studies on the topic for the last 10 years. Although intuitively correct, this is a limited resource; in a deep surgical field, sooner or later, the vectors of vision will be blocked by either the edges of the craniotomy (including the base of the skull), or the brain itself.…”

Venous-Preserving Sylvian Dissection

“…[13,15,19] Venous infarction or severe cerebral edema due to venous congestion may follow, resulting in neurological deficits. [11,15,17] Considering it is difficult or impossible to foresee the consequence of sacrificing the veins, the surgeon should endeavor to save the superficial sylvian veins while reserving a wide enough space within the surgical field for safe manipulation. However, few techniques to preserve these veins have been described.…”

Open Surgical Evacuation of Spontaneous Putaminal Hematomas: Prognostic Factors and Comparison of Outcomes between Transsylvian and Transcortical Approaches

“…Transsylvian transinsular approach has an advantage of minimal disruption of a normal cerebral cortex, even though it requires a small insular cortex incision, which is known not to have any neurologic deficit in most cases 15,22,23) . However, it has some disadvantages such as increased risk of surgically induced trauma to the frontal and temporal lobe due to retraction and of vasospasm due to manipulation of perisylvian vessels, as well as the time consuming in such cases as difficult sylvian dissection 22) . On the contrary, the transcortical approach requires a small cortical incision at the thinnest cortex to hematoma, through which the hematoma can be evacuated effectively with minimal brain retraction.…”

“…In particular, transsylvian approach can be considered "minimally invasive" because it doesn't invade pia matter of frontal and temporal lobes. Neurosurgeons specialized in vascular surgery, frequently use this approach to clip the intracranial aneurysms 22) . But, sylvian fissure dissection can be a difficult job for other neurosurgeons and neurosurgeons in beginner stage.…”

“…Disadvantages of the transsylvian approach are hemodynamic change due to major vessel injury, sacrifice of cortical and sylvian veins, manipulative transgression of the thin arachnoid membrane and vasospasm due to mechanical damage to the vessel walls, continuous seepage of small amounts of blood into basal cisterns and damage to the hypothalamus 1,22,23) . In contrast to transsylvian approach to clip the aneurysm, which requires wide sylvian dissection, transsylvian transinsular approach to evacuate putaminal hematoma often requires a small distal sylvian fissure dissection to expose insular cortex.…”