gms | German Medical Science

Objective: Meningiomas of the lateral ventricles are commonly located in the atria. Surgical access to such tumours is challenging because of their deep location and proximity to critical neurovascular structures, particularly if situated on the dominant side. Although a number of approaches have been described in the literature, most carry the risk of post-operative neuropsychological, visual or speech deficits, especially when operating on the dominant hemisphere. The supracerebellar transtentorial transcollateral sulcus (STTCS) approach offers the potential to circumvent functionally important structures, reducing the risk of these approach-related neurological deficits.

Method: Careful anatomical study was firstly performed on ten human cadavers, verifying the suitability of the STTCS approach. The atrium of the lateral ventricle was entered through the collateral sulcus in each human specimen from the inferior transtentorial direction, analyzing approach-related brain injury. Two patients with dominant hemisphere atrial meningioma’s underwent surgical resection utilizing the STTCS approach.

Results: The preclinical anatomical study showed antraumatic exposure of the atrium of the lateral ventricle: only the "U" fibers of the collateral sulcus were damaged, and the fibers of the optic radiation in the inferolateral wall of the atrium were preserved. In both clinical cases the atrial tumors were fully resected without approach-related morbidity. Neuronavigation was used to carefully plan the incision, craniotomy and exposure, and also intra-operatively to orientate the operating surgeon at key steps, particularly when raising the tentorial flap in-line with the tumour. Endoscopy was used to provide increased light intensity, an extended viewing angle, and higher magnification when compared to a microscope. Specially designed tube-shaft designed instruments were also employed to assist with manipulation through the narrow surgical corridor.

Conclusions: The STTCS approach provides good access to tumors located in the atrial region, reducing the risk of iatrogenic language or visual field deficits. In dominant hemisphere lesions, the SCTT approach is an effective alternative to existing techniques.