Supracerebellar Infratentorial Infratrochlear Trans-Quadrangular Lobule Approach to Pontine Cavernous Malformations

2021 ◽  
Vol 20 (3) ◽  
pp. 268-275
Author(s):  
Caleb Rutledge ◽  
Daniel M S Raper ◽  
Roberto Rodriguez Rubio ◽  
Ethan A Winkler ◽  
Adib A Abla
Keyword(s):  
Superior Cerebellar Artery ◽  
Surgical Removal ◽  
Modified Rankin Scale ◽  
Trochlear Nerve ◽  
Middle Cerebellar Peduncle ◽  
Cavernous Malformations ◽  
Suboccipital Craniotomy ◽  
Cerebellar Artery ◽  
Scale Scores ◽  
Cerebellar Peduncle

Abstract BACKGROUND Brainstem cavernous malformations with symptomatic hemorrhage have a poor natural history. Those without a pial or ependymal presentation are often observed given the morbidity of resection. Surgical removal is considered only in patients with accessible lesions that have repeated symptomatic hemorrhagic. OBJECTIVE To describe a novel supracerebellar infratentorial infratrochlear trans-quadrangular lobule approach to safely resect lesions in the upper pons. METHODS We use a hybrid paramedian/lateral suboccipital craniotomy in the gravity-dependent supine position. Opening the cerebellomesencephalic fissure over the tentorial surface of the cerebellum brings the trochlear nerve, branches of the superior cerebellar artery, and the quadrangular lobule of the cerebellum into view. Removal of small a portion of the quadrangular lobule defines an entry point on the superomedial aspect of the middle cerebellar peduncle, and a surgical trajectory aimed superior to inferior. RESULTS A total of 6 patients underwent this approach. All presented with symptomatic hemorrhage and all cavernous malformations were completely resected. Five patients were improved or unchanged with modified Rankin scale scores of 1 or 2. CONCLUSION The trans-quadrangular lobule approach allows safe resection of upper pontine cavernous malformations along a superior to inferior trajectory.

Lateral inferior cerebellar peduncle approach to dorsolateral medullary cavernous malformation

2014 ◽  
Vol 121 (3) ◽  
pp. 723-729 ◽  
Author(s):  
Vivek R. Deshmukh ◽  
Leonardo Rangel-Castilla ◽  
Robert F. Spetzler
Keyword(s):  
Cavernous Malformation ◽  
Case Series ◽  
Cavernous Malformations ◽  
Excellent Outcome ◽  
Suboccipital Craniotomy ◽  
Scale Scores ◽  
Far Lateral ◽  
Cerebellar Peduncle ◽  
Inferior Cerebellar Peduncle ◽  
Foramen Of Luschka

Object Brainstem cavernous malformations (BSCMs) present a unique therapeutic challenge to neurosurgeons. Resection of BSCMs is typically reserved for lesions that reach pial or ependymal surfaces. The current study investigates the lateral inferior cerebellar peduncle as a corridor to dorsolateral medullary BSCMs. Methods In this retrospective review, the authors present the cases of 4 patients (3 women and 1 man) who had a symptomatic dorsolateral cavernous malformation with radiographic and clinical evidence of hemorrhage. Results All patients underwent excision of the cavernous malformation via a far-lateral suboccipital craniotomy through the foramen of Luschka and with an incision in the inferior cerebellar peduncle. On intraoperative examination, 2 of the 4 patients had hemosiderin staining on the surface of the peduncle. All lesions were completely excised and all patients had a good or excellent outcome (modified Rankin Scale scores of 0 or 1). Conclusions This case series illustrates that intrinsic lesions of the dorsolateral medulla can be safely removed laterally through the foramen of Luschka and the inferior cerebellar peduncle.

scholarly journals Left Retrosigmoid Craniotomy for Resection of Cavernous Malformation: 2-Dimensional Operative Video

2019 ◽  
Vol 18 (1) ◽  
pp. E2-E2
Author(s):  
Benjamin K Hendricks ◽  
Robert F Spetzler
Keyword(s):  
Preoperative Planning ◽  
Cavernous Malformation ◽  
Video Recording ◽  
Close Inspection ◽  
Middle Cerebellar Peduncle ◽  
Cavernous Malformations ◽  
Institutional Review Board Approval ◽  
Institutional Review ◽  
Surgical Field ◽  
Cerebellar Peduncle

Abstract Pontine cavernous malformations are highly morbid lesions that require thorough preoperative planning of the surgical approach and meticulous surgical technique to successfully remove. The patient in this case has a large pontine cavernous malformation coming to the parenchymal surface along the pontine–middle cerebellar peduncle interface. The depth of the surgical field and narrow trajectory of approach require use of lighted suction, lighted bipolar forceps, and stereotactic neuronavigation to successfully locate and remove the entire lesion. The cavernous malformation is removed in a piecemeal manner with close inspection of the resection cavity for any remnants. Postoperative imaging demonstrates gross total resection of the lesion. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

Left retrosigmoid craniotomy for cavernous malformation of the middle cerebellar peduncle

2014 ◽  
Vol 36 (v1supplement) ◽  
pp. 1 ◽  
Author(s):  
Jonathan Russin ◽  
David J. Fusco ◽  
Robert F. Spetzler
Keyword(s):  
Cerebrospinal Fluid ◽  
Cavernous Malformation ◽  
Lateral Wall ◽  
Petrous Bone ◽  
Sigmoid Sinus ◽  
Middle Cerebellar Peduncle ◽  
Cavernous Malformations ◽  
Lateral Border ◽  
History Of ◽  
Cerebellar Peduncle

We present a 25-year-old female with a history of multiple intracranial cavernous malformations complaining of vertigo. Imaging is significant for increasing size of a lesion in her left cerebellar peduncle. Given the proximity to the lateral border of the cerebellar peduncle, a retrosigmoid approach was chosen. After performing a craniotomy that exposed the transverse-sigmoid sinus junction, the dura was open and reflected. The arachnoid was sharply opened and cerebrospinal fluid was aspirated to allow the cerebellum to fall away from the petrous bone. The cerebellopontine fissure was then opened to visualize the lateral wall of the cerebellar peduncle. The cavernous malformation was entered and resected.The video can be found here: http://youtu.be/P7mpVbaCiJE.

The Supratonsillar Approach to the Inferior Cerebellar Peduncle: Anatomy, Surgical Technique, and Clinical Application to Cavernous Malformations

2006 ◽  
Vol 59 (suppl_4) ◽  
pp. ONS-244-ONS-252 ◽  
Author(s):  
Michael T. Lawton ◽  
Alfredo Quiñones-Hinojosa ◽  
Peter Jun
Keyword(s):  
Surgical Technique ◽  
Surgical Approach ◽  
Fourth Ventricle ◽  
Cerebellar Tonsil ◽  
Cavernous Malformations ◽  
Suboccipital Craniotomy ◽  
Cerebellar Tissue ◽  
Cerebellar Peduncle ◽  
Arteries And Veins ◽  
Inferior Cerebellar Peduncle

Abstract OBJECTIVE: To introduce the supratonsillar approach, an approach that traverses the tonsillobiventral fissure in a trajectory over the cerebellar tonsil to the inferior cere-bellar peduncle, and to demonstrate the utility of this approach for resecting peduncular cavernous malformations. METHODS: Anatomy of the cerebellar tonsil and surrounding fissures, arteries, and veins are reviewed using cadaveric brain specimens. The surgical approach uses the three-quarter prone position, a suboccipital craniotomy, and wide splitting of the tonsillobiventral fissure. RESULTS: Of our experience with 171 patients with cavernous malformations, six patients had lesions in the inferior cerebellar peduncle that were resected using the supratonsillar approach. All cavernous malformations were removed completely and no patients experienced surgical complications or new deficits. @@CONCLUSION:@@ The supratonsillar approach differs from the transvermian and telove-lar approaches to the fourth ventricle, with a more superolateral trajectory that leads instead to the inferior cerebellar peduncle. By splitting the tonsillobiventral fissure and mobilizing the tonsil inferomedially, the point of access to the lesion is deepened and transgression of normal cerebellar tissue is minimized. This elegant approach is ideally suited to the removal of cavernous malformations.

Subtonsillar Approach to the Foramen of Luschka: An Anatomic and Clinical Study

Neurosurgery ◽  
2003 ◽  
Vol 52 (4) ◽  
pp. 860-866 ◽  
Author(s):  
Walter C. Jean ◽  
Khaled M. Abdel Aziz ◽  
Jeffrey T. Keller ◽  
Harry R. van Loveren
Keyword(s):  
Clinical Study ◽  
Cleavage Plane ◽  
Cerebellar Tonsil ◽  
Middle Cerebellar Peduncle ◽  
Suboccipital Craniotomy ◽  
Tela Choroidea ◽  
Cerebellomedullary Fissure ◽  
Lateral Decubitus ◽  
Cerebellar Peduncle ◽  
Foramen Of Luschka

Abstract OBJECTIVE Conventional approaches to tumors of the foramen of Luschka are limited because the foramen is viewed from either the fourth ventricle laterally (transvermian approach) or the cerebellopontine angle medially (suboccipital approach). The definitive approach is subtonsillar, because the foramen of Luschka is actually the end of the natural cleavage plane between the cerebellar tonsil and the medulla. We describe the microsurgical anatomic features of the foramen of Luschka region and the operative technique for the subtonsillar approach to this region. METHODS In the anatomic study, five formalin-fixed, silicone-injected, cadaveric heads were used. In the clinical study, the records for five patients treated via the subtonsillar approach were examined; several illustrative cases are presented. RESULTS The foramen of Luschka is formed by the tela choroidea and the rhomboid lip and exists at the lateral end of the cerebellomedullary fissure, which is a natural cleavage plane between the cerebellar tonsil and the medulla. The subtonsillar approach is performed via a suboccipital craniotomy; the patient is positioned in the lateral decubitus position, with the tumor side down. After the cerebellar tonsil is freed from arachnoid adhesions, it can be retracted rostrodorsally from the medulla, to expose the cerebellomedullary fissure. Clinically, the tela choroidea and rhomboid lip are significantly attenuated by tumor expansion. Therefore, by dissecting in a subtonsillar manner around the tumor, one can reach the foramen of Luschka without traversing any neural tissue. CONCLUSION The subtonsillar approach yields a panoramic view to the foramen of Luschka laterally and up to the middle cerebellar peduncle superiorly. This approach minimizes the distance between the tumor and the surgeon, while maximizing neural preservation. We think this is the definitive approach to this difficult region of the posterior fossa.

Trochlear Nerve Palsy as the Sole Initial Sign of an Aneurysm of the Superior Cerebellar Artery

Neurosurgery ◽  
1992 ◽  
Vol 30 (2) ◽  
pp. 258???261 ◽  
Author(s):  
T. Edward Collins ◽  
Thomas F. Mehalic ◽  
Therese K. White ◽  
Roger T. Pezzuti
Keyword(s):  
Nerve Palsy ◽  
Superior Cerebellar Artery ◽  
Trochlear Nerve ◽  
Cerebellar Artery ◽  
Trochlear Nerve Palsy ◽  
Initial Sign

The Superior Cerebellar Artery Aneurysm: A Posterior Circulation Aneurysm with Favorable Microsurgical Outcomes

Neurosurgery ◽  
2017 ◽  
Vol 80 (6) ◽  
pp. 908-916 ◽  
Author(s):  
Ana Rodríguez-Hernández ◽  
Brian P. Walcott ◽  
Harjus Birk ◽  
Michael T. Lawton
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Surgical Techniques ◽  
Artery Aneurysm ◽  
Posterior Circulation ◽  
Superior Cerebellar Artery ◽  
Microsurgical Clipping ◽  
Cerebellar Artery ◽  
Neurological Morbidity ◽  
Scale Scores ◽  
Permanent Morbidity

Abstract BACKGROUND: Superior cerebellar artery (SCA) aneurysms are usually grouped with aneurysms that arise from the upper basilar artery or more broadly, the posterior circulation. However, the SCA aneurysm has distinctive anatomy that facilitates safe surgical management, notably few associated perforating arteries, and excellent exposure in the carotid-oculomotor triangle. OBJECTIVE: To demonstrate the outcomes of patients treated with microsurgery in a continuous surgical series. METHODS: Sixty-two patients harboring 63 SCA aneurysms were retrospectively reviewed from a prospectively maintained database, focusing on clinical characteristics, surgical techniques, and clinical outcomes. RESULTS: Of 31 patients (49%) presenting with subarachnoid hemorrhage, the SCA aneurysm was the source in 16 (25%). Thirty-three aneurysms were complex (52%) and 43 patients (59%) had multiple aneurysms. Fifty-seven SCA aneurysms (90.5%) were clipped and 5 were bypassed/trapped or wrapped. Complete angiographic occlusion was achieved in 91.7%. Permanent neurological morbidity occurred in 3 patients and 3 patients that presented in coma after subarachnoid hemorrhage died. All patients with “simple” aneurysms and without subarachnoid hemorrhage had improved or unchanged modified Rankin scale scores. Overall, outcomes were stable or improved in 82.5% of patients. CONCLUSION: SCA aneurysms are favorable for microsurgical clipping with low rates of permanent morbidity and mortality. Microsurgery should be considered alongside endovascular techniques as a treatment option in many patients.

Trochlear Nerve Palsy as the Sole Initial Sign of an Aneurysm of the Superior Cerebellar Artery

Neurosurgery ◽  
1992 ◽  
Vol 30 (2) ◽  
pp. 258-261 ◽  
Author(s):  
T. Edward Collins ◽  
Thomas F. Mehalic ◽  
Therese K. White ◽  
Roger T. Pezzuti
Keyword(s):  
Nerve Palsy ◽  
Superior Cerebellar Artery ◽  
Trochlear Nerve ◽  
Cerebellar Artery ◽  
Trochlear Nerve Palsy ◽  
Initial Sign

The inferior medullary velum: anatomical study and neurosurgical relevance

2013 ◽  
Vol 118 (2) ◽  
pp. 315-318 ◽  
Author(s):  
R. Shane Tubbs ◽  
Anand N. Bosmia ◽  
Marios Loukas ◽  
Eyas M. Hattab ◽  
Aaron A. Cohen-Gadol
Keyword(s):  
Average Length ◽  
Single Cells ◽  
Posterior Inferior Cerebellar Artery ◽  
Anatomical Study ◽  
Ependymal Cells ◽  
Middle Cerebellar Peduncle ◽  
Cerebellar Artery ◽  
Cerebellar Peduncle ◽  
Small Clusters ◽  
Immunohistochemical Analyses

Object Although it is often visualized surgically, details regarding the inferior medullary velum are lacking in the literature. The present study is intended to better elucidate this neuroanatomical structure using microsurgical and immunohistochemical analyses. Methods To study the inferior medullary velum, the authors performed microdissection in 15 adult cadavers. Following gross study, specimens were examined histologically. Results The inferior medullary velum extended from the flocculus to the middle cerebellar peduncle and stretched between the inferior cerebellar peduncle and the nodule and pyramid. The average thickness of the velum was found to be 0.5 mm (range 0.35–0.8 mm) and the average length was found to be 6 mm (range 5.5–7.2 mm). Arterial branches were identified in all specimens that arose from medullary branches of the posterior inferior cerebellar artery and supplied the inferior medullary velum. Histologically and from internal to external, a choroid plexus epithelium as a single cell layer was adjacent to a cuboidal layer of ependymal cells with no visible cilia. The next layer contained scattered glia in single cells or small clusters. The most external layer was composed of flat spindle cells resembling fibroblasts. No neurons of any type were identified. Only rare axons traversed the thin hypocellular zone that disappeared toward the midline. Conclusions Based on this cadaveric study, the authors conclude that division of the inferior medullary velum should be relatively harmless as no neuronal cells were identified in this structure, which appears to be a vestigial bridge of tissue between the left and right sides of the cerebellum.

Brainstem Cavernous Malformations

Neurosurgery ◽  
2015 ◽  
Vol 76 (3) ◽  
pp. 265-278 ◽  
Author(s):  
Roxanna M. Garcia ◽  
Michael E. Ivan ◽  
Michael T. Lawton
Keyword(s):  
Logistic Regression ◽  
Surgical Outcomes ◽  
Clinical Decision Making ◽  
Motor Dysfunction ◽  
Grading System ◽  
Developmental Venous Anomaly ◽  
Modified Rankin Scale ◽  
Cavernous Malformations ◽  
Maximal Diameter ◽  
Scale Scores

Abstract BACKGROUND: Once considered inoperable lesions in inviolable territory, brainstem cavernous malformations (BSCM) are now surgically curable with acceptable operative morbidity. Recommending surgery is a difficult decision that would be facilitated by a grading system designed specifically for BSCMs that predicted surgical outcomes. OBJECTIVE: Informed by our efforts to develop a supplementary grading system for arteriovenous malformations, we hypothesized that a similar system might predict long-term outcomes and guide clinical decision-making. METHODS: A consecutive, single-surgeon series of 104 patients was used to assess preoperative clinical and imaging predictors of microsurgical outcomes. Univariable logistic regression identified predictors and a multivariable logistic regression model tested the association of the combined predictors with final modified Rankin Scale scores. A grading system assigned points for lesion size, location crossing the brainstem's midpoint, presence of developmental venous anomaly, age, and time from last hemorrhage to surgery. RESULTS: Average maximal diameter of BSCMs was 19.5 mm; 50% crossed the axial midpoint; 54.8% had developmental venous anomalies; mean age was 42.1 years; and median time from last hemorrhage to surgery was 60 days. One patient died (0.96%), and 15 patients (14.4%) experienced worsened cranial nerve or motor dysfunction, of which 10 increased their modified Rankin Scale scores (9.6%). BSCM grades ranged from 0 to 7 points and predicted outcomes with high accuracy (receiver operating characteristic = 0.86, 95% confidence interval: 0.78-0.94). CONCLUSION: Rather than developing a grading system for all cerebral cavernous malformations that is weak with BSCMs, we propose a system for the patients who need it most. The BSCM grading system differentiates patients who might expect favorable surgical outcomes and offers guidance to neurosurgeons forced to select these patients.

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