Article
A systematic anatomical comparison of midline, paramedian supracerebellar infratentorial and occipital transtentorial approaches to the posterior incisural space and case illustrations by two staged surgeries for complex falcotentorial meningiomas
Systematische anatomische Vergleichstudie von Mittellinien-, paramedianen supracerebellären infratentoriellen und okzipitalen transtentoriellen Zugängen zum hinteren Tentoriumschlitz und Fallillustrationen anhand von zweizeitig resezierten komplexen falco-tentoriellen Meningeomen
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Authors
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Lucas Serrano
- University Medical Centre, Johannes Gutenberg University Mainz, Department of Neurosurgery, Mainz, Deutschland
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Ali Ayyad
- Hamad Medical Corporation, Department of Neurosurgery, Doha, Katar
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Eleftherios Archavlis
- University Medical Centre, Johannes Gutenberg University Mainz, Department of Neurosurgery, Mainz, Deutschland
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Malte Ottenhausen
- University Medical Centre, Johannes Gutenberg University Mainz, Department of Neurosurgery, Mainz, Deutschland
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Jens Conrad
- University Medical Centre, Johannes Gutenberg University Mainz, Department of Neurosurgery, Mainz, Deutschland
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Eike Schwandt
- University Medical Centre, Johannes Gutenberg University Mainz, Department of Neurosurgery, Mainz, Deutschland
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Amr Nimer
- Charing Cross Hospital - Imperial College Healthcare NHS Trust, Department of Neurosurgery, London, Vereinigtes Königreich
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Florian Ringel
- University Medical Centre, Johannes Gutenberg University Mainz, Department of Neurosurgery, Mainz, Deutschland
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Sven Rainer Kantelhardt
- University Medical Centre, Johannes Gutenberg University Mainz, Department of Neurosurgery, Mainz, Deutschland
| Published: | June 4, 2021 |
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Outline
Text
Objective: The posterior incisural space (PIS) represent a neurosurgical challenge given its depth and complex anatomy. To access the PIS, the midline supracerebellar infratentorial approach (MSIA) has been traditionally applied, but several neurosurgeons propose that a paramedian supracerebellar infratentorial (PSIA) or interhemispheric occipital transtentorial approach (IOTA) might enable a better accessibility. We systematically compared these 3 approaches in cadaver specimens and present the application of PSIA/IOTA as staged surgery for resection of complex falcotentorial meningeomas.
Methods: We performed 8 cadaver dissections assessing morphometrical features related to exposure, operability, brain retraction and obstacles to the PIS during MSIA, PSIA and IOTA. Additionally, we operated two patients presenting supra-infratentorial growing falcotentorial meningiomas through a two-staged endoscopic assisted PSIA combined with IOTA.
Results: Superficial vermian draining veins at an average depth of 11.38±1.5 mm and the superior vermian vein at a depth of 54.13±4.12mm limited the access to the PIS during MSIA. MSIA required sacrifice of these veins and retraction of the vermian culmen of 20.88±2.03mm to obtain comparable operability indexes (as described by Salma et al.) to PSIA and IOTA [1]. Cerebellar and occipital lobe retraction averaged 14.31±1.014mm and 14.81±1.17mm during PSIA and IOTA respectively, which was significantly lower than during MSIA (both p<0.001). Only few tiny veins were encountered along the access through PSIA and IOTA. The application of PSIA provided high operability scores around the pineal gland, the ipsilateral colliculus and splenium, and acceptable scores on contralateral structures. The main advantage of the IOTA was improving surgical manoeuvres along the ipsilateral splenium. Staged PSIA and IOTA enabled successful resection of both falcotentorial meningiomas. Postoperative course was uneventful and patients recovered without new neurological deficits.
Conclusion: Although IOTA and PSIA may render some difficulties related to tentorial incision and spatial orientation, these approaches may provide advantages in terms of brain retraction, vein sacrifice and operability. Their application can be effective for staged surgery of complex falcotentorial meningiomas.
References
- 1.
- Salma A, Wang S, Ammirati M. Extradural endoscope-assisted subtemporal posterior clinoidectomy: a cadaver investigation study. Neurosurgery. 2010 Sep;67(3 Suppl Operative):ons43-8; discussion ons48. DOI: 10.1227/01.NEU.0000375577.16079.E7
