Article
The transfalcine interhemispheric approach to contralateral paramedian, parafalcin lesions
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Authors
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Jörg Baldauf
- Klinik für Neurochirurgie, Ernst-Moritz-Arndt Universität, Greifswald, Deutschland
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Henry W. S. Schroeder
- Ernst-Moritz-Arndt-Universität Greifswald, Klinik und Poliklinik für Neurochirurgie, Greifswald, Deutschland
| Published: | June 9, 2017 |
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Outline
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Objective: Deep located lesions within the paramedian, parafalcin region are sometimes difficult to access. Ipsilateral approaches may contain a high risk of damaging eloquent areas or associated white matter tracts and can be limited due to venous anatomy of sinusoidal draining veins. Therefore, a transfalcine contralateral approach to these lesions may have some advantages. The authors report their recent experience regarding the approach.
Methods: Between 2014 and 2016 four patients received surgery via the transfalcine interhemispheric approach for contralateral lesions. To avoid retraction of the cortical surface of the ipsilateral hemisphere the patients head was rotated moderately with the upper body in supine position. The falx had to be located as parallel to the ground as possible to support the descent of both hemispheres with the contralateral side fixed by the falx. A lumbar drain was placed before surgery to release CSF to achieve more space for manipulation. The advantage and disadvantage of the approach was analyzed with respect to clinical outcome of the patients and pre- and postoperative MR imaging.
Results: Four patients underwent the approach with an average age of 35 years (range 21-48years; female-male: 3:1). Lesions included 2 glioblastomas, 1 cavernoma and 1 metastasis of a melanoma. Measurement of mean maximal lateral extension (falx to lateral tumor border) was 21mm. In all but one complete tumor removal was achieved during initial surgery. In one patient with a GBM a small tumor remnant was resected in a second attempt. There was no need of additional retraction using a spatula. There were no complications related to the approach. Postoperative MRI revealed no changes of the ipsilateral hemisphere regarding the approach. No functional deficits have been observed in any patient.
Conclusion: The transfalcine interhemispheric approach to contralateral paramedian, parafalcin lesions is safe but challenging. Excessive retraction of the cortical surface of the ipsilateral hemisphere can be avoided by proper positioning of the patient, lumbar drainage and simply using gravity. Lateral extension of a lesion can limit the approach as well as the presence of many or large ipsilateral sinusoidal draining veins. The latter has to be estimated before surgery.
