NEUROSURGICAL OPERATIVE ATLAS

Volume 8
AANS Publications Committee
Editors SETTI S. RENGACHARY ROBERT H. WILKINS

The American Association of Neurological Surgeons

© 1999 For copies of this Cumulative Index contact: The American Association of Neurological Surgeons 22 South Washington St. Park Ridge, Illinois 60068-4287 email: aanspubs@valley.net voice: 847-692-9500 fax: 847-692-6770

Contents
Volume I
Optic Gliomas. Edgar M. Housepian / 1-13 Fibrous Dysplasia Involving the Craniofacial Skeleton. James T. Goodrich, Craig D. Hall / 14-22 Depressed Skull Fracture in Adults. Fred H. Geisler / 23-33 Cervical Hemilaminectomy for Excision of a Herniated Disc. Robert H. Wilkins, Sarah J. Gaskill / 34-38 Lateral Sphenoid Wing Meningioma. Joseph Ransohoff / 39-45 Selective Microsurgical Vestibular Nerve Section for Intractable Ménière’s Syndrome. Edward Tarlov / 46-53 Chiari Malformations and Syringohydromyelia in Children. W. Jerry Oakes / 54-60 Carotid Body Tumors. Fredric B. Meyer, Thoralf M. Sundt, Jr. / 61-69 Olfactory Groove Meningiomas. Joshua B. Bederson, Charles B. Wilson / 70-78 Cerebral Aneurysms at the Bifurcation of the Internal Carotid Artery. Eugene S. Flamm / 79-88 Treatment of Unilateral or Bilateral Coronal Synostosis. John A. Persing, John A. Jane / 89-98 Convexity Meningioma. Sarah J. Gaskill, Robert H. Wilkins / 99-105 Occipital Lobectomy. Milam E. Leavens / 106-112 Spinal Meningiomas. Michael N. Bucci, Julian T. Hoff / 113-116 Percutaneous Trigeminal Glycerol Rhizotomy. Ronald F. Young / 117-123 Lumbar Hemilaminectomy for Excision of a Herniated Disc. Patrick W. Hitchon, Vincent C. Traynelis / 124-129 Transoral Surgery for Craniovertebral Junction Anomalies. Arnold H. Menezes / 130-135 Anterolateral Cervical Approach to the Craniovertebral Junction. Dennis E. McDonnell / 136-153 Correction of Malposition of the Orbits. John A. Persing / 154-163 Removal of Cervical Ossified Posterior Longitudinal Ligament at Single and Multiple Levels. Ralph B. Cloward / 164-170 Technique of Ventriculostomy. Joseph H. Piatt, Jr., Kim J. Burchiel / 171-175 Cerebellar Medulloblastoma. Arthur E. Marlin, Sarah J. Gaskill / 176-183 Shunting of a Posttraumatic Syrinx. David J. Gower / 184-190 Direct Surgical Treatment of Vein of Galen Malformations. Harold J. Hoffman / 191-200 Spinal Nerve Schwannoma. Phyo Kim, Burton M. Onofrio / 201-206 Combined Craniofacial Resection for Anterior Skull Base Tumors. Ehud Arbit, Jatin Shah / 207-217 Diagnostic Open Brain and Meningeal Biopsy. Richard P. Anderson, Howard H. Kaufman, Sydney S. Schochet / 218-222 Ventriculoperitoneal Shunting. David C. McCullough / 223-230 Ventriculoatrial Shunting. Paul J. Camarata, Stephen J. Haines / 231-239 Excision of Acoustic Neuromas by the Middle Fossa Approach. Derald E. Brackmann / 240-248 Upper Thoracic Sympathectomy by a Posterior Midline Approach. Prem K. Pillay, Issam A. Awad, Donald F. Dohn / 249-255 Carotid Endarterectomy. Daniel L. Barrow, Christopher E. Clare / 256-266 Transsphenoidal Excision of Macroadenomas of the Pituitary Gland.

NEUROSURGICAL OPERATIVE ATLAS: TABLE OF CONTENTS

George T. Tindall, Eric J. Woodard, Daniel L. Barrow / 267-278 Computer-Directed Stereotactic Resection of Brain Tumors. Patrick J. Kelly / 279-293 Sagittal Synostosis. A. Leland Albright / 294-300 Glossopharyngeal Rhizotomy. Burton M. Onofrio / 301-304 Occipitocervical and High Cervical Stabilization. Volker K.H. Sonntag, Curtis A. Dickman / 305-315 Petroclival Meningiomas. Ossama Al-Mefty, Michael P. Schenk, Robert R. Smith / 316-326 Facial Reanimation without the Facial Nerve. Mark May, Steven M. Sobol / 327-336 Omental and Musculocutaneous Free Flaps for Coverage of Complicated Neurosurgical Wounds. Daniel L. Barrow, Foad Nahai / 337-348 Repair of “Growing” Skull Fracture. Tadanori Tomita / 349-354 Occipital Encephaloceles. William O. Bell / 355-362 Foramen Magnum Meningiomas and Schwannomas: Posterior Approach. Chad D. Abernathey, Burton M. Onofrio / 363-371 Penetrating Wounds of the Spine. Edward C. Benzel / 372-378 Percutaneous Radiofrequency Rhizolysis for Trigeminal Neuralgia. James Fick, John M. Tew, Jr. / 379-390 Extended Costotransversectomy. Eddy Garrido / 391-396 Surgical Resection of Posterior Fossa Epidermoid and Dermoid Cysts. Lee Kesterson / 397-406 Luque Rod Segmental Spinal Instrumentation. Edward C. Benzel, / 407-412 En Bloc Anterior Temporal Lobectomy for Temporolimbic Epilepsy. Michel F. Levesque / 413-422 Cingulotomy for Intractable Pain Using Stereotaxis Guided by Magnetic Resonance Imaging. Samuel J. Hassenbusch, Prem K. Pillay / 423-432 Cerebellar Astrocytomas. A. Leland Albright / 433-439 Extreme Lateral Lumbar Disc Herniation. Robert S. Hood / 440-444 Tentorial Meningiomas. Laligam N. Sekhar, Atul Goel / 445-455

Volume II
Surgical Repair of Trigonocephaly. Ken R. Winston, Michael J. Burke / 1-8 Dorsal Root Entry Zone (DREZ) Lesioning. Blaine S. Nashold, Jr., Amr O. Ei-Naggar / 9-24 Ophthalmic Segment Aneurysms. Arthur L. Day / 25-41 Chronic Subdural Hematoma. James E. Wilberger, Jr. / 42-48 Tailored Temporal Lobectomy Using Subdural Electrode Grids. Issam A. Awad, Joseph F. Hahn / 49-55 Gunshot Wounds of the Brain. Suzie C. Tindall, Ali Krisht / 56-59 Transtorcular Occlusion of Vein of Galen Malformations. J. Parker Mickle, Ronald G. Quisling, Keith Peters / 60-66 Detection of an Epileptic Focus and Cortical Mapping Using a Subdural Grid. Sumio Uematsu / 67-78 Anteromesial Temporal Lobectomy for Epilepsy. Issam A. Awad, Prem K. Pillay / 79-87 Anastomosis of the Facial Nerve After Resection of an Acoustic Neuroma. Charles M. Luetje / 88-90 An Extended Subfrontal Approach to the Skull Base. Chandranath Sen, Laligam N. Sekhar / 91-100

NEUROSURGICAL OPERATIVE ATLAS: TABLE OF CONTENTS

Pansynostosis: Surgical Management of Multiple Premature Suture Closure. James T. Goodrich, Craig D. Hall / 101-112 Distal Anterior Cerebral Artery Aneurysms. H. Hunt Batjer, Duke Samson / 113-126 Tethered Spinal Cord, Intramedullary Spinal Lipoma, and Lipomyelomeningocele. W. Jerry Oakes / 127-135 Interstitial Brachytherapy. Jeffrey D. McDonald, Philip H. Gutin / 136-144 Lateral Extracavitary Approach to the Thoracic and Lumbar Spine. Dennis J. Maiman, Sanford J. Larson / 145-153 An Extreme Lateral Transcondylar Approach to the Foramen Magnum and Cervical Spine. Chandranath Sen, Laligam N. Sekhar / 154-162 Retrolabyrinthine Presigmoid Approach for Sectioning of the Vestibular Nerve for Ménière’s Disease. Charles M. Luetje / 163-166 Stereotactic Surgical Ablation for Pain Relief. Ronald F. Young / 167-177 Anterior Screw Fixation of Odontoid Fractures. Ronald I. Apfelbaum / 178-188 Carpal Tunnel Syndrome. Setti S. Rengachary / 189-199 Transantral Ethmoidal Orbital Decompression For Graves’ Ophthalmopathy. Lawrence W. DeSanto / 200-206 Middle Fossa Approaches for Invasive Tumors Involving the Skull Base. Laligam N. Sekhar, Atul Goel, Chandranath Sen / 207-218 Transthoracic Excision of a Spinal Metastasis with Vertebral Body Reconstruction. Gregory J. Bennett / 219-228 Anterior Cervical Discectomy and Fusion-the Cloward Technique. Ralph B. Cloward / 229-240 Cubital Tunnel Syndrome. Setti S. Rengachary / 241-245 Caspar Plating of the Cervical Spine. H. Louis Harkey, Wolfhard Caspar, Yaghoub Tarassoli / 246-256 Surgical Management of Anterior Communicating Artery Aneurysms. Timothy C. Ryken, Chistopher M. Loftus / 257-265 Basilar Bifurcation Aneurysm: Pterional (Transsylvian) Approach. H. Hunt Batjer, Duke S. Samson / 266-281 Thalamotomy for Tremor. Roy A. E. Bakay, Jerrold L. Vitek, Mahlon R. Delong / 282-295 Endovascular Treatment of Carotid Cavernous Fistulas. Arvind Ahuja, Lee R. Guterman, Kimberly Livingston, Leo N. Hopkins / 296-304 Combined Transsylvian and Middle Fossa Approach to Interpeduncular Fossa Lesions. Chandranath Sen, Laligam N. Sekhar / 305-311 Aneurysms of the Ophthalmic Segment of the Internal Carotid Artery. Daniel L. Barrow / 312-322 Lumbar-Peritoneal Shunting. Setti S. Rengachary / 323-333 Surgery of the Cavernous Sinus. Harry van Loveren, Magdy El-Kalliny, Jeffrey Keller, John M. Tew, Jr. / 334-344 Encephaloceles of the Anterior Cranial Base. Alan R. Cohen / 345-353 Cotrel-Dubousset Instrumentation: Internal Fixation for Thoracolumbar Fractures and Tumors. Bruce E. van Dam / 354-358 Posterior-Lateral Lumbar Spinal Fusion. Edward S. Connolly / 359-366 Correction of Exorbitism. Constance M. Barone, Ravelo V. Argamaso, David F. Jimenez, James T. Goodrich / 367-372 Meralgia Paresthetica. Setti S. Rengachary / 373-379 Depressed Skull Fracture in Infants. Lyn C. Wright, Marion L. Walker / 380-383 Combined Presigmoid-Transtransversarium Intradural Approach to the Entire Clivus and

Barone. Paul W. Allen B. Ausman. Sidney Eisig. Goodrich. Goodrich.NEUROSURGICAL OPERATIVE ATLAS: TABLE OF CONTENTS Anterior Craniospinal Region. Joseph G. Martin B. James I. James T. Paul Kurt Maurer. Kantrowitz / 84-93 Surgical Management of Chiari I Malformations and Syringomyelia. G. Janecka / 183-192 Surgical Management of Prolactinomas. Louis Harkey. Marlin. Anand. James T. de los Reyes. Goodrich. George J. Ravelo V. Sumio Uematsu / 417-427 Endocrine-Inactive Pituitary Adenomas. Goodrich. Timothy A. Ossama Al-Mefty / 1-11 Craniofacial Techniques Used in Resection of Anterior Skull Base Tumors. Translabial. Mario Ammirati. Simeon A. A. Morawetz / 94-102 Open-Door Maxillotomy Approach for Lesions of the Clivus. Jeffrey S. Sidney Eisig. Foley / 448-461 Volume III Tuberculum Sellae Meningiomas. Jimenez. Camins. Patterson / 176-182 Transfacial Approaches to the Clivus and Upper Cervical Spine. Schenk / 103-112 Peripheral Nerve Repair. Lauer. Franco DeMonte. Wilson / 428-437 Posterior Decompression and Fusion for Cervical Spondylotic Myelopathy. James T. Sarah J. Susan E. Peter M. Rengachary / 167-175 Thoracic Outlet Syndrome: Supraclavicular First Rib Resection and Brachial Plexus Decompression. Setti S. Mackinnon.Argamaso / 151-158 Transoral-Transclival Approach to Basilar Artery Aneurysms. Argamaso / 12-20 Occipital Transtentorial Approach to Pineal Region Neoplasms. H. James N. Ravelo V. Cisneros. Oppenheim / 66-75 Exposure of the Skull Base via the Midface. Balaji Sadasivan / 21-26 Meningioma of the Lateral Ventricle. H. Smith / 31-37 Repair of the Myelomeningocele. Parent / 193-202 . David F. Setti S. Charles B. Grubb. Kevin T. Gaskill / 58-65 Acoustic Neuromas: Surgical Anatomy of the Suboccipital Approach. Melvin Cheatham / 384-395 Partial Median Corpectomy with Fibular Grafting for Cervical Spondylotic Myelopathy. Alan Crockard. Kantrowitz / 76-83 Exposure of the Skull Base by Transoral. David G. Ravelo V. Goodrich / 410-416 Percutaneous Radiofrequency Rhizotomy for the Treatment of Paraplegic Spasms. Allan J. Vinod K. Argamaso. Richard B. McLone / 38-44 Anterior Clinoidal Meningiomas. Charles Nussbaum / 438-447 Surgical Correction of Swan Neck Deformity. Ivo P. Robert L. Ossama Al-Mefty / 45-57 Dandy-Walker Malformation. Arthur E. Edward Tarlov / 27-30 Preauricular-Infratemporal Fossa Approach to Tumors that Involve the Lateral Cranial Base. Feghali. Andrew D. Strait / 144-150 Craniofacial Techniques for Managing Orbital Trauma. Peter G. Belzberg. Dachling Pang / 129-143 Tethered Cord Syndrome Secondary to Previous Repair of a Myelomeningocele. Campbell / 113-128 Surgical Management of Split Cord Malformations. James T. Michael P. Allen B. Detwiler / 159-166 Frontal Lobectomy. R. Constance M. Rengachary / 396-409 Correction of Orbital Hypertelorism and Orbital Dystopia. Klara. A. James T. and Transmandibular Routes.

Stephen L. Frederick A. Michael L. Nazzaro / 270-282 Surgical Treatment of Arteriovenous Malformations of the Cerebral Convexity.NEUROSURGICAL OPERATIVE ATLAS: TABLE OF CONTENTS Sectioning of the Filum Terminale. Traynelis. Alan R. Christopher S. Philip R. Mackinnon / 225-234 Spheno-Orbital Craniotomy for Meningioma. Peter Gruen. Weinstein / 344-358 Management of Basilar and Posterior Cerebral Artery Aneurysms by Subtemporal Approaches. Boop. Diaz. Boop. Vallo Benjamin. Edward H. Frederick A. Loftus / 427-435 Submuscular Transposition of the Ulnar Nerve at the Elbow: Musculofascial Lengthening Technique. Fessler / 337-343 Anterior Cervical Discectomy and Fusion: Smith-Robinson Technique. Donovan / 260-269 Medial Sphenoid Ridge Meningiomas. Susan E. Foley / 292-301 Microvascular Decompression of the Facial Nerve. Vincent C. Stuart Lee / 244-251 Acrylic Cranioplasty. John S. Fisher III / 283-291 Lumbar Microdiscectomy. Wink S. Apuzzo / 37-42 . Timothy M. Richard D. William M. Ondra. Robert H. Levy. Crowell. William M. Robert M. Seth M. Lee Dellon / 436-443 Superficial Temporal Artery to Middle Cerebral Artery Bypass Grafting. K. Martin Holland / 375-381 Image-Guided Neurosurgery: Frame-Based and Frameless Approaches. Klara. Chadduck / 203-209 Repair of Diastematomyelia. Thomas B. Vidovich / 235-243 Surgical Treatment of Anterior Sacral Meningocele. William M. Henry T. Boop. Frederick A. Chadduck / 215-219 Untethering of the Spinal Cord After a Previous Myelomeningocele Repair. Ogilvy / 359-374 Subcutaneous Transposition of the Ulnar Nerve for Tardy Ulnar Palsy. William M. A. Fredric L. Charlie Jiang. Lutz Nolte. Michael L. Kennerdell. Michael L. Cheatham. McCulloch. Maroon. Michael G. Frederick A. Edelman. Chadduck / 220-224 Secondary Carpal Tunnel Syndrome. Danko V. Apfelbaum / 19-28 Supracerebellar Infratentorial Approaches to the Pineal Region. Setti S. Issam A. Awad / 444-456 Volume IV Spinal Vascular Malformations. Ducker / 324-336 Vertebral Artery and Posterior Inferior Cerebellar Artery Aneurysms: Surgical Management. Hoffman / 312-323 Postlaminectomy Instability: Posterior Procedures. Boop. Lucia Zamorano. J. Joseph C. Ronald I. Kevin T. Apuzzo / 29-36 Third-Ventricle Exposure by the Interhemispheric Corridor. Chadduck / 210-214 Repair of a Lipomyelomeningocele. Timothy C. Christopher M. J. Oldfield / 1-18 Posterior C1-2 Screw Fixation for Atlantoaxial Instability. Jules M. Majeed Kadi / 482-401 Anterior Stabilization of the Cervical Spine Using a Locking Plate System. Melvin L. Peter M. Zeidman. Ryken. Fernando G. Rengachary / 402-413 Endoscopic Neurosurgery. Wilkins / 302-311 Craniofacial Resection of Neoplasms of the Anterior Skull Base. Rengachary / 252-259 Preauricular Transzygomatic Infratemporal Craniotomy for Skull Base Tumors. Cohen / 414-426 Surgical Management of Brain Abscess. Setti S.

Mackinnon / 225-234 Ulnar Nerve Entrapment at the Wrist. Delashaw. Ellenbogen. Awad / 107-116 Surgical Treatment of Intracranial Glomus Tumors. Jr. Firlik. Ellenbogen. Gordon McComb. / 85-94 Fourth Ventricular Ependymoma. Park / 183-190 Surgical Treatment of the Subclavian Steal Syndrome. Carrau. Ossama Al-Mefty / 117-130 Technique of Temporal Lobectomy. Fred H. / 75-84 Neurosurgical Aproaches to the Orbit. James T. Fernando G. Donald Dietze. George E. Susan E. Hae-Dong Jho. Interbody Fusion. Michael H. Geisler / 57-64 Intracranial Pressure Monitoring. Issam A. F. Charbel / 43-58 Selective Denervation for Spasmodic Torticollis. Delashaw. Diaz / 33-42 Surgical Management of Posterior Plagiocephaly. Goodrich / 209-214 Gamma Knife Radiosurgery of Intracranial Lesions. Ravelo V. James T. Leroy Young. Antonio A. Goodrich. and Lateral Stabilization. Abson Kraemer. Ossama Al-Mefty / 199-208 Lambdoidal Synostosis. John P. V. / 159-164 Transsphenoidal Surgical Treatment of Cushing’s Disease. Constance M. Malik. Vinod K.NEUROSURGICAL OPERATIVE ATLAS: TABLE OF CONTENTS Arteriovenous Malformations of the Basal Ganglia. Coffey / 215-224 Submuscular Transposition of the Ulnar Nerve at the Elbow. Murali Guthikonda. Jr. Ramesh P. Anand. John T. Ravelo Argamaso / 67-74 Neurosurgical Approaches to the Orbit. Thalamus. Darden II. John H. Schenk. Donald W. Richard G. Franco DeMonte. Dennis D. Richard G. Griffith R. and Adjacent Ventricles. Pierce / 191-198 Surgery for Tumors Affecting the Cavernous Sinus. J. Wirt / 147-158 Translabyrinthine Removal of Acoustic Neuromas. Young / 235-249 Volume V Endoscopic Pituitary Surgery. R. S. Robinson Hicks / 85-90 Stabilization of the Cervical Spine (C3-7) with Articular Mass (Lateral Mass) Plate and . Fady T. Wyler / 131-138 Treatment of Moyamoya Syndrome in Children with Pial Synangiosis. Allen R. Jill M. Michael Scott / 139-146 Isthmic Spondylolysis and Spondylolisthesis: Treatment by Reduction. Leonetti. Yong Ko / 1-12 Torcular and Peritorcular Meningiomas. David F. Babu / 23-32 Basilar Bifurcation Aneurysms: Transsylvian Transclinoidal Transcavernous Approach. Vallo Benjamin. Michael P. Robert J. Johnny B. Part 2: Craniotomy for Surgical Exposure of the Orbit. Diana L. J. Bruce V. Anand. Andrew D. Part 1: Orbital Anatomy and Lateral Orbitotomy. Mayer / 43-56 Acute Subdural Hematoma. T. Vinod K. Schneider / 95-106 Sectioning of the Corpus Callosum for Epilepsy. Spencer / 75-84 Far-Lateral Disc Herniation Treated by Microscopic Fragment Excision. Johnny B. Jimenez. William F. Ghaus M. Timothy C. Barone. Richard G. Harsh IV / 13-22 Surgical Resection of Lower Clivus-Anterior Foramen Magnum Meningioma. Ricardo L. DeSalles / 59-66 Unilateral Coronal Synostosis. Marion / 65-74 Temporal Lobectomy Under General Anesthesia. Fessler. Jr. Argamaso. Chandler / 165-172 Upper Thoracic Spinal Exposure Through a Lateral Parascapular Extrapleural Approach. David Peace / 173-182 Selective Dorsal Rhizotomy for the Spasticity of Cerebral Palsy. McElveen.

Borba / 91-100 Stabilization of the Cervical Spine with the Orion Anterior Cervical Plate System. B. Robert G. Scott Shapiro / 233-240 Endoscopic Third Ventriculostomy for Obstructive Hydrocephalus. Nancy E. Wu / 171-176 Management of Extradural Non-Neoplastic Lesions of the Craniovertebral Junction via the Transcondylar Approach. Borba. and Allogeneic Bone Matrix in Anterior Cervical Fusions Following Cervical Discectomy. Matthew Cheney. Stephen D. Iacono / 43-50 Sinus Skeletonization Technique: A Treatment for Dural Arteriovenous Malformations at the Tentorial Apex. Iacono. Gary L. Larry A. Ojemann / 129-134 Management of the Vertebral Artery During Excision of Extradural Tumors of the Cervical Spine. Lonser. Andres M. Timothy A. Lee / 155-164 Microsurgical Decompresson of the Root Entry Zone for Trigeminal Neuralgia. Rutka / 5-12 Posteroventral Pallidotomy for Parkinson’s Disease Patients. Shokei Yamada. Chandranath Sen / 165-170 The Anterior Cervical Approach to the Cervicothoracic Junction. Flannagan / 57-64 Endoscopic Approaches to the Ventricular System.NEUROSURGICAL OPERATIVE ATLAS: TABLE OF CONTENTS Screws. Mark R. Lee H. Neil R. Isao Yamamoto / 35-42 Bridge Bypass Coaptation for Cervical Nerve Root Avulsion. Smith. Kuslich / 227-232 Banked Fibula. Robert P. Lowery / 101-108 Texas Scottish Rite Hospital System for Internal Stabilization of Thoracolumbar Fractures. Kim H. Rea / 109-120 Application of Frameless Stereotaxy in the Management of Intracranial Lesions. Jimenez / 65-74 Surgical Management of Cranial Dural Arteriovenous Fistulas. Joseph. the Locking Anterior Cervical Plate. Robert P. Lozano. Glenn Pait. Burchiel. Luis A. Brooke Swearingen. Ossama Al-Mefty. Bailes / 75-84 . Monsein. Turner. Joseph A. Baskin. Kim J. Taha. Tamargo / 1-4 The Separation of Craniopagus Twins. Strait / 219-226 Microsurgical Lumbar Decompression Using Progressive Local Anesthesia. Ronald Tribell / 177-184 Far Lateral Lumbar Disc Herniation. Miller. Bradford M. Mullin. Julian E. Jamal M. Chandranath Sen. Epstein / 185-198 Repair and Reconstruction of Scalp and Calvarial Defects. Hoffman. Mark Eisenberg / 135-142 Posteroventral Pallidotomy for Patients with Parkinson’s Disease. Warren Schubert. Jonathan J. Helder Tedeschi / 51-56 Microsurgical Carotid Endarterectomy. Manwaring / 241-246 Volume VI Treatment of Carotid-Cavernous Sinus Fistulas Using a Superior Ophthalmic Vein Approach. Hutchison / 27-34 Anterolateral Transforaminal Approach for a Large Dumbbell-Shaped Cervical Neurinoma. David F. Julian E. B. Glenn Pait. Tantuwaya. Patrick P. Johnson / 121-128 A Modified Transfacial Approach to the Clivus. Gary L. Paul B. Evandro De Oliveira. James T. Michael P. Harold J. Lokesh S. Joseph R. Russell R. T. Epstein. Dennis A. Sargent. Shokei Yamada / 143-154 Functional Hemispherectomy. Julian K. William D. Luis A. Jacques Favre / 13-26 Microelectrode-Guided Pallidotomy. T. Jeffrey Aldridge / 199-218 Sagittal Synostosis. Rafael J. Bailes.

Manwaring / 109-114 Surgical Anatomy of the Temporal Lobe. Kyle L. R. Tissue Biopsy. Sr. Ronald F. Cabbell. Germano / 147-156 Anterior Cervical Spine Stabilization with the Codman Locking Plate System. John P. Ray / 1-10 Total Sacrectomy. Gorecki / 237-250 Stereotactic Microsurgical Craniotomy for the Treatment of Third Ventricular Colloid Cysts. George. David W. R. Raj Murali / 99-106 . Bhat.NEUROSURGICAL OPERATIVE ATLAS: TABLE OF CONTENTS Intraventricular Endoscopy: Diagnostic Ventriculoscopy. Baskin. Ziya L. Henson. Marvin M. Jr. Cyst Fenestration. Romsdahl. Spetzler / 59-68 Petrosal Approach for Resection of Petroclival Meningiomas. Young / 93-98 Techniques of Peripheral Neurectomy for Control of Trigeminal Neuralgia. Michael T. Dickman. Kureshi / 193-200 Combined Fronto-Orbital and Occipital Advancement for Total Calvarial Reconstruction.” Gary L. Ross / 251-256 Hemispherectomy. Berkley Rish. Carson. Wildrick. David A. / 83-92 Stereotactic Radiosurgery of the Trigeminal Nerve Root for Treatment of Trigeminal Neuralgia. Jonathan J. Randy F. Benjamin S. Scott L. Hae-Dong Jho / 43-52 Pedical Subtraction and Lumbar Extension Osteotomy for Iatrogenic “Flatback. Atul L. Theresa A. Gokaslan. John Hurlbert. John A. Volker K. Gillis. Roper / 115-124 Multiple Subpial Transection. Steven N. Timothy M. Lee / 131-146 Trans-Sulcal Approach to Mesiotemporal Lesions. Manwaring / 85-98 Endoscopic Carpal Tunnel Release Through a Monoportal Approach. Baskin. John P. Zeidman. Wolfgang Losken / 201-212 Repair of Meningoceles. Stephen S. William T. Robert F. Lowery.. A. Gorecki / 221-236 Implantation of Drug Infusion Pumps. Smith. Richard G. Jonathan J. Gary L. Lawton. Eugene Pennisi / 183-192 Surgical Management of Infected Ventriculoperitoneal Shunt. Polly. H. H. Bhat. Jay Menon / 99-108 Endoscopic Excision of Colloid Cysts. Sonntag / 157-166 Posterior Cervical Fusion with Tension Band Wiring. Donald A. Eric M. John A. Sohaib A. Curtis A. Jane. Timothy M. A. Couldwell / 69-82 Surgical Resection of Esthesioneuroblastoma. Joseph R. Ian F. Charles D. David W. Peter Klara. Zuckerberg / 257-264 Volume VII Posterior Lumbar Interbody Fusion Augmented With the Ray Threaded Fusion Cage. and Shunting. Leavens / 11-20 Treatment of Fractures at the Thoracolumbar Junction with Kaneda Anterior Spinal Instrumentation System. Atul L. Lowery. Walter W. Lovely / 167-172 Primary Anterior Treatment of Thoracolumbar Burst Fractures. Whisler / 125-130 Stereotactic Depth Electrode Implantation in the Evaluation of Candidates for Ablative Epilepsy Surgery. Mark R. Davis / 21-28 Cannulated Screws for Odontoid and Atlantoaxial Transarticular Screw Fixation. Pollack. Gabriel / 213-220 Installation of a Dorsal Column Stimulator for Pain Relief. Eugene Pennisi / 53-58 The Surgical Treatment of Dolichoectactic and Fusiform Aneurysms. Milam E. Isabelle M. Kim H. Seth M. Anson. John Hurlbert / 29-42 Anterior Microforaminotomy for Cervical Radiculopathy: Disc Preservation Technique. Kim H. Ellenbogen / 173-182 Technique for Reduction of Spondylolisthesis Using Custom Texas Scottish Rite Hospital Forceps. Aaron L. Fernandez. Kroll. George. Thomas J.

Andres Lozano / 125-134 Magnetic Resonance Image-Guided Stereotactic Cingulotomy for Intractable Psychiatric Disease. Jain. Antonio A. De Salles. Stephen T. Nesbit. Onesti. James Tait Goodrich / 211-218 Tethered Cord Syndrome: Management of Lipomyelomeningoceles. Barrow. Thomas Kopitnik. Adam I. Berman. Friedlander / 13-22 Surgical Removal of Tentorial and Posterior Fossa Dural Arteriovenous Malformations. Hoffman / 173-182 Surgical Resection of Craniopharyngiomas. John M. Ahn / 157-162 Blood Flow-Monitored Transthoracic Endoscopic Sympathectomy. Lewis. Duke Samson. Yu / 201-210 Tethered Cord Syndrome: Management of Myelomeningocele. Ann Marie Flannery. Frankel / 47-56 Dural Arteriovenous Malformations of the Transverse and Sigmoid Sinuses. Stieg. McConnell / 235-240 The Transparaspinal Approach to Dumbbell-Shaped Spinal Tumors. Jimenez / 149-156 Thoracic Sympathectomy. Sanjay Behari / 249-256 Evaluation and Management of Severe Facial Nerve Injury Resulting From Temporal Bone Trauma. Florence C. Vijendra K. W. Ricardo Segal. Brown. Kuether. Murali Guthikonda.F. Fernando G. and Hypertrophied Filum Terminale. Jeffrey A. Rees Cosgrove / 135-140 Magnetic Resonance Image-Guided Pallidotomy. Wolfson Jr. Eric L. David F. Edwin Nemoto. Tew Jr. Robert F. Ugur Türe / 183-190 Optic Nerve Sheath Fenestration in the Management of Pseudotumor Cerebri. John J. Ali F. Philip E. Stanley L. / 163-172 Surgical Management of Craniopharyngiomas. Aijaz Alvi / 257-260 Volume VIII Surgical Management of Paraclinoid Carotid Aneurysms. Roger H. Marwan Hariz / 141-148 Endoscopic Carpal Tunnel Release via a Biportal Approach. Todd A. Ely Ashkenazi. Deepak Awasthi. Osama S. Abdelaziz. Peter M. Michael Horowitz / 35-46 Surgical Treatment of Arteriovenous Malformations of the Ventricular Trigone. / 23-34 Surgical Resection of the Arteriovenous Malformations of the Posterior Fossa. G. Gouda / 107-116 Microvascular Decompression for Hemifacial Spasm. Jack C. Jost Michelsen / 241-248 Posterior Occipito-axial Fusion for Atlantoaxial Dislocation Associated with Occipitalized Atlas. James Tait Goodrich / 219-226 Excision of Colloid Cyst via the Transcallosal Approach. Samuel S. Barnwell / 57-68 . Daniel L. Gary M. Ferson. Sidney K. Barnett. Jonathan D. Dennis E.NEUROSURGICAL OPERATIVE ATLAS: TABLE OF CONTENTS Percutaneous Balloon Compression for the Treatment of Trigeminal Neuralgia. Wirschafter / 191-200 Surgical Correction of Unilateral and Bilateral Coronal Synostosis. Jan J. Keating. Robert M. Lovely / 117-124 Thalamic Deep Brain Stimulation for the Control of Tremor. Patrick Johnson. Diaz / 1-12 Surgical Management of Middle Cerebral Artery Aneurysms. Thomas J. Harold J. Diastematomyelia. Krisht. J. Kruse / 227-234 Laparoscopy Assisted Lumboperitoneal Shunt Placement in the Management of Pseudotumor Cerebri.

O’Brien. / 79-86 The Orbitocranial Zygomatic Approach to Aneurysms of the Upper Basilar Trunk. Casey. and Convexity Dural Arteriovenous Malformations. Ian Storper / 135-142 Surgical Management of Esthesioblastomas. Martin / 69-78 Use of the Operating Arm System in Skull Base Surgery. and Basal Ganglia. John A. Origitano / 87-94 Extradural Approaches for Resection of Trigeminal Neurinomas. Lowery. Giuseppe Lanzino. T. Kerry R. Mark R. Ziya L. Larson. Parviz Kambin. Jeffrey Bruce. Warwick. Raymond Evenhouse. Ronald E. Hoffman / 161-170 The Contralateral Transcallosal Approach to Lesions In or Adjacent to the Lateral Ventricle. William Hutchison. Ramesh Pitti Babu. Celso Agner. Michael T. Marc Chang / 209-216 Excision of Herniated Thoracic Disc Via the Transthoracic Approach. Lee. Lewis L. Gary K. Theodore H. C. Mary Louise Hlavin.NEUROSURGICAL OPERATIVE ATLAS: TABLE OF CONTENTS Operative Management of Anterior Fossa. Charbel. Andres M. Hardy / 217-224 Surgical Management of Advanced Degenerative Disease of the Lumbar Spine with Multiplanar Deformity. Sadler. Diaz Day / 95-106 Surgical Management of Trigeminal Schwannomas. Marcos Tatagiba / 107-120 Surgical Management of Cholesterol Granulomas of the Petrous Apex. Gary L. Jonathan Sherman. Patel. Jane. Tew Jr. Ramesh Pitti Babu. Eisenberg. Dierdre McConathy / 185-194 Chronic Subthalamic Nucleus Stimulation for Parkinson’s Disease. Mark S. Paul C. Lawton. Rajiv Midha. Rezai. Gokaslan. Ali R. Spetzler / 171-178 Posterior Fossa Decompression Without Dural Opening for the Treatment of Chiari I Malformation. Schwartz. Lozano / 195-208 Arthroscopic Microlumbar Discectomy. Persky / 143-152 Surgical Treatment of Brainstem Gliomas. Steinberg. J. Thalamus. McCormick / 235-242 Surgical Treatment of Lateral Lumbar Herniated Discs. Wesley A. Aman B. Chang / 127-134 Management of Jugular Foramen Tumors. Walsh / 253-260 Peripheral Nerve Suture Techniques. Russell W. Garrett L. Christopher I. Crone / 179-184 Computed Tomography-Assisted Preformed Prosthesis for Repair of Cranial Defects. Mark B. Jeffrey J. Neil A. Sr. King. Jeffrey J. Fady T. John M. Eugene Pennisi / 225-234 The Retropleural Approach to the Thoracic and Thoracolumbar Spine. Manuel Dujovny. Madjid Samii. Michael Cowan / 153-160 Brainstem Gliomas. Kenneth F. / 243-252 “Trap Door” Exposure of the Cervicothoracic Junction. Ossama Al-Mefty / 121-126 Surgical Management of Angiographically Occult Vascular Malformations of the Brainstem. Robert F. Superior Sagittal Sinus. A. Harold J. Larson. Steven D. Shaffrey. Margot Mackay / 261-269 . Michael F.

7:59-67 middle cerebral artery. 4:11-13 Arteriovenous malformations (AVMs) anterior fossa. 5:233-239 implant systems. 6:51-56 intradural. 5:57-63 Allogeneic bone matrix. 8:162. 8:3-4. 8:23-34. 8:35-36. 8:23-46 spinal cord. 8:3-4. 5:101-108 stabilization. 8:23-34 thalamic. 8:10-11 ventricular trigone. 7:29-41 . 4:13-18 Anterior cervical spine discectomy. 8:43. 6: 43-50 Broad-based siphon aneurysms. 6:131-146 Acoustic neuromas. 4:8-10 posterior fossa. 5:33-42 broad-based siphon. 8:38-40 deep parenchymal. 8:13-22 paraclinoid carotid artery. 8:36. 6:157-166 Anterior foramen magnum meningioma. 4:9-10 juvenile. 7:6-10 Bone-wiring procedures. 5:233-239 Basal ganglia AVMs. 5:214-215 Acute subdural hematoma. cavernous. 8:1-12 superior hypophyseal. 6:201-211 Cannulated screws. 8:169-170 Atlantoaxial dislocation with occipitalized atlas. 5:110. 4:159-164 Acrylic cranioplasty. 8:10-11 Burst fractures. 8:164 focal intrinsic astrocytomas. 8:153-159 Bridge bypass coaptation. 8:164. 4:43-58 upper basilar trunk. 8:10-11 upper basilar trunk. 8:3-4 carotid ophthalmic. 5:233-239 Aneurysms basilar bifurcation. 8:36. 8:40-42 cerebellar tonsil. 8:43-44 cerebellar vermis. 8:36 dural. 8:36. 7:249-256 Atlantoaxial instability. C1-2 screw fixation. 8:3-4. 7:201 Arteriovenous fistulas (AVFs) cranial dural. 6:75-84 dural. 6:173-182 C Callostomy.A Ablative epilepsy surgery. 7:227-233 Calvarial defects. 7:59-67 fusiform. 6:201-211 posterior lumbar interbody fusion. 4:43-58 cerebellar hemisphere. 5:199-217. 5:199-217 Calvarial reconstruction. 4:3-7. 4:19-28 Atlantoaxial transarticular screw fixation. 8:69-79 glomus. 8:87-94 ventral paraclinoid. 8:2-3. 8:127-133 Angioma. 4:43-58 Basilar bifurcation aneurysms. 8:169-170 dorsally exophytic gliomas. 4:11-16 perimedullary. 8:161-163 diffuse intrinsic astrocytomas. 8:45-46 craniocervical astrocytomas. 7:29-41 A B C D E F G H I J K L M N O P Q R S T U V W X Y Z B Banked fibula. 8:69-78 tentorial dural. 8:87 ventral paraclinoid. 5:219-225 Bone graft harvesting fractures. 7:43-52 Apert syndrome. 8:165-169 gliomas. 7:201-210 Birth defects. 8:3-4. 5:91-100 Brainstem AVMs. 4:7-10 superior sagittal sinus dural. 5:23-32 Anterior fossa dural AVMs. 8:162. 8:1-2. 5:33-42 Bilateral coronal synostosis. 8:47-56 Astrocytomas brainstem. 8:10-11 carotid cave. 8:165-169 craniocervical. 8:3-4 dolichoectatic. 8:10-11 Angiographically occult vascular malformations. 8:69-78 basal ganglia. 7:251-254 calvarial defects. 8:10-11 carotid-superior hypophyseal. 7:24-25 atlantoaxial dislocation. 8:69-78 Anterior microforaminotomy.

5:129 Cingulotomy for psychiatric disease. 5:85-89 far lateral lumbar. 8:36 Degenerative disc disease. 5:233-239. 8:10-11 Carotid-superior hypophyseal aneurysms. 8:200-201. 8:205-206 Deep parenchymal AVMs. 7:227-233 fenestration. 8:3-4 Carpal tunnel syndrome. 5:101-108 stabilization. 6:75-84 Dural AVMs anterior fossa. 8:43-44 Cerebellar vermis AVMs. 4:165-172 Cyst colloid. 4:139-146 Cholesterol granulomas of petrous apex.Carotid cave aneurysms. 8:2-3. 4:183-190 Drug infusion pumps. 8:36. 6:167-171 Cervical nerve root avulsion. 6:221-235 Dorsal lipomyelomeningocele. 4:13-18 Cavernous sinus tumors. 8:35-36. 7:219-226 Direct end-to-end repair of peripheral nerves. 4:199-207 Cerebellar hemisphere AVMs. 7:43-52 discectomy. 8:185-194 Cranial dural arteriovenous fistulas. 8:121-125 Chondrosarcoma. 4:3-7. 7:59-67 Dorsal column stimulation. 5:101-108 Chiari I malformation. cervical. 5:101 Deep brain stimulation control of tremor. 7:149-156 Cavernous angiomas. 7:125-134 subthalamic nucleus. 8:29-32 . 7:241-242 Convexity dural AVMs. 6:237-250 Dumbbell-shaped cervical neurinoma. 5:91-100 stabilization (Orion system). 8:40-42 Cerebellar tonsil AVMs. 8:263-269 Disc herniation far lateral. 7:227-233 Complex spinal schwannomas. 4:107-116 Cranial defects. 5:185-197 lateral. 6:35-41 Dumbbell-shaped spinal tumor. 7:43-52. 4:183-190 Cervical fusion. 5:233-239 Dolichoectatic aneurysms. 8:169-170 Craniopagus twins. 5:177-184 Crouzonís syndrome. 5:135-141 implant systems. 8:3-4 Carotid endarterectomy. 6:43-50 Cervical neurinoma. 6:251-256. 5:233-239 extradural tumors. 6:75-84 Craniocervical brainstem astrocytomas. 6:251-256. 6:99-108. 4:59-65 Diastematomyelia. 7:201-210 Corpus callosum sectioning. 8:38-40 Cerebral palsy. 6:109-114. 6:201-211. 6:35-41 Cervical radiculopathy. 7:201 Cubital tunnel syndrome. 8:69-78 Coronal synostosis. 8:217-224 Disc preservation. 8:179-183 Children cerebral palsy. 4:235-249 Cushingís disease. 6:5-11 Craniopharyngiomas. 4:38-39. 8:225-233 Denervation for spasmodic torticollis. 8:69-78 convexity. 6:157-166 Colloid cyst. 4:183-190 moyamoya syndrome. 4:67-73. 7:183-190 Craniovertebral junction lesions. 8:36. 6:85-98 D Decompressive corpectomy. 7:43-52 Cervical spine C1-2 screw fixation. 5:129-133 Codman locking plate system. 7:43-52 Discectomy. 6:51-56. 7:221-225 Dorsal rhizotomy. 6:109-114. 8:69-78 inferior petrosal sinus. 6:1-4 Carotid ophthalmic aneurysms. 8:243-251 thoracic. 8:169-197. 6:57-64 Carotid-cavernous sinus fistulas. 7:173-181. 6:157-166 stabilization (articular mass). 7:135-140 Clivus. 4:19-28 degenerative disc disease. 7:241-248 Dural AVFs.

5:155-164 Fusiform aneurysms. 6:76. 5:135-141 Focal intrinsic brainstem astrocytomas. 7:162 Hydrocephalus. intracranial. 7:257-260 Facial pain. 4:95-106 Frameless stereotaxy. 5:185-197 thoracic disc. 6:131-146 Endarterectomy. 5:233-239. brainstem. 6:7584 intradural. 5:155-164. 8:165-169 Foramen magnum. 5:215-217 Functional hemispherectomy. 5:185-197 Fascicular peripheral nerves repair. 5:227-232 Far lateral disc herniation. 7:59-67 Fusion tension band wiring. 5:23-32 Fourth ventricular ependymoma. 5:190-191 Full thickness calvarial bone graft. 6:51-56. 6:109-114 fenestration of the third ventriculostomy. 8:161-163 Extradural non-neoplastic lesions. 7:251-254 Granulomas. 4:107-116 medial temporal onset. 7:53-58 I Idiopathic intracranial hypertension. 7:117-124 Hemispherectomy. 5:57-63 Hemicorticectomy. 6:261-264 Hyperhidrosis. 8:267 Fields of Forel. 8:153-159 Glomus AVM. 4:225-233 Electrode implantation. 4:11-16 Flat-back syndrome. petrous apex cholesterol. carotid. 8:200 Fistulas carotid-cavernous sinus. 8:217-224 Horner’s syndrome and anterior microforaminotomy.petrous apex. 6:167-171 G Galen. 7:219-226 F Facial nerve injury. 7:157-162. 5:199-217. 6:57-64 Endoscopy approaches to the ventricular system. . 4:3-7. 5:75-83 Esthesioblastomas. 7:24-25. 5:121-128 Full facetectomy. 7:149-156 colloid cysts. 8:69-78 tentorial. 4:117-130 Grafts. intracranial lesions. 8:121-125 H Hematoma. 7:51 complication of thoracoscopic sympthectomy. 6:98. 6:257-264 Herniation far lateral disc. 5:1-12 thoracoscopic sympathectomy. 5:177-184 Extradural cervical spine tumors. 5:241-246. 5:85-89 far lateral lumbar disc. 8:267-269 bone. ulnar nerve transposition. 5:155 Hemifacial spasm. 8:23-34 E Elbow. 6:65-74 carpal tunnel release. 5:241-246 intraventricular. 7:163-171 Ependymoma. 5:85-89. vein of. 4:9-10 Glomus tumors. 6:1-4 dural arteriovenous. 6:99-107. fourth ventricular. 8:32-34 Gamma Knife radiosurgery. 7:6-10. 6:85-98 pituitary surgery. 7:83-91. 6:65. 8:23-46 superior sagittal sinus. 4:95-106 Epilepsy ablative surgery. acute subdural. 6:131-146 corpus callosum sectioning. 8:143-151 Exophytic gliomas. 8:24-27 posterior fossa. 7:158 Hypertrophied filum terminale. 4:215-224 Gliomas. intracranial lesions.

5:227-232 Lumbar disc herniation. 8:243-251 Lateral mass plate and screws. 5:109-119 Lumboperitoneal shunt placement for pseudotumor cerebri. 4:81-83 Lateral ventricles. 4:37-42 Internal stabilization. 7:219-226 J Jugular foramen tumors. 5:75-83 Locking anterior cervical plate. 5:65-74 Intradural arteriovenous fistulas. anterior. 7:235-240 M Meningioma anterior foramen magnum.7:191-200 Implantation of drug infusion pumps. 5:91-100 Lateral orbitotomy. 6:27-33 Microforaminotomy. 7:51-52 Intracranial glomus tumors. 6:125-129 Myelomeningocele. 7:162 Interhemispheric corridor and thirdventricle exposure. 7:141-148 MRI-guided stereotactic cingulotomy. 4:11-16 Intraventricular endoscopy. 6:85-98 Intraventricular shunt. 8:211 Kaneda anterior spinal instrumentation system. 7:117-124 Middle cerebral artery aneurysms. 5:227-232 root entry zone decompression. 5:23-32 lower clivus. 6:85-98 Isthmic spondylolysis/spondylolisthesis. 7:135-140 Multiple subpial transection. 7:21-27 L Labbé. 4:85-93. 7:219-226 Lobectomy. 7:103-106 Mesiotemporal lesions. 7:53-58 Lumbar spine arthroscopic microlumbar. 4:209-214 Lateral disc herniation. 6:147-156 Microelectrode-guided pallidotomy. 8:209-216 degenerative disease. 5:165-170 Microvascular decompression for hemifacial spasm. 8:227 thoracolumbar fractures. far-lateral. 5:185-197 foraminal stenosis. 7:101-103 Interbody fusion. 5:109-119. 6:213-219 Mental neurectomy. 4:131-137. temporal. 4:117-130 Intracranial hypertension. 8:135-142 Juvenile AVMs. 4:147-157 Locking plate system. 5:185197 Lumbar extension osteotomy for flat-back syndrome. 8:29-32 Infraorbital neurectomy. 7:103-104 Inferior petrosal sinus dural AVMs. 4:75-83. 4:8-10 K Kambin instrumentation for microlumbar discectomy. 5:121-128 Intracranial pressure monitoring. 5:233-239 . 7:69-81 torcular/peritorcular. 7:43-52 Microsurgery carotid endarterectomy. 7:191-200 Intracranial lesions. 6:251-256 lumbar decompression. 6:57-64 craniotomy for colloid cysts. 8:225-233 far lateral disc herniation. 6:157-166 Low back pain. 6:193-200 Inferior dental neurectomy. vein of. 5:23-32 Lumbar decompression. 8:13-22 Moyamoya syndrome. 8:58-60 Lambdoidal synostosis. 4:44-45. 5:13-21 Meningoceles. 5:67-69 Lipomyelomeningoceles. 5:233-239 Intervertebral disc damage. 4:215-224. 5:85-89 far lateral lumbar disc herniation. 4:147-157 Intercostal neuralgia. 5:227-232 Lower clivus-anterior foramen magnum meningioma. 6:237-250 Infection of ventriculoperitoneal shunt. 4:139-146 MRI-guided pallidotomy. 5:23-32 petroclival.

4:81-83 Orbitotomy. 8:24-27 Pfeifferís syndrome. 6:35-41. 7:107-116 Perimedullary AVFs. 8:133 Optic nerve injury. 4:159-164 Non-neoplastic lesions of the craniovertebral junction. 4:81-83 Orion anterior cervical plate system. 6:13-26 Pseudotumor cerebri lumboperitoneal shunt placement. 8:261-269 Peripheral neurectomy for trigeminal neuralgia. 6:167-171 Posterior fossa dural AVMs. 6:13-26 subthalamic nucleus. 5:112-113. 7:125-134 MRI-guided pallidotomy. 6: 43-50 Nerve root injury. 7:83-91. 6:13-26 subthalamic nucleus. 8: 143-151 Neuroma. 8:205-206 Paraclinoid carotid artery aneurysms. 7:249-254 Posterior plagiocephaly. 5:227-232 low back. 6:27-33 MRI-guided. 8:196-197.N Nerve root avulsion. postoperative. 7:53-58 Percutaneous balloon compression for trigeminal neuralgia. 8:196-197. 7:249-254 Odontoid transarticular screw fixation. 8:200-201. 4: 139-146 Pineal region masses. 7:141-148 posteroventral. 5:177-184 O Obstructive hydrocephalus. 4:29-36 Pituitary Cushing’s disease. 5:116-117 Pedicle subtraction for flat-back syndrome. 8:23-46 Posterior lumbar interbody fusion. posterior. 7:83-91. 8:79-85. 5:143-153. 7:99-106 Peritorcular meningiomas. 7:99-106 Neurinoma. 5:165-170 Pallidotomy microelectrode-guided. 5: 43-55 Pneumothorax. 5:91-100 Posterolateral tentorium dural AVMs. 4:165-172 surgery. olfactory. 4:75-81 craniotomy. 8:12 Optic nerve sheath fenestration. 7:162 Posterior C1-2 screw fixation. 8:95-105 Neuroblastomas. 8:1-12 Parkinsonís disease deep brain stimulation for control of tremor. 5: 43-55 Posterior stabilization. 8:25-29 Posteroventral pallidotomy. 5:1-12 Plagiocephaly. 7:69-81 Petrous apex cholesterol granulomas. 7:141-148 posteroventral pallidotomy. 8:121-125 dural AVMs. 4:85-93 lateral orbitotomy. 5:241-246 Occipitalized atlas. 7:191-200 Orbit anatomy. 5:13-21 Petroclival meningiomas. 5:143-153. 7:201 Pial synangiosis. 7:51 Neurectomy for trigeminal neuralgia. 5:101-108 P Pain facial. 7:29-41 Olfactory neuroblastomas. 8:205-206 Pedical screw. 5:227-232 relief. 7:235-240 . 7:249-254 Occipitoaxial fusion. 6:221-235 trigeminal neuralgia. 4:19-28 Posterior cervical fusion with tension band wiring. 8:200-201. 7:1-10 Posterior occipitoaxial fusion for atlantoaxial dislocation. 5:143-153. acoustic. 8:143-151 Operating Arm System. 4:11-13 Peripheral nerve suture techniques.

5:165-170 S Sacrectomy. 8:57-68 Spasmodic torticollis. 6:85-98 ventriculoperitoneal. 4:147-157 posterior. 4:59-65 Spasticity. 7:219-226 Spinal cord AVMs. 4:107-116 temporal lobectomy. 5:57-63 Substantia nigra pars reticulata/pars compacta. 5:109-119 Stereolithography for cranial repair. supratrochlear neurectomy. 4:183-190 spasmodic torticollis. 7:127-128. 7:29-41 Seizures ablative epilepsy surgery. 4:7-10 Spinal exposure. 8:1-2. 8:200-201. 5:91-100 cervical spine with the Orion system. 8:205-206 R Radiosurgery of intracranial lesions. 4:19-28 atlantoaxial transarticular. 4:59-65 Rod placement and thoracolumbar junction fractures. 4:1-18 Spondylolisthesis. 6:157-166 cervical spine with articular plates and screws. 4:147-157 Stabilization cervical. . 7:11-20 Sagittal synostosis. 7:191-200 Psychiatric disease. 8:10-11 Superior sagittal sinus dural AVMs. 7:135 Pulse generator for subthalamic nucleus stimulation. 7:241-248 Spinal vascular malformations. 5:101-108 posterior. 5:91-100 thoracolumbar fractures. 5:219-225 Sathre-Chotzen syndrome. 7:21-27 Spinal plate/screw placement. 5:121-128 Subclavian steal syndrome. 7:135-140 Stereotactic depth electrode implantation. 6:51-56 Sinus. transverse-sigmoid. 4:38-39. 7:1-10 Raynaud’s syndrome. 6:193-200 Sinus fistulas. upper thoracic. 6:183-191 Spondylolysis. carotid-cavernous. 4:173-182 Spinal instrumentation. 6:1-4 Sinus skeletonization technique. 4:147-157. surgery for. 5:199-217 Schwannomas complex spinal. 5:91-100 thoracolumbar fractures. 4:183-190 Spina bifida. 7:158 Revascularization and dolichoectatic/fusiform aneurysms. 8:205-206 Superior hypophyseal aneurysm. 7:94-96 Ray Threaded Fusion Cage. 7:93-97 Stereotaxy. 7:141 Stereotactic microsurgical craniotomy. 5:109-119 Spinal tumor. 7:241-242 trigeminal. 7:11-20 Sacrum tumors. 8:107-120 Screw fixation atlantoaxial instability. 6: 251-256 Stereotactic radiosurgery of trigeminal nerve root. 7:201 Scalp reconstruction. 7:94-96 Radiosurgical localization. 8:196-197. 7:23-25 Spinal stabilization cervical spine. 6:157-166 lateral. sagittal. 4:215-224 Radiosurgical dose planning. 7:61-65 Rhizotomy dorsal. 6:131-146 corpus callosum sectioning. 7:24-27 Root entry zone decompression.optic nerve sheath fenestration. 8:74-77 Sinus. 8:69-78 Supraorbital. 7:29-41 odontoid transarticular. frameless. 4:131-137 Shunt intraventricular. dumbell-shaped. 8:188 Stereotactic cingulotomy for psychiatric disease. 4:191-198 Subdural hematoma. 6:131-146 Stereotactic imaging and deep brain stimulation for control of tremor. 8:201 Subthalamic nucleus.

4:1-18 Vein of Galen. 4:67-73. 4:67-73. 4:43-58 Thalamic mapping for control of tremor. 4:173-182 Thoracolumbar spine burst fractures. 6:173-182 fractures. 6:115-124 Tension band wiring. 8:3-4. 7:201-210 Upper basilar trunk aneurysms. 4:44-45. 6:193-200 Vertebral artery. 4:199-207 dumbell-shaped spinal. 7:257-260 Temporal lobe. 8:32-34 Vein of Labbé. 8:57-68 Tremor. craniopagus. 4:117-130 jugular foramen. 8:24-27 V Vascular malformations angiographically occult. 8:200 . 8:58-60 Ventral intermediate thalamotomy. 7:125-134 Trigeminal neuralgia percutaneous balloon compression. 5:165-170 stereotactic radiosurgery of the trigeminal nerve root. 4:209-214 sagittal. 5:109-119 Thalamic AVMs. 5:75-83. 7:61-62 Torcular/peritorcular meningiomas. 6:51-56 Tentorial dural AVMs. 5:109-119 junction fractures. 8:47-56 Ventriculoperitoneal shunt. 5:241-246 Third-ventricle exposure. 7:241-248 ependymomas. 7:134 Ventral paraclinoid aneurysms. 8:135-142 orbital region. 8:87-94 AVMS. 7:11-20 Twins. 8:217-224 Thoracic spine exposure. 7:125. 8:23-34 Tethered cord syndrome. 6:201-211. 6:5-11 U Ulnar nerve entrapment. 7:21-27 Thoracoscopic sympathectomy. 7:107-116 peripheral neurectomy. 7:125-134 Third ventricular colloid cysts. 4:225-233 Unilateral coronal synostosis.7:99-101 Sympathectomy. 7:163-171 Transverse-sigmoid sinus. 7:99-106 microvascular decompression of root entry zone. 7:157-162 Thrombectomy. 7:201-210 lambdoidal. 5:135-141 W Wrist. 4:37-42 Thoracic disc herniation. 4:235-249 submuscular transposition. 5:135-141 intracranial glomus. 7:219-226 Texas Scottish Rite Hospital forceps. 6:183-191 system. 8:10-11 Ventricular AVMs. 4:36 sacrum. 6:167-171 Tentorial apex. 8:127-133 spinal. 4:235-249 Z Zona incerta. 8:10-11 AVMs. 8:87 Upper clivus dural AVMs. 8:107-120 Tumors cavernous sinus. 4:219-225 T Temporal bone trauma. 4:95-106 extradural cervical spine. 4:131-137. 8:52-58 Ventricular system. 5:13-21 Transthoracic endoscopic sympathectomy. 7:93-97 Trigeminal schwannomas. 7:157-162 Synostosis coronal. 6:251-256 Third ventriculostomy for obstructive hydrocephalus. 6:65-74 Ventricular trigone AVMs. 8:3-4. 4:87-90 pineal region. ulnar nerve entrapment.

M. The ophthalmic artery arises distal to the distal dural ring on the superior surface of the ICA. under the anterior clinoid process and continues intracranially as the C6 segment. The dura encircling the ICA as it exits the cavernous sinus forms the distal dural ring. PH. F.S. the difficulty in obtaining proximal carotid control prior to aneurysm clipping.C. The proximal C6 segment of the ICA remains hidden under the anterior clinoid process beyond the distal dural ring. thus form- ANATOMY © 1999 The American Association of Neurological Surgeons ing a loop and reversing its course by 180 degrees. vascular. its membranous epineurium blends with the adventitia of the ICA and extends across to fuse with the periosteum of the sphenoid bone. As it encircles the ICA.. INTRODUCTION Of the many nomenclatures proposed to designate the segments of the ICA. At times.. The C5 and C6 segments of the ICA together constitute the paraclinoid segment. it emerges either from the roof or from the cavernous sinus. After the ICA completes the second bend. Two branches arise from this segment of the ICA: the ophthalmic artery and the superior hypophyseal artery. and is termed the C5 segment. we have used the modified Fischer classification proposed by the University of Cincinnati group as it describes the segments of the ICA in an anterograde sequence (Figure 1). As the oculomotor nerve crosses this anterior loop coursing toward the superior orbital fissure. The ICA traverses anteriorly through the cavernous sinus as the C4 segment and bends twice as it exits the sinus: medially and superiorly at first and subsequently posteriorly and superiorly.A. The paraclinoid segment of the internal carotid artery (ICA) extends from the proximal dural ring up to the origin of the posterior communicating artery.D. M. This so-called anterior loop is oriented approximately 45 degrees to the base of the skull. and travels through the optic foramen lying inferior and lateral to the optic nerve. FERNANDO G. DIAZ. The surgical management of these aneurysms has technically challenged most neurosurgeons because of the complex anatomy of this region and. the ophthalmic artery is adherent to the dura of the optic canal floor and hence is insepa- 1 . most importantly. Aneurysms arising from this segment of the ICA account for 5% to 10% of all intracranial aneurysms.D. the tissue between the oculomotor nerve and the ICA is called the carotid-oculomotor membrane. bends forward.D. A clear understanding of the anatomy of this ICA segment and its adjacent osseous. The segment of the ICA between the proximal and distal dural rings is extracavernous. and neural structures will optimize chances for successful surgical treatment of aneurysms of the paraclinoid segment.SURGICAL MANAGEMENT OF PARACLINOID CAROTID ANEURYSMS MURALI GUTHIKONDA. but not intradural. this layer is termed the proximal dural ring.

types I through IV (Figure 2). 1996. Presenting symptoms are either visual or due to rupture with subarachnoid hemorrhage (SAH).2 NEUROSURGICAL OPERATIVE ATLAS. van Loveren HR. Any of the four variants of the aneurysms described below can enlarge. arises from the medial surface of the ICA as it emerges from the distal dural ring and crosses over the diaphragma sellae. and thin-walled. Depiction of the segments of the ICA in an anterograde sequence. with permission) rable. Based on the site of origin and direction of projection as it relates to the C5 and C6 segments. . The type I(a) CLASSIFICATION aneurysm variant is the most common paraclinoid aneurysm. displacing the optic nerve upward and medially. The type I(b) aneurysm variant represents a small subset of aneurysms that arise from the superior surface of the C6 segment of the ICA. Neurosurgery 38:425-433. making classification difficult and impractical. often a few millimeters from the ophthalmic artery origin. Keller JT: Segments of the internal carotid artery: a new classification. ACA = anterior cerebral artery. Types I(a) and I(b): Type I aneurysms are also called carotid-ophthalmic aneurysms. sessile. These aneurysms project superiorly into the subarachnoid space. 8 ACA MCA PCoA Figure 1. which can be single or multiple. (Reproduced from Bouthillier A. the aneurysms in this location can be classified into four variants. The paraclinoid segment consists of C5and C6segments (University of Cincinnati modification of the Fischer classification). it arises from the dorsal surface of the C6 segment close to the ophthalmic artery. VOL. They are typically broad-based. PCoA = posterior communicating artery. These aneurysms can at times erode the anterior clinoid process to a thin shell. The superior hypophyseal artery.

Illustration showing the four variants of aneurysms.GUTHIKONDA AND DIAZ : PARACLINOID CAROTID ANEURYSMS 3 OA type IV type I(b) type I(a) OA B type II type III type III(a) OA SHA DS A type III(b) Figure 2. . Insets A and B show variants in types III and IV. The type IV variant is a large broad-based aneurysm extending from the distal C4 segment to the proximal C6 segment. the type I(a) aneurysm is closely related to the ophthalmic artery (OA) origin and the type I(b) aneurysm has no branch relation and is often sessile. Type III(a) and III(b) aneurysms (supra. widening the distal dural ring. The type II variant arises from the ventral surface of the C6 segment without branch relation. arise on the medial surface of C6 and C5 segments.and infradiaphragmatic variants). DS = diaphragma sellae. Type I(a) and I(b) variants arise from the dorsal surface of the C6 segment. closely related to the superior hypophyseal artery (SHA) origin.

If the superficial temporal artery (STA) is greater than 1. The base expands into the cavernous sinus and into the subarachnoid space. and IV are best visualized on the lateral projection. II. Types III(a) and III(b): Type III aneurysms (also called carotid-superior hypophyseal aneurysms) are closely related to the origin of the superior hypophyseal artery. Their clinical condition is classified according to the Hunt and Hess grading system. The dome often elevates the roof of the cavernous sinus and. type III is best seen in anteroposterior and submento-vertical projections (Figure 3). INITIAL MANAGEMENT In patients with large or giant aneurysms. A vascular bypass is carried out in patients who do not tolerate the BTO or who have significant perfusion defects on SPECT. The direction of projection allows classification of an aneurysm into one of the four types: types I(a). I(b). and span from distal C4 to proximal C6 segments. Type III(a) aneurysms arise from the medial surface of the proximal C6 segment. Patients presenting with symptoms of SAH are admitted to the intensive care unit. retro-orbital pain is also a presenting symptom. All patients above 50 years of age undergo thin-section CT of the clinoidal region with bone windows to determine whether calcification is present within the aneurysm wall and the ICA. project above the diaphragma sellae. visual field impairment. especially a type IV variant or an aneurysm with extensive calcification. 8 Type II: Type II aneurysms. If the anterior clinoid process has been eroded by the aneurysm and if the erosion is not detected. This variant is the so-called carotid cave aneurysm. The dome may extend into the cavernous sinus in larger aneurysms. Type IV: Type IV aneurysms (also called broadbased siphon aneurysms) are often large or giant.5 mm. presenting symptoms can include SAH. At least one half of the circumference of the vessel wall forms the broad base of the aneurysm. enlarges the proximal and distal dural rings. and pulmonary arterial and wedge pressures. thus projecting outside the cavernous sinus under the anterior clinoid process. the extent of hemorrhage is graded according to the Fischer classification. Nimodipine is administered in doses of 60 mg every 4 hours orally or via a nasal gastric tube. Any evidence of erosion of the clinoid process is noted. The presence or absence of hydrocephalus is noted. The type III(b) variant arises from the medial surface of the C5 segment and projects below the diaphragma sellae and can be mistaken for a sellar mass on computed tomography (CT). and systemic vascular resistance are optimized for each patient. All patients receive intravenous phenytoin. at times. Both variants can enlarge to the extent of presenting both above and below the diaphragma sellae. If a patient tolerates the test occlusion clinically and SPECT does not reveal perfusion defects. cardiac index. balloon test occlusion (BTO) with systemic hypotension and single photon emission CT (SPECT) are used to evaluate the patient’s tolerance for carotid occlusion as a definitive therapy and to assess the need for a bypass procedure. arise from the ventral surfaces of the C6 segment of the ICA. VOL. a vein bypass graft is used from the cervical ICA to the M2 segment of the MCA. if the STA is less than 1. Respiratory support is provided for patients with impaired sensorium. They have a broad base and the dome projects toward the r oof of the cavernous sinus. and those presenting with SAH undergo bedside evaluation by confrontation methods. These aneurysms often present with third cranial nerve palsy and rarely with SAH.5 mm in diameter. at times. and diplopia. Indwelling catheters are used to monitor systemic arterial pressure. A ventriculostomy is not performed unless the patient has impaired consciousness in association with CT evidence of hydrocephalus. and therapeutic levels are maintained. Computed Tomography Cerebral Angiography Based on the type of paraclinoid-carotid aneurysm. PREOPERATIVE RADIOLOGICAL EVALUATION Patients presenting with SAH undergo cranial CT. All patients diagnosed with paraclinoid-carotid aneurysms undergo a detailed preoperative neuroophthalmological evaluation. with contralateral central scotoma because of the involvement of the knee fibers of von Willebrand. ocular symptoms of decreased visual acuity. and can present with SAH. the aneurysm can be inadvertently torn while drilling the clinoid process. also called ventral paraclinoid aneurysms. Patients presenting without SAH undergo detailed visual field evaluation. PRESENTING SYMPTOMS Selective internal carotid angiography is performed on all patients via transfemoral selective catheterization. Visual symptoms are usually ipsilateral but can be bilateral.4 NEUROSURGICAL OPERATIVE ATLAS. central venous pressure. an STA to M2 segment of the middle cerebral artery (MCA) bypass is carried out. Balloon Test Occlusion and Single Photon Emission CT . Cardiac output. permanent balloon occlusion of the ICA and trapping of the aneurysm are offered as definitive therapy.

II (B). .GUTHIKONDA AND DIAZ : PARACLINOID CAROTID ANEURYSMS 5 A B C D Figure 3. Types I (A). and IV (D) are best visualized on lateral angiography and type III (C) on anteroposterior projection. The four variants of aneurysms seen by angiography.

If the hole fails to penetrate both the inner and outer tables because of a large frontal sinus.. Three burr holes are placed using a 7-mm Acra-Cut perforator. midway between the coronal suture and orbital ridge. and sufentanil (0.5 mg/kg). Anesthesia is maintained with a percentage concentration of Forane at subminimal alveolar concentration (i. A full-length silicone gel pillow is placed on the table. Anesthetic Technique The skin incision starts 1 cm anterior to the preauricular area just above the zygomatic arch. thus allowing the bundle to be mobilized along with the scalp. sufentanil (1-2 mcg/kg). The neck is included in the sterile operative field. VOL. The angle of the mandible and the anterior margin of the sternocleidomastoid muscle are marked after prepping so that the carotid artery can either be compressed digitally or exposed for proximal control. using an acorn-shaped dissecting burr. Patient Positioning . Small and asymptomatic infradiaphragmatic variants may not require surgical intervention if diagnosed preoperatively.and infradiaphragmatic variants of the paraclinoid aneurysm. this opening exposes the floor of the anterior cranial fossa superiorly and the orbit inferiorly. Figure 5 shows frontal and oblique views of the craniotomy and oblique osteotomy. If the subperiosteal plane is maintained around the orbital ridge.g. A keyhole opening is made at the level of the orbital roof. the mean arterial pressure is lowered to 40 to 60 mm Hg by increasing the concentration of Forane. The three burr holes are connected parallel to the midline and posteriorly. and curves forward toward the forehead. lidocaine (1. 8 The exact dimensions of an aneurysm filled with a thrombus are better determined by a magnetic resonance imaging (MRI) study. or both. trapping. the amount required to prevent movement with skin incision). If the anterior branch of the STA is larger than the posterior branch. or a vein bypass procedure. A third burr hole is made in the squamous temporal bone above the midzygomatic arch. the chance of disruption of the orbital periosteum is lessened. Surgery is delayed for patients classified in a Hunt and Hess Grade V or with multiple systemic problems (e. a nitroprusside infusion. continues toward the midline. SURGICAL TECHNIQUE Timing of Surgery Patients who are classified in Hunt and Hess Grades I-IV undergo surgery within 24 hours after admission. The first burr hole is made 1 cm above and lateral to the nasion.. the craniotomy is made as close to the midline as possible. the scalp incision starts posterior to the main trunk. The supraorbital ridge and the frontozygomatic suture are exposed.5-gm/kg bolus prior to craniotomy. The infradiaphragmatic variant is visualized only after the diaphragma sellae is divided around the superior surface of the dome of the aneurysm. ending at the hairline in the opposite midpupillary line (Figure 4). the incision is made anterior to the STA trunk. Coronal MRI of the sellar area may preoperatively identify types III(a) and III(b). the supra. The head is rotated 15 degrees to the contralateral direction. Mannitol is administered as a 0. A second burr hole is made 5 cm posterior to the first one and 1 cm from the midline. which could cause herniation of the periorbital fat. The orbital periosteum is separated superiorly and laterally from within the orbit. If the posterior branch is larger.0 mcg/kg/min). For left-sided aneurysms. sepsis or aspiration pneumonia) until their clinical grade or general condition improves. continuous infusion of propofol (25-75 mcg/kg/min). thus keeping the main trunk with the scalp flap. if enclosed in an osseous foramen. Once the dura mater and orbital periosteum are separated from either side of the orbital roof. and 100% oxygen. Intra-arterial and Swan-Ganz catheters are inserted to monitor blood pressure and pulmonary arterial and wedge pressures. The temporalis muscle is incised along with the scalp and retracted forward toward the orbital ridge.6 Magnetic Resonance Imaging and MR Angiography NEUROSURGICAL OPERATIVE ATLAS. Mean arterial pressure is maintained at 70 to 80 mm Hg. OPERATIVE PROCEDURE Craniotomy and Orbital Osteotomy The patient is positioned supine with the head and thorax elevated by 15 degrees.e. The anesthetic agents used include propofol (2. The supraorbital nerve and vessel are retracted with the scalp flap. an osteotome is used to isolate the bony margins around the neurovascular bundle.1 mg/kg). its lateral-most part is nibbled using a needle-nose Leksell rongeur. the neck is neutral so that the projected plane of the orbital roof is perpendicular to the ground. This knowledge will help in planning the extent of diaphragmatic division needed to provide adequate exposure of the aneurysm. posterior to the frontozygomatic suture. vecuronium (0. the inner table is drilled separately to expose the dura.5 mg/kg). If a temporary clip cannot be applied or if the aneurysm ruptures during dissection.5-1. A motorized operative table permits most changes in positioning during surgery. Precautions are taken to avoid perforation of the periorbital fascia.

elevated as a single flap. . Note the keyhole burr hole with orbit inferiorly and frontal dura superiorly. and that the pterion is drilled down. Frontal (A) and posterior oblique (B) views outlining the frontotemporal craniotomy with supraorbital ridge osteotomy. A B Figure 5.GUTHIKONDA AND DIAZ : PARACLINOID CAROTID ANEURYSMS 7 facial nerve STA Figure 4. Scalp incision preserving the STA trunk and the frontalis innervation.

Using a fine diamond-tipped burr. As a result. Next. The tips of the blade are inclined toward the tip of the anterior clinoid process to create a conical exposure (wide near the surface and narrow at the depth near the anterior clinoid process). C5 segment. as they are not as precise and atraumatic as the drill. Elevation and traction of the frontal lobe must be done gently. keeping in mind that the contents of the superior orbital fissure are on its inferolateral aspect. The distal dural ring is divided circumferentially around the ICA across the floor of the optic canal (after the ophthalmic artery is dissected free) and across the roof of the cavernous sinus toward the diaphragma sellae. Bleeding encountered from the cavernous sinus. The temporal lobe is retracted laterally to expose the oculomotor nerve as it enters the roof of the cavernous sinus. the entire optic canal is unroofed in a posteroanterior direction under continuous irrigation. The dura over the anterior clinoid process and the optic canal is coagulated. both medial and lateral to the cavernous carotid artery. This allows the entire contents of the superior orbital fissure to be retracted away from the anterior loop of the ICA. The pterional area is drilled down and thinned. The frontal sinus is often entered and the entire mucosa and posterior wall are removed. The frontonasal duct is obliterated by a small piece of temporalis muscle graft. The bone flap is removed in one piece with the orbital rim. the cervical carotid artery is exposed for proximal control. 8 An osteotomy extends across the orbital ridge from the supraorbital burr hole into the orbital roof using a C1 dissecting tool. the optic strut is drilled further. and elevated medially as a flap in order to expose the roof of the optic canal and the anterior clinoid process (Figure 6A). thus leaving the dural flaps to protect the brain surface. A self-retaining retractor system is attached to the Mayfield clamp. Curettes and rongeurs are not used. thus cranializing the sinus. the optic strut is further isolated by the elevation of the dura from the floor of the optic canal superiorly and the second deflection of the anterior loop of the ICA downward. all arachnoid strands are sharply divided. the retractor blades are adjusted. The cavernous carotid artery is isolated (Figure 6C). VOL. The cisterns around the optic nerve and the ICA are opened widely. The frontal lobe is elevated from the optic nerve and optic chiasm. the anterior loop of the ICA is directly underneath. incised. A second osteotomy is performed across the frontozygomatic suture and the lateral wall of the orbit. Under microscopic magnification. the ICA can be exposed in three areas: Cervical carotid artery (C1). The dura is elevated from the anterior cranial fossa and the tip of the middle fossa. In type I aneurysms that project superiorly. the anterior clinoid process is drilled from its tip to the base. basal surface of the frontal lobe. usually from its lateral to medial end. dividing all arachnoid strands until the entire area is exposed. the orbital roof will fracture. The dura is opened in a T-shaped fashion. Its stem continues along the sylvian fissure: one limb extends medially across the orbital ridge toward the midline and the other limb extends laterally toward the temporal pole and the floor of the middle fossa. the dome of the aneurysm may be adherent to the frontal lobe. The cavernous sinus is opened by incising its roof. Using a diamond-tipped dissecting tool. The lamina terminalis is exposed and opened to allow drainage of cerebrospinal fluid from the ventricles. Once the anterior clinoid process is resected. thus enabling placement of a temporary clip for proximal control. If the aneurysm is large and encroaches on the entire cavernous sinus. and the optic nerve is medial (Figure 6B). the cranial bone flap with the supraorbital ridge is lifted from the dura and rotated forward and down. Cavernous carotid segment (C4). The pterion and greater wing of the sphenoid are drilled flat until the entire shiny inner cortical bone is seen and the lateral edge of the superior orbital fissure is visualized. Dissection of the lateral aspect of the ICA must remain close to the artery to prevent injury of the sixth cranial nerve. The C5 segment is dissected from the inferior surface of the optic strut. is controlled by gentle packing with small pieces of Gelfoam. Proximal Control (C4 and C5 Segments) .8 NEUROSURGICAL OPERATIVE ATLAS. The entire MCA complex is exposed. extending from the distal dural ring to the posterior clinoid process. the sylvian fissure is opened widely. Dural Opening and Arachnoidal Dissection Resection of the Anterior Clinoid Process Once the frontal lobe is elevated. enabling temporary clip placement for proximal control. connecting the keyhole opening to the supraorbital osteotomy across the orbital roof. thus minimizing the retraction pressure that is on the To attain proximal control. The sylvian veins are preserved and are left attached to the temporal lobe. At this point. A sickle-shaped knife is used to incise the dural sleeve on the medial margin of the oculomotor nerve from the point of its entrance into the roof of the cavernous sinus to the superior orbital fissure. The posterior part of the orbital roof and the lateral part of the lesser wing are removed using a fine rongeur.

B. . A. C. the optic canal is unroofed and anterior clinoid process drilled away.GUTHIKONDA AND DIAZ : PARACLINOID CAROTID ANEURYSMS 9 optic canal anterior clinoid process II A III II optic strut C5 III C6 II B distal dural ring ophthalmic artery proximal dural ring C5 C4 superior hypophyseal artery C6 III C Gelfoam Figure 6. II and III indicate cranial nerves. note the oculomotor nerve seen through the membranous layer after clinoidectomy. The cavernous sinus roof is opened and the C4 and C5 segments of the ICA are exposed for proximal control. carotidoculomotor membrane is incised medial to the third nerve and the nerve is retracted laterally. dural incision outlined over the anterior clinoid process and the optic canal.

as the base is very thin and fragile and may tear with approximation of the clip blades. Wide mobilization of the carotid artery with circumferential division of the distal dural ring followed by proximal and distal temporary clipping make the segment of the ICA become slack. Type III (Superior Hypophyseal Aneurysm) The optic nerve sheath is incised longitudinally to facilitate gentle medial retraction of type II aneurysms. When faced with this variant. If the clip slides toward the carotid artery and compromises the lumen. along with the dura on the roof of the cavernous sinus. Often. Proximal control is achieved in large aneurysms by exposing the cavernous carotid artery (C4 segment). and bleeding is controlled by packing with Gelfoam. multiple serial clips are needed to obliterate the entire length of the aneurysm neck. Type I(b) (Carotid-Ophthalmic Aneurysm) Preoperative studies do not always clarify whether a type III aneurysm is projecting above or below the diaphragma sellae. the tuberculum sella is drilled medial to the optic nerve. the distal dural ring is incised circumferentially around the carotid artery. and the nerve is retracted laterally. which lie between the optic nerve and the ICA and the aneurysm. A right-angled fenestrated clip is placed. with the blades on the undersurface of the ICA parallel to its long axis and the parent vessel passing through the fenestration. are sharply divided. At times. If the aneurysm projects significantly into the cavernous sinus. The supradiaphragmatic variant aneurysm can be visualized and a 90-degree angled fenestrated clip is applied from a lateral direction. At times. A 90-degree curved fenestrated clip (placed encircling the ICA) will obliterate the aneurysm.10 ISOLATION AND CLIPPING OF THE ANEURYSM NEUROSURGICAL OPERATIVE ATLAS. the rigid dura of the roof of the cavernous sinus that encircles the aneurysm does not allow the clip blades to approximate. After restoration of the patency of the carotid artery and obliteration the aneurysm. The dura is incised along the roof of the cavernous sinus medial to the oculomotor nerve. 8 inspected for inadvertent encroachment of the C5 segment. VOL. allowing the clip blades to approximate and occlude the neck of the aneurysm. Type I(a) (Carotid-Ophthalmic Aneurysm) Type I(b) aneurysms are difficult to obliterate because they are broad-based and sessile. and extending medially across the diaphragma sellae. the optic nerve sheath is incised and the nerve is gently retracted medially. The four variants of aneurysms are shown with ideal placement of clips in Figure 7. A right-angled fenestrated clip is applied encircling the carotid artery. The ophthalmic artery is identified. After isolating the ophthalmic artery. The distal dural ring along the floor of the optic canal is incised and the C5 segment is mobilized laterally for proximal control. The dura on the floor of the optic canal under the ophthalmic artery is incised. is incised around the aneurysm. The arachnoid strands. In these instances. Most aneurysms projecting superiorly can be clipped by using a 45-degree angled clip. Dura forming the roof of the cavernous sinus can be incised circumferentially around the waist of the aneurysm. The pituitary gland is identified medial to the aneurysm. proximal control is achieved by exposing the C4 or C5 segments of the ICA. a portion of the parent vessel may need to be included in the clip blades. a second fenestrated clip may need to be placed parallel to the first one so as to totally obliterate and occlude the neck of the aneurysm. At times. Definitive assessment of the location can only be made by exploration. The carotid artery is displaced laterally. thus enabling the mobilization of the C5 and C6 segments. A temporary clip is placed on the C4 and C6 segments. The distal dural ring is often widened or made incompetent by the large aneurysm. The ophthalmic artery is identified. the dura along the floor of the optic canal is incised and the C5 segment is mobilized laterally. the temporary clips are removed. The optic nerve sheath is incised and the optic nerve is gently retracted medially to bring the supradiaphragmatic variant into view. and the aneurysm is trapped. a second clip is placed tangentially. In type I(a) aneurysms. placing the blades parallel to the long axis of the carotid artery. The tips of the clip blades must be Type II (Ventral Paraclinoid Aneurysm) When clipping a type IV aneurysm. leaving a cuff of the dura attached to the periphery of the aneurysm. The roof of the cavernous sinus is opened during this process. the optic canal sheath is incised longitudinally to allow gentle retraction of the optic nerve. thus allowing satisfactory clip placement with the blades parallel to the carotid artery. Type IV (Broad-Based Siphon Aneurysm) . In the infradiaphragmatic variant. a carotid segment can be so ectatic that the aneurysm neck may be located medial to the optic nerve. the aneurysm is hidden under the diaphragm and not visible when the C6 segment is displaced laterally. the clip blades are placed on the inner curvature of the artery along the neck of the aneurysm. The optic nerve is retracted laterally and the clip is applied from its medial aspect. the aneurysm is collapsed with a 25-gauge needle and the first clip is removed. This dural ring. With large aneurysms.

Illustrations depicting the four variants of aneurysms with ideal clip placement. .GUTHIKONDA AND DIAZ : PARACLINOID CAROTID ANEURYSMS 11 ophthalmic artery MCA type I ACA type II type III type IV Figure 7.

thus allowing successful clipping. In large and complex aneurysms. Four patients underwent a bypass procedure to the M2 segment of the MCA. CT and MRI studies can provide information regarding their size. As optic nerve dysfunction is the most frequent complication. This sinus communication must be obliterated prior to closure. followed by endovascular balloon occlusion of the ICA. using a saphenous vein bypass in two patients and an STA in the other two. A clear understanding of the paraclinoid segment of the ICA anatomy is important to ensure successful treatment of aneurysms presenting in this area. the procedure may be terminated or a bypass pr ocedure performed. relation to the adjacent structures. Postoperative endovascular trapping of the aneurysm was completed following the confirmation of the patency of the bypass. Wound closure is done in the usual fashion to achieve a watertight dural closure.12 Pitfalls NEUROSURGICAL OPERATIVE ATLAS. Identification of the aneurysms into one of four types facilitates operative planning. CONCLUSIONS . The remaining patients underwent trapping without a bypass. The sphenoid sinus and the posterior ethmoid sinuses may have opened during clinoidectomy and be recognized and obliterated. Surgical Experience COMPLICATIONS This is the most frequently encountered postoperative complication in the management of paraclinoidcarotid aneurysms. A subgaleal suction drain is left in place for 24 hours. Cerebrospinal Fluid Rhinorrhea The anterior clinoid process and optic strut may be pneumatized and must be recognized while drilling. and the angiography is completed. The fronto-orbital bone flap is replaced and secured with plates and screws. medially. In patients with complex and large aneurysms. Closure Patency of the carotid artery is easily evaluated using microDoppler ultrasound after aneurysm obliteration. Preoperative CT scans may alert the surgeon to the possibility of calcification. Complete exposure of the anterior loop and extensive mobilization is preferred. Attempts to clip a heavily calcified aneurysm may be dangerous because of the risks of avulsion of the aneurysm. A small local periosteal flap is rotated from the scalp over the sinus and sutured to the adjacent dura. the chances for injury can be decreased by following the principles of drilling: “Hold tight and stroke gently. VOL. The frontal sinus entry must be identified and properly managed. The frontal sinus is obliterated with fat or muscle and secured in place with cryoprecipitate. 8 Type IV aneurysms and. Role of Intraoperative Angiography Using the above classification. thus allowing the artery to be retracted laterally rather than retracting the nerve Optic Nerve Injury and Blindness Patients with ICA aneurysms of the paraclinoid segment who are considered for surgical intervention should be evaluated thoroughly using selective angiography. 99 (95%) of 115 patients who had aneurysms near the paraclinoid segment underwent successful clipping of the aneurysm. and presence of calcification. or the inability to obliterate the aneurysm. very little retraction should be applied to the optic nerve. The ICA is punctured percutaneously or by an open method. If a calcified aneurysm is encountered and if the presenting symptoms are not due to SAH. less frequently. The ophthalmic artery must be identified before incising the dura on the floor of the optic canal and the distal dural ring to avoid inadvertent injury. and the microvasculature of the optic nerve should not be disturbed. Although the optic nerve can be injured while unroofing the optic canal. A small fat graft obtained from deep temporal fat or from the abdomen is secured in place with fibrin glue. Retraction must be minimal and brief. a radiolucent headholder is used in preparation for angiography and the patient’s neck is included in the sterile operative field. embolic phenomena with ischemic complications.” The dura covering the optic nerve must not be disrupted by the drill. The pial vessels of the optic nerve must not be disrupted while incising the dural sleeve. variants of paraclinoid aneurysms may contain significant calcification in the vessel wall. The field is continuously irrigated with cool saline to decrease the chance of thermal injury to the nerve. Obliteration of a markedly calcified aneurysm is difficult in elderly patients.

aneurysms in this region are the third most common site associated with subarachnoid hemorrhage (SAH). It is of paramount importance to understand the normal neurovascular course as well as the common variants of the MCA branches in order to adequately interpret angiographic anatomy and effectively deal with surgical lesions. including the following: 1) they are frequently associated with hematomas that may be adherent to and difficult to dissect from the fundus of the aneurysm. MCA aneurysms are frequently broad-based and include a portion of the distal M2 segment. into the MCA and the anterior cerebral artery (Figure 1). at the junction of the carotid and sylvian cisterns. M. INTRODUCTION there are three surgical approaches to MCA aneurysms: 1) proximal to distal. the aneurysms occur at the bifurcation of the M1 segment of the MCA. The first segment (M1) of the MCA courses laterally 1 cm posterior to the sphenoid wing and enters the deep sylvian fissure running horizontally in its sphenoidal portion. In addition.. STIEG. 2) the anatomical variability of the M1 segment and the associated medial and lateral lenticulostriate vessels require meticulous technique. © 1999 The American Association of Neurological Surgeons The internal carotid artery bifurcates lateral to the optic chiasm. This chapter reviews the anatomy of the sylvian fissure as well as the preoperative assessment and management of aneurysms associated with the MCA.D. The middle cerebral artery (MCA) is the second most common site of aneurysm formation. Currently. Several important and variable vessels arise from the M1 segment. in Yasargil’s 1984 series it represented 20% of all aneurysms. the MCA is the larger branch. they may occur proximal or distal to this point. and 3) the overall anatomic complexity of the sylvian fissure demands patient microsurgical dissection.D. exposing the internal carotid artery within the basal cistern and dissecting along the path of the sylvian fissure. thereby requiring unusual or multiple clip configurations. 2) a transtemporal approach through the superior temporal gyrus.SURGICAL MANAGEMENT OF MIDDLE CEREBRAL ARTERY ANEURYSMS PHILIP E. In approximately 70% of cases. Dandy provided the first report on surgical treatment of MCA aneurysms. Typically.D. FRIEDLANDER. which can be classified in the inferior medial (perforating) or superior lateral (temporal) groups. In addition. Each case resulted in a fatality. More specifically. the various surgical techniques for treatment of these lesions and the complications associated with their management are discussed. PH. and 3) the transsylvian approach with direct splitting of the sylvian fissure. SURGICAL ANATOMY 13 . The mean length of the M1 segment is 14 to 17 mm. however. In 1944. ROBERT M. M. Aneurysms in this location are particularly challenging to the microvascular surgeon for several reasons. Successful treatment of an aneurysm in this region was first reported by Dott.

Schematic view of the sylvian fissure after microsurgical opening. 8 temporal lobe posterior communicating artery anterior clinoid artery anterior choroidal artery oculomotor nerve anterior temporal artery optic nerve A1 segment of the anterior cerebral artery inferior trunk of the M2 segment artery of Heubner sylvian fissure lenticulostriate vessels M1 segment of the MCA superior trunk of the M2 segment frontal lobe Figure 1.14 NEUROSURGICAL OPERATIVE ATLAS. M2: branches of the main MCA (M1) segment. VOL. The origin of the MCA from the internal carotid artery and its proximal branches are demonstrated. .

the superior trunk in 36%. The uncal artery arises 30% of the time as a lateral M1 branch and 70% as a direct branch from the internal carotid artery. grade of patient. the superior and inferior segments. the posterior temporal cortex. and the angular and posterior parietal regions. and operating room personnel. However. aneurysm size and complexity. the superior half of the internal capsule. Aneurysms in this region are frequently associated with large hematomas and mass effect causing a worsened neurological picture. which form secondary to intimal deficiencies at the proximal bifurcation. The MCA bifurcation is located just medial to the high point of the limen insulae at the junction of the sphenoidal and opercular-insular subdivisions of the sylvian cistern. each case must be individualized and surgical decisions should be based on age. or the distal internal carotid artery. Recent data suggest that size is the critical issue in deciding to operate. The lenticulostriate vessels course medially into the lateral aspect of the anterior perforated substance. Two additional patterns are described. the polar temporal artery. and the parietal and central sulcus territories. Because the sylvian cistern is surrounded by brain. All aneurysms greater than 10 mm are treated unless there are medical contraindications. Two M2 branches arise from the bifurcation. The M1-M2 junction is usually located 1. demonstrating significant variations in size and number (range two to 29). Therefore. In this situation. emergent surgery may also be indicated based on mass effect.5 cm deep to the superior temporal sulcus. the inferior trunk is larger in 41% of cases. The M2 segments then turn superior-posterior reaching the insular surface. The anterior temporal branch courses anteriorly and turns above the superficial aspect of the sylvian fissure en route to the anterior temporal lobe surface. a single large vessel originates from the M1 segment and then divides into smaller perforators. creating the impression of a trifurcation as well as causing confusion as to the location of the true bifurcation. the surgeon must perform a r elative PATIENT SELECTION . In this case. and the lateral segment of the anterior commissure. ruptured lesions commonly present with intraparenchymal hemorrhage in addition to SAH. The surgeon must also be careful in this situation not to confuse the anterior temporal artery take-off with the true M1 bifurcation. the anterior temporal artery supplies the distribution of both vessels. Fenestrations are reported in the proximal portion of the M1 in 2% of cases and are often associated with aneurysms. a large branch originating from the inferior M2 segment usually supplies the respective territories. The two segments separate initially at the bifurcation and then come into close proximity in the opercular-insular portion of the sylvian fissure. a true trifurcation or greater number of branching vessels is found in up to 22% of cases. medical issues. The junction of the temporal and frontal operculas can be used as superficial cortical landmarks to commence exploration of the bifurcation of M1 and M2. The superior lateral group of vessels includes the uncal artery. It is important to be aware of the more common vascular abnormalities present in the MCA. MCA bifurcation aneurysms are often embedded in the parenchyma. the polar temporal artery is hypoplastic and the anterior temporal artery is reciprocally larger. McCormick noted in his landmark autopsy study of 1000 consecutive brains that the MCA was the least likely major intracranial vessel to harbor an anatomical abnormality. On the other hand. supplying a portion of the nuclei of the basal ganglia. In true M1 bifurcations. proximal A1. aneurysms appear more frequently in patients with anatomical neurovascular abnormalities. The territory supplied by the superior trunk includes the inferior frontal cortex. For lesions less than 10 mm in size. one (30%) where there are two main branches that thereafter divide and the other (30%) where the small lenticulostriate vessels directly arise from the M1 segment. and the anterior temporal artery. Often distal to the true bifurcation. and they are of equal size in 23%. large M3 branches might arise. the frontal opercular cortex.5-2 cm posterior to the anterior aspect of the insular portion of the sylvian fissure and 2-2.STIEG AND FRIEDLANDER : SURGICAL MANAGEMENT OF MIDDLE CEREBRAL ARTERY ANEURYSMS 15 The inferior medial group (lenticulostriate perforators) originates on the inferior medial surface of the M1 segment. The management of incidental aneurysms in this region is controversial because of conflicting data on their natural history. The patient in a poor neurological status (Grades IV-V on the Hunt-Hess scale) may improve following a ventriculostomy and become a good candidate for surgery. Lenticulostriate vessels may also arise from the proximal portion of one of the two M2 segments. An alternate variant in which both the polar temporal artery and the anterior temporal artery are hypoplastic has been described. On occasion. The territory supplied by the inferior trunk includes the middle temporal cortex. Yasargil notes that in 40% of cases. An accessory MCA may also be present and originate from the junction of A1 and A2. In this case. Albeit uncommon. They may arise as individual branches directly from the M1 segment or as larger feeders that branch into multiple smaller arteries. VASCULAR ABNORMALITIES ASSOCIATED WITH THE MIDDLE CEREBRAL ARTERY We recommend that the patient presenting in good neurological status (Grades I-III on the Hunt-Hess scale) after an SAH be treated urgently as the risk for rehemorrhage is significant.

is routinely used (Figure 2). After Surgicel and narrow cottonoid patties are placed around the margins of the craniotomy. A standard frontotemporal or pterional incision. branching points of the M1 segment of the MCA. The skin is dissected separately and reflected inferiorly over a rolled sponge with fishhook retractors. Adequate bone removal of the orbital roof and lesser wing of the sphenoid down to the orbital meningeal artery is required to provide proximal exposure to the sylvian fissure. The disadvantages of this approach include minimal release of cerebrospinal fluid (CSF) resulting in manipulation and retraction of a firm. made completely behind the hairline. thereby providing proximal and distal control of the aneurysm. Subsequently. This minimizes ve- SURGICAL APPROACHES The transtemporal approach utilizes the skin incision and bony removal described above with slightly less removal of the lateral orbital roof and lesser wing of the sphenoid bone. after a rupture occurs. craniotomy. The muscle is reflected inferiorly with the skin flap to provide adequate bony exposure. elevated above the heart. VOL. Three burr holes are placed individually in the pterion or keyhole region. as demonstrated in Figure 2. and rotated 45 degrees contralateral to the incision. a temporal craniectomy is required to allow retraction of the temporal lobe. all bony margins are waxed to prevent air emboli. and at the posterior margin of the incision at the height of the temporalis muscle. and dural opening described earlier. 8 risk analysis between the surgical morbidity/mortality rate and the risk for aneurysm rupture which. This position allows the surgeon to pursue any of the three surgical approaches. the dura is placed on stretch with sutures and covered with moist patties to facilitate dural closure upon completion of the case. This approach was initially advocated and popularized for patients who presented with large temporal lobe hematomas. Care is taken to avoid venous outflow obstruction in the neck. The temporalis muscle is then incised along the superior temporal line and the posterior margin of the incision. A 3-4 cm cortisectomy is made in the superior temporal gyrus and centered approximately 2 cm posterior to the anterior-most aspect of the sylvian fissure. Position Transtemporal Approach Incision and Craniotomy The subfrontal/pterional approach utilizes the positioning. The skull is immobilized with the Mayfield headholder. A subpial resection of the superior temporal gyrus is utilized to enter the horizontal portion of the sylvian fissure. has a mortality rate of up to 60%. Placing the incision in this location prevents injury to the frontalis branch of the seventh cranial nerve. A retractor blade is advanced subfrontally and secured under microscopic visualization to provide exposure of the olfactory tract and optic and carotid cisterns. the neck is flexed slightly to the contralateral shoulder to flatten the orbital roof and the vertex is lowered slightly. stiff brain parenchyma. The lenticulostriate vessels. the aneurysm fundus is often exposed first with no proximal control. thereby allowing the egression of spinal fluid and subsequent softening of the brain parenchyma. A transtemporal approach is advantageous in that it requires a smaller craniotomy and provides a direct approach to the essential anatomy with good visualization of the inferior M2 trunk. nous run-in. It is important to stay deep to the fat-pad in the keyhole region to avoid injury to the frontalis branch of the seventh nerve. In addition. These maneuvers facilitate opening of the sylvian fissure with minimal traction on the frontal and temporal lobes. The exposure is then Subfrontal/Pterional Approach . In addition. There is also more tissue resection than required by the other approaches. The incision is started no more than 1 cm anterior to the tragus of the ear at the root of the zygoma and extends behind the hairline up to the midline. the aneurysm neck. and the fundus are also identified. The temporal squamous bone is removed with rongeurs and the lateral roof of the orbit and lesser wing of the sphenoid bone are drilled down until the orbital meningeal artery is visualized. enabling the surgeon to identify the M2 segments of the MCA. Leaving the superior tuft of muscle allows for a better cosmetic closure upon completion of the case. Finally. the temporal squamous bone slightly above the root of the zygoma. This bony removal provides better exposure of the proximal sylvian fissure and allows gentle traction on the temporal lobe.16 NEUROSURGICAL OPERATIVE ATLAS. Again. These cisterns are opened sharply with an arachnoid knife. Dissection is then taken from distal to proximal within the sylvian fissure to identify the M1 segment. there is less brain retraction and less manipulation of the M1 segment. the dura is opened in a crescent moon-shaped fashion centered over the sylvian fissure. In addition. This may subject the patient to an increased risk for seizures. SURGICAL TECHNIQUE The patient is placed supine on the operating table with a roll under the ipsilateral shoulder. A standard pterional bone flap is elevated with cuts between the burr holes. either through positioning or methods used to secure the endotracheal tube. surgical decision making is multifactorial and each case must be treated individually.

elevating the facial nerve with it. This allows gentle traction on the temporal lobe. placement of burr holes. removed with rongeurs. note the location of the skin and muscle incision within 1 cm of the tragus to avoid injury to the frontalis division of the facial nerve. Schematic views of the head position. B. The temporalis muscle is incised within its superior attachment to facilitate closure and provide better cosmesis. B craniotomy . A. and location of the craniotomy. the skin flap is reflected individually. skin and muscle incisions. The craniotomy is centered over the sylvian fissure. Note the position of temporal squamous bone. both the skin and muscle are isolated with fishhook retractors.STIEG AND FRIEDLANDER : SURGICAL MANAGEMENT OF MIDDLE CEREBRAL ARTERY ANEURYSMS 17 zygoma ronguered bone facial nerve temporalis muscle temporalis muscle incision skin incision craniotomy A temporalis muscle facial nerve Figure 2. Subsequently the temporalis muscle is elevated. leaving the superior tuft of muscle.

as well as the neck of the aneurysm. we try to place a clip parallel to the M1 and M2 segments. The positioning. Once dissection is complete. This approach offers several advantages. microscope. which extend along the frontal surface of the anterior cerebral artery. are more commonly seen in this location (Figure 4). as well as the limen insula. Because of this wide opening. Initially. which may induce spasm in these vessels. Thus. however. surgical technician. and wide exposure of the MCA bifurcation. and finally the M1 segment. an M3 segment of the MCA is identified and followed proximally. the surgeon can also visualize the medial lenticulostriate vessels. vessel spasm may diminish the surgeon’s ability to visualize all vessels preoperatively. Transsylvian Approach Saccular narrow-necked aneurysms are the least common form found in this region (Figure 3). which include in their neck either a portion of the proximal M1 or distal M2 vessel wall. a proximal temporary clip on the M1 segment may be all that is needed to soften the neck of the aneurysm and facilitate clip placement. 8 taken distally along the internal carotid artery to its bifurcation and into the proximal sylvian fissure. The proximal clip should be placed first and none of the clips should limit the surgeon’s view. There are several guidelines to follow during temporary clip application. including early release of CSF and proximal control of the aneurysm. using sharp dissection. providing wide exposure. Subsequently. The atmosphere of the operating suite is calm and quiet with the surgeon in a seated position. and craniotomy described above facilitate the application of sharp microdissection techniques to enter the opercular-insular segment of the sylvian fissure for the initial exposure. minimal brain dissection. Disadvantages of this approach include late proximal control in addition to frontal and temporal retraction to provide complete exposure of the aneurysm neck and branches of the MCA. sequentially providing exposure of the lateral lenticulostriate vessels. Lesions of this size rarely require temporary occlusion for placement of the permanent clip. it is punctured with a 26-gauge spinal needle to ensure occlusion. straight instruments are utilized. The transsylvian approach is the one that we most commonly use and it has recently been described by many other authors. Broad-based aneurysms. One must be prepared for temporary occlusion at all times but particularly under conditions of untimely aneurysm rupture or for complete dissection of the aneurysm. short. Blood is removed from the sylvian fissure during dissection and the thin wisps of arachnoid can be identified and cut sharply. this is a superficial exposure and non-bayoneted. retraction is required of both the frontal and the temporal lobes. Concerns regarding a wide opening of the sylvian fissure include prolonged frontal lobe retraction and extensive manipulation of the entire M1 and M2 segments. However. the objective is to occlude the aneurysm with a clip while preserving the normal anatomy without any stenosis. incision. complete dissection of the neck and fundus of the aneurysm as well as the surrounding vessels in this region is essential to avoid postoperative complications. as demonstrated. the neck of the aneurysm. The superficial and thickened arachnoid over the sylvian fissure is opened from the point of entry anteriorly. This is not the case when there is a thick dense hematoma that r equires sharp dissection and suctioning. With this exposure. and finally the clips should not be placed in a CLIP APPLICATION . The entire M1 segment is exposed within the horizontal portion and into the opercular-insular region of the sylvian fissure. Arteries within the sylvian fissure either run frontally or temporally and can be reflected in their respective directions. their preservation is always ideal. as there is minimal collateral flow in this distal region of the arterial tree. This dissection provides an excellent view of the anatomy of the sylvian fissure. Small cortical veins within the sylvian fissure can be sacrificed without great concern. and bipolar cautery are all ergonomically positioned to maintain economy of motion and ease of access. the fissure will open with gentle retraction on both the frontal and temporal lobes. providing exposure of the bifurcation of the M1 segment into the M2 segments. Advantages of this technique include early CSF release and brain softening. however. In many cases. a trifurcation instead of bifurcation is a common anatomical variant. In addition. and the M1 and M2 segments of the MCA. as demonstrated in Figure 4. however. Dissection is taken along the M2 segment of the MCA. After the aneurysm has been obliterated. again using sharp dissection. surgical assistant. The venous drainage typically runs parallel to the sylvian fissure and is associated with the temporal surface. the preservation of flow within the lenticulostriate vessels should be maximized. The sylvian fissure is opened 3 cm distal to the anterior lip of the inferior frontal surface. Commonly. VOL.18 NEUROSURGICAL OPERATIVE ATLAS. on occasion a clip can be placed perpendicular to the proximal and distal vessels. temporary trapping may be needed for sharp dissection of the aneurysm fundus from a distal branch. Ideally. This should be visualized on the preoperative angiogram. The self-retaining retractor system. An aneurysm clip is selected after the anatomy is completely displayed. controlled suction devices. removal of subarachnoid blood.

and a broad-based aneurysm including a segment of the inferior M2 trunk in its neck is demonstrated. B. A. The fundus of the aneurysm is left intact. the association between the M1. the fundus of the aneurysm has been punctured and aspirated to ensure complete occlusion and removal of any mass effect. Preservation of all distal arteries is essential.STIEG AND FRIEDLANDER : SURGICAL MANAGEMENT OF MIDDLE CEREBRAL ARTERY ANEURYSMS M1 segment inferior trunk of the M2 segment 19 superior trunk of the M2 segment A B Figure 3. B. . temporary clips have been placed across the M1 and M2 segments. high-magnification view of the MCA bifurcation demonstrating the M1 and M2 segments with lenticulostriate vessels on the M1 segment. All three distal M2 branches have been preserved and the aneurysm is punctured to ensure complete occlusion. The distal temporary clips are removed first and the proximal M1 temporary clip is then removed. three M2 trunks. C. a permanent clip has been placed across the neck of the aneurysm perpendicular to the axis of the parent vessel. high-magnification views of the MCA trifurcation. A. M1 segment A B inferior trunk of the M2 segment superior trunk of the M2 segment C Figure 4. clip application is parallel to the parent vessels and occludes the portion of the aneurysm neck that extends into the M2 trunk. The clips are placed to allow maximum exposure for the surgeon and maintain flow through the lenticulostriate vessels. In addition. A narrow-necked aneurysm between the superior and inferior M2 trunks is demonstrated. Larger aneurysms with hematoma may be opened widely for evacuation of the mass. Sharp dissection techniques are utilized to create a plane between the fundus of the aneurysm and the parent vessel.

Prior to making the skin incision. the superficial temporal artery (STA) is mapped out on the scalp using Doppler ultrasound. The vessel is irrigated with heparinized saline and anastomosed to the M2 branch with running 10-0 Prolene sutures. The thrombus can be removed with an ultrasonic aspirator. temporary trapping allows the surgeon to perform an aneurysmorrhaphy. as the dura cannot be closed tightly in this situation. Under conditions of temporary trapping. Care must be taken to closely oppose the galea during the closure to avoid leakage of CSF from the wound. Calcified plaque in the wall of the aneurysm can be either surgically removed or crushed with a hemostat. In either situation. VOL. both of which limit closure of the clip. the distal (M2) temporary clips are removed first to assess the anastomosis. Should an intimal flap occur. an STA-to-MCA bypass in an end-to-end fashion is performed. adequate bone removal will ensure patency of the STA as it enters the sylvian fissure. The surgeon must remember to open the aneurysm distal enough on the fundus to allow closure of the aneurysm with a clip. After removal of the distal temporary clips. the aneurysm has been trapped by permanent clips on the M1 and M2 segments and subsequently opened for debulking of the hematoma within the aneurysm. At that time. Infiltration of the scalp with lidocaine is avoided. dissecting the hematoma or atheroma too proximally may result in the creation of an intimal flap in the parent vessel. The aneurysm may include the entire trifurcation. Fusiform aneurysms of the MCA bifurcation also present significant challenges (Figure 5). Beyond 15 minutes. Fenestrated clips including one of the M2 branches have also been used. cooling to 33°C and placing the patient in burst suppression with etomidate or barbiturates). Also.20 NEUROSURGICAL OPERATIVE ATLAS. the risk of ischemic injury rises sharply. In addition to facilitating dissection between the aneurysm fundus and the parent vessels. A suture is placed at each pole of the anastomoses with one run along the frontal surface and the other along the temporal surface of the anastomosis. Cerebral protection is used during performance of the bypass procedure. MANAGEMENT AND AVOIDANCE OF COMPLICATIONS Preoperative Management For All Patients Adequate angiograms need to be obtained and carefully studied prior to surgery in order to thoroughly understand the variable MCA anatomy for the individual patient. When only one M2 branch is involved in a fusiform aneurysm. A rubber dam is placed under the recipient vessels to facilitate visualization of the suture. which could result in vessel stenosis and ischemia. as demonstrated. Intermittent 10-minute periods of temporary occlusion with reconstitution of flow between the periods can be used in specific circumstances when the aneurysm has not been opened. and clipping. A general medical evaluation needs to . micropituitaries. These aneurysms. the temporary clip on the STA is removed. respectively. We will discuss general and location-specific management issues as well as strategies to avoid complications in patients with MCA aneurysms. aneurysmorrhaphy. finally. Multiple clip configurations have been designed to enable the surgeon to apply them parallel to the parent vessels. or sharp dissection. The STA and its adventitia are isolated along its full length for use later in the case. reconstitution of flow in the distal M2 vessels is often needed and can be provided by bypass procedures. As demonstrated. we recommend puncture with a 26-gauge spinal needle to rule out residual filling. Five minutes of temporary occlusion is usually well tolerated. Moreover. cannot be excluded from the circulation by straightforward clip applications. Indications for opening the aneurysm widely include a large thrombus within the aneurysm or calcium in the fundus. A proximal temporary clip is placed on this vessel and the distal ends are transected at the appropriate length. In addition. or may involve one of the M2 branches. thereby enabling the clip to approximate the walls of the aneurysm. One or two branches of the STA are isolated for use in the procedure. the surgeon may note bleeding from the aneurysm which would require placement of a tandem clip or adjustment of the primary permanent clip. The mechanisms of action for the protective measures are poorly understood but focus on decreasing cerebral oxygen requirements (general anesthesia. Intraoperative angiography is used to evaluate the bypass before closure of the craniotomy. is performed. 8 region of atheroma which could result in an embolic complication. dissection and occlusion may result once flow is restored in the parent vessels. the distal M2 temporary clips are removed first. Cerebroprotective maneuvers are used in order to minimize the effects of induced cerebral ischemia during temporary occlusion. Again. increasing collateral flow (elevating systolic blood pressure 20% to 30%) and fr ee radical scavenging (0. The adventitia is dissected away from the distal end. the proximal temporary clip is removed. After the aneurysm has been secured. which include a portion of the parent ves- sel. The surgeon must anticipate the need for bypass on the basis of the preoperative angiogram.5 gm mannitol/kg body weight). The clips should also be placed to minimize torque on the M1 and M2 segments. an end-to-side anastomosis between the involved M2 segment and the normal M2 segment. Hypothermic circulatory arrest is considered only in the most extreme cases.

placed as close to the aneurysm as possible. In addition. . schematic of a fusiform aneurysm involving a distal portion of the M1 segment as well as proximal portions of both M2 trunks. can maintain flow to the lenticulostriates. Branches of the STA are anastomosed to the M2 trunks in an end-to-end fashion to maintain distal flow. Frequently. the lenticulostriate vessels are adherent to the surface of large aneurysms in the region and must be meticulously dissected free prior to placing the permanent clips as demonstrated. The aneurysm is opened and the hematoma evacuated as needed. B. an end-to-end STA-to-MCA anastomosis is demonstrated. A.STIEG AND FRIEDLANDER : SURGICAL MANAGEMENT OF MIDDLE CEREBRAL ARTERY ANEURYSMS 21 M1 segment A1 segment inferior trunk of the M2 segment A superior trunk of the M2 segment STA recipient M2 distal branches B Figure 5. demonstrations of permanent clip application across the M1 segment and two distal M2 segments. The clips are placed as close to the aneurysm as possible.

Seizures can be avoided by using antiepileptic medications at the time of admission. Computed tomography (CT) angiography provides invaluable information prior to proceeding with aneurysm clipping following hematoma evacuation. VOL. Intraoperative rupture can be prevented by avoiding hypertension as well as careful microsurgical technique. hemorrhage. A specific challenge of MCA bifurcation aneurysms is the inadvertent occlusion of an M2 or M3 branch during clipping of the aneurysm. one should consider an M2 occlusion or stenosis due to clip rotation. to delay placement of a ventricular drain until surgery because of the associated increased risk of rehemorrhage. This has been described after closure or postoperative swelling of the sylvian fissure. induced hypertension (160-170 mm Hg). Because of the urgency in such situations. However. CONCLUSIONS . if the patient requires immediate CSF drainage. and the aggressive management of vasospasm. and etomidate or barbiturateinduced burst suppression. The surgeon must be prepared for using any of the three described approaches for aneurysms in this region. projection of the aneurysm. placement of a ventriculostomy with gradual lowering of the intracranial pressure is the goal. ischemic time must be kept at a minimum. cerebral protection. or persistent brain edema. we prefer. If one cannot confirm either complete obliteration of the aneurysm or patency of all the distal branches. or the complexity of the aneurysm neck. if possible. An urgent CT scan will rule out a hemorrhagic complication and expeditious angiography will confirm vessel patency. For Patients with Ruptured Aneurysm Patients with ruptured MCA aneurysms may present in extremis.5 gm/kg body weight). conventional angiography may not be performed.22 NEUROSURGICAL OPERATIVE ATLAS. meticulous dissection techniques. In order to avoid a stroke following temporary vessel occlusion. however. We feel most comfortable with the transsylvian approach. Delayed hydrocephalus and vasospasm should be treated in the standard fashion. A methodical approach to these aneurysms with a thorough understanding of the anatomy. mannitol (0. intraoperative or early postoperative angiography should be per- Intraoperative Management MCA aneurysms are common and often very challenging for the microvascular neurosurgeon. Avoidance of aneurysmal rehemorrhage can be achieved by early and aggressive blood pressure control as well as proceeding with early surgery. Surgical results have improved immeasurably over the past several decades with the advancements in microsurgical technique. This complication can be avoided by thorough preoperative evaluation of the angiogram and circumferential evaluation of the aneurysm neck either during temporary occlusion or following clipping. This latter technique is utilized when we have concern regarding the stability of the aneurysm fundus. Postoperative Management If subacute neurological deterioration (several hours postoperatively) occurs and is not related to seizures. 8 be performed to optimize the preoperative condition of the patient. Cerebroprotective aids employed to avoid ischemic complications after temporary occlusion include moderate hypothermia (33°-34°C). secondary to a large intraparenchymal hematoma. When the patient presents with early symptomatic hydrocephalus. should result in a good surgical outcome. as well as the need for possible bypass procedures. occasionally we open the proximal sylvian fissure. as well as patient. formed.

produce a venous infarction.SURGICAL REMOVAL OF TENTORIAL AND POSTERIOR FOSSA DURAL ARTERIOVENOUS MALFORMATIONS ADAM I. Venous occlusion is safe when the primary drainage is antegrade through a dural venous sinus or when a single draining vein INTRODUCTION © 1999 The American Association of Neurological Surgeons can be identified as it exits the dura. yet venous hypertension from arterialized veins is responsible for their clinical presentation. Ligation may worsen the venous hypertension. Tentorial and posterior fossa DAVMs are a unique subset of intracranial DAVMs that do not have an associated venous sinus and frequently have multiple draining veins that are tortuous and aneurysmal. microsurgery for deep-seated DAVMs was associated with high morbidity from postopera- 23 .D. treatment is directed to the arterial side. M. LEWIS. The therapeutic strategy for deep-seated DAVMs includes transarterial embolization followed by either stereotactic radiation or surgical excision. however. Many intracranial and spinal DAVMs can be cured by ligating the draining vein or occluding an associated dural venous sinus. When a DAVM is not associated with a venous sinus and cortical venous drainage is present. TEW.D. Ischemia may develop in the surrounding brain from stagnant venous drainage and poor perfusion. Unlike parenchymal arteriovenous malformations (AVMs). and obstructive hydrocephalus occurs when large venous aneurysms obstruct CSF pathways. elongate. Transarterial embolization is performed to reduce the blood flow to the DAVM and decrease the venous hypertension. the arterial supply does not have to be eliminated before the venous drainage because the leaves of the dura protect the nidus from bleeding. Therefore. Our understanding of the anatomy and pathophysiology of dural arteriovenous malformations (DAVMs) has evolved rapidly with advancements in the field of interventional neuroradiology. DAVMs with no cortical venous drainage can be partially treated. Because some dural arteries are too small to cannulate. or cause hemorrhage by diverting flow into nonarterialized veins. ligating multiple draining veins may be catastrophic. Communicating hydrocephalus occurs because venous hypertension impedes cerebrospinal fluid (CSF) absorption. The arterialized veins dilate. Instead. and rupture to cause subarachnoid or intraparenchymal hemorrhage. DAVMs arise from abnormal arteriovenous shunts. M. JOHN M. embolization is followed by stereotactic radiation or surgical excision of the nidus. endovascular techniques are rarely curative. JR. The common presentation is subarachnoid hemorrhage (SAH) caused by a ruptured venous aneurysm.. tentorial and posterior fossa DAVMs require complete obliteration to prevent recurrent hemorrhage. In the past. an approach that is similar to that for parenchymal AVMs.

and planning the operative approach based on the relationship of the nidus to the surrounding brain structures. After the imaging studies are complete. they suffer progressive neurological deterioration or symptoms related to hydrocephalus. craniotomy. widens the angle of exposure. mesencephalic. The findings of the initial cerebral angiogram may be negative if only the internal carotid arteries and vertebrobasilar circulation are injected in search of a SURGICAL PLANNING The best approach to deep-seated DAVMs includes a scalp incision. the inferior petrosal sinus. the most common surgical finding is the tentorial artery from the meningohypophyseal trunk feeding a tentorial nidus with a single draining petrosal. treatment begins with transarterial embolization of the feeding arteries through the external carotid artery. Combining skull base approaches with conventional craniotomies has been an important addition in the management of patients with deep-seated DAVMs.g. or pontine vein (Figure 1A). This approach is safe in a small subset of patients who have had transarterial embolization and a single fistula (e. Four approaches are illustrated as the applicable technique for the surgical management of tentorial and posterior fossa DAVMs. which establish the location of the nidus in relation to the skull base. Postoperative angiography provides better resolution. the lower clivus. 8 tive hemorrhage if draining veins were occluded prematurely and residual DAVM was present. Direct surgical excision of the dural nidus is indicated if the ruptured venous aneurysm is not eliminated by embolization or if the feeding arteries are too small to embolize. selective arterial injections can be safely performed. the posterolateral tentorium. the goal of treatment is complete angiographic obliteration. VOL. Less frequently. and the foramen magnum. Bone windows on the angiogram. and occipital artery. The skull base approach expands the field of view. Patients with tentorial and posterior fossa DAVMs are commonly men between 50 and 70 years of age who have suffered an SAH. Decreasing arterial flow reduces the vascularity to the DAVM and the effect of venous hypertension. An anterior . clip. and excise the dural leaflet. including those located at the petrous apex. and minimizes retraction of the brain. To identify venous aneurysms and to determine the extent of venous congestion and stagnant flow. and dural opening that removes a significant portion of arterial supply from the external carotid artery. improves maneuverability that is needed to coagulate. Occluded vessels that have been embolized preoperatively also provide a good road map intraoperatively for understanding the surgical anatomy. stereotactic radiation is a reasonable option. PATIENT SELECTION ruptured saccular aneurysm. After removal of the dural component. Limited exposure with conventional craniotomies and lar ge venous aneurysms accompanying the dural nidus also discouraged the use of microsurgery. the late venous phase should be imaged as well.24 NEUROSURGICAL OPERATIVE ATLAS. Some authors recommend open craniotomy with direct transvenous embolization or ligation of the draining veins. Surgery is also recommended if the symptoms fail to resolve or new symptoms arise after embolization. The following are descriptions of the surgical approaches that provide access to most tentorial and posterior fossa DAVMs. MR imaging and MR angiography also serve as screening studies for DAVM thrombosis after stereotactic radiation. and a variety of projections can be performed to expand the findings of intraoperative angiography. If patients improve neurologically after embolization and do not have a venous aneurysm. superficial temporal artery. SURGICAL APPROACHES DAVMs of the Petrous Apex and Upper Clivus At the petrous apex. determining the degree of venous hypertension. establishing the ventricular size. the remaining arterial supply from the internal carotid artery is coagulated and incised. the falx-tentorial junction. A subtemporal craniotomy with zygomatic osteotomy or suboccipital craniotomy is performed to provide access to the fistula. Selection of the external carotid arteries is important because a majority of the arterial supply may arise from branches of the middle meningeal artery. petrous apex DAVMs). Because DAVMs with cortical venous drainage have an aggressive natural history. The first imaging study obtained is usually computed tomography (CT).. Magnetic resonance (MR) imaging and MR angiography are useful for identifying the source of hemorrhage (usually a ruptured venous aneurysm). which frequently shows SAH or obstructive hydrocephalus from a large dilated venous aneurysm. The dura around the nidus is resected to eliminate the remaining dural supply. Intraoperative angiography with imaging of the internal and external carotid arteries and the vertebrobasilar system documents obliteration of the DAVM. are particularly helpful to determine if a skull base exposure is required in addition to a conventional craniotomy. Large branches from the meningohypophyseal trunk may also be embolized. Removal of the petrous bone eliminates the transosseous supply and exposes dura around the entire DAVM nidus.

The greater superficial petrosal nerve.. The superior semicircular canal. which lies under the greater superficial petrosal nerve. The patient’s head is placed in a radiolucent Mayfield headrest to permit intraoperative angiography. incision provides exposure from the cavernous sinus to the arcuate eminence of the petrous bone. The scalp is reflected inferiorly with the frontalis fat pad to avoid injury to the facial nerve. After induction of general endotracheal anesthesia. A zygomatic osteotomy may be performed to permit reflection of the temporalis muscle below the floor of the middle fossa and minimize temporal lobe retraction. falciform crest.. To avoid postoperative CSF leakage. Removal of bone around the foramen ovale allows mobilization of the trigeminal root and improved retraction of the temporal fossa dura medially. After opening the dura. the geniculate ganglion. and internal auditory canal (i. thus exposing the tentorial artery. A frontotemporal. petrous carotid artery. Exposure below the internal auditory canal requires a posterior petrosectomy and suboccipital approach.LEWIS AND TEW : SURGICAL REMOVAL OF TENTORIAL AND POSTERIOR FOSSA DAVMS 25 petrosectomy in combination with a subtemporal approach is necessary when there is transosseous arterial supply through the petrous bone or when the nidus is located along the upper one half of the clivus (Figure 1B). The remaining bone between the third division of the trigeminal nerve. the veins and venous aneurysms of intracranial DAVMs need not be removed. Occlusion of the feeding artery leads to collapse of the venous aneurysm. Kawase’s triangle) is removed inferiorly along the posterior fossa dura to the inferior petrosal sinus (Figure 1F). The arterial supply is generally bilateral with contributions from the anterior circulation. The head is rotated so that the sagittal sinus is parallel to the floor and then tilted downward 10 degrees so that the zygoma is the highest point in the surgical field (Figure 1C). The dura is opened along the inferior temporal lobe and the tentorium is split from the superior petrosal sinus toward a point posterior to the trochlear nerve. and the thorax is elevated 15 degrees. The middle meningeal artery is sacrificed at the foramen spinosum. numerous feeding arteries in the tentorium are usually visualized and coagulated using bipolar electrocautery. Removal of approximately 30 ml of CSF aids in retraction of the temporal fossa dura.e. The dural incision is then extended inferolateral to the inferior petrosal sinus to expose the upper posterior fossa (Figure 1G). The tentorial artery from the meningohypophyseal trunk can be seen communicating with arterialized vein(s). and external carotid system to form a plexi- . The temporalis muscle and fascia are reflected inferiorly. which provides the posterior border of the anterior petrosectomy. A lumbar catheter is connected to a closed drainage system for 24 to 72 hours. An anterior petrosectomy requires removal of bone between the petrous portion of the internal carotid artery. Intraoperative angiography is performed to document complete obliteration of the petrous apex DAVM. Frequently. and the internal auditory canal. The zygoma remains attached to the masseter muscle to improve healing after closure. The electrocautery causes the tentorial dura to shrink and retract. DAVMs of the Posterolateral Tentorium Posterolateral tentorial DAVMs are usually the largest and most complex deep-seated DAVMs (Figure 2A). and a pericranial fat graft is packed. identified with a facial nerve stimulator. the microscope is used to dissect the temporal fossa dura away from the petrous bone. This approach provides access to the upper half of the clivus and anterior aspect of the posterior fossa down to the inferior petrosal sinus. with the level set at the external auditory canal. a lumbar catheter placed to drain CSF improves exposure and prevents postoperative CSF leakage. exposed mastoid air cells are closed with bone wax. Positioning for a subtemporal approach is supine with a gelatin roll under the right shoulder. To avoid injury to hearing or the facial nerve. Similar to ligating spinal DAVMs. is sectioned near the facial hiatus to prevent injury to the geniculate ganglion. The posterior loop of the internal carotid artery is not exposed. A high-speed drill is used to perform the subtemporal craniotomy and additional bone is removed with a burr to make the craniotomy flush with the floor of the middle fossa. the third division of the trigeminal nerve. Pericranium and fibrin glue (i. posterior circulation. or inverted question-mark. is located beneath the hard white bone of the arcuate eminence at a 120-degree angle to the greater superficial petrosal nerve (Figure 1D). When an anterior petrosectomy is required. Drainage of CSF should not exceed 10 mL per hour to avoid pneumocephalus. combination of thrombin and cryoprecipitate) are placed along the defect in the temporal lobe dura. Clips are placed on the superior petrosal sinus and the sinus is divided. the sinus is thrombosed. is exposed using a high-speed diamond-tipped drill. Drilling begins anterior to the arcuate eminence in the soft bone of the meatal plane to expose the dural sleeve of the internal auditory canal (Figure 1E). and cochlea are not exposed. Selfretaining retractors are placed at the edge of the petrous ridge before drilling the petrous bone. The tentorium is incised with scissors and coagulated using bipolar electrocautery. This position brings the skull base into view and diminishes the need for retraction of the temporal lobe.e. The petrous carotid artery. thus avoiding injury to the geniculate ganglion and cochlea. leaving a superior cuff of fascia for closure.

posterior fossa. and tentorium forms the superior petrosal sinus. The addition of a posterior petrosectomy provides a presigmoid approach with sectioning of the superior petrosal sinus to mobilize the junction of the transverse-sigmoid sinus and protect the vein of Labbé when the temporal lobe is retracted. Under the microscope. Philadelphia: WB Saunders. A lumbar catheter inserted to drain CSF will improve exposure and prevent postoperative CSF leakage. pp 40-43) . positioning for the subtemporal approach.26 NEUROSURGICAL OPERATIVE ATLAS. petrous internal carotid artery. C. E. Vol II. The femoral arterial catheter used for intraoperative angiography is placed prior to positioning the patient in the right lateral decubitus position. van Loveren HR: Atlas of Operative Microneurosurgery. and deep venous structures. enables the surgeon to excise a large area of the tentorium. leaving a superior fascial cuff. The fifth through the 10th cranial nerves can be visualized. respectively. Further exposure may be obtained with sacrifice of conduction hearing by total petrosectomy and sealing the semicircular canals. a line drawn from the tip of transverse crest to the intersection of the carotid artery with the trigeminal nerve (Miller’s line) approximates the basal turn of the cochlea. mastoid tip. Burr holes are made at the anterior mastoid point and asterion. Keller JT: Atlas of Opera tive Microneurosurgery. The area in red represents the location of the DAVM nidus. and descends 3 cm posterior to the ear. The head is rotated until the sagittal sinus is parallel to the floor and is tilted 10 degrees downward so that the zygoma is the highest point in the surgical field (Figure 2C). An axillary roll is used and the thorax is elevated 15 degrees. GSPN = greater superficial petrosal nerve. the bone overlying the transverse sinus is removed with a high-speed drill. occlusion of the dominant transverse-sigmoid sinus worsens venous hypertension and may cause a hemorrhagic venous infarction or postoperative hydrocephalus. F. schematic drawing of the petrous apex DAVM with arterial supply from the tentorial artery and drainage into a petrosal vein with an associated bilobed venous aneurysm. The bone of the sinodural angle is removed with a diamond-tipped drill to expose the Figure 1. The temporal skin flap is reflected inferiorly and the temporalis muscle is reflected separately. the dural reflection of the temporal lobe. under the microscope. and the seventh and eighth cranial nerve complex. B. An inverted question-mark incision (hatched line) is outlined over the temporal squama. Sectioning of the transverse-sigmoid sinus and a labyrinthectomy is not r equired for most posterolateral DAVMs. hatched area represents boundaries of subtemporal craniotomy (1) and anterior petrosectomy (2). A pneumatic craniotome is used to perform the temporal craniotomy (Figure 2D). B reprinted from Tew JM Jr. In our experience. The addition of a suboccipital craniotomy provides a retrosigmoid approach with access to the lower clivus and foramen magnum. 1994. 8 form nidus with multiple draining veins. which are above and below the transverse-sigmoid junction. The mastoid air cells are removed. The patient’s head is placed in a radiolucent Mayfield headrest. Philadelphia: WB Saunders (in press). C-G reprinted from Tew JM Jr. anterior cerebellum. The incision terminates at the insertion of the neck musculature to the skull. the bone overlying the petrous internal carotid artery (ICA) and internal auditory canal (IAC) is removed to define the borders of the anterior petrosectomy. To gain additional exposure of the petrous bone. After the dura is opened. Kawase’s triangle is bounded by the mandibular division of the trigeminal nerve. Thrombosis of the superior petrosal sinus is frequently seen in petrous apex dural arteriovenous malformations. VOL. The cortical bone of the superior semicircular canal forms a 50-degree angle with the IAC. the temporal lobe dura is retracted to visualize the floor of the middle cranial fossa and petrous bone. D. This presigmoid approach gives access to the upper two thirds of the clivus. van Loveren HR. Removal of the bone within this anatomical triangle represents the anterior petrosectomy. The middle fossa and meatal bone plates are dissected until the antrum is identified (Figure 2E). A subtemporal craniotomy with removal of the posterior petrous bone and mastoid minimizes retraction of the temporal lobe. A. the contents of the upper posterior fossa are exposed. G. a J-shaped incision extends vertically from the root of the zygoma crosses the superior temporal line. Solid lines represent bony removal including the suboccipital craniotomy and zygomatic osteotomy. (Figure A reprinted with permission from the Mayfield Clinic. Vol I. after removal of the bone in the meatal plane. Bone overlying the sinus between the burr holes is removed with a drill. and provides access to draining veins and venous aneurysms below the tentorium (Figure 2B). The vein drains into the contralateral superior petrosal sinus. removes the transosseous arterial supply. and brainstem.

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B

A
GSPN

C

E

ICA

IAC

Kawase’s triangle

D

cochlea Miller’s line

F

G
CN V CN VIII

geniculate ganglion transverse crest

CN IV

superior petrosal sinus

Figure 1.

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anterior border of the sigmoid sinus and the posterior semicircular canal. The mastoid air cells of the mastoid tip are then removed to expose the posterior fossa dura and digastric ridge, which serves as a landmark to the stylomastoid foramen, the beginning of the fallopian canal, and the location of the facial nerve (Figure 2F). Thirty milliliters of CSF are removed and a dural incision is made from the posterior fossa (inferior to the superior petrosal sinus), to the middle fossa, and up to the petrous apex. The superior petrosal sinus is divided with clips. Under the microscope, the tentorium is divided toward the incisura directed posterior to the trochlear nerve (Figure 2G). The leaves of the tentorium are coagulated with bipolar electrocautery to obtain hemostasis and to shrink and retract the dura. Feeding arteries entering the tentorium are coagulated with bipolar electrocautery and cut with microscissors. Frameless stereotaxis may be useful to guide the approach and corroborate location of the DAVM in the tentorium. After excising the dura leaflet, the draining veins are coagulated and divided. In addition to documenting obliteration of the DAVM, intraoperative angiography reveals residual DAVMs, which cannot be visualized because they are concealed by cavernous and tentorial dura. Placing a metal clip at the operative site provides information on the intraoperative angiogram regarding the relative position of the remaining nidus to the skull base. A free abdominal fat graft used to close the defect in the mastoid and temporalis muscle is split to cover the mastoid defect. The bone flap and zygo-

matic bone are secured with titanium plates. The temporalis and cervical muscles are reattached to their respective fascial cuffs. The lumbar catheter is connected to a closed drainage system for 24 to 72 hours with the level set at the external auditory canal. CSF drainage should not exceed 10 mL per hour. A compression dressing is applied.

DAVMs of the inferior petrosal sinus are often supplied by the ascending pharyngeal artery, occipital artery, posterior meningeal artery, and muscular branches of the vertebral artery (Figure 3). The posterior auricular artery and meningohypophyseal trunk may contribute to the arterial supply. The arteriovenous connection commonly occurs at the end of the inferior petrosal sinus near the jugular bulb. Venous drainage is antegrade through the internal jugular vein or spinal medullary veins and may also occur retrograde through cortical veins into the transverse-sigmoid or cavernous sinuses (Figure 4A and B). Lower clivus and foramen magnum DAVMs gain supply from the posterior meningeal, meningojugular, occipital, and anterior spinal arteries, as well as the muscular branches of the vertebral artery. Drainage is into either the spinal medullary veins or the mesencephalic veins that drain toward the vein of Galen and straight sinus. A right far lateral suboccipital craniotomy is required to isolate the transverse-sigmoid sinus and jugular bulb, visualize the ventral brainstem

DAVMs of the Inferior Petrosal Sinus

Figure 2. DAVM of the posterolateral tentorium. A, arterial supply from the intracavernous carotid artery branches and external carotid artery supply. Venous drainage flows into mesencephalic and cerebellar veins. B, hatched area represents boundaries of the subtemporal, suboccipital, and posterior petrosectomy. The dotted area represents sigmoid and transverse sinuses exposed but not sacrificed. The area in red represents the location of the DAVM nidus. C, positioning for the posterior petrosectomy. D, the temporalis muscle is reflected anteroinferiorly, leaving a superior fascial cuff. Burr holes placed on either side of the transverse sinus reduce the risk of injury to the sinus. The bone between the burr holes is removed with a burr. A pneumatic craniotome is used to per form the craniotomy. E, the spine of Henle is a landmark to the antrum. The antrum floor is the cortical bone of the lateral semicircular canal, which serves as a guide to deeper structures. The mastoid air cells are removed, and the middle fossa and meatal bone plates are dissected until the antrum is identified. F, the bone of the sinodural angle is removed with a diamond-tipped drill. The sigmoid sinus and posterior semicircular canal are exposed. The posterior semicircular canal is identified by following the lateral semicircular canal until it bisects the posterior semicircular canal. The mastoid air cells of the mastoid tip are then removed to expose the digastric ridge, which serves as a landmark to the stylomastoid foramen and the beginning of the fallopian canal. Removal of the sigmoid plate exposes the superior petrosal sinus. G, the superior petrosal sinus is divided and the tentorium is incised ventrally toward the incisura in a course toward the trochlear nerve. The feeding arteries and dural nidus are encountered along the path to the incisura. (Figure A reprinted with permission from the Mayfield Clinic; B reprinted from Tew JM Jr, van Loveren HR, Keller JT: Atlas of Operative Microneurosurgery, Vol II. Philadelphia: WB Saunders (in press); C-G reprinted from Tew JM Jr, van Loveren HR: Atlas of Operative Microneurosurgery, Vol I. Philadelphia: WB Saunders, 1994, pp 40, 45, 47-49, 51)

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B

C A D

E

spine of Henle

lateral semicircular canal

transversesigmoid junction

sigmoid sinus fallopian canal

F

G

superior petrosal sinus tentorium CN IV

Figure 2.

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A

B

Figure 3. Thrombosis or stenosis of a major sinus may cause retrograde flow into cortical veins. A, right anterior posterior vertebral artery angiogram demonstrating a DAVM of the inferior petrosal sinus with stenosis of the right internal jugular vein and venous drainage through the contralateral transverse-sigmoid sinus into the left internal jugular vein. B, lateral vertebral angiogram demonstrating retrograde venous drainage into the superior sagittal sinus and vein of Galen via the straight sinus. (Reprinted with permission from Lewis AI, Rosenblatt SS, Tew JM Jr: Surgical management of deep-seated dural arteriovenous malformations. J Neurosurg 87:198-206, 1997)

Figure 4. DAVM of the inferior petrosal sinus. A, the inferior petrosal sinus DAVM is fed by both posterior meningeal arteries and muscular branches from both vertebral arteries. The occipital artery is causing the constriction of the right internal jugular vein. The jugular bulb is dilated and arrows within the lumen of the dural sinuses show that venous drainage is retrograde. B, hatched area represents boundaries of the far lateral suboccipital approach. The area in red represents the location of the DAVM nidus. C, a lateral hemisphere incision is outlined over the suboccipital bone and cervical spine. The hatched line represents the scalp incision. The solid line represents the bony removal including the suboccipital craniotomy, opening the foramen magnum, laminectomy of the posterior arch of C1, and partial resection of the posteromedial condyle. D, mastoid emissary veins and the epidural venous plexus may be arterialized. Hemostasis of these veins is best achieved with bipolar electrocautery or compression with Oxycel or other hemostatic agent. E, the posterolateral one third of the occipital condyle is removed with a high-speed diamond-tipped drill. F, after removal of the posterior arch of C1, the extradural horizontal segment of the vertebral artery is mobilized out of the vertebral groove on C1 to obtain proximal control of the primary arterial supply to the DAVM. G, the posterior fossa and spinal dura are reflected laterally with dural retention sutures. An incision begins in the spinal arachnoid and proceeds through the cisterna magna while cerebrospinal fluid is aspirated. (Figure A reprinted with permission from the Mayfield Clinic; B, D-F reprinted from Tew JM Jr, van Loveren HR, Keller JT: Atlas of Operative Microneurosurgery, Vol II. Philadelphia: WB Saunders (in press); C and G reprinted from Tew JM Jr, van Loveren HR: Atlas of Operative Microneurosurgery, Vol I. Philadelphia: WB Saunders, 1994, pp 69 and 72)

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B

C D

A

E

occipital condyle

vertebral artery

vertebral venous plexus

G F
cisterna magna foramen transversarium vertebral artery mobilized

C2 nerve root

Figure 4.

the right hemisphere is dependent. The far lateral exposure isolates the vertebral artery. for a right occipital approach. middle meningeal. The head is rotated 45 degrees from parallel toward the floor and flexed until the posterior neck muscles are stretched but not tight. The surrounding venous plexus and vertebral muscular branches are coagulated and divided using bipolar electrocautery (Figure 4D). fascia lata. An occipitocervical fusion is not necessary if only one third of the condyle has been removed. or other dural substitutes are used to close the dural defect. The straight sinus is frequently thrombosed and a vein of Galen aneurysm is present. The wall of the aneurysm remains in situ to avoid injury to the brainstem. Fourth. The tentorial and falx dura are coagulated and cut to eliminate the remaining meningeal arterial supply. Arterial supply from branches of the superficial temporal artery are coagulated during the opening and approach to the vein of Galen DAVM (Figure 6F). bilateral approaches can be achieved by sectioning the falx and retracting the contralateral hemisphere. which is anteromedial to the jugular bulb. and resect the involved dural segment. The vertex becomes the highest point in the operative field (Figure 6C). The resected tentorium and falx dura overlying DAVMs of the Vein of Galen . The femoral arterial sheath for intraoperative angiography is inserted before the patient is placed in the lateral oblique position. The trajectory is posterior to the splenium of the corpus callosum. A cuff of nuchal fascia and splenius capitis muscle is preserved to reapproximate the cervical musculature during closure. The head is placed in a radiolucent Mayfield headrest to permit intraoperative angiography. Additional bone is removed in the mastoid region with a burr. behind the splenium of the corpus callosum and above the internal cerebral veins and the vein of Galen. and dural opening assist with the elimination of the arterial supply over the convexity. The feeding branches to the nidus are coagulated and the dural leaflet is excised. VOL.32 NEUROSURGICAL OPERATIVE ATLAS. Dissection continues from medial to lateral until the foramen transversarium is identified. The interhemispheric trajectory places the neurosurgeon at the falx-tentorial junction. The skin flap is reflected inferiorly. Bovine pericardium. This exposure provides a caudal-to-rostral and lateral-to-medial field of view for DAVMs of the inferior petrosal sinus and lower clivus. A subperiosteal dissection of the lamina of C1 and C2 is performed 2 cm lateral to the midline. After induction of general endotracheal anesthesia. the head is placed in neutral position. Second. The suboccipital bone is removed in one piece with the fascial cuffs attached using a pneumatic drill. an interhemispheric approach is used (Figure 6A and B). A femoral arterial sheath is inserted before positioning the patient in a left lateral oblique position. The intracranial vertebral artery is identified and followed to the nidus. in most cases. The lateral portion of the foramen magnum and the posteromedial third of the occipital condyle are removed with a diamondtipped drill (Figure 4E). and superficial temporal arteries. This incision allows dissection of the extracranial vertebral artery and exposes the suboccipital bone. the remaining dural arterial supply is eliminated by excising the falx and tentorium surrounding the nidus. The mastoid process is the highest point. The skin flap is reflected toward the transverse sinus and the dura is opened in cruciate fashion (Figure 6E). The arterial supply of midline DAVMs is often bilateral from the tentorial. 8 and lower clivus. mastoid region. the thrombus within the venous aneurysm is removed to decompress the mesencephalon. are responsible for hemorrhage or obstructive hydrocephalus (Figure 5). A right posterior parasagittal craniotomy is performed for midline DAVMs (Figure 6D). craniotomy. The dura is opened in the midline at C1 and extended laterally up to the transverse-sigmoid sinus (Figure 4G). A midline suboccipital incision is performed from the spinous process of C2 toward the superior temporal line and inferior to the mastoid tip (Figure 4C). which is the primary arterial supply to most posterior fossa DAVMs. Division of the feeding arteries as they enter the DAVM is important to avoid occluding vessels of passage. Bone overlying the foramen transversarium is removed with a diamond-tipped drill to mobilize the vertebral artery (Figure 4F). The bone flap is replaced with plates and a standard closure with reapproximation of the nuchal fascia is performed. Sharp dissection of the soft tissues between the foramen magnum and the arch of C1 identifies the vertebral artery as it pierces the dura. the scalp incision. The arachnoid is opened and the tentorial arteries from both meningohypophyseal trunks are coagulated and divided. An axillary roll is placed and the thorax is elevated 15 degrees. the patient’s head is placed in a radiolucent Mayfield headrest for intraoperative angiography. The arch of C1 is removed with a rongeur or drill. and deep venous structures. Venous drainage is via cerebellar and vermian veins. First. Third. arterial branches from the meningohypophyseal trunk and posterior cerebral arteries are coagulated and cut as they enter the vein of Galen aneurysm. Because DAVMs of the vein of Galen and falx-tentorial junction are midline. leaving a superior fascial cuff. Venous aneurysms are very common and. A lumbar catheter is optional. There are four major steps in the operation.

vein of Galen DAVMs). A. however. Intraoperative angiography is useful to identify a residual DAVM. postoperative angiography with selective injection of the external carotid artery and venous phase images should be performed to confirm complete DAVM obliteration. and plan the operative approach based on the relationship of the nidus to the surrounding brain structures. Ligating the draining veins prior to obliterating the arterial supply may lead to devastating hemorrhagic venous infarction.g. The capsule is left in situ to prevent injury to the brain stem from excessive manipulation. T1-weighted axial MR image showing a partially thrombosed vein of Galen aneurysm with edema in the right subcortical nuclei due to venous hypertension. B. Patients may develop transient. Thrombus within the aneurysm is removed with an ultrasonic aspirator to decompress the mesencephalon. Thrombus within the venous aneurysm can be removed to decrease mass effect. (Reprinted with permission from Lewis AI. In addition. the aneurysm wall should be left in situ to avoid injury to the surrounding brain (e. . Surgical obliteration of a DAVM requires coagulation of the dura followed by excision of the dural leaflet to prevent the fistula from redirecting into another location or diverting flow into nonarterialized veins. T1-weighted sagittal MR image showing the DAVM posterior and inferior to the splenium of the corpus callosum. 1997) the vein of Galen aneurysm is removed with scissors. Rosenblatt SS. The presumed cause of the delayed postoperative deterioration is the exacerbation of preoperative venous hypertension. clipping or removing the venous aneurysm is unnecessary because it will collapse and thrombose when the DAVM nidus is obliterated. J Neurosurg 87:198-206. delayed neurological worsening. An interhemispheric approach with a parieto-occipital trajectory avoided sectioning the corpus callosum. Tew JM Jr: Surgical management of deep-seated dural arteriovenous malformations. identify thrombus within the venous aneurysm. MR imaging and MR angiography are performed to identify the source of hemorrhage. Patients may also require postoperative ventriculoperitoneal shunting for OUTCOME AND COMPLICATIONS communicating hydrocephalus after SAH or preoperative shunting for obstructive hydrocephalus caused by giant venous aneurysms.. However. follow the ventricular size.LEWIS AND TEW : SURGICAL REMOVAL OF TENTORIAL AND POSTERIOR FOSSA DAVMS 33 A B Figure 5.

superficial temporal artery. Philadelphia: WB Saunders (in press)) . Vol II. the risk of air embolism is significantly reduced compared with the sitting position. E. Also. 8 B C A D feeding arteries E vein of Galen aneurysm F occluded straight sinus Figure 6. the affected side is positioned down to allow the hemisphere to retract with the aid of gravity. van Loveren HR. in the dependent position. There are a paucity of bridging veins to the sagittal sinus in this location. VOL. F. and superficial temporal artery. Schematic drawing of the falx-tentorial DAVM with bilateral arterial supply from the meningohypophyseal trunk.34 NEUROSURGICAL OPERATIVE ATLAS. the venous drainage is into a partially thrombosed vein of Galen aneurysm and the right basal vein of Rosenthal. the area in red represents the location of the DAVM nidus along the tentorium and falx. C. A. (Figure A reprinted with permission from the Mayfield Clinic. Figures B-F reprinted with permission from Tew JM Jr. Coagulation of the feeding arteries is performed as they enter the vein of Galen DAVM. D. Keller JT: Atlas of Operative Microneurosurgery. the site of the bone flap is shown. minimal retraction of the occipital lobe is required to expose the falx-tentorial junction. a cruciate incision is performed to retract the dura toward the sagittal sinus. B. This position is more comfortable than the sitting position because it allows the surgeon to use both hands side-by-side.

and the ease or difficulty of surgical resection. Attempts at classifying cerebral hemispheric AVMs has met with limited acceptance. 2) the cerebellar hemisphere. We subdivide posterior fossa AVMs into lesions involving the following: 1) the cerebellar vermis. and intraventricular hemorrhage are the most common presenting findings of patients newly diagnosed with posterior fossa AVMs. The natural history of these lesions left untreated is poor because of the high incidence of hemorrhage and the neurological deterioration associated with AVMs of the posterior fossa. This classification system accurately predicts the vascular supply to the lesion.D. AVMs of the cerebellar vermis are some of the most common vascular malformations found in the posterior fossa. most patients newly diagnosed with an AVM of the cerebellum or brainstem benefit from surgical treatment directed at eliminating the lesion and preventing future hemorrhage. These five groups lend predictability to the anticipated vascular supply. For this reason. but may also present with progressive neurological deterioration or cranial neuropathy. venous drainage. They are more likely to become symptomatic than supratentorial AVMs because of the concentration of vital neurological structures within the limited confines of the posterior fossa. INTRODUCTION Accurate classification of an AVM in the posterior fossa is necessary to guide preoperative planning and the optimal surgical treatment. and aids in determining the necessity of adjunctive preoperative embolization. it is extremely rare for AVMs to simultaneously involve both the cerebellum and the brainstem. M. Infratentorial AVMs commonly present with hemorrhage. Approximately 20% of all arteriovenous malformations (AVMs) of the brain occur in the posterior fossa.SURGICAL RESECTION OF ARTERIOVENOUS MALFORMATIONS OF THE POSTERIOR FOSSA THOMAS KOPITNIK.D. M. but invariably the lesion is confined to the cerebellar tissue or the brainstem tissue. we will focus on AVMs involving the cerebellum. 3) the cerebellar tonsil. MICHAEL HOROWITZ.D. The primary arterial supply to vermian AVMs is usually via the superior cerebellar arteries (SCAs) and the posterior inferior cerebellar 35 . Mixed intraparenchymal. Because 95% of posterior fossa AVMs are confined to the cerebellum and only 5% are true brainstem lesions. 4) the pial surface of the brainstem. and 5) the deep parenchyma of the brainstem. due in part to the variability of most AVM CLASSIFICATION © 1999 The American Association of Neurological Surgeons supratentorial lesions and the complexities of the proposed classification systems. DUKE SAMSON. Large AVMs of the cerebellum may appear to involve the entire contents of the posterior fossa. M. subarachnoid. Despite the complexity of the posterior fossa. not both. We classify AVMs of the posterior fossa into five groups relative to the involved brain tissue and blood supply. aids in preoperative planning including the optimal surgical approach.

36 NEUROSURGICAL OPERATIVE ATLAS. The arterial feeding to tonsillar AVMs is usually via a unilaterally dilated PICA with occasionally some secondary feeding from distal inferior branches of the AICA if the lesion extends into the cerebellar hemisphere (see Figure 6B). Unlike ruptured cerebral aneurysms presenting with subarachnoid hemorrhage. Surgical resection of the AVM without treatment of a proximal saccular aneurysm markedly increases the risk of aneurysm rupture due to an abrupt increase in arterial pressure within the feeding vessel as surgical resection of the AVM is performed. Failure to treat a proximal aneurysm may result in catastrophic subarachnoid hemorrhage after an AVM is removed distal to an aneurysm. These aneurysms usually occur distally along the major feeding vessels to the AVM nidus. Small pre-aneurysmal dilatations on the intracranial vertebral or basilar artery are frequently found in association with large cerebellar AVMs and do not usually require treatment. the anterior inferior cerebellar artery (AICA) often provides deep lateral feeding to larger and deeper vermian AVMs through branches of the AICA. 8 arteries (PICAs) bilaterally (see Figure 2C). with the dominant supply depending largely on the specific hemispheric location of the lesion (see Figure 5C). Venous drainage can be lateral into the sigmoid sinus but is more common into the midline inferior vermian veins. the patient’s age. Pial AVMs of the brainstem do not usually present on the ventricular surface and have superficial representation of both arterial supply and venous drainage. These deep branches of the AICA enter the foramen of Luschka and supply the lateral roof of the fourth ventricle and middle cerebellar peduncle. uvula. Ventricular involvement is common and venous drainage is via periependymal venous channels that ultimately connect into the galenic system. AVMs within the cerebellar hemisphere usually have venous drainage superiorly and laterally into the petrosal system or superiorly into the galenic system. Similarly. pyramid. and PICA). Although AVMs of the cerebellar hemisphere may partially involve the middle cerebellar peduncle. Although the SCA and PICA provide the majority of arterial input to vermian AVMs. and intraventricular hemorrhage. subarachnoid. and nodulus typically derive the dominant arterial supply from the PICA bilaterally and the SCA to a much lesser extent. AVMs occurring superior to the horizontal fissure and involving the folium. with a majority of the hemorrhage usually within the PATIENT SELECTION AND TIMING OF INTERVENTION . VOL. Vermian AVMs usually drain superiorly into the galenic system through the precentral cerebellar vein or through superior vermian veins bridging into the tentorium. Brainstem AVMs are usually small and should be further subgrouped into superficial lesions confined to the pia or the deep parenchyma. Conversely. The cerebellar hemisphere also represents a common location of cerebellar AVMs due to the relatively large anatomical region represented by the cerebellar hemisphere. On the other hand. The superficial pial lesions are usually supplied by dilated branches of the SCA or AICA and drain into the prepontine or petrosal venous system. life expectancy. the more arterial input from the SCA can be anticipated. Cerebellar AVMs confined to the cerebellar tonsil occur less frequently and are limited in size by the nature of their location. proximal saccular aneurysms associated with an AVM should be treated prior to or in conjunction with treatment of the AVM. If angiography demonstrates prominence and significant feeding from the deep branches of the AICA. culmen. Because of the natural history of untreated AVMs and the limited tolerance of the posterior fossa contents to hemorrhage. general medical condition. AICA. AVMs below the horizontal fissure within the tuber. the more prominent the supply from the AICA. declive. AVMs of the cerebellum are usually sharply demarcated and distinct from AVMs of the brainstem. The dominant arterial feeding supply of either the SCA or the PICA distribution depends upon the anatomical location of the vascular malformation within the vermis relative to the horizontal fissure. and lingula usually have significant arterial input from the vermian branches of the SCA and lesser input from the PICAs. the more superior the malformation is located within the cerebellar hemisphere. central lobule. As potential treatment options are contemplated. and neurological status are considered together. Aneurysms commonly occur on the major feeding vessels associated with posterior fossa AVMs and are often the source of both intraparenchymal and subarachnoid hemorrhage. The arterial supply to AVMs of the cerebellar hemisphere is unilateral and typically involves all three vascular territories (SCA. the estimated risk of future hemorrhage. the AVM usually involves the lateral aspect of the ventricular wall and middle cerebellar peduncle. Brainstem AVMs are rare lesions that pose unique challenges to treatment and should be classified as separate and distinct entities from cerebellar AVMs. deep parenchymal AVMs of the brainstem are rarely seen ominous lesions with arterial supply usually through deep vertebrobasilar perforator vessels into the ventral aspect of the malformation. most patients with cerebellar AVMs should undergo treatment aimed at eliminating the vascular malformation. The closer the AVM is located to the cerebellopontine angle (CPA) cistern. AVMs of the cerebellum typically present with mixed intraparenchymal.

angiographic opacification of the contralateral vertebral artery will yield valuable information regarding feeding to the lesion that is often obscured during ipsilateral vertebral angiography due to overlap and prominence of an individual feeding pedicle. CT is useful for determining the size and configuration of an initial hemorrhage. complete hemostasis unfortunately cannot be obtained until the AVM has been resected. We prefer to defer definitive AVM resection for 4-6 weeks following a significant posterior fossa hemorrhage if the patient’s neurologi- cal condition remains stable. Patients with posterior fossa and intraventricular hemorrhage may rapidly deteriorate due to acute obstructive hydrocephalus and should either be treated with external ventricular drainage or undergo close neurological observation to detect early deterioration from acute hydrocephalus. Once a hematoma cavity begins to resolve and liquefy. operative intervention is best delayed for 4-6 weeks until a portion of the intraparenchymal clot has liquefied and the peak time for parenchymal edema has passed. Patients often tolerate large hematomas of 5-6 cm without significant neurological sequelae if hydrocephalus is adequately treated. Occasionally. Despite a lesion lateralized to one cerebellar hemisphere. potential improvement of the patient’s preoperative neurological status. If an arteriogram has been obtained in the presence of a large intraparenchymal hematoma. Following cerebral angiography. The surgeon must therefore be prepared to potentially encounter an AVM significantly larger than the lesion visualized on an arteriogram obtained shortly after the initial hemorrhage. If the patient is neurologically stable. and some degree of obstructive hydrocephalus. If surgery is required acutely following AVM hemorrhage. respectively. An adequate bone flap should be fashioned to accommodate cerebellar swelling and possible hemorrhaging from the malformation during resection. both vertebral arteries must be studied individually. and time for extensive radiological investigation of the vascular lesion. When an acute posterior fossa hemorrhage occurs from a suspected cerebellar AVM. the surgical resection is greatly facilitated. if present. Diagnostic cerebral angiography. This delay in operative intervention allows for liquefication of the clot. due to the location of the clot. Potential adjunctive preoperative embolization can be planned only after completion and careful review of the diagnostic arteriogram. accompanied by large bony craniectomy and duraplasty. and for sequential follow-up study of hemorrhage resolution. is the definitive diagnostic test. The information obtained from these computer renderings does not replace high-quality angiography or multiplanar MR imaging. Repeat arteriography prior to the delayed surgical procedure often reveals portions of the AVM that were not apparent on the initial arteriogram. Spiral CT shows great potential for future study of complex vascular lesions due to the relatively quick acquisition times and threedimensional spacial reconstruction capability. the hematoma may compress and partially obscure a significant portion of the AVM during angiography. clot evacuation without AVM resection should be performed if possible and. several factors must be considered. If the patient’s neurological condition has deteriorated to such an extent as to warrant emergency posterior fossa exploration and clot evacuation. We reserve acute emergency surgical intervention only for patients with a potentially recoverable posterior fossa hemorrhage who are either moribund despite external ventricular drainage or deteriorate neurologically during a period of observation. and the limits of a planned resection margin. the next consideration is whether an associated hematoma is producing significant mass effect within the posterior fossa and whether emergency clot evacuation is required. there is limited indication for CT angiography (spiral CT) or MR angiography in the management of a posterior fossa AVM. Preoperative embolization of selected feeding vessels can be of significant benefit prior to a surgical PREOPERATIVE PREPARATION AND RADIOLOGICAL EVALUATION . MR imaging will demonstrate the degree to which AVMs of the cerebellar vermis may involve the superior medullary velum or whether large hemispheric and tonsillar AVMs involve the middle and inferior cerebellar peduncles. If hydrocephalus has been adequately treated or is not present. if necessary. There are few other lesions in vascular neurosurgery where the surgeon’s conceptualization of the normal and pathological anatomy is as critical as in the surgical management of posterior fossa AVMs. the subtle involvement of adjacent structures. The volume of subarachnoid blood is usually underestimated on computed tomography (CT) due to the bony confines of the posterior fossa and the poor parenchymal resolution obtained with routine CT techniques.KOPITNIK ET AL : SURGICAL RESECTION OF AVMS OF THE POSTERIOR FOSSA 37 cerebellar parenchyma. MR imaging provides information to aid in determining the anatomical limits of the AVM. Anticipation of this possible eventuality should be factored into the decision-making process when emergency clot evacuation is considered. which includes injection of both internal carotid and both vertebral arteries. one of the first considerations must be whether external ventricular drainage is immediately necessary. For complete evaluation of posterior fossa AVMs. Complete angiographic evaluation combined with high-quality multiplanar magnetic resonance (MR) imaging is crucial to preoperative planning. At the present time.

This axiom usually requires a customized removal of bone to include the foramen magnum for caudal lesions and exposure of the transverse sinus and torcula for superiorly located vermian lesions. The table is rotated so the patient’s head is aligned to the surgeon’s preference with regard to operating room orientation (Figure 1B). Although em- . with no portion of the AVM concealed beneath bone. bolization of the SCA territory does not eliminate the necessity for dissection over the cerebellar tentorial surface. it is also the most surgically accessible vessel within the posterior fossa and can almost always be surgically transected immediately adjacent to the AVM nidus. to avoid iatrogenic ischemia to exceptionally vulnerable tissue such as the brainstem. The patients are positioned prone on chest rolls with the neck flexed. which typically have significant SCA supply. Feeders such as these are difficult to access early in the procedure and can be a significant source of hemorrhage deep in the resection bed late in the operative procedure. This avoids initial dissection around fragile arterialized venous structures prior to surgical transection of other more accessible feeding vessels early in the procedure. VOL. with preoperative embolization of the SCA territory. Embolization is not without inherent risk and an estimated 5% morbidity to overall patient management risk is introduced with each embolization procedure. Prior to initiating resection of the AVM. which is not easily accessible early in an operative resection of the lesion. and lateral margins of the AVM can be easily visualized. We embolized nine brainstem AVMs prior to the attempted surgical resection of 23 such lesions and found an unacceptably high morbidity rate with preoperative embolization of these dangerous lesions. A wide stellate durotomy is performed in a fashion to optimize posterior fossa exposure (Figure 2A). much closer to the nidus than can be routinely achieve with an embolization catheter. The vascular supply to these extremely rare lesions is best accessed surgically as close to the malformation as possible. 8 floor Figure 1. The patient’s head is then laterally canted toward the shoulder contralateral to the side of the operating table where the surgeon will stand. The operating room table is placed in extreme reverse Trendelenburg position to bring the patient’s nuchal region horizontal with respect to the floor. lateral (A) and superior (B) views. and the patient’s lower extremities and knees are padded and flexed against table support to prevent caudal movement (Figure 1A). this dissection can be done late in the operative procedure when a portion of the arterial pressure has been eliminated from the venous structures and exposure of the superior aspect of the cerebellum has been maximized. Obscuring a margin of the AVM by poor bony exposure can limit the ability to control hemorrhage during the procedure. SURGICAL TECHNIQUE AVMs of the cerebellar vermis are midline lesions and are best approached via a midline exposure. Vermian AVMs can be resected via a large midline incision extending from above the inion to the C3-4 region. We prefer the prone-concord position for patients undergoing resection of vermian AVMs. inferior. Because large cerebellar AVMs and small AVMs superior to the horizontal fissure typically have venous drainage directed superiorly into the galenic system. AVMs of the Cerebellar Vermis procedure to resect a posterior fossa AVM. Prone-concord position used for midline exposure of a posterior fossa AVM. On the other hand. Patients with brainstem AVMs are not ideal candidates for adjunctive embolization.38 NEUROSURGICAL OPERATIVE ATLAS. the superficial margins of the malformation are inspected to ensure that the bony removal and dural opening have been adequate and that subsequent AVM resection can proceed unhindered. Preoperative embolization of deep AICA feeding arteries to large vermian or cerebellar hemispheric AVMs can significantly lessen the difficulty with intraoperative bleeding from along the roof of the fourth ventricle. preoperative SCA embolization aids the surgical resection and requires less initial dissection over the tentorial surface of the cerebellum early in the procedure. Embolization should be directed primarily at deep arterial feeding to the AVM. A large craniotomy bone flap is elevated such that the superior. Aggressive embolization of SCA feeders distal to the dorsal aspect of the brainstem can be very helpful prior to a planned surgical resection of superiorly located cerebellar AVMs. although the PICA may be easily accessed with an embolization catheter. regardless of the location of the lesion within the vermis.

A.KOPITNIK ET AL : SURGICAL RESECTION OF AVMS OF THE POSTERIOR FOSSA 39 A B C Figure 2. C. exposure. B. AVM of the cerebellar vermis. . clip ligation of the PICA bilaterally adjacent to the nidus. schematic representation of the arterial supply and venous drainage.

deeper stages of the resection from small but often numerous periependymal feeders. The initial microdissection of a vermian AVM is directed at accessing both PICAs within the subarachnoid space at the midline and dissecting the vessels to their entrance into the inferior aspect of the malformation (Figure 2C). After superficial feeding has been eliminated. Superficial dissection along the superior margin is then performed with caution so as not to jeopardize rostral venous outflow from the AVM. the patient is best placed in the park-bench lateral position (Figure 3B). and surgeon preference. Venous drainage of vermian AVMs is usually directed superiorly through the dilated superior vermian or precentral cerebellar venous system (Figure 2B). If the patient is very large or has limited range of motion of the cervical spine. The venous outflow is transected only after the AVM resection has been completed and the lesion is ready to be delivered from the operative field. We prefer the lateral position for most operative procedures involving AVMs of the cerebellar hemisphere. The patient can usually be positioned supine with a blanket-roll under the ipsilateral shoulder and hip and the head positioned lateral and horizontal with respect to the floor (Figure 3A). This will eliminate possible superficial AICA feeding to the malformation. and access to the CPA cistern is imperative to surgically control this blood supply to the AVM. After PICA feeding has been eliminated. Vertex view of the patient for the lateral (A) and park-bench lateral (B) positions. To resect cerebellar hemispheric AVMs. especially in a large patient. The optimal surgical approach and operative patient positioning for AVMs involving the cerebellar hemisphere is greatly dependent upon the size of the malformation. which is usually minimal in all but large vermian AVMs. AVM of the cerebellar hemisphere. the necessity for exposure of the CPA cistern. The disadvantage of the park-bench lateral position is that the ipsilateral shoulder can decrease the working room of the operative field. The distal PICA arterial supply to the AVM is divided as close to the nidus as possible to minimize iatrogenic infarction of adjacent but uninvolved cerebellar tissue. It is advisable to protect the floor of the fourth ventricle with a soft cotton strip so that if bleeding occurs during later. VOL. we generally use a large C-shaped incision centered on the mastoid process and elevate a large subgaleal-subcutaneous skin flap (Figure 4A). The majority of the posterior cervical muscles are detached from the occiput and reflected posteriorly and inferiorly (Figure 4B).40 NEUROSURGICAL OPERATIVE ATLAS. circumferential dissection of the superficial pial margin of the AVM from an inferior to superior direction is performed on each lateral margin. the location of the lesion within the hemisphere. the lesion can be expediently removed without inadvertently injuring the floor of the fourth ventricle. continued feeding to the AVM is usually present through deep SCA and deep lateral AICA feeders within the superior medullary velum and lateral roof of the fourth ventricle. In order to AVMs of the Cerebellar Hemisphere . 8 Figure 3. Most lateral cerebellar hemispheric AVMs have significant blood supply from the AICA. which is typically through the superior vermian venous system.

If troublesome bleeding occurs during resection from deep periependymal feeding vessels. Similarly. large cerebellar hemispheric AVMs have deep arterial supply from deep branches of the AICA along the lateral aspect of the roof of the fourth ventricle and superior medullary velum (Figure 5B). there is a high likelihood of AICA feeding along the deep margin of the AVM. and posteromedial extents of the bony resection depend on the size and location of the AVM. but sufficient bone must be removed so that exposure is adequate and dissection unhindered (Figure 4C). Surgical resection of AVMs of the lateral cerebellar hemisphere. The PICA can be identified caudally in proximity to the cerebellar tonsil and followed to its point of entry into the malformation. expedient entry into the fourth ventricle allows the surgeon to access the periependymal feeding from the AICA supply proximally as the vessels enter the foramen of Luschka. The superior. Often. On review of a preoperative MR image. . C. skin incision. we extend the lateral extent of the bony craniotomy to the level of the sigmoid sinus laterally. A.KOPITNIK ET AL : SURGICAL RESECTION OF AVMS OF THE POSTERIOR FOSSA 41 Figure 4. By working around the venous structures and undercutting the cerebellar tissue under the venous drainage. or partially involves the middle cerebellar peduncle. the major feeding from the hemispheric SCA branches can be transected close to the malformation without compromising the venous drainage (Figure 5C). bone removal (shaded area). maximize exposure of the CPA cistern. After the dura has been widely opened and the malformation inspected to confirm the location of the major arterial feeders and the venous drainage. Occasionally. inferior. the AICA is identified in the CPA cistern and dissected to its entry into the AVM where it is ligated and divided. the primary initial task is to microdissect and transect the arterial feeders as close to the nidus as possible (Figure 5A). scalp and muscle reflected. the deep supply from the SCA to cerebellar hemispheric AVMs is partially obscured by the superiorly and laterally draining venous outflow of the malformation. if the AVM presents or is immediately adjacent to the fourth ventricle. B. where it is transected.

exposure. AVM of the cerebellar hemisphere. schematic representation of the arterial supply and venous drainage. B. . 8 B A C Figure 5. C. VOL.42 NEUROSURGICAL OPERATIVE ATLAS. transection of SCA feeding to an AVM close to superiorly located venous drainage. A.

more commonly. and inferiorly to include the foramen magnum. The surgical resection of these lesions is usually associated with considerable and persistent deep arterial bleeding that can only be managed by cautery and careful. These malformations are extremely rare and can present with intraparenchymal or subarachnoid hemorrhage or a variety of fluctuating neurological symptoms. the feeding vessels to the malformation are identified and sequentially transected. and minimally involve the underlying parenchyma. The margins of the malformation are identified and the lesion is circumferentially dissected until the small feeding vessels at the depths of the resection bed are reached. the posterior arch of C1 must be removed to completely expose the caudal extent of tonsillar AVMs (Figure 6A). With sequential occlusion of the smaller feeding vessels entering the malformation. it is usually simple and expedient to perform a limited tonsillar resection in order to remove the AVM. Superficial brainstem AVMs that involve the anterior surface of the brainstem usually have no deep perforator feeding. The venous drainage of AVMs involving the cerebellar tonsil is either lateral into the sigmoid sinus or. The complexity of pial AVMs of the lateral brainstem in conjunction with the limited space available in the CPA usually precludes complete circumferential dissection during the initial phases of AVM resection. it is often necessary to gently elevate the nidus away from the brainstem within a shallow plane of pial dissection beginning posterolaterally and continuing anteromedially along the ventral surface of the brainstem (Figure 10). medulla. The small size of the feeding vessels along with their irrigation of adjacent normal tissue makes adjunctive embolization difficult and minimally successful. Deep parenchymal brainstem AVMs often involve the floor of the fourth ventricle. AVMs confined to the tonsil are relatively rare but easy to resect. and the arterial supply to these malformations cannot be accessed beyond the margins of the AVM without significant risk of iatrogenic ischemia and infarction of adjacent normal brainstem parenchyma. surgical resection can be accomplished by working within the resolving hematoma cavity without significant disruption of normal brainstem tissue. Under high-power magnification. when the lesion is small and associated with an intraparenchymal hematoma. Bone is removed laterally to the sigmoid sinus. persistent microdissection. and venous drainage is usually through dilated periependymal veins into the galenic venous system. and CPA cistern. and adequate bony exposure should be per formed in the caudal direction to include wide opening of the foramen magnum. After the PICA feeding has been transected close to the AVM. with the venous drainage through lateral pontine veins into the petrosal system (Figure 8). Occasionally. Following the initial dissection of the AVM. which can be easily accessed in the subarachnoid space at its lateral and posterior medullary segments. patients with deep parenchymal brainstem AVMs are poor candidates for microsurgical resection because of the multitude of problems mentioned above. Occasionally. Although AVMs from both groups may present with similar clinical signs and symptoms. the malformation can be completely undercut from the pial surface. and the arterial supply of these lesions is usually via dilated branches of the AICA with occasional supply from the SCA (Figure 7). superiorly to the tentorium. In a similar fashion. pons. The feeding vessels to deep brainstem AVMs are usually vertebrobasilar perforator arteries originating ventrally and coursing through normal brainstem tissue prior to penetrating the deep margins of the malformation (Figure 11). In general. surgical resection of deep parenchymal AVMs of the brainstem carries extremely high morbidity and mortality rates. Deep parenchymal AVMs of the brainstem pose an entirely different surgical risk than superficially located lesions. and delivered from the operative field. The approach to parenchymal AVMs of the brainstem should traverse the minimum amount of normal tissue required to access the lesion. They often occur on the anterior or lateral surface of the brainstem in the CPA. tectal plate. divided. These lesions usually derive their blood supply solely from the PICA (Figure 6C). Superficial AVMs of the brainstem primarily involve the pial-arachnoid layers. . the indications for surgical treatment and outcomes from the two groups are markedly different. into the inferior vermian venous system (Figure 6B). We have found preoperative embolization of superficial brainstem AVMs to be extremely hazardous and of little value as an adjunct to their resection. These patients can be positioned prone-concord or lateral. The cistern of the CPA is opened widely from the cisterna magna to the tentorium. These malformations are intimately associated with normal brainstem parenchyma. AVMs of the brainstem are best divided into two distinct groups: superficial or pial AVMs and deep parenchymal AVMs.KOPITNIK ET AL : SURGICAL RESECTION OF AVMS OF THE POSTERIOR FOSSA 43 Because of the somewhat small size of the cerebellar tonsil. Brainstem AVMs in the CPA are usually approached with the patient in a lateral position with an extreme lateral bony exposure in order to maximize access to the CPA cistern (Figure 9). and the remaining feeding vessels and draining veins cauterized. floor of the fourth ventricle. AVMs of the Cerebellar Tonsil Brainstem AVMs include those lesions with parenchymal representation in the mesencephalon. and cerebrospinal fluid is allowed to egress to provide relaxation of the AVMs of the Brainstem cerebellum.

A. AVM of the cerebellar tonsil. . electrocautery of PICA feeding vessel. VOL. schematic representation of the arterial supply and venous drainage.44 NEUROSURGICAL OPERATIVE ATLAS. exposure. B. C. 8 B A C Figure 6.

AVMs of the posterior fossa frequently present with clinically significant hemorrhage within the substance of the cerebellum or brainstem. Feeding arteries that are easily accessed microsurgically should not undergo unnecessary embolization due to the risk of iatrogenic tissue infarction. It is common to find aneurysms on proximal feeding arteries of posterior fossa AVMs that are the source of subarachnoid or intraparenchymal hemorrhage. cerebellar tonsillar AVMs. MR image (A) and anteroposterior angiogram (B) of a superficial AVM of the brainstem. cerebellar hemispheric AVMs. Embolization as an adjunct to surgical resection is useful to decrease the blood flow to cerebellar AVMs primarily through embolization of the deep feeding vessels. or both. dependent upon the patient’s neurological condition. Embolization of brainstem AVMs carries a high risk and is of little benefit as an adjunct to surgical resection. within the subarachnoid space. Classification into one of the above locations helps anticipate the suspected arterial supply and likely venous drainage. AVMs of the posterior fossa require full radiological evaluation prior to treatment. including four-ves- SUMMARY sel angiography and high-quality MR imaging.KOPITNIK ET AL : SURGICAL RESECTION OF AVMS OF THE POSTERIOR FOSSA 45 A B Figure 7. superficial brainstem pial surface AVMs. which are not easily accessed initially during an operative resection. AVMs of the posterior fossa are best subdivided by location into cerebellar vermian AVMs. . and deep parenchymal brainstem AVMs. The natural history of posterior fossa AVMs suggests that surgical treatment to eliminate these aggressive lesions is indicated in the majority of circumstances. The surgical resection of posterior fossa AVMs is best delayed until partial resolution of any hematoma.

Illustration depicting a deep parenchymal AVM of the brainstem with deep perforators feeding from the basilar artery. VOL. Illustration depicting an AVM of the superficial CPA surface of the pons. 8 Figure 8. Figure 10.46 NEUROSURGICAL OPERATIVE ATLAS. . Figure 11. Figure 9. Illustration depicting ligation of feeding arteries and elevation of a superficial pontine AVM. Illustration depicting the initial lateral exposure of a superficial pontine AVM presenting to the CPA cistern.

and psychological reaction to the knowledge that he or she harbors a potentially dangerous lesion must all be taken into consideration. and relationship of the malformation to associated hematomas. In addition to no treatment. ROGER H. Once the patient has stabilized. Surgical intervention is typically delayed for 2 or 3 weeks to allow for recovery from the hemorrhage.D. Factors related to the AVM that are of importance in decision-making include the precise location. INTRODUCTION As with other AVMs.SURGICAL TREATMENT OF ARTERIOVENOUS MALFORMATIONS OF THE VENTRICULAR TRIGONE DANIEL L. the emergency operation is usually performed to remove the hematoma. occupation. the various therapeutic options are reviewed with the patient and family. M. a patient presenting with a large hematoma and associated mass effect may require urgent evacuation of the hematoma. Infrequently. The patient’s age. M. Since the incidence of AVM rebleeding is very low immediately after the initial hemorrhage and cerebral vasospasm is exceed- PATIENT SELECTION © 1999 The American Association of Neurological Surgeons ingly rare. neurological condition. These lesions are invariably located in eloquent or functionally important brain and have a complex arterial supply and deep venous drainage. After the AVM has been localized and defined by appropriate imaging studies. health.D. a number of tangential approaches have been utilized rather than the more conventional perpendicular approaches used for AVMs on the cerebral convexity. BARROW. lesions in the region of the ventricular trigone most commonly come to clinical attention during the third or fourth decades of life. Treatment recommendations are then tailored to the individual patient and lesion. venous drainage. size. these malformations present with seizures or a visual field deficit in the absence of hemorrhage. immediate surgery is usually not indicated for the patient presenting with a hemorrhage. To expose and resect these complex lesions. with the actual resection of the AVM reserved for a later date. The decision is made after careful consideration of a variety of factors related to both the patient and the malformation. arterial supply. These deep-seated lesions most frequently produce symptoms after an intraventricular and/or intracerebral hemorrhage. FRANKEL. Occasionally. Because of the poor natural history of untreated AVMs. surgical resection. the intricate neurovascular operation can be carried out more electively. and stereotactic radiosurgery. Involvement of the choroid plexus with the AVM may add to the overall size of the lesion. In this situation. Arteriovenous malformations (AVMs) in the region of the ventricular trigone present unique challenges to the neurosurgeon. most of these 47 . options include embolization.

Magnetic resonance imaging (MRI) provides anatomical information that complements the angiogram and is extremely useful in planning the most appropriate operative approach. It is our preference to operate on AVMs under normal blood pressure and to prevent hypotension. If the patient’s head is elevated above the heart to any significant degree. the risk of surgical removal with an immediate cure is significantly less than the risk of the natural history of the untreated malformation. This approach is particularly useful for AVMs associated with a hematoma extending into the temporal lobe. the presence of an intracerebral hemorrhage. preoperative embolization allows for a more gradual redistribution of arterial blood flow to the surrounding normal brain and theoretically reduces the risk of postoperative reperfusion complications. patients are given anticonvulsants. a small amount of superficial cortical venous drainage is there as well. MRI demonstrates the precise relationship of the vascular malformation and associated hematoma to the trigone. and prophylactic antibiotics. The posterior cerebral artery usually feeds these lesions. and the relationship of the AVM to the trigone based on angiographic and MRI localization (Figure 1). Blood pressure control using oral or parenteral medications is also commonly necessary in the acute period. 8 lesions require some form of therapy. Embolization alone rarely cures an AVM in the region of the ventricular trigone and is therefore not often of benefit as a sole treatment. Stereotactic radiosurgery is a reasonable option for treating small AVMs in this region. profound hypotension or excessive retraction to the adjacent brain may result in ischemic injury. 2) a parieto-occipital transcortical approach. with the posterior choroidal and posterior temporal arteries being predominant. indicates the proximity to adjacent anatomical structures. and reveals the cortical surface closest to the AVM. The latter can be ipsilateral and parafalcine or contralateral and transfalcine. Furthermore. Reduction or elimination PREOPERATIVE PREPARATION The advantages of general anesthesia to achieve a relaxed brain and to control blood pressure provide a more optimal environment for successful operations on these lesions. The parieto-occipital approach. is used for AVMs involving the superior and medial walls of the trigone (Figure 1C). We have found preoperative embolization to be an important adjunct to the surgical resection of AVMs in this region. and thalamoperforating arteries. Since all operative approaches to AVMs in the region of the ventricular trigone require violation of the cortex. Venous drainage is typically deep into the galenic system. the vein of Labbé is involved or the lesion has purely superficial venous drainage. SURGICAL TREATMENT . Selection of the approach should be based upon the presence of preoperative neurological deficits. The interhemispheric approach is reserved for selected AVMs situated along the medial aspect of the trigone that may also involve the splenium of the corpus callosum (Figure 1B). Patients presenting with an intracerebral and/or intraventricular hemorrhage are managed aggressively to control intracranial hypertension and may require a ventriculostomy for control of hydrocephalus. Occasionally. They include: 1) a lateral temporal approach through the inferior or middle temporal gyrus. of the deep arterial supply by embolization reduces the critical blood supply and diminishes surgical difficulty and risk. pericallosal. a precordial Doppler ultrasound and an atrial catheter are placed preoperatively to optimally monitor for and manage potential air emboli. if present. Noncontrasted computed tomography is the initial diagnostic study performed acutely in the patient presenting with a hemorrhage. The transtemporal approach is used for AVMs located along the lateral. It is. Prior to the induction of general anesthesia. After initial stabilization of the patient. as described by Heros. The surgical approaches to these malformations often expose the deep arterial supply at a later stage of the procedure. An invasive arterial line is placed to provide access for arterial blood gas determinations and to allow for continuous monitoring of the arterial pressure. This allows determination of the extent and location of the hemorrhage and the diagnosis of hydrocephalus. ANESTHETIC TECHNIQUE We have utilized three basic approaches in the surgical management of AVMs in the region of the ventricular trigone. middle cerebral. and 3) an occipital interhemispheric approach. patients are placed on prophylactic anticonvulsants. Other arteries that occasionally contribute include the anterior choroidal. Invasive cerebral angiography is essential to define the angioarchitecture of the AVM. Since autoregulation is often impaired in the brain adjacent to an AVM. In the majority of trigonal AVMs. however. VOL. A Foley catheter is used for urinary drainage and measurement. a very useful adjunct to surgery. systemic corticosteroids. or inferior wall of the trigone (Figure 1A). anterior. diagnostic imaging studies are carried out to define the anatomical features of the lesion. In rare instances.48 NEUROSURGICAL OPERATIVE ATLAS. but the significant time interval required for the radiation to have its beneficial effects as well as the risk of radiation injury represent significant detractors to this therapeutic modality.

A = AVM along the lateral. The deep venous drainage is usually on the medial aspect of the AVM and is preserved until the AVM is completely devascularized.to 2-cm incision is created in the inferior temporal gyrus. Dissection must be carried circumferentially around the nidus to the feeders that are sequentially coagulated and/or clipped and divided (Figure 5). To minimize injury to the eloquent cortex. the surgeon usually encounters the nidus of the AVM prior to the feeding arteries. . the patient is placed in a supine position with the ipsilateral shoulder elevated and the head parallel to the floor with the vertex angled slightly downward. The middle temporal gyrus may be traversed in the nondominant hemisphere. The head is held in position by a radiolucent headholder. If a hematoma is present. The operating microscope is used to assist in guiding the dissection slightly posteriorly and superiorly toward the trigone with suction and bipolar cautery (Figure 4). After induction of anesthesia. A temporal craniotomy is extended to the floor of the middle cranial fossa (Figure 2). anterior. The cortisectomy should be planned in order to provide the most direct access to the AVM while protecting the vein of Labbé. Utilizing this approach. The vein of Labbé is identified and a 1. or inferior wall of the trigone. Self-retaining retractors are used to maintain exposure (Figure 3 lower).BARROW AND FRANKEL : ARTERIOVENOUS MALFORMATIONS OF THE VENTRICULAR TRIGONE 49 Figure 1. minimal force should be used in placing the retractors. A small horizontal cortical incision parallel to the optic radiations will minimize the Temporal Approach risk of visual field deficits (Figure 3 upper). A horseshoeshaped incision is made around the auricle of the ear from the zygomatic arch to the retromastoid region. Various relationships of trigonal AVMs to the ventricular trigone. Dural tack-up sutures are placed and the dura is opened. C = AVM involving the superior wall of the trigone. the brain relaxes significantly due to the drainage of cerebrospinal fluid and minimal retraction is necessary to maintain adequate exposure. The AVM is localized along with any associated hematoma utilizing intraoperative ultrasound. B = AVM on the medial aspect of the trigone. it is evacuated to provide more relaxation and exposure. Once the trigone is entered.

Skin incision (solid line) and temporal craniotomy (hatched line) for the temporal approach to AVMs of the ventricular trigone. VOL. 8 Figure 2. Figure 4. Illustration of the direction of the operative approach through the inferior or middle temporal gyrus to the ventricular trigone.50 NEUROSURGICAL OPERATIVE ATLAS. Temporal approach. .

Figure 5. Temporal approach.BARROW AND FRANKEL : ARTERIOVENOUS MALFORMATIONS OF THE VENTRICULAR TRIGONE 51 Figure 3. Temporal approach. Illustrations demonstrating the horizontal cortical incision parallel to the optic radiations (upper) and use of self-retaining retractor to maintain exposure (lower). . Illustration of coronal section of the brain demonstrating the relationship of the AVM to the ventricular trigone and the operative approach through the inferior temporal gyrus.

The surgeon has a direct view to the trigone from a superior angle using this approach. and prolonged retraction of parasagittal veins is avoided. Patient is in a semi-sitting “slouch” or lounging position with the head slightly flexed. Arrow = direction of approach to the ventricular trigone. Once the dura is exposed. the risk of neurological injury is minimized. or lateral surface of the nidus exposes the feeding arteries (Figure 8). it can be opened with the flap based on the sagittal sinus. Again. Parieto-occipital transcortical approach. the exact location of the cortical incision should be made by directly measuring 7.0 cm lateral to the midline (Figure 7A).5 to 2. extending to the midline and based inferiorly. and the approach to the trigone is aimed toward the ipsilateral pupil (Fig- ure 7B).52 Parieto-Occipital Approach NEUROSURGICAL OPERATIVE ATLAS. As with the transtemporal approach. VOL. medial. . approximately 2. The external landmark for the cortical incision is a point approximately 9 cm cephalad to the inion and 1. intraoperative ultrasound or an image-guided stereotactic navigational system may be used to increase the precision of the approach. 8 The patient is placed in a semi-sitting “slouch” or lounging position. the surgeon usually initially encounters the nidus of the AVM.0 cm lateral to the midline (Figure 7A). A horseshoe-shaped skin incision is centered over this point. A laterally oriented cortical incision is then created. there is less retraction required than for the parasagittal approach in order to reach this superior region of the trigone. This is opposed to the oblique tangential view given to the superior portion of the trigone obtained from a parasagittal approach. After opening the dura. circumferential dissection around the superior. with the head slightly flexed (Figure 6). In addition.0 cm above the occipital pole and 2. Figure 6. Burr holes are placed and a parieto-occipital craniotomy is created that is centered on the above landmark (Figure 7A). Since placement of the cortical incision is between the parietal sensory association fibers and the occipital visual association fibers.0 cm in length.

Parieto-occipital transcortical approach.BARROW AND FRANKEL : ARTERIOVENOUS MALFORMATIONS OF THE VENTRICULAR TRIGONE 53 A B Figure 7. Illustration of laterally oriented cortical incision with exposure maintained by self-retaining retractors. . hatched line = craniotomy. Parieto-occipital transcortical approach. Solid line = skin incision. Figure 8. The AVM is encountered on the superior surface of the ventricular trigone and extends into the ventricular system. Posterior (A) and lateral (B) views of external and internal landmarks for approach to the ventricular trigone.

The craniotomy crosses the midline instead of basing itself on the superior sagittal sinus and is mainly contralateral to the AVM. A variation of this approach involves parafalcine dissection contralateral to the side of the AVM in order to approach the AVM from a more perpendicular trajectory. Patient is positioned with the side of the craniotomy dependent to allow gravity to assist with occipital lobe retraction. The calcarine or parieto-occipital sulci are opened to expose the most medial aspect of the AVM (Figure 11). and is approached transcortically as described above. VOL. Figure 9. Retraction is minimized by the positioning of the patient. hatched line = craniotomy. so that gravity assists in retraction of the occipital lobe (Figure 9). One disadvantage of this approach is that the surgeon often exposes the venous Parasagittal Interhemispheric Approach drainage before the arterial supply. Parasagittal interhemispheric approach.54 NEUROSURGICAL OPERATIVE ATLAS. The dura is opened contralateral to the AVM and the flap is based on the superior sagittal sinus. An occipital craniotomy is created with the medial burr holes placed over the superior sagittal sinus (Figure 10). Solid line = skin incision. The horseshoe-shaped incision is made across the midline with the base of the flap on the side contralateral to the lesion. The dural opening is based medially on the superior sagittal sinus. allowing access to the hemisphere ipsilateral to the lesion. The falx is split. which allows the side with the lesion to fall away from the falx. . Venous drainage is then coagulated and/or clip ligated and divided. A horseshoe-shaped incision is made in the occipital region based laterally. The occipital lobe can then be retracted from the falx since there are usually no veins draining from this area of the cortex to the superior sagittal sinus. Feeding vessels are then coagulated and divided with larger arteries requiring clips. 8 The patient is positioned in the lateral position with the ipsilateral shoulder on a roll and the head parallel to the floor with the AVM side down. The patient can be positioned in a semisitting slouch position. The former must be protected until the AVM is devascularized.

Circumferential dissection around the AVM is utilized to devascularize the lesion. The craniotomy is centered over the occipital lobe extending to the occipital tip. Illustration of an AVM on the medial surface of the ventricular trigone. . and the AVM is exposed via an interhemispheric approach. Figure 11. Arrow points to location of AVM and relationship to the ventricular trigone on insert. The calcarine fissure has been opened and the AVM is approached beneath the surface of the occipital lobe.BARROW AND FRANKEL : ARTERIOVENOUS MALFORMATIONS OF THE VENTRICULAR TRIGONE 55 Figure 10. Parasagittal interhemispheric approach. Parasagittal interhemispheric approach.

most complications can be avoided by using meticulous technique. As with other AVMs. and the dura is closed in a watertight fashion. language cortex. the patient must undergo appropriate risk stratification with regard to other medical conditions that may affect the intraoperative and postoperative hospital course. Arteries en passage that supply the AVM but extend beyond to perfuse normal brain must be identified. poor intraoperative hemostasis. The judicious use of preoperative embolization to devascularize the lesion and intraoperative angiography to document achievement of the surgical goals are additional adjuncts that enhance the safety and efficacy of surgical treatment of these lesions. Multimodal imaging obtained during the preoperative work-up is important for providing the surgeon with spatial conceptualization of the lesion with respect to the regional anatomy. Some potential complications are unique to these lesions due to their anatomical relationships to the optic radiations. AVMs in the region of the ventricular trigone are not common. INTRAOPERATIVE ANGIOGRAPHY Once complete removal of the malformation is documented by intraoperative angiography. During this stage of inspection. 8 Once the AVM has been surgically removed. the margin of resection must not be too wide. and thalamus. Since these AVMs are in eloquent or functionally important cortex. Complications and misadventures may occur at any point in the diagnostic or therapeutic process in the management of trigonal AVMs. COMPLICATIONS Preoperatively. Under constant irrigation. involvement of the choroid plexus. or normal perfusion pressure breakthrough. Selective angiography and MRI assist in determining which approach is optimal for the individual AVM. If discovered postoperatively. The resection cavity is filled with saline. Once excellent hemostasis is obtained. incompletely resected AVMs are associated with a significant risk of hemorrhage and require reoperation. Only pedicles devoted to the AVM are coagulated or clipped. All risks that apply to craniotomy in general and AVM surgery specifically exist in the surgical management of trigonal AVMs. The Surgicel layer should turn brown when adequate hemostasis has been achieved. care must be taken to protect the venous drainage until the malformation has been devascularized to avoid congestion and bleeding from the nidus. VOL. the anesthesiologist is asked to perform a Valsalva maneuver on the patient to ensure that there are no venous bleeders. the surgeon examines the resection bed with a piece of cotton or cottonoid patty and suction. we routinely per form intraoperative angiography to document complete obliteration of the malformation. Gelfoam or Avitene packing may obscure underlying bleeding and are avoided. Any bleeding points are carefully coagulated with bipolar cautery because one should not rely on hemostatic agents to arrest bleeding in the resection bed. and location in functionally important cortex. Dissection must closely follow the nidus as there may or may not be a clear gliotic plane to follow. If any portion of the AVM is identified on intraoperative angiography. the resection bed is re-explored and residual malformation resected. Choosing the correct approach to expose the AVM will avoid retraction injury to the surrounding normal cortex and minimize the risk of damage to the optic radiations. . The bone flap is replaced with sutures or miniplates. deep arterial feeders and venous drainage. the resection bed is carefully inspected under the operating microscope to be certain that there is absolute hemostasis. Postoperative hemorrhage may occur due to rebleeding from the retained AVM. Their surgical treatment is confounded by the lack of cortical representation. the resection bed is lined with a single layer of Surgicel. Once proper hemostasis is achieved. and the wound is closed in layers. the patient’s blood pressure is maintained at a normal or slightly elevated level. HEMOSTASIS AND CLOSURE The surgical management of intracranial AVMs presents some of the most complex decision-making and technical challenges in neurosurgery. These technical challenges have resulted in the development of the surgical approaches described above.56 NEUROSURGICAL OPERATIVE ATLAS. Intraoperatively. Any areas of red indicate inadequate hemostasis and require removal of the Surgicel and complete control of the bleeding site.

which uses the combined neurosurgical and neurointerventional services with specific emphasis on surgical treatment. PH. which may also fill dural sinuses and cortical veins in a retrograde direction. in addition to petrous and cavernous branches of the internal carotid artery and the posterior meningeal branch of the vertebral artery. middle meningeal. there can also be branches from the subclavian artery. STANLEY L. The management of dural arteriovenous fistulas (DAVFs) r equires a clear understanding of the angioarchitecture of the lesion. M.DURAL ARTERIOVENOUS MALFORMATIONS OF THE TRANSVERSE AND SIGMOID SINUSES TODD A. M. The crucial aspect of these lesions is the venous drainage. middle. and posterior cerebral arteries. Venous drainage is the most important factor in assessing the risk of stroke as well as directing treatment of the lesion. the arterial supply to DAVFs does not strongly guide the therapy. KUETHER. This vast number of potential supplying arteries is the basis for treatment failure when only supplying arteries are embolized or surgically ligated.D. The nidus of the DAVF is located in the wall of the sinus. and location of the vein of Labbé. venous drainage. or convexity dura is involved in the lesion.. and therapy is directed at this portion of the sinus. M.D. is usually small and can be spread over several centimeters of the sinus. The arterial supply to these lesions can originate from any of the arteries that supply the dura. They represent 10% of all intracranial vascular malformations.D. These arteries include transcranial perforating vessels from the occipital.D. NESBIT. A distinction must be made between the normal venous drainage pattern of the brain into cortical veins and dural sinuses and the drainage of the DAVF. For this reason. Hypertrophied arteries and veins supplying the fistula can give the appearance that the bone. Occluding any portion of the arterial supply often leads to hypertrophy of the remaining supplying vessels. 57 . The nidus can generally be defined on the early phase of the angiogram. The lesions are acquired in life and are more appropriately referred to as fistulas rather than malformations. BARNWELL. This chapter describes the treatment approach. and ascending pharyngeal branches of the external carotid artery. Supply can also come from the dural INTRODUCTION © 1999 The American Association of Neurological Surgeons branches that arise from the anterior. GARY M. These lesions can be extremely complex and require an understanding of the arterial supply. A case is also presented to illustrate the concepts presented in this chapter. Dural arteriovenous malformations of the transverse and sigmoid sinuses are abnormal direct shunts between the dural arterial supply and the dural venous system. brain. Infrequently. although the true nidus is located within the dura and around the sinus. nidus location. posterior auricular.

The result is reflux of blood into the cortical veins. In the presence of jugular venous outflow restriction. These headaches are often more prominent on the side of the fistula and can change in character with the fistula. have drainage into cortical veins (Figure 1D). They are similar to the DAVFs of the anterior cranial fossa/ethmoidal groove that virtually always drain to cortical veins and present with hemorrhage. and venous drainage of the DAVF. Cortical venous drainage may result from large fistulas with high flow rates and/or venous outflow restriction in the dural sinuses or jugular vein. The vein of Labbé is commonly involved with cortical venous drainage. subdural. A variety of fistulas may drain entirely into cortical veins and not the adjacent dural sinuses (Figure 1E). 8 Patients with DAVFs can present with a number of different clinical symptoms. It is equally important to understand and characterize the venous drainage of the brain with specific attention to the vein of Labbé. This group would also include those fistulas that drain retrograde into the straight sinus. Symptoms related to raised intracranial pr essure may also occur as a result of impaired cerebrospinal fluid absorption. Rarely. Patients with spontaneous brain hemorrhages must be fully evaluated for a possible DAVF. This pattern occurs when the ipsilateral sigmoid sinus. The arterial supply to the fistula is usually small and the sinus pressure is not sufficiently elevated to cause retrograde flow toward the torcula. The direction of flow is not only dependent on the flow rate but also the presence of any stenosis in the ipsilateral sigmoid sinus or jugular vein. ANGIOARCHITECTURE This category applies to fistulas that. Venous hypertension without hemorrhage can also result in neurological deficits as a result of cerebral edema and infarction. Both states result in high pressures in the transverse and sigmoid sinuses. Only when a microcatheter is advanced through the stenosis can a determination of patency be made. The critical finding in this group is cortical venous drainage. Most commonly.58 PATIENT SELECTION NEUROSURGICAL OPERATIVE ATLAS. DAVFs with cortical drainage can also result in seizures. DAVFs with normal antegrade flow drain into the involved sinus and down the ipsilateral jugular vein (Figure 1A). The flow may also appear angiographically to be entirely retrograde in cases of severe stenosis. even small DAVFs may have some retrograde flow. This vein may be very small and inconsequential or large and provide a significant and cru- Antegrade and Retrograde Flow Through the Transverse-Sigmoid Sinus with Cortical Venous Drainage Flow into Cortical Veins Only Normal Antegrade Flow The Vein of Labbé Antegrade and Retrograde Flow Through the Transverse-Sigmoid Sinus DAVFs with antegrade and retrograde flow are usually larger and the sinus pressure is sufficient to cause antegrade flow to the ipsilateral jugular vein as well as retrograde flow toward the torcula (Figure . in addition to drainage through the involved dural sinuses. it is not a single vein but several veins that enter the sinus at the junction of the transverse and sigmoid sinuses. This pattern has a much higher risk for hemorrhage. These categories are not rigid and some lesions may not fit exactly within a single category. and jugular vein. the patient will develop a pulse-synchronous bruit. subarachnoid. DAVFs may present with epidural. or intracerebral hemorrhage. the fistula may drain entirely into cortical veins even if the underlying sinus is completely normal. These symptoms depend on the location. These categories are graphically illustrated in Figure 1. Some fistulas appear to drain entirely toward the torcula. 1B). The vein of Labbé provides venous drainage from the parietal and posterior temporal lobes. Memory or visual impairment may be noted by the patient. in rare instances. rather than across the torcula to the contralateral transverse sinus. Any stenosis in the ipsilateral sigmoid sinus or jugular vein may increase the retrograde flow. flow. This may occur angiographically if the associated sinus is thrombosed. The sagittal and straight sinuses drain via the torcula and contralateral transverse sinus and jugular vein. These fistulas have the highest risk of hemorrhage because of the high venous pressure. jugular bulb. so loud it can be heard by others in the room. or jugular vein is occluded (Figure 1C). The character of the bruit can change as flow dynamics within the fistula change. The connection between the fistula and the sinus has either thrombosed or was never present. Many patients present with a new headache pattern that may relate to pressure changes within the sinus. This bruit may be barely audible to the patient or. contralateral transverse sinus. Usually. VOL. Retrograde Flow to the Torcula The angioarchitecture of DAVFs involving the transverse and sigmoid sinuses can be divided into five categories based on the patterns of venous drainage of the fistulas. The sagittal and straight sinuses may drain to the right and/or left transverse sinus. This chapter emphasizes these aspects of the DAVF.

antegrade and retrograde flow with cortical venous drainage into the right vein of Labbé. All drainage is through the sinus wall into the right vein of Labbé. C. normal antegrade flow down the right jugular vein.KUETHER ET AL : DURAL ARTERIOVENOUS MALFORMATIONS OF THE TRANSVERSE AND SIGMOID SINUSES 59 Figure 1. Flow in the sinus is normal with no connection to the fistula located in the wall of the sinus. retrograde flow to the torcula with right sigmoid sinus occlusion. A B C D E . E. A. antegrade and retrograde flow toward the torcula with right sigmoid sinus stenosis. D. The angioarchitecture of a right DAVF of the transverse-sigmoid sinus supplied by the right occipital artery. flow into cortical veins only. B.

Patients with hemorrhage. In many cases. the goal of treatment is complete occlusion. liquid adhesives. CONSERVATIVE TREATMENT The decision to surgically treat an individual must be based on knowledge of the patient’s symptoms. if the pressure is sufficiently high. or neurological deficits have one of these risk factors. Transarterial embolization may be used as either definitive treatment of a DAVF or as a preoperative adjunct. DAVFs of the transverse and sigmoid sinuses have arterial supply from the occipital artery. or infarction. or Sotradecol). The risks and benefits of each treatment must be weighed against the risk of stroke from the fistula. Subtotal treatment may not provide patients with protection from further hemorrhage. Although the incidence of spontaneous closure is not known. However.60 NEUROSURGICAL OPERATIVE ATLAS. These conditions lead to venous hypertension. which can also result in cerebral edema and associated neurological deficits. A thorough understanding of possible collateral connections between branches is imperative to reduce the risk of neurological deficit resulting from EMBOLIZATION Transarterial Embolization . palliative therapy may be more appropriate for the initial treatment. raised intracranial pressure. and an understanding of the risks of surgical treatment. the fistula may eventually need more definitive treatment for cure.or high-risk DAVFs may close without treatment. The pressure in a normal dural sinus is less than 10 mm Hg. Low-risk fistulas may not require surgical treatment if the patient can tolerate the symptoms. or cerebral edema with associated neurological deficits are considered at high risk and should have definitive treatment that results in complete obliteration of the fistula. infarction. However. pressure rises within the sinus. DAVFs of the transverse and sigmoid sinus may alter drainage of the vein of Labbé. since the fistula may return with hypertrophy of residual arterial feeders. many patients have already noticed that they can stop their bruit by compressing this artery. The spontaneous remission of DAVFs has been reported in rare instances. alcohol. Every effort should be made to cure these high-risk lesions. with most patients eventually undergoing additional treatment. COMPRESSION THERAPY TREATMENT More definitive treatment of DAVFs of the transverse and sigmoid sinuses requires one or a combination of the following: transarterial embolization. If the fistula is treated. the patient is able to cope very well with a loud bruit and no treatment is indicated. treatment plans can proceed. However. 8 cial pathway of venous drainage from the brain. Risk factors for hemorrhage and stroke include cortical venous drainage and retrograde flow into the torcula and straight sinus. Before being evaluated in a clinic. or intraoperative transvenous embolization with surgical resection. hemorrhage. Direct arterial to sinus shunts increase the pressure in the sinus. therefore. Nearly all DAVFs associated with hemorrhage. appropriate treatment is offered to those who cannot tolerate the bruit. Usually. flow will reverse direction. This is what is referred to as cortical venous drainage. platinum microcoils. transvenous embolization. patients with high-risk fistulas. As the pressure in the sinus rises. General classes of embolic agents include particles (Gelfoam or polyvinyl alcohol (PVA)). such as those with cortical venous drainage. The following is a review of the different treatment options. the vein of Labbé drains the posterior temporal lobe into the transverse-sigmoid sinus junction. angiographic anatomy. Depending on the size of the shunt and the presence of venous outflow restriction in the sigmoid sinus or jugular vein. The vein of Labbé may not be seen on the delayed phase of the internal carotid angiogram if there is r etrograde flow that is dif ficult to distinguish from a small or absent vein. risk factors for hemorrhage or neurological deficits. or sclerosing agents (glucose. should not perform compressive therapy and if possible should undergo more definitive treatment. Low. Compression therapy is an appropriate option for the compliant patient with a low-risk fistula. The arteries are compressed in an increasing fashion over several days to a maximum of 30 seconds 3 times per hour. in patients who have low-risk fistulas. it needs to be considered when discussing the natural history of these lesions. The vein is seen on late phases of an internal car otid angiogram on lateral and frontal projections. VOL. flow in the vein of Labbé ceases. Subtotal occlusion may not protect the patient from further episodes of bleeding. This treatment is continued for 3 weeks before follow-up. Compressive therapy has a relatively low chance of resulting in fistula thrombosis. the options for treatment are INDICATIONS FOR TREATMENT In many instances. If the fistula recurs. Compression of the carotid artery may also lead to thrombosis of the fistula. Once the indications for treatment and the angioarchitecture of the fistula have been determined. A common indication for treatment is patient intolerance of the bruit. more broad. Microcatheters are navigated into as many arteries supplying the fistula as possible which are then occluded with an embolic agent. These therapies are primarily based on fistula angioarchitecture.

Without cortical venous drainage. Tranvenous embolization can be performed either percutaneously. The coils are placed across the entire length of involved sinus. Catheter Normal Antegrade Flow Through the Transverse-Sigmoid Sinus to the Jugular Vein . The fistula may also progress to complete thrombosis. Treatment is offered only when there is intolerance of these symptoms. the clinical problem relates to a bruit or to headaches. especially when reassured that the risk of stroke is small. If neurological deficits result. Surgical resection of lesions affecting the transverse and sigmoid sinuses has been well described previously but is reviewed in this chapter. Many patients are surprisingly tolerant of the bruit. or intraoperatively with direct exposure of the sinus. However. Care must be taken to avoid sinus occlusion where normal veins. Embolization of cortical veins is generally not safe secondary to their thin walls. This sinus may be more difficult to embolize due to its small size and deep location. especially the vein of Labbé. the arterialized veins draining retrograde from the sinus are divided. Any normal draining vein is preserved. Resection of the sinus is not needed. The placement of coils transvenously must be precise. operative exposure and intraoperative coil placement allow for more precise placement of the coils. This may alleviate the patient’s symptoms to a degree that can be tolerated. This recurrence is due to the large number of arterial feeders that supply a fistula. via the femoral vein. normal daily activities. any residual will continue to allow flow through the fistula and will enlarge with time. In cases of close proximity. The sinus is exposed via a process described later in this chapter. it is probably not safe to embolize that artery with small particles or liquid adhesives. transarterial embolization is usually effective in eliminating or reducing the bruit for some time. Virtually all external carotid artery branches relevant to a DAVF of the transverse and sigmoid sinuses also have anastomoses with either the internal carotid artery or the vertebral artery. whether performed percutaneously or directly after operative exposure. Knowledge of the arterial supply to the cranial nerves is also important to avoid complications. embolization is safe due to the low chance of hemorrhage from dural sinuses. other patients experience serious interruptions of sleep. The sinus can then be punctured and coils placed in the sinus along the entire length involved in the DAVF. The risk of hemorrhage or stroke is low since the fistula flows antegrade through the sinuses. increasing the risk of hemorrhage. There is usually enough separation between a normal vein of Labbé and the fistula to allow placement of coils across the fistula while preserving the vein. Surgical Resection Transvenous Embolization The approach to treating DAVFs of the transverse and sigmoid sinuses depends largely on the angioarchitecture of the fistula. although the effect may be short-lived. preventing a catastrophic hemorrhage. It is usually not possible to embolize every arterial pedicle. Arterial embolization is an effective approach to eliminating or reducing the intensity of the bruit. the main concern is a low cure rate with isolated arterial embolization. which include the following. This approach is safe but carries increased risk in the presence of cortical venous drainage. Provocative testing of an artery can easily be performed by neurological testing during selective intraarterial lidocaine injection. In those cases embolization may divert flow into the cortical veins. As mentioned previously. surgery is the best approach to occlude the veins draining the fistula. and work. However. An example of when surgical resection may be required is the case of a fistula with underlying transverse and sigmoid sinus thrombosis that drains into the superior petrosal sinus. When the sinus is thrombosed and venous drainage of the DAVF is only into cortical veins. and the remaining arteries will hypertrophy and re-establish the fistula. • Normal antegrade flow through the transversesigmoid sinus to the jugular vein • Antegrade and retrograde flow through the transverse-sigmoid sinus • Retrograde flow to the torcula • Antegrade and/or retrograde flow through the sinus with cortical venous drainage • Flow into cortical veins only CLINICAL APPROACH TO DURAL ARTERIOVENOUS FISTULAS OF THE TRANSVERSE AND SIGMOID SINUSES In this type of malformation. which increase the risk of perforation. Although arterial embolization can be performed with little risk if particles or coils are used. This operative exposure allows for occlusion of these fragile retrograde draining veins prior to sinus embolization. drain antegrade into the sinus. a high rate of recurrence remains. If the entire involved portion is not occluded.KUETHER ET AL : DURAL ARTERIOVENOUS MALFORMATIONS OF THE TRANSVERSE AND SIGMOID SINUSES 61 arterial embolization. There are relatively few instances in which it is necessary to resect the involved sinus. In the presence of cortical venous drainage. a DAVF may still be embolized safely if the sinus is surgically exposed. Even if the arterial supply to the DAVF is almost completely closed. Surgical resection of the involved sinus is technically superior and more likely to result in cure of the DAVF. this is based on the five patterns of venous drainage from the fistula. After exposing the cortex around the sinus.

it is the surgical interruption of the draining veins that provides the cure. Incomplete therapy may provide a risk reduction if the cortical venous drainage is occluded. Preoperative transarterial embolization may be useful to reduce flow through the fistula and reduce surgical blood loss. transarterial embolization is performed to reduce flow through the fistula. The vein of Labbé usually does not fill because it is either occluded or blood from the posterior temporal lobe drains anteriorly toward the cavernous sinus. The surgical exposure is determined by whether the veins drain supra. Although the sigmoid sinus may appear occluded. After the patient is placed under general anesthesia. the fistula cannot be safely occluded. indicates that the involved sinus can be safely occluded percutaneously without causing a venous occlusive stroke. a microcatheter can sometimes be navigated through the apparent occlusion. The venous phase of an angiogram of the ipsilateral internal carotid artery generally shows venous drainage to the opposite transverse sinus or anteriorly to the cavernous sinus. After treatment. the fistula is located closer to the sigmoid sinus. Once again. The high pressure in the sinus prevents normal drainage from the vein of Labbé into the transverse sinus. so therapy is directed at curing these lesions. the vein drains into the transverse sinus that flows retrograde to the torcula and contralateral transverse sinus. Surgery is the definitive therapy for these lesions. A more extreme situation arises when the pressure is elevated enough to result in retrograde flow in the vein of Labbé from the fistula and cortical venous drainage. If the vein of Labbé is located at the same portion of sinus that contains the fistula. Occlusion of the venous drainage is then performed. The treatment of these lesions is similar to that described above. The first step in treating these lesions is transarterial embolization to reduce the flow into the DAVF. it must be confirmed that flow in the superior sagittal sinus can enter the opposite transverse sinus. Often the coils are packed down to the jugular bulb. or the opposite transverse sinus is small. Antegrade and/or Retrograde Flow Through the Sinus with Cortical Venous Drainage A DAVF that drains entirely toward the torcula is usually a high-flow lesion associated with severe venous outflow restriction or occlusion of the ipsilat- Retrograde Flow to the Torcula The fistula present when the involved sinus is thrombosed and the venous drainage of the DAVF is entirely through the cortical veins is perhaps the fistula with the highest risk. Intraoperative angiography is particularly helpful to ensure that all draining veins are occluded. If flow in the vein of Labbé cannot be preserved. the catheter must either be navigated through the occluded sinus or through the opposite transverse sinus and across the torcula. The presence of cortical venous drainage defines these lesions as high risk for causing stroke. directed toward the torcula. transvenous embolization should not be performed. it can be sacrificed. the selective angiogram can be performed rapidly through this sheath. Transvenous embolization is required to cure this lesion. A curative approach is taken in those patients with symptomatic recurrence after one or two arterial embolization procedures if the contralateral transverse and sigmoid sinuses can provide venous drainage from the brain. transarterial embolization may be all that can be offered since surgical resection is likely to also result in occlusion of the vein of Labbé. This case may represent a progression of the above lesions as the sinus thrombosis progresses to occlusion. Transvenous embolization is then performed during the same procedure to occlude venous drainage from the fistula. Coils are placed in the involved segment of sinus draining the fistula. To place the coils. VOL. maintaining flow in the vein of Labbé. This sheath is then kept sterile. the vein must not be occluded. A portable digital subtraction angiographic machine can be used in conjunction with a radiolucent headholder. Antegrade and Retrograde Flow Through the Transverse-Sigmoid Sinus eral sigmoid sinus. Coils are placed in the involved section of sinus.or in- Flow Into Cortical Veins Only . If the vein of Labbé does not fill. which requires surgical resection or surgical exposure with intraoperative embolization. Prior to occluding the sinus transvenously. but it is important to understand the limitations of this approach and to avoid multiple lengthy arterial embolization procedures in those patients with recurrent DAVF after a similar procedure. The contralateral transverse and sigmoid sinuses will provide sufficient venous outflow from the brain. If transvenous embolization is performed. First. the important factor is the vein of Labbé. when an intraoperative angiogram is required. In this instance. flow in the vein of Labbé must also be preserved during the embolization. The presence of retrograde flow in the transverse sinus.62 NEUROSURGICAL OPERATIVE ATLAS. a sheath can be placed with a continuous infusion of heparin. 8 improvements have allowed for more complete arterial occlusion. Generally. allowing for the coils in the sinus to occlude the fistula without compromising flow in the vein of Labbé. However. Transarterial embolization is first performed to reduce flow through the DAVF.

The authors have encountered a patient who spontaneously thrombosed before surgery. Initially. The sitting position increases the risk of air embolism. Head position for surgical exposure of a DAVF of the right transversesigmoid sinus. or posterior auricular artery. These arteries should always be embolized preoperatively if they supply the Scalp Flap . It is not necessary to remove the sinus since it is already occluded.KUETHER ET AL : DURAL ARTERIOVENOUS MALFORMATIONS OF THE TRANSVERSE AND SIGMOID SINUSES 63 C B A Figure 2. These DAVFs are treated the same way as above with the exception that the underlying sinus must not be damaged since it is carrying normal venous blood. superficial temporal. which allows for scalp retraction and access from the mastoid to the inion (Figure 2). drops and air embolism may occur. Skin incision (A). The patient can be positioned in a park bench threequarter prone position or in a supine position with the shoulder elevated and the head turned sharply in a headholder. The region that must be accessible extends from the mastoid to the inion. and dural incisions (C) are shown. the high pressure in the sinus prevents air from entering the sinus. As the fistula is closed. pressure in the sinus SURGICAL EXPOSURE WITH INTRAOPERATIVE EMBOLIZATION The incision is generally shaped like a hockey stick. Positioning the Patient As with any surgery around the dural sinuses. These lesions cannot be treated percutaneously since the draining veins are too tortuous and thin to safely catheterize and embolize. or both. Either of these positions allows for intraoperative angiography if a sheath has been placed in the femoral artery prior to positioning. The vein of Labbé may drain in a normal fashion into the sinus and must be preserved when this is encountered. fratentorially. a fistula will be identified that drains entirely into cortical veins only. the appropriate anesthetic precautions must be taken to treat possible air embolism. Rarely. Bleeding from the scalp edges can be significant secondary to hypertrophy of either the occipital. craniotomy (B). with a normal patent transverse sinus. The patient is positioned three quarters prone on the operating table.

The positioning. The bone flap is then carefully elevated while separated from the underlying dura. During this process. Preoperatively. clipped. decreasing the venous hypertension in the brain. This exposes the occipital lobe and cerebellum. Sinus Ligation . These sutures are placed 2 cm apart and serve to provide hemostasis of epidural bleeding and prevent a postoperative epidural hematoma. The cuff is closed with a running suture and the hemostat removed. Blood loss could approach 300 ml/min in some cases. Occasionally. Preoperative transarterial embolization is very effective at reducing blood loss during sinus exposure and may prevent massive hemorrhage. As the coils are placed in the sinus during a percutaneous procedure. SURGICAL RESECTION After hemostasis has been achieved. Pieces of Gelfoam are prepared to be placed over any bleeding site in the dura or laceration in the sinus. clipped with Weck clips. bleeding is controlled as quickly as possible with bipolar coagulation. Gelfoam is then systematically elevated while coagulating using bipolar cautery. Raney clips are applied to the scalp edges. The drill can also be used to remove the bone directly over the sinus until it can be visualized through a very thin layer of bone. leaving enough cuff of sinus to close with a running suture. and coils are placed in the sinus over the involved segment. if left open. The dura should be bluntly dissected off the bone before cutting the bone with the craniotome. flow through the fistula should be significantly lower. The sinus is then punctured with a catheter. incision. Cortical Vein Ligation After the dura has been opened parallel to the transverse sinus both above and below the sinus. it is important to verify that there is no drainage through the superior petrosal sinus because. Beginning at the edges. and divided. it may allow the fistula to continue to drain toward the cavernous sinus. large feeding or draining vessels are encountered that can be coagulated and divided. the margins of the dura are tacked up to the bone edges with multiple interrupted sutures. a craniotome can be used to complete the removal of the bone flap. A large Weck clip. Gelfoam is quickly placed on the dura and sinus and pressure is manually applied. one burr hole set is located above the sinus and one set below the sinus (Figure 2). Once the extent of exposure has been determined. A #3 Penfield dissector can then be used to separate the dura and sinus from the overlying bone. Craniotomy The dura 1-2 cm above and below the transverse sinus is opened parallel to the transverse sinus. These sets of burr holes are placed at the medial and lateral extents of the craniotomy. exposing the mastoid tip. Venous bone bleeding is easily controlled with bone wax. Fishhooks are then used to retract the flap for adequate exposure. and cut. two sets of burr holes are drilled. A burred bit can be used to remove the bone overlying any area of concern. Once the sinus has been safely crossed. The craniotomy must be carefully planned to include the necessary portion of the sinus as well as to avoid any catastrophic bleeding.64 NEUROSURGICAL OPERATIVE ATLAS. Usually the vein of Labbé is one of the veins draining retrograde and can be safely occluded. there is a risk that the outflow of the fistula through the sinus may then be diverted to the cortical veins. Once the flap is elevated. This is continued until hemostasis is obtained. and the flap is reflected to its base. Reports have warned that blood transfusions should be started prior to elevating the bone flap. is then placed across the transverse sinus between the portion of the sinus involved by the fistula and the torcula. Cortical veins draining the fistula are coagulated using bipolar cautery. It cannot be emphasized enough that great care must be taken when using the craniotome to avoid laceration of the sinus. These cortical veins are too thin to catheterize and embolize. Hemostats are then placed across the sinus and the sinus is cut between the hemostats. 8 fistula. Preoperative embolization is usually performed within 48 hours prior to surgery. Care is taken to avoid any incision that may result in an ischemic flap. If the patient has had transarterial embolization. VOL. attention must be directed to the patient’s monitors for signs of venous air embolism. This ensures that there is no retrograde flow from the fistula to the torcula. Intraoperative angiography is necessary to ensure that the coils are deposited in the proper area. With routine preoperative embolization. or ligature. Operative exposure prior to embolization is safest because of the risk of diverting flow to the cortical veins if a purely percutaneous approach is used. the need for transfusion has been significantly reduced and is usually not required. Some of the deep cervical fascia and musculature are separated from the occipital bone with a Bovie. This excessive flow in the veins could cause catastrophic hemorrhage. Pressure in the sinus is generally elevated enough as a result of the fistula in addition to the recumbent position to prevent air embolism. any retrograde-filling cortical veins that are identified can be coagulated. and craniotomy should be performed in a manner similar to that described for surgical exposure with intraoperative embolization.

The tentorium is then slowly incised. we present the case of a 75-year-old woman who presented with a loud bruit. The bone flap is replaced with titanium microplates and the scalp is closed in a layered fashion. the sinus must be subtotally resected allowing the vein of Labbé to drain through the superior petrosal sinus or the distal sigmoid sinus. it must be preserved. headaches. when initially opening the dura. The hemostat may be used to begin elevating the lateral portion of the sinus from the wound. When the fistula has been resected. Bleeding from these channels can be controlled with cautery. POSTOPERATIVE CARE ILLUSTRATIVE CASE As an example of the above treatment discussion. the arterialized veins draining the sinus can be sacrificed since the brain is not dependent on venous drainage from these sites. The dural vascular supply is interrupted. This is the point at which preoperative transarterial embolization can play a very beneficial role. DAVFS INVOLVING THE TORCULA Patients are monitored closely in a neurointensive care unit following surgery. or Surgicel. cortical venous drainage from the fistula is occluded as described above. lateral projection. The fistula is most commonly located near the sigmoid-transverse sinus junction. Surgery is the best approach and may be preceded by preoperative transarterial embolization to reduce blood flow in the fistula. controlling any dural bleeding with cautery or Weck clips. First. A postoperative angiogram can be performed either prior to discharge or on an outpatient basis. Angiogram of the left common carotid artery. The dura is closed using an allograft dural substitute in a watertight fashion. a femoral artery introducer can be placed prior to positioning the patient. The superior petrosal sinus is cut and the dura is reflected off the floor of the middle fossa laterally to the transverse-sigmoid sinus junction. Fistula Resection DAVFs involving the torcula are mentioned since they are almost always associated with cortical venous drainage and hemorrhage. hemorrhage. the petrous bone and superior petrosal sinus are ultimately encountered and may contain many vascular channels feeding the fistula. As mentioned previously. the residual sigmoid sinus can simply be packed with Surgicel and sutured. If the vein of Labbé appears to be draining antegrade into the sinus. normalappearing veins. or venous infarction. or by drilling the bone with a diamond-tipped burr.KUETHER ET AL : DURAL ARTERIOVENOUS MALFORMATIONS OF THE TRANSVERSE AND SIGMOID SINUSES 65 Figure 3. an intraoperative angiogram can be easily performed to verify complete closure of the fistula. ataxia. Prior to closure. anticoagulation of any type is avoided to improve the likelihood of fistula thrombosis. As the fistula is encountered. If the fistula drains entirely to the cortical veins and not into the torcula. Closure Once the sinus has been divided. Their neurological status is closely observed for any signs that may indicate cerebral edema. If the fistula drains into the torcula. the torcula can be sacrificed only if all venous drainage from the brain is directed away from the torcula toward the cavernous sinus. Repeat angiography is performed to document the status of the fistula if there is any change in the characteristics of the patient’s symptoms. the surgeon must be prepared to control brisk hemorrhage. However. must be preserved as well as that portion of the sinus to avoid venous infarction. and cog- . It is usually not necessary to resect the sigmoid sinus since the fistula most commonly involves the sinus at the junction with the transverse sinus. preserving flow through the sinus. exposing the tentorium. If an intraoperative angiogram is planned. the next step is to begin dividing the tentorium toward the petrous bone. bone wax. Depending on the treatment. taking care to avoid any air embolism. particularly the vein of Labbé if flow is antegrade. As resection is carried further anteriorly. demonstrating a markedly enlarged left occipital artery (arrow) and multiple external carotid and small cavernous carotid artery branches (arrowhead) supplying the left transverse-sigmoid sinus DAVF.

accessory meningeal. A. The left occipital. The left sigmoid sinus was embolized by placing an angiocatheter into the left transverse sinus through which a microcatheter was positioned at the fistula site near the sigmoid sinus (Figure 5). Post-embolization angiography (Figure 4) demonstrated marked devascularization of the DAVF. anteroposterior projection. Left transversesigmoid DAVF seen with retrograde venous drainage toward the torcula and contralateral sigmoid sinus (arrow). although supply remained from the internal carotid artery and a branch of the occipital artery. tested with lidocaine. The sigmoid sinus appeared thrombosed. No cortical venous drainage was identified at this time.66 NEUROSURGICAL OPERATIVE ATLAS. This would require surgical exposure of the sinus. . and embolized with PVA particles (500-1000 µ). and intracavernous branches of the internal carotid artery. or across the torcula from the right transverse sinus. ascending pharyngeal artery. An attempt was made to catheterize the left sigmoid sinus. No vein of Labbé was identified. due to occluding thrombus. Reduction of flow to the fistula with residual arterial supply from the left occipital artery. B. 8 A B Figure 4. but it could not be accessed either through the left internal jugular vein. with the predominant venous drainage retrograde toward the torcula. nitive changes. which may be an indication that this represented a lesion at higher risk for stroke or hemorrhage. The patient r eturned 2 months later for transve- nous embolization. middle meningeal. VOL. Also noted during this procedure was some reflux into the straight sinus. transarterial embolization may result in improvement of symptoms but will not cure these lesions due to hypertrophy of remaining arterial feeders. The sinus was then occluded with multiple fiber platinum coils (Figure 6). Angiograms of the left common carotid artery following arterial embolization. An intraoperative angiogram was obtained that confirmed sinus occlusion and no residual fistula. The patient underwent surgical exposure of the left transverse-sigmoid sinus as previously described. lateral projection. and posterior auricular arteries were selectively catheterized. studied angiographically. Definitive treatment of this lesion with occlusion of the venous drainage was necessary. As discussed above. An angiogram was performed (Figure 3) which demonstrated a large high-flow left transverse-sigmoid sinus DAVF with supply from the left vertebral artery and both right and left internal and external carotid arteries. internal maxillary. There also was some reflux into cortical veins. due to multiple torcular septations. Transarterial embolization was performed to reduce flow through the fistula.

the left occipital cortex.KUETHER ET AL : DURAL ARTERIOVENOUS MALFORMATIONS OF THE TRANSVERSE AND SIGMOID SINUSES 67 retention suture MEDIAL A left occipital lobe LATERAL retention sutures Figure 5. Intraoperative fluoroscopy image with an angiocatheter (arrow) being used to guide a microcatheter for coil embolization of the left transverse-sigmoid sinus (arrowhead). and the cerebellum. left cerebellum left transverse sinus angiocatheter retention suture B Figure 6. intraoperative photograph showing exposure of the transverse and sigmoid sinuses and angiocatheter positioned in the transverse sinus directed toward the sigmoid sinus. line diagram of photograph depicting anatomic structures of the transverse sinus. . B. A.

transarterial embolization. either percutaneously or after operative exposure. These lesions can only be cured by occlusion of the venous drainage. Based on the fistula characteristics. or a combination of the above. Dural arteriovenous fistulas of the transverse-sigmoid sinus can be very complex to treat and require a clear understanding of the arterial supply. 8 Figure 7. this can be successfully achieved by transvenous embolization. VOL. and location of the vein of Labbé. transvenous embolization.68 NEUROSURGICAL OPERATIVE ATLAS. Depending on the angioarchitecture of the D A V F . The patient returned 6 months later with complete resolution of her symptoms. nidus location. of the left common carotid artery injection with no evidence of residual DAVF. venous drainage. surgical resection. or surgical resection. This approach to DAVFs requires a combined effort from both the neurosurgical and neurointerventional services to provide each patient with the best treatment possible. . lateral projection. The venous drainage is the most important factor in assessing the risk of stroke and hemor- CONCLUSIONS rhage. These lesions can present with a wide variety of symptoms and may pose a significant risk to the patient. and a follow-up angiogram (Figure 7) demonstrated no residual fistula. a treatment regimen can be developed which may include conservative therapy. Postoperative angiogram.

In most cases. These branches may then anastomose with meningeal branches of the ophthalmic artery. the recurrent meningeal artery. M. In some cases. PATEL. MARTIN. transverse. 2) through meningeal branches of the posterior ethmoidal artery. NEIL A. while the anterior ethmoidal artery serves as the principal branch to the dura of the anteromedial anterior fossa floor. The intraorbital ophthalmic artery also gives off anterior and posterior ethmoidal arteries in the region of the ethmoidal air cells. The principal external carotid arterial supply to the anterior fossa dura comes from the middle meningeal branches.D. the internal carotid artery supplies the anterior fossa dura through branches of the ophthalmic artery. the anterior ethmoidal artery perforates the cribriform plate. AND CONVEXITY DURAL ARTERIOVENOUS MALFORMATIONS AMAN B. WESLEY A. these DAVMs are quite interesting in that they are distinguished by their high incidence of hemorrhage.OPERATIVE MANAGEMENT OF ANTERIOR FOSSA. Four sites of anastomosis exist between the ophthalmic artery and meningeal branches of the external carotid artery: 1) through the recurrent meningeal branch. and its branches course along the anterior cranial fossa floor and ascend in the falx cerebri. SUPERIOR SAGITTAL SINUS. Dural arteriovenous malformations (DAVMs) of the anterior fossa are a rare subgroup of malformations that have been only sporadically reported. INTRODUCTION The anterior fossa dura receives its blood supply from both the internal and the external carotid arteries. and sigmoid sinuses. the smaller of the two branches. it gives off a small branch. The posterior ethmoidal artery. They account for only 10% of all DAVMs and are distinguished by their high incidence of hemorrhage and unusual anatomy. which is in contrast to the indolent symptomatology associated with the more common lesions involving the cavernous. which is also the predominant supply to the frontal convexity dura. M. which runs back into the middle fossa through the lateral part of the superior orbital fissure and may anastomose with branches from the middle meningeal artery. After entering the orbit. Nevertheless. The ophthalmic artery usually arises from the supraclinoid portion of the internal carotid NORMAL ANATOMY © 1999 The American Association of Neurological Surgeons siphon and passes through the optic canal inferior to the optic nerve.D. After the anterior falx branch. comprising approximately 5% to 10% of DAVMs. supplies the basal dura in the region of the planum sphenoidale. 3) 69 . the anterior meningeal branches of the anterior ethmoidal artery supply a large portion of the dura of the frontal convexity as well (Figure 1). The anterior ethmoidal artery also gives rise to the anterior falx branch that supplies the falx cerebri. Lesions associated with the dural convexity and superior sagittal sinus are also unusual. KING. M. The pertinent microsurgical anatomy and operative treatment of anterior fossa and superior sagittal sinus DAVMs are reviewed in this chapter.D.

magnetic resonance imaging (MRI) without contrast enhancement may reveal the draining vein at the floor of the anterior cranial fossa as a flow void. Normal anatomy of the blood supply to the anterior fossa dura. meningeal branches ant. 4 = middle meningeal artery to meningeal branch of anterior ethmoidal artery. In addition to demonstrating acute or subacute intraparenchymal or subarachnoid hemorrhage. and 4) through meningeal branches of the anterior ethmoidal artery. recurrent meningeal a. 1 = Middle meningeal artery to recurrent meningeal artery. subarachnoid. and internal car otid artery occlusion. The most prominent branches that supply this site are the middle meningeal. especially in the coronal projection. carotid a. an intracranial hemorrhage can be seen on computed tomography (CT). ethmoidal a.70 NEUROSURGICAL OPERATIVE ATLAS. there is supply from the anterior falcine branch of the ophthalmic artery or the posterior meningeal branch of the vertebral artery. meningeal branches ant. DAVMs. ethmoidal a. ethmoidal a. Most frequently. 3 = middle meningeal artery to anterior falx branch of the anterior ethmoidal artery. int. ext. These collateral routes can become prominent in pathological conditions such as meningiomas. ant. superficial temporal. intraparenchymal bleeding is massive and located in the anteromedial aspect of the frontal lobe. Subarachnoid hemorrhage is most often seen in the interhemispheric fissure. the external carotid artery can contribute blood supply through transcalvarial branches of the superficial temporal artery and through branches of the internal maxillary artery (Figure 1). 2 = middle meningeal artery to meningeal branch of the posterior ethmoidal artery. Figure 1. or a combination of the two. 3 2 1 4 ant. ethmoidal a. The latter three supply the dura via transosseous perforations. In this way. ophthalmic a. In most cases. 8 mid. post. In addition. Enlarged veins or varices may be demonstrated on contrast-enhanced CT. carotid a. maxillary a. falx branch ant. The four sites of anastomosis between the ophthalmic artery and meningeal branches of the external carotid are depicted. internal maxillary. VOL. and occipital arteries. the behavior of a DAVM mimics that of a pure pial AVM. The presence of venous ectasia or varices may be confirmed. through the anterior falx branch of the anterior ethmoidal artery. Anterior fossa DAVMs almost universally involve the dura in the region of the cribriform plate and the Radiographic Features . Arterial supply to the dura of the superior sagittal sinus and convexity is primarily from branches of the external carotid artery. Bleeding is either intraparenchymal. Less commonly.

PATEL ET AL : ANTERIOR FOSSA. CT may also show associated bony thickening. When an aneurysm is not present. CT is most useful for detecting hemorrhagic complications (e. The goal of operative treatment is to divide this fistulous connection. DAVMs of the superior sagittal sinus are most often located in the middle and posterior thirds of the sinus and are supplied by hypertrophied branches of the external carotid artery. Contrast enhancement is useful to demonstrate the enlarged . or subarachnoid) and associated hydrocephalus from prior hemorrhage or increased intracranial pressure (ICP). and enlarged dural grooves. supplying the DAVM through frontal branches of the superficial temporal artery (transosseous) and the anterior branches of the middle meningeal artery. This connection is dilated into a varix. cerebral angiography consistently demonstrates focal aneurysmal dilatation of the venous channel (venous aneurysm or varix) near the site of the dural-to-pial anastomosis. there may be supply from the internal maxillary artery. AND CONVEXITY DAVMS 71 falx AVM ethmoidal branches ophthalmic a. a hypertrophied anterior ethmoidal artery supplies the lesion (Figure 2). Anterior fossa DAVMs usually drain exclusively into pial veins of the anterior frontal lobe. In patients with hemorrhage from anterior cranial fossa DAVMs. intraparenchymal. Additional blood supply can be obtained from the posterior ethmoidal artery or the anterior falx artery. sclerosis. which is usually the source of hemorrhage. However.. subfrontally into the cavernous sinus.g. The anterior ethmoidal supply is bilateral in about one half of cases. the lesion more frequently causes insidious nonhemorrhagic symptoms or is an incidental finding. Anterior fossa DAVM is demonstrated in the region of the cribriform plate and the anterior falx. Enlarged middle meningeal arteries and veins may lead to prominent dural grooves on plain skull radiography. In patients with a long history of hyperemia. The external carotid artery may contribute additional feeders. Such a varix has been described in approximately 90% of cases of anterior fossa DAVM and appears to be the source of hemorrhage. from which they empty into the superior sagittal sinus or. Additionally. intraventricular. in rare cases. Usually. thickening and sclerosis of the overlying bone may be found. The lesion shows a hypertrophied anterior ethmoidal artery with a fistulous connection to leptomeningeal veins. anterior falx. Figure 2. SUPERIOR SAGITTAL SINUS.

MRI will demonstrate acute and subacute intraparenchymal. Intravenous antibiotics (1 gm Ancef and 80 mg gentamicin) are given on arrival and throughout the pr ocedure and are continued for 24 hours postoperatively. It is not uncommon to find DAVMs a distance away from the superior sagittal sinus because of drainage into cortical veins which may travel a variable path before reconnecting with the superior sagittal sinus. 8 draining vein and varices. Therefore. the replacement of intravascular volume by the intravenous administration of crystalloid or colloid solution is indicated before the induction of anesthesia. particularly if it is a sinus cut off from its normal drainage channel. We use Dilantin as the first drug of choice. there is a decrease in intravascular volume immediately prior to intracranial surgery. or the headache itself may be intolerable (DAVMs cause more prominent headaches than cortical malformations). Cerebral angiography reveals that the primary pedicles supplying superior sagittal sinus and convexity DAVMs are the middle meningeal arteries. confirm sinus thrombosis. Intracranial hemorrhage is serious and quite possibly is an indication for emergency treatment. due to shunting or to sinus occlusion. serum electrolytes.72 NEUROSURGICAL OPERATIVE ATLAS. or posterior cerebral arteries may also supply the DAVM. Headache and bruit are symptoms that require individual judgment regarding the circumstances of the particular case.” in which a triangular area of non-enhancement is seen within the sinus. This is especially true if it drains a sinus that has a major obstruction. Monitoring includes direct arterial pressure. a continuous bruit can be quite intolerable and may be an indication for surgical treatment. Patients with altered levels of consciousness should not receive premedication. and resultant CO2 retention. venous ectasias (or aneurysms) may be seen. intervention becomes even In most patients. Less commonly. If there is dilatation of the draining vein (venous aneurysm or varix). central venous pressure. which is continued every 6 hours during the course of the operation. Venous air embolism is detected by a change in the precordial ultrasonic Doppler signal and the presence of increased end-tidal nitrogen or decreased end-tidal CO2. All patients are also given 10 mg Decadron on arrival to the operating room. more urgent. other branches of the external carotid artery. middle cerebral. Pial veins that normally connect with a dural sinus involved by a DAVM may also be recruited for venous drainage. subarachnoid. In these. with an intravenous loading dose of 15 mg/kg. corresponding to clot. hypoventilation. a large accumulation of cortical veins over a silent area such as the frontal lobe might in time cause serious functional impairment without giving adequate warning. Patients presenting with intraparenchymal hemorrhage should be given an anticonvulsant agent. VOL. with DAVMs in this location. may supply these lesions through transosseous perforations. It is important to carefully evaluate both external carotid arteries. After the induction of anesthesia and insertion of a catheter into the bladder. Associated superior sagittal sinus venous thrombosis may also be detected. Anesthetic Technique . 10 to 20 mg furosemide can be given if additional brain relaxation is required. temperature. 100 gm of mannitol is given intravenously. urinary output. followed by a maintenance dose of 300 mg at bedtime. end-tidal CO2 and blood oxygen saturation. Other indications for surgical treatment include severe papilledema that threatens visual function and local cortical dysfunction that may increase without treatment. Additionally. Minimal preoperative medication with a benzodiazepine eliminates the risk of narcotic-induced obtundation. Pial cortical contributions from branches of the anterior cerebral. and intermittent measurement of arterial blood gases. since DAVMs in this location not uncommonly have bilateral symmetric blood supply. Dementia may be present if pressure within the sinus is elevated in such a way as to prevent normal pial cerebral venous drainage. the high dural sinus pressure causes retrograde flow in the pial veins that normally drain into the sinus. Again. and osmolality. In addition. For example. Contrast enhancement may demonstrate the nidus within the leaves of the sinus. hematocrit. as well as the flow voids of the enlarged draining veins. and further enhance the pial venous drainage. DAVMs may drain directly into the superior sagittal sinus. In cases of thrombosis of the superior sagittal sinus. and subdural hemorrhage. PREOPERATIVE PREPARATION INDICATIONS FOR TREATMENT One of the most serious and urgent indications for treatment is the presence of a single cortical draining vein that could rupture. cardiac rate and rhythm by electrocardiography. A serious headache may indicate an elevated ICP. there is supply from the anterior falcine branch of the ophthalmic artery or the posterior meningeal branch of the vertebral artery. namely the superficial temporal and occipital arteries. The most posterior DAVMs may derive some blood from the meningohypophyseal trunk through the arteries of Bernasconi and Casaneri. A peripheral nerve stimulator is used to measure the degree of muscle relaxation. in which case hemorrhage is rare. these are notoriously associated with intracerebral hemorrhage. contrast enhancement may demonstrate the so-called “empty delta sign.

the frontal branch of the facial nerve may be injured. However. Since anterior fossa DAVMs have an extraordinarily high risk of hemorrhage. The patient is placed in the supine position with careful attention to padding of all pressure points. and intermittent doses or infusion of narcotic. Because of the difficulty of catheterizing the ophthalmic artery and the significant risk of visual deficit from occlusion of this vessel or its retinal branches. These include conservative management. and barbiturate or propofol. partial embolization may be feasible.5 to 1 µg/kg) and vecuronium (0. The craniotomy is performed unilaterally to the superior sagittal sinus. If the incision is too far forward or extends below the zygomatic process. A skin incision is made just above the zygomatic process behind the hairline and extending medially. and surgical obliteration. slightly extended. muscle relaxant. minimal brain retraction is required. In some cases symptomatic treatment is indicated. A unilateral low frontal craniotomy approach allows exposure to the region of dural pathology and is usually undertaken from the side of maximal leptomeningeal venous drainage or from the nondominant hemisphere. dural incision osteotomy incision TREATMENT OF ANTERIOR FOSSA DAVMS A number of therapeutic options are available for treating DAVMs. SUPERIOR SAGITTAL SINUS. General Considerations Figure 3. Ventilation is controlled to keep the arterial pCO2 between 35 and 40 mm Hg before the skull is opened and between 25 and 30 mm Hg after.5 mg/kg) are added after controlled hyperventilation with 100% oxygen has been instituted. while in others palliation without complete obliteration of the DAVM is acceptable. Anesthesia is maintained with the continuous administration of oxygen. The larynx is intubated after intravenous lidocaine (1. underlying . when approached via a low frontal craniotomy. The patient is placed in the supine position with the head maintained in a vertical position and slightly extended. A unilateral exposure allows transfal- Operative Technique cine access for interruption of ipsilateral and contralateral leptomeningeal venous drainage.1 mg/kg) or atracurium (0. AND CONVEXITY DAVMS 73 Anesthesia is induced with the intravenous administration of propofol or thiopental. In addition. ending at or just beyond the midline at the hairline (Figure 3). the main blood supply to anterior fossa DAVMs is from the internal carotid artery through the ophthalmic artery branches.5 mg/kg) and additional thiopental (2 mg/kg) have been administered to prevent systemic and intracranial hypertension during intubation. The extension of the head will facilitate retraction of the frontal lobe. The skin incision. conservative management is rarely indicated and complete obliteration should be the goal in most patients. Direct surgical intervention has been advocated for anterior fossa DAVMs and has been associated with excellent results in experienced hands. and dural opening for the operative approach to anterior fossa DAVMs. endovascular therapy. craniotomy. and held in the vertical position with the skeletal-fixation headrest. In cases of anterior fossa DAVM that have supply from the external carotid branches. nitrous oxide or air. low concentrations of isoflurane.PATEL ET AL : ANTERIOR FOSSA. The skin incision is just behind the hairline and extends past the midline to allow exposure farther anteriorly. The skin. This is preferred over a bifrontal approach because it avoids unroofing of a potentially arterialized superior sagittal sinus. The open surgical management of fistulas in this location is normally successful. The head is elevated. Fentanyl (3 to 6 µg/kg) or sufentanil (0. and endovascular therapy probably has no role because of the high risk of occluding the central retinal artery. This is a unilateral low frontal craniotomy approach. A complete review of the patient’s medical history and careful examination of the angiographic relationships are critical before initiating therapeutic intervention. A radiolucent headrest may be used if there may be a need for intraoperative angiography. complete endovascular obliteration of anterior fossa DAVMs seems impractical at the present time.

tions must be carefully considered and planned. Palliative treatment can also be considered for medically unstable patients or to prevent further bleeding in patients who have hemorrhaged and who are not able to tolerate an open surgical pr ocedure. recruit pial veins. the patient is placed in a supine or semilateral position with the head elevated so that the scalp over the center of the DAVM is uppermost (Figure 5). If the frontal sinus was entered on turning the bone flap it must be cranialized. Any potential site of CSF leakage. 8 temporalis muscle. The cosmetic result of the scar and bone flap should also be considered. The dura is then opened over the inferior frontal and anterior temporal regions. and the pericranial tissue are turned together. In cases where the DAVM has ruptured. The most important step in surgery is occlusion of the vascular connection between the dura of the cribriform plate area and the pial vessels. the mucosa removed. It is probably not necessary to excise the venous aneurysm from the cerebral parenchyma because once the varix is disconnected from the dura it will thrombose and involute. and adequate access to any potential bleeding. it should be evacuated initially to allow safe retraction of the frontal pole. packed with muscle or Gelfoam. The bone flap should extend just off the midline. However. treatment op- Superior sagittal sinus DAVMs may be treated by a combination of embolization and surgery for complete extirpation. In most situations. The planned skin incision must allow for full exposure of the DAVM. minimal skin incision. it should be excised since residual DAVM can enlarge. The pericranium should be left intact to serve as a dural substitute at the end of the operation. Therefore. when the DAVM is discovered incidentally or secondary to symptoms not related to hemorrhage. the use of a frameless stereotactic system may aid in the positioning. We use pericranium and muscle in addition to fibrin glue to seal potential sites of CSF leakage. the patient is placed supine with the head slightly extended (Figure 4). If the falx or the anterior fossa dura is extensively involved by a nidus. and subsequent craniotomy. and a wide enough base left to provide sufficient vascularization. which is rare. dural sutures are placed to control epidural bleeding. The incision should be placed well behind the posterior limit of the DAVM. If a large intracerebral hematoma is present. A free bone flap is then turned. adequate removal of the dura surrounding the AVM. Complications TREATMENT OF SUPERIOR SAGITTAL SINUS AND CONVEXITY DAVMS General Considerations DAVMs that involve the superior sagittal sinus or the dural convexity are associated with a variety of anatomical configurations. Blood supply to the scalp flap must be adequate. with the base broader than the apex. the patient will be at risk for the development of an intracranial infection. The lateral portion of the sphenoid wing is removed using the drill. exposing the anterior and lateral inferior frontal and anterior temporal bone. one in the posterior frontal region and the other in the temporal region. VOL. is made.74 NEUROSURGICAL OPERATIVE ATLAS. the vascular malformation consists of simple fistulous connections between the dura and the pial veins without a significant dural nidus (Figure 2). The apex of the flap must extend sufficiently far across Operative Technique . cerebrospinal fluid (CSF) leak. operative treatment with or without preoperative embolization must be considered. If this is not done. a strong case can be made for palliative treatment to prevent the possibility of hemorrhage. Two additional burr holes may be placed. For lesions in the middle third of the sagittal sinus. A wide area of the head should be prepped and draped so that the opening can be enlarged if necessary. For superior sagittal sinus DAVMs located anterior to the coronal suture (anterior third of the superior sagittal sinus). With DAVMs of the convexity that can be visualized on MRI or CT. Unilateral or bilateral anosmia is an expected complication of this operation. anosmia. the clinical status of the patient must be taken into account. and thus increase the chance of future hemorrhage. The surgical treatment of superior sagittal sinus DAVMs is based upon the venous flow pattern determined on preoperative or intraoperative angiography. especially in the region of the cribriform plate. The temporalis muscle can be left attached to the superior temporal line on both sides of the head. The major potential complications include worsening of mental function due to frontal lobe retraction or anterior cerebral artery injury. The frontal lobe is protected with Instat and is carefully elevated over the orbital roof with self-retaining retractors. A bicoronal skin incision is used. and sealed with a pericranial flap. A burr hole is placed just below the anterior end of the superior temporal line. infection. which allows exposure of the floor of the anterior fossa. To minimize venous congestion and edema. After drill holes are made around the craniotomy opening. A horseshoe-shaped incision. Preparatory embolization may minimize the risk of scalp and dural bleeding during operative treatment of these DAVMs. Embolization of the DAVM is generally the best option for palliation. In addition to the anatomical characteristics of the DAVM. the head is positioned so that the DAVM is uppermost in the operative field and is held in skeletal fixation. must be sealed. and postoperative seizure.

Patient positioning. skin incision. AND CONVEXITY DAVMS 75 AVM incision sup. and craniotomy for DAVMs of the anterior third of the superior sagittal sinus. A bicoronal skin incision is used.PATEL ET AL : ANTERIOR FOSSA. and craniotomy for DAVMs of the middle third of the superior sagittal sinus. skin incision. A horseshoe-shaped incision is used. sagittal sinus Figure 4. SUPERIOR SAGITTAL SINUS. . The patient is placed supine with the head slightly extended. The patient is placed supine with the head elevated so that the scalp over the center of the DAVM is uppermost. Patient positioning. incision osteotomy AVM Figure 5.

A craniotome is used after the dura has been stripped. extends about 2 cm across the midline. 8 osteotomy incision Figure 6. A free bone flap is raised and a sufficient number of burr holes on either side of the sinus are made to allow easy stripping of the dura. and is based in the posterior temporal-inferior occipital region. If the dura is densely adherent over the . sup. osteotomy AVM incision AVM Figure 7. The DAVM depicted here receives blood supply from bilateral middle meningeal arteries.76 NEUROSURGICAL OPERATIVE ATLAS. For DAVMs located in the posterior third of the sagittal sinus. Superior sagittal sinus DAVM following the craniotomy. sagittal sinus the midline to allow adequate bone removal on both sides of the sagittal sinus. This shows a malformation at the middle third of the superior sagittal sinus. Patient positioning. VOL. skin incision. The skin incision is horseshoe shaped. The patient is placed in the lateral position and the head is well elevated and turned 45 degrees toward the floor to bring the center of the DAVM to the highest point. with a nidus located over the sinus. The skin incision is horseshoe shaped. and craniotomy for DAVMs of the posterior third of the superior sagittal sinus. the patient is placed in the lateral position (Figure 6). The head is elevated and turned at least 45 degrees toward the floor to bring the center of the DAVM to the highest point. The dural stripping and bone cuts over the sinus are made last. after all other burr holes have been connected (Figure 7).

it may be possible to excise the sinus and not cause significant parenchymal venous hypertension. one should divide the attachment of the fistulous vein to the sinus. CT visualizes the presence of a hematoma or increased cerebral edema. If an air embolus is detected by a reduction in end-tidal CO2 or if air is heard on the precordial Doppler. can be interrupted when the dura is opened. if present. As the bone flap is elevated. AND CONVEXITY DAVMS 77 Figure 8. If the sinus is not used as a primary outlet for the brain venous drainage. hemorrhage. Drawing showing the arterial supply to the superior sagittal sinus DAVM interrupted following coagulation. If a fistula is located in the wall of the sinus and drains exclusively through cortical veins. sinus. The dura is then tacked up in the periphery by holes drilled into the bone. and dural bleeding is controlled with cautery. and Surgicel. openings in the frontal sinus need to Complications . Once the opening is covered and the vital signs are stable. This is most frequently encountered in the anterior third of the sinus. If the nidus drains directly into the sinus. the dura should be stripped over the sinus under direct vision. Gelfoam. which is the main source of symptoms. a free flap should be raised unilateral to the sinus. Increased cerebral edema can be treated with an increase in the steroid dose and a prolonged steroid taper. this would need to be accomplished bilaterally secondary to the bilateral arterial supply. Gelfoam and cottonoids are placed directly over the sagittal sinus. Bleeding from the bone is controlled with bone wax. As in anterior fossa DAVMs. In the figure depicted here. it is sufficient to interrupt the arterial supply to the DAVM by coagulating and interrupting the feeding vessels. which are occasionally associated with an occluded dural sinus and variceal or aneurysmal leptomeningeal venous structures. can be treated by coagulation of the pathological dural leaflet and interruption of leptomeningeal arterialized venous drainage (Figure 8). It is possible to do this with impunity since cortical blood flow has already found collateral pathways. Leptomeningeal venous drainage. SUPERIOR SAGITTAL SINUS. increased neurological deficit. The wall of the sinus can thus be coagulated without entering the sinus lumen. the patient’s head can be lowered.PATEL ET AL : ANTERIOR FOSSA. This is usually sufficient treatment for DAVMs that drain exclusively into the sinus. and a second free bone flap should be raised across the midline. This will decrease the venous hypertension within the superior sagittal sinus. and wound infection. Postoperative complications include venous air embolus. the patient can be returned to the original position. Paramedian lesions. since the high-pressure arterial flow into the superior sagittal sinus will be interrupted. This opening of the dura and coagulation of vessels is done lateral to the sinus.

For anterior fossa DAVMs. IMMEDIATE POSTOPERATIVE MANAGEMENT . The wound is then covered with a sterile dressing. Central tack-up sites are drilled into the bone flap and tack-up sutures are placed partial thickness through the dura. This area can be packed with muscle or pericranium and subsequently sealed with fibrin glue. and mesh or burr-hole covers can be used to cover large defects. the patient should undergo cerebral angiography to confirm the absence of residual DAVM. anticonvulsant medication can likely be stopped within 2 to 3 months. Prior to discharge from the hospital. Steroid doses are usually tapered over 5 to 10 days. The length of time for anticonvulsant medication has not been established. and further treatment is planned depending on electroencephalographic findings. depending on the patient’s neurological status and the extent of cerebral edema. The galea is then closed using 3-0 Vicryl sutures in an inverted interrupted fashion. Close observation in the ICU setting is indicated for at least the first postoperative night. A portable monitor is used to follow blood pressure and heart rate as the patient is transported to the recovery room or intensive care unit (ICU). If a seizure disorder has been present.78 NEUROSURGICAL OPERATIVE ATLAS. and a pressure head wrap is placed. If there is no history of seizures. The bone flap is replaced and held in place using miniplates. 8 be dealt with as described in the previous section. closure of the dura in the region of the cribriform plate may be difficult. The skin is closed using skin staples or 3-0 nylon in a running interlocking pattern. The dura can be closed primarily or by taking a piece of pericranium and sewing it into the dural defect. VOL. GENERAL WOUND CLOSURE As the patient awakens from anesthesia. The temporalis muscle is reapproximated using 3-0 Vicryl sutures in a simple interrupted fashion. anticonvulsants are continued for 6 months to a year. Antibiotics are continued for 24 hours. intravenous agents are used to control blood pressure tightly.

the OAS allows the neurosurgeon to visualize the anatomy along the trajectory to the lesion and delineate lesion boundaries. INTRODUCTION room. neural. During surgery. or cerebrospinal fluid (CSF) drainage can increase the error. This improved surgical technique increases the safety. MA). and efficiency of skull base surgery. achieving a more complete resection. The system facilitates planning of the optimal surgical approach and. TEW. The accuracy of the OAS ranges from 1 to 4 mm. JR.D. with potentially decreased morbidity.D. M. JOHN M. LARSON. and may reduce complications from the operation. Inc. skull base lesions.USE OF THE OPERATING ARM SYSTEM IN SKULL BASE SURGERY JEFFREY J. real-time localization of patient anatomy by displaying a point in the surgical field on a preoperative image set. During surgery.D. in doing so. WARNICK. retraction. such as the Operating Arm System (OAS) (Radionics. Burlington. the OAS aids in navigating around critical neural and vascular structures. The OAS aids in the preoperative planning of surgical approaches by allowing the surgeon to visualize the operative trajectory to a skull base lesion on the computer graphic workstation. target shifts resulting from intraoperative tumor swelling. The OAS includes an ergonomic digitized arm that senses the position of its probe tip and an integrated computer graphic workstation that stores and manipulates imaging data.. frameless stereotactic navigation. which is viewed on a computer workstation in the operating BACKGROUND © 1999 The American Association of Neurological Surgeons The OAS is effective for cortical and subcortical lesions. However.. and vascular structures around the skull base as well as by the presence of critical neurovascular structures surrounding or invested by the lesion. Frameless stereotactic systems such as the OAS are powerful new tools for preoperative surgical planning and for interactive. The OAS is an advanced neurosurgical instrument used in the operating room for interactive. M. lesion debulking. accuracy. which suffices for most neurosurgical procedures. M. limiting the usefulness of the OAS in defining the margins of some intra-axial lesions. RONALD E. reduces operating time. The surgical treatment of skull base lesions is frequently limited because of extension of the tumor into the bony. imageguided surgery. These limitations have in part been overcome by the use of frameless stereotactic systems. PATIENT SELECTION 79 . plans the craniotomy trajectory. The OAS is well suited for skull base lesions because target shifts are usually not encountered when a lesion is affixed to the skull base. It provides precise. and deep-seated vascular lesions.

the correct attachment of the Operating Arm System to the Mayfield headholder and the optimum placement of the arm so as not to interfere with access to the surgical target. A and B. 8 A B C Figure 1. VOL. C.80 NEUROSURGICAL OPERATIVE ATLAS. frontal (A) and lateral (B) views of the placement of four reference fiducials on rigid areas of the forehead and one fiducial in the mastoid region respectively. (Reproduced with permission from the Mayfield Clinic) . Dashed line indicates skin incision. The articulating operating arm should be tested for proper positioning before calibration to ensure proper reach and probe trajectory.

Error of less than 3 mm is generally acceptable for skull base lesions. as well as fixation of the operating arm to the head holder. Skin incisions are minimized with the OAS because the incision is placed precisely over the desired craniotomy site. can result in less postoperative pain. Care is taken during skull fixation to minimize scalp and fiducial movement that would increase error during stereotactic registration.) are placed on the patient’s head prior to imaging. the craniotomy is customized to provide a corridor to the skull base lesion. Skin Incision Using the OAS. MRI is preferred for skull base lesions when superior resolution of soft tissue is required. The articulating arm must have freedom of movement to allow the probe tip to reach all fiducials and also provide the desired trajectory to the lesion (Figure 1C). including skin incision.. IMAGE SELECTION Stereotactic registration is obtained following fixation of the operating arm and skull. Imaging data and registration are performed in the operating room and take approximately 15 minutes. It is not necessary to tailor the fiducial placement to account for location of the skin incision since stereotactic registration of the OAS is performed before surgery. Following registration. This application scheme forms a plane passing through the target structure. and transoral. Application of Fiducial Markers The OAS facilitates planning the surgical approach to a skull base lesion by allowing the surgeon to visualize trajectories to the boundaries of the lesion and directing the optimal surgical pathway. OPERATIVE PROCEDURE Skull Fixation and Operating Arm Placement Frameless stereotaxy with the OAS requires threepoint skull fixation. transmaxillary.LARSON ET AL : THE OPERATING ARM SYSTEM IN SKULL BASE SURGERY 81 Computed tomography (CT) or magnetic resonance imaging (MRI) can be used for frameless stereotactic surgery. Craniotomy A B Figure 2. Inc. The fiducials can be outlined with a permanent marking pen to ensure accurate replacement in the event that a marker is inadvertently removed. Additionally. far lateral transcondylar approaches. when the scalp and muscle dissection is minimized. . and lesion resection. or transsphenoidal approaches. The fiducials can be removed after registration so that they will not interfere with the sterile preparation or skin incision. the computer workstation calculates and displays the registration error. Smaller skin incisions are cosmetically more appealing and. For optimal performance. four reference fiducials are applied to rigid areas of the head (i. The OAS depth probe is indispensable in showing the lesion in relation to a proposed craniotomy.e. such as when the stereotactic imaging study is performed on an outpatient basis prior to hospital admission. Stereotactic Registration Fiducial markers (Radionics. The hand-held depth probe is a retractable calibrated probe that allows the surgeon to “scan” into the depths of a patient’s anatomy before making an incision and compare various approaches to a lesion (Figure 2). The Operating Arm System depth probe shown fully expanded (A) and fully contracted (B). forehead and mastoids) where scalp elasticity is minimal (Figure 1A and B). craniotomy. The articulating operating arm should be tested for reach and probe trajectory before registration. occipital condyles. such as during anterior or posterior petrosal approaches. CT bone windows are useful for visualizing skull base approaches that require extensive drilling in the temporal bone. PRESURGICAL PLANNING The OAS can be used at all stages of surgery. intraoperative navigation and localization. or clivus.

the depth probe identifies the exact position of the sinuses. Illustration of the depth probe identifying the transverse and sigmoid sinuses before craniotomy (dashed line).. transmaxillary. The sella opening is configured to the specific anatomy of the lesion. or transsphenoidal approach. This allows for maximum exposure through a transoral. This interactive presurgical planning helps determine the extent of the opening required (i. The lesion is surveyed with the depth probe before soft-tissue dissection. This is especially helpful when anatomical landmarks are not clearly visible or when the lesion is invested in critical structures. (Reproduced with permission from the Mayfield Clinic) underlying critical structures and landmarks are identified with the depth probe (rather than with topographical landmarks. fissures.82 NEUROSURGICAL OPERATIVE ATLAS. 8 sigmoid sinus asterion transverse sinus Figure 3. For example. when basing a craniotomy on the sigmoid sinus-transverse sinus junction for a suboccipital or posterior petrosal exposure. During transsphenoidal surgery. the OAS helps identify the midline of the sella and the medial extent of the internal carotid artery in the cavernous sinus (Figure 5). tumor extensions are difficult to identify intraoperatively because they frequently involve the foramina. The boundaries of a skull base lesion are easily detected using the OAS. which can be inconsistent) during placement of the burr holes and craniotomy. For example. allowing for the safe and accurate positioning of the burr holes and craniotomy and eliminating the search for accurate topographical landmarks (Figure 3). and dural folds of the skull base Intraoperative Navigation and Lesion Resection . VOL. inclusion of a transmandibular or transpalatal approach) and maximizes exposure to this region (Figure 4).e. During anterior approaches to the skull base. the OAS shows the corridor to a clival or upper cervical lesion.

LARSON ET AL : THE OPERATING ARM SYSTEM IN SKULL BASE SURGERY 83 A Figure 4. . computer screen of the Operating Arm System showing the location of the tip of the depth probe (green circle) in relation to the target. depth probe passing through the presumed transoral opening. Green circle indicates location of the probe tip. B. Computer screen of the Operating Arm System used to identify the location of the internal carotid artery in a patient with a clival giant cell tumor. A. B Figure 5. Operating room setup for using the Le Fort approach to a clival chordoma.

preoperative MRI. VOL. B. into ventricles or cysts. Errors during image acquisition are due to patient movement. Target shifts are reduced by avoiding hyperventilation. making the OAS an important navigational tool in the operating room for real-time interactive surgery. The OAS is a useful adjunct to skull base surgery. postoperative MRI demonstrating complete resection. stereotactic registration. and brain retraction. Care must be taken to avoid scalp movement when placing the head in three-point fixation. Although frameless stereotactic technology has not obviated the need for high-level surgical skills and comprehension of the complex anatomy of the skull base. Errors during stereotactic registration occur when different parts of a fiducial are selected on the computer workstation and the scalp. The accuracy of the operating arm is 1 to 4 mm. it does provide useful information that can be incorporated when performing a skull base procedure. Target shifts are less of a problem for skull base lesions because the lesions are often fixed to the skull base. C. Brainstem lesions are visualized with the OAS before opening the surface of the brainstem (Figure 7). CSF.84 NEUROSURGICAL OPERATIVE ATLAS. A. Using the operating arm probe. This technique minimizes morbidity to cranial nerve nuclei often related to resecting brainstem lesions that do not extend to the surface of the brainstem. Scalp elasticity increases error by displacing the fiducials. errors can occur while using the OAS during image acquisition. CONCLUSION . Thin-slice. osmotic diuresis. and intraoperative navigation. Fiducials that have recognizable parts on both the fiducial itself and the image of the fiducial on the computer workstation decrease selection error. The OAS can be used to stereotactically guide surgical instruments. the neurosurgeon can more completely resect a tumor by identifying extensions of skull base tumor intraoperatively (Figure 6B and C). 8 A B Figure 6. Patient with a tentorial meningioma with dural tail. (Figure 6A). such as endoscopes. As with any frameless stereotactic system. Error during intraoperative navigation results from target shifts during surgery. intraoperative view of the computer screen for the Operating Arm System showing the dural tail (green circle). fast-acquisition images minimize the error associated with patient movement and CAUTIONS improve the resolution.

Illustration indicating placement of the depth probe to identify the brainstem lesion and location of the cranial nerve nuclei before opening the floor of the fourth ventricle. (Reproduced with permission from the Mayfield Clinic) . nucleus VI motor nucleus V nucleus VII obex Figure 7.LARSON ET AL : THE OPERATING ARM SYSTEM IN SKULL BASE SURGERY 85 C Figure 6C.

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14. 7.. 2. exposing the superior orbital fissure. ORIGITANO. 12. the overall surface area of exposure is enhanced utilizing this cranial base approach (Figure 1). M.S. PH. 6. Optional intradural removal of the posterior clinoid process.THE ORBITOCRANIAL ZYGOMATIC APPROACH TO ANEURYSMS OF THE UPPER BASILAR TRUNK T. This allows for maximum soft-tissue mobilization and minimal © 1999 The American Association of Neurological Surgeons 87 . 15.. Optional mobilization of the third nerve by tentorial release. Lesions of the pre-pontine cisterns. PATIENT POSITIONING All surgical approaches begin with patient fixation and positioning. 8. Optional tentorial splitting. 4. 10. wide-perimeter dural opening with dural pleating.A. A tailored extradural removal of portions of the greater and lesser wings of the sphenoid. Threepoint pin fixation is carried out in such a fashion as to place all pins behind the ears.C. A low. 3. This approach takes advantage of removal and/or relocation of soft tissue and bone to maximize the viewing and working area while minimizing the overall working distance. 5. Intra. The rotational removal of the temporalis muscle out of the temporal fossa. require three-point pin fixation of the head for maximum stability. A tailored supraorbital osteotomy. 13. being deep and constrained. The orbitocranial zygomatic approach represents a modification of the classical pterional approach to the pre-pontine cistern that allows maximal exposure of the region of interest. 11.D.D. F.or transfacial management of the temporalis fascia to preserve the frontalis branch of the facial nerve. which preserves the temporalis fascia and pericranium. Mandatory microsurgical dissection of the sylvian fissure. 9. A pterional-based craniotomy. INTRODUCTION The orbitocranial zygomatic approach consists of the following sequential steps: 1.C. Optional extradural entry into the posterior fossa through Kawase’s triangle. A tailored orbital osteotomy. Skin incision. While the overall dimensions of the pre-pontine space (upper basilar trunk) are fixed by the inherent spatial anatomy. A tailored zygomatic osteotomy. Optional extradural removal of the anterior clinoid process.

The neurovascular bundle is then brought forward with the pericranial sheet graft. VOL. The initial incision is made down to. but not including. overdrainage of CSF collapses the cisterns. The skin incision is marked out behind the hairline. At this point.88 NEUROSURGICAL OPERATIVE ATLAS. The temporal muscle is folded inferiorly over the cut zygoma. The second osteotomy at the temporal root must be made diagonally to reflect the architecture of the bony attachment. Care should be taken not to substitute spinal drainage for microdissection to gain operating space. The first osteotomy is made parallel to the zygomatic process of the frontal bone using the posterior bony rim as a cutting guide. the temporalis fascia or pericranium. thereby beginning the process of bringing the surgeon closer to the target (Figure 2). in continuity. Attempts should be made to preserve. These maneuvers flatten the exposure. especially where it is most adherent at the coronal suture. Bleeding on the back wall of the muscle should be controlled with precise bipolar cautery. running along the hairline to the contralateral temporal line. Reckless use of cautery can result in ELEVATION OF BONE FLAP . care is taken to find and preserve the supraorbital neurovascular bundle. the frontal branch of the superficial temporal artery. Spinal drainage should remain closed during the extradural drilling so that the cerebrospinal fluid (CSF) can act as a buffer for the brain against inadvertent dural contact. Scissors are utilized to protect the underlying soft tissue. lidocaine with epinephrine is injected. 4 to 6 cm behind the posterior flap and cutting from the temporal line to the temporal line with a unipolar cautery. Two veins are encountered during the transaction. At this point. a lumbar spinal drain is placed to be utilized if necessary. Splitting the fascia is accomplished by gentle dissection with a periosteal elevator starting at the root(s) of the zygomatic process of both the temporal bone and the frontal bone and moving to the zygoma. At this point. Remember that the only remaining blood supply to the temporalis muscle at this point is from its deep arterial supply. A large diploic vein is encountered in the region of the keyhole. the frontal branch of the facial nerve is safely protected and the resulting maneuver exposes the bone from the root of the zygomatic process of the frontal bone to the zygomatic process of the temporal bone. The zygoma itself can be left attached to the muscle on its underside. A foramen can be converted to a notch by utilizing a 1to 2-mm Kerrison to open the foramen or by drilling circumferentially around the foramen. It may be in a notch or a true foramen. Skin clips are applied for additional hemostasis. Head positioning r equires three degrees of freedom of movement: rotation. approximately 30 degrees from the neutral position. is elevated off the muscle to the level of the zygoma. a cut is made 1 cm below and parallel to the temporal line to the coronal suture. a curvilinear cut in the temporalis fascia is made through both the superficial and the deep temporalis fascia. This must be controlled with bone wax packing. The flap is now elevated with further cutting along both temporal lines. First. 8 interference of pin(s) to the operator’s hands. Care should be taken not to tear the tissue. The anterior flap is raised to the level of the keyhole. utilizing a combination of #1 and #4 Penfield dissectors. A variety of techniques can be used depending on how reattachment along the temporal line is planned. These cuts are oriented to maximize the area for temporal muscle displacement. Treatment with a pentobarbital bolus prior to pin placement will diminish the patient’s physiological response to pin placement. Prior to pin fixation. and the fascia is cut to the root of the zygomatic process of the temporal bone. Mobilization of the inferior border of the temporalis muscle now occurs. A second cut is made perpendicular to the temporal line from behind the pterion to the base of the zygoma. The ability to rotate the table sideto-side during the operative procedure greatly enhances the surgeon’s operative flexibility. the transition of instruments between surgeon and nurse and. Also. The pericranial flap is now harvested by reaching ELEVATION OF SCALP FLAP The zygomatic osteotomies are now made. both superficial and deep with the fat pad in between. which should be anticipated and controlled with bipolar cautery. in addition. and extension 15 to 20 degrees with neutral head tilt. Generally. Again. A cut is started just behind the keyhole down to the muscle. This will leave a cuff of tissue for reapproximating during reconstruction. A brain spatula should be passed under the zygoma to protect the muscle. Great care must be taken to obtain and maintain hemostasis to avoid postoperative discoloration down into the neck. assistant’s aid is facilitated. making their dissection more difficult. At the zygoma the fascia splits. Scissors are placed over the muscle. with the superficial fascia and fat pad going superficial to the bone and the remaining fascia deep to it. when necessary. The anterior border of the temporalis muscle is not attached to the bone. starting in front of the tragus of the ear. the temporalis muscle is taken down. Once accomplished. Anterior and posterior skin flaps are raised. the anterior flap is well away and below the bone. Further forward mobilization of all planes of the soft tissue anterior flap occurs by releasing the periorbitum from the superior and lateral orbital walls. The temporalis fascia. the muscle below is protected by a brain spatula. Dissection is taken down to just below the original level of the zygoma. As the flap is elevated to the level of the supraorbital rims.

ORIGITANO : ORBITOCRANIAL ZYGOMATIC APPROACH TO UPPER BASILAR TRUNK ANEURYSMS 89 Figure 1. Care is taken to preserve the neurovascular bundle of the pericranial flap and mobilization of the temporalis fascia to preserve the facial nerve. blue = orbitocranial zygomatic approach). . Figure 2. The surface area viewed is enhanced and the working distance shortened with multiple operative corridors (purple = classical pterional approach. Initial soft tissue transfers and bone work begin the process of widening and flattening the operative approach. Increased view and working space afforded by orbitocranial zygomatic approach.

To protect the brain during bone work. Dural bleeding is controlled with bipolar cautery. a robust anterior clinoid process can project into and limit the oculocarotid triangle. the arachnoid is opened deep to superficial. and proceeds down into the sylvian fissure. There is also great potential risk of over-retraction leading to brain injury in a still tethered brain. The dura is now opened. if necessary. A final cut up the sylvian fissure completes the dural opening. 2) behind the pterion. The extent of the supraorbital osteotomy is tailored to the size of the lesion. This maneuver allows the frontal lobe dura to be pleated back on itself and tacked to the pericranium.and lateral orbital ridges. sparing entry into the frontal sinus. and inferior temporal gyri (Figure 4A). With complete microdissection of the sylvian fissure. The burr holes are connected with a craniotome. which can then be removed as a single piece with a drill or piecemeal with microdissection back to the base of the anterior clinoid process. the spinal drain has not been opened to this point. Elevation of the temporal dura anteriorly would allow exposure of the V2 and V3 roots. great care must be taken to ensure hemostasis of all dural and bony surfaces to avoid continued bleeding during the intradural dissection. Tacking the dura flat increases the flatness of the approach while decreasing the necessity for retraction and CSF diversion. simply contours an object in place without significant pulling force. Bony exposure places the surgeon in front of and below the temporal lobe. the clinoid process can be safely removed extradurally. At this point. Craniotomy microsurgical dissection. While use of retractors may be tempting. malleable retractors under direct visualization. approximately 1 cm above the floor of the anterior fossa. I define retraction as the application of a pulling force against the brain. Occasionally. Again. Dissection is now directed toward releasing the uncus and opening the space lateral to the carotid artery. 3) at the keyhole (giving access to the anterior cranial fossa and orbit). Sharp dissection with scissors is used for the most superficial arachnoid. increasing their mobility and thus opening both the opticocarotid and the oculocarotid corridors to the basilar tip. the fissure is dissected by opening the arachnoid and dissecting down to the artery. At this point. again tenting over the adjacent soft tissue covered by Oxycel. Traction. with visualization of the superior. further flattening the approach and improving hemostasis. the veins entering the sphenoparietal sinus are bipolar coagulated and cut. The dura is then cut around the front and side of the temporal lobe. on the other hand. The temporal lobe can now be mobilized up and out of the middle cranial fossa and held by a small amount of traction via a brain blade. Gentle dissection of the periorbitum from the superior and lateral orbital walls is now undertaken. Burr holes are placed: 1) at the base of the zygomatic process of the temporal bone. The dural opening starts low across the frontal lobe. Utilizing a fine cutting blade or reciprocating saw. 8 a dead temporalis muscle. under microscopic magnification and illumination. which is opened. The optic nerve is freed from the frontal lobe. the temporal lobe has been released circumferentially. exposing the dura over the temporal lobe superolaterally from temporal pole to root of the zygoma.90 NEUROSURGICAL OPERATIVE ATLAS. the extent of the lateral orbital cut can be modified. and 4) just behind the orbital ridge medial to the temporal line. The difference between traction and retraction is not a matter of mere semantics. providing access to the floor of the middle temporal fossa. The blade is brought in THE ORBITAL ZYGOMATIC APPROACH . middle. it is important to not open the CSF drain at this point. The posterior communicating artery is freed and the third nerve is identified and freed as it enters the tentorial edge. The frontal and temporal lobe dura are now elevated off their respective bones. the brain blade can be placed to position the entire temporal lobe in space. The drain remains closed to keep the cisterns and sylvian fissure expanded during the initial Opening of the Dura The microscope is now brought onto the field. the sylvian fissure is opened. If necessary for maximal working space. With prepontine lesions. the periorbitum is further dissected free of the superior and lateral orbital walls. the entire temporal lobe from tip to the root of the zygoma is exposed. This keeps the fissure and cisterns expanded with CSF and easier to dissect. raising a free bone flap. The dura is stripped off the bone with a #3 Penfield dissector. Furthermore. A pterional craniotomy is now per formed (Figure 3). A second benefit to removing the anterior clinoid process and opening the optic canal is the ability to intradurally mobilize both the ipsilateral optic nerve and the carotid artery. supraorbital osteotomy is necessary. Following Yasargil’s technique. A rongeur is utilized to remove the bone from around the temporal tip. Often only a superolateral. using the gentle opening pressure of the bipolar cautery to dissect. they tend to immobilize the brain and limit the freedom and visualization of dissection. Mobilization of the temporalis muscle in this fashion again leads to a flatter operative site. it is suggested that no retractors be placed at this time. compressing the orbit. Likewise. At this point. which can be a nuisance. Microdissection is carried down to the carotid cistern. protecting the dura and periorbitum with soft. VOL. the orbital osteotomies are performed. With removal of the supra. and the A1 segment is untethered.

A. B. The temporal lobe being freed from the middle cranial fossa is positioned up and out. tailored orbital osteotomy. Bone work. Mobilization of the carotid artery and optic nerve can enhance the operative space. B. The third nerve is the pathway to the brainstem and the basilar artery. with soft tissue transfer and bony removal. pterional craniotomy. A. removal of the superior and lateral orbital walls permitting an unobstructed view to the tentorial edge. the view down the orbitocranial zygomatic approach with its fullest exposure. a wide view of the temporal lobe and frontal/subfrontal region is possible. .ORIGITANO : ORBITOCRANIAL ZYGOMATIC APPROACH TO UPPER BASILAR TRUNK ANEURYSMS 91 Figure 3. and tailored zygomatic osteotomy. A B B A Figure 4. The dura is opened as demonstrated by the dotted line and tented back against the soft tissue with some compression of the periorbitum.

with a low-riding basilar artery. At times. minimizing the limitations of the traditional approaches (Figure 5). At times. geometry. Operative view through the orbitocranial zygomatic approach to the upper basilar trunk and bifurcation. in combination with a foreshortened length. Rotation of the scope allows a view through the opticocarotid and oculocarotid triangles for visualization of the contralateral posterior cerebral artery. The third nerve acts as an approach vector to the basilar artery.92 NEUROSURGICAL OPERATIVE ATLAS. The posterior communicating artery is followed along its entire course with great care to preserve all of its perforators. The untethered temporal lobe will assume a position allowing a corridor for visualization and work of approximately 4 to 5 cm (Figure 4B). anteriorly to the temporal tip and slightly medially. can hinder advancement of the clip. By rotating the table. one has proximal control of the basilar artery. At this point. and posterior cerebral arteries can all be identified. the arachnoid along the nerve is cut and the nerve is followed back to the brainstem. the pos- ADJUNCTS TO THE APPROACH . The basilar. the perforators off the posterior communicating artery. Injury of a posterior communicating artery perforator should not be taken lightly as it can lead to hemiparesis. Dissection is carried along the posterior cerebral artery to the basilar junction (and aneurysm). The head and microscope are now positioned to bring the third nerve into the middle of the field. The approach thus maximizes the viewing angles and operative corridors. superior cerebellar. VOL. A number of adjuncts can be applied to cope with variations in aneurysm size. This permits further mobilization of a now laterally untethered carotid artery. Transection of the posterior communicating artery at its most proximal perforator (as related to the carotid artery) will allow the entire complex to be rotated back out of harm’s way. The posterior clinoid process is identified just medial to the third nerve. Utilizing microsurgical dissection. and position along the clivus. expanding the oculocarotid triangle. a more subtemporal view is obtained and dissection of the back wall and perforators is performed. 8 Figure 5.

Studies can be reformatted in: 1) simultaneous axial. Data collection takes approximately 60 seconds with reformat times of 5 to 10 minutes. The tentorium is then split behind the third nerve. with the patient generally recovering over 4 to 6 weeks. exposing several millimeters of the bone. the third nerve can be mobilized and the tentorium split. coronal. The third nerve may now be mobilized forward or back. a very low-lying short basilar artery exists with an apex aneurysm whose dome is at or below the posterior clinoid artery. This approach and adjuncts can be utilized to reach aneurysms of the basilar apex. deafness. The vessels of interest can be followed with a cursor along their route and cross-referenced in all three planes. Retrograde suction can lead to large volumes of blood loss if the collateral anterior circulation is robust. Generally. With the middle cranial fossa empty. which can obscure visualization of critical structures. no more than 3 to 5 mm of bone needs to be exposed and drilled. and 3) three-dimensional rendering. Care is taken to stay directly over the nerve while transecting the dura. Preoperative CT angiography is performed utilizing spiral CT with venous injection. which can lead to a greater obstruction than the primary anatomy. The reader is referred to the works of Kawase for a detailed description. The dura over the posterosuperior aspect is bipolarly cut and gently dissected forward. the surgeon is encouraged. Remember that perforator vessel integrity is beyond angiographic resolution and must be assured by careful postclipping inspection. Calcification of the neck can be readily identified. Great care must be taken not to injure the third nerve during the drilling process. the dura over the course of the third nerve is opened for approximately 1 cm. The surgeon should be prepared for the presence of a unilateral dilated pupil in the recovery room. if possible. Utilization of a cell-saver to reconstitute the blood volume should be considered. or the Kawase approach. this can be determined clinically. constituting 425 injections. Manipulation of the third nerve will lead to palsy. To avoid injury. . Intraoperative angiography may be critical for large and giant basilar apex aneurysms to assure major vessel patency (particularly contralateral posterior cerebral and superior cerebellar arteries) and aneurysm obliteration. Overzealous takedown of the bone or dura can lead to cavernous sinus bleeding. Retrograde suction can collapse or at least soften the aneurysm. and sagittal planes with point-to-point tracking. The third nerve is visualized entering the tentorium. P1 and P2 segments of the posterior cerebral artery. Complications from this approach can include carotid artery injury. Radiological adjuncts to basilar artery surgery include intraoperative balloon proximal control and angiography and preoperative computed tomography (CT) angiography. Intraoperative balloon proximal control can also be of help in dealing with large and giant basilar apex lesions. Occasionally. which can be robust. This maneuver avoids placement of a proximal clip. The precise anatomical relationship of the aneurysm geometry and spatial orientation to its osseous environment are well visualized.ORIGITANO : ORBITOCRANIAL ZYGOMATIC APPROACH TO UPPER BASILAR TRUNK ANEURYSMS 93 terior clinoid artery can become an obstacle. Again. which can then be drilled. Intraoperative angiography usually relieves the surgeon of a vascular catastrophe in these cases. allowing for final dissection and clip application. drilling of the posterior clinoid becomes less onerous as it allows for the use of shorter drills as the hand is brought closer to the target. the fourth nerve must be identified prior to this maneuver and its trajectory projected. Most importantly. we place the catheter in the parent artery of interest preoperatively with a slow heparin drip through the catheter. A more sophisticated adjunct to expose the basilar trunk is the anterior petrosectomy. reproducing those views that best demonstrate the lesion preoperatively. CT can confirm if there is any doubt. to prepare for proximal clip control should the balloon fail. 2) multiplanar volume rendering. Generally. The tentorial edges can then be tented back with 6-0 retention sutures to give a V-shaped corridor to the basilar artery. we have experienced one embolic event utilizing this protocol. taking care not to injure the fourth nerve which is situated behind it. For low-lying aneurysms or large aneurysms that require lower basilar artery control. Key to assuring obliteration is to take multiple views. Bleeding is generally controlled by packing with a hemostatic agent. entry into the cavernous sinus can occur and should be controlled with minimal packing with a hemostatic agent and pressure with a cottonoid patty. Aneurysms below the upper one third (midbasilar) of the basilar artery are better approached petrosally. A full description is beyond the scope of this chapter and is mentioned here for completeness. This extradural approach relies on the identification of key temporal bone anatomy and requires an intimate knowledge of the temporal bone anatomy. To assure intraoperative angiography when needed. and the superior cerebellar artery. Even with proximal endovascular control. With the aid of a scythe blade or a #11 bladed knife. especially with regard to clip trajectory. In our series of 100 intraoperative angiograms. aneurysm neck geometry can be rendered from multiple views including inside of the aneurysm. it is not for the uninitiated. and facial paralysis. These lie anatomically in the midbasilar region and should be approached petrosally.

This construct is reapproximated to the cranium with microplates and screws. A sheet of bacteriostatic hemostatic agent is cut and placed over the superior and lateral orbital bone defect prior to tacking down the pericranium. burr holes. it may be hard to determine immediately postoperatively. CONCLUSION . an ice bag to the eye appears to control and diminish the consequences. the mucosa is cauterized and the sinus packed with an antibiotic-soaked hemostatic agent. care should be taken not to constrict the base of the temporalis muscle. It is possible to plate with all plates hidden by the temporalis muscle. one must have the strictest hemostasis. followed by skin staples. the surgeon will find that long-bayoneted instruments are cumbersome and no longer necessary. A wire-passer drill hole at the junction of the zygomatic process of the frontal bone and supraorbital ridge can facilitate this maneuver. Care should be taken to secure it high above the keyhole to avoid a cosmetic defect. The zygoma is now reattached with a microplate and screws. I humbly acknowledge and am grateful to Drs. It should be stressed that the blade need only be placed for the moments before and during clipping when a static field is required. wider. not as a substitute for hemostasis but to encourage obliteration of the large subgaleal dead space. Eye swelling and ecchymosis are rare if the periorbitum has not been violated. If possible. A small piece of temporalis muscle is then packed into the opening into the sinus. Because of the lower. however. and allow the material to set before continuing the closure (20 to 40 minutes). I perform a duraplasty with a generous piece of pericranium to provide nonconstricting dural closure. The supraorbital bone is now reapproximated to the pterional free flap by a microplate and screws on the underside.94 NEUROSURGICAL OPERATIVE ATLAS. Ossama Al-Mefty. Generally. Sugita never did this. the view without the blade is adequate (Figure 5). “Is all of this necessary? Yasargil never did this. It is always asked. the additional osteotomies will add approximately 20 minutes to the approach and closure times. Epidural tenting sutures are placed circumferentially over the hemostatic agent along with a central tenting suture. This may aid in reducing the incidence of postoperative hydrocephalus in a patient with subarachnoid hemorrhage. Drake. The spinal drain is removed prior to extubation. and the subgaleal drain is removed in 24 to 48 hours. If the frontal sinus was entered. Drake never did this. The brain blade is removed. return is generally seen in 1 to 6 weeks. Generally. It either occurs. With WOUND CLOSURE AND COMPLICATIONS reattachment. A mixture of short-bayoneted and straight bipolars of variable lengths can now accommodate the dissection. A drain is placed under the posterior skin flap. 8 Wound closure begins with opening the lamina terminalis. A galeal closure of inverted suture is placed. the intradural space is filled with warm saline to check for a watertight closure and to evacuate air. hydroxyapatite bone cement can be used to fill the bone cuts. the temporalis fascia should be reapproximated anatomically. Postoperative swelling against a constricting zygoma can lead to loss of the temporalis muscle. Gazi Yasargil. flatter operative field. and temporal craniectomy site. The temporalis muscle is now brought back into its anatomical location. this now represents the primary blood supply of the muscle. Critical inspection of the skin flaps is now undertaken with a goal of maximum hemostasis. using grenade suction. If further cosmesis is required. or Sugita? The concepts and techniques in this chapter are not my own but ones that have been learned from the master surgeons willing to share with their students. Any forehead and scalp numbness noted by the patient should resolve and is a result of manipulating the supraorbital neurovascular bundle. The pericranial flap is then pulled over the sinus opening packed with muscle and sutured to the dura. Just prior to closure. With experience. If used. VOL.” Which one of us is a Yasargil. leave the area well drained. If the sinus is not entered. the pericranium is laid back down in its anatomical position. and Evandro DeOliveira for sharing their experience and wisdom. Blood loss for this exposure (excluding retrograde suction or aneurysm rupture) is estimated to be approximately 100 to 150 cc. If there is no facial nerve function.

This chapter is concerned with the surgical treatment of the ganglion and peripheral types of neurinomas of the trigeminal nerve. The preoperative imaging studies must be carefully reviewed to determine the exact location of the mass. These tumors may be approached adequately by unroofing 95 . may extend peripherally. a lateral location will not necessitate removal of the anterior clinoid process and decompression of the optic canal (Figure 1A-C). These tumors are divided into four types and classification is by their location. The key concept is that these two types of neurinomas are located extradurally and that a contemporary cranial base strategy can result in total resection with low morbidity. These are best approached via a retrosigmoid approach. for example. Anterior and medially located tumors may not require unroofing of the foramen ovale or rotundum for adequate exposure of the tumor (Figure 1I). This is mainly determined by the size of the tumor and the presence of any inferior extension of tumor eroding the petrous bone or involving the carotid canal. the “dumbbell” type. The large majority of ganglion-type tumors may be approached via an INTRODUCTION © 1999 The American Association of Neurological Surgeons entirely extradural temporopolar approach. Ganglion tumors located laterally may also be approached via an extradural subtemporal transpetrosal approach. including radiosurgery. An important consideration in the surgical approach to these tumors is determining an appropriate surgical strategy for extradural bone removal. M. The first two types are not addressed in this chapter.D. laterally located tumors approached via an extradural subtemporal transpetrosal approach may not require full petrous apex removal for adequate exposure (Figure 1D-H). This tumor requires a combined petrosal type of strategy and is not addressed here. The first type includes tumors arising from the trigeminal nerve root. This condition necessitates surgical intervention. Neurinomas arising from the trigeminal nerve are rare tumors that occupy the cavernous sinus and parasellar regions. contained within the posterior fossa. when very large. DIAZ DAY. No benefit has been demonstrated by other therapies. spans the posterior and middle fossas. These masses involve both the nerve root and the ganglion. These tumors typically cause a variable degree of trigeminal dysfunction and sometimes diplopia. In the case of a ganglion tumor. The necessary degree and locations of extradural bone removal are then determined for the individual patient. and. A second type of tumor. Peripheral neurinomas are handled by one of these extradural strategies or by a variation.EXTRADURAL APPROACHES FOR RESECTION OF TRIGEMINAL NEURINOMAS J. Also.

A.96 NEUROSURGICAL OPERATIVE ATLAS. coronal view of the same neurinoma. VOL. E . C. E. illustration of a laterally positioned neurinoma approached via an extradural subtemporal approach. B. 8 A B C D Figure 1. axial MRI of a small lateral trigeminal neurinoma. D. axial MRI of a small ganglion tumor that would not require optic canal unroofing and anterior clinoid resection. illustration of an anterolaterally located ganglion tumor.

) G.DAY : EXTRADURAL APPROACHES FOR RESECTION OF TRIGEMINAL NEURINOMAS 97 F G H I J Figure 1. pigmented trigeminal neurinoma. M. intraoperative photograph of an exposed pigmented neurinoma located between V2 and V3. extensive tumor requiring global exposure of the cavernous sinus. I.D. J. . exposure following removal of a well-encapsulated tumor. Fukushima. H. (Photo courtesy of T. F. anterior and medially located tumor not requiring unroofing of foramen rotundum or ovale.

In addition ANESTHETIC TECHNIQUE The scalp incision is made beginning just anterior to the tragus of the ear. no specific neurophysiological monitoring modality is of particular benefit in these cases. PREOPERATIVE PREPARATION to two large-bore intravenous lines. typically magnetic resonance imaging (MRI). and chest x-ray. The head is draped in the usual fashion for a frontotemporal craniotomy.98 NEUROSURGICAL OPERATIVE ATLAS. The majority of patients will be referred with a diagnostic imaging study. anticonvulsant prophylaxis is stopped on the seventh to 10th postoperative day if the patient has not had any seizures. Measurements may be taken from the images to provide the surgeon with an accurate concept of the operative window that will be created through petrous apex removal. this is placed in the subclavian vein. Otherwise.” elevating the back and the knees. The incision continues superiorly. utilizing an interfascial Procedure . The end-tidal CO2 is monitored and maintained between 25 and 30 mm Hg. the patient receives a maintenance dose of 3-5 mg/kg/day. and the carotid canal in interpreting this study. the superior orbital fissure. 25 gm/kg. The single pin arm is placed in the area of the midpupillary line on the contralateral side. Patients are administered anticonvulsant medication in the operating room. In the majority of cases involving an entirely extradural surgery. The patient’s medical history is obtained and a detailed neurological examination completed. Patients undergo the usual preoperative laboratory blood work. Furosemide. In the younger patient in whom there is usually an adequate degree of cerebral compliance. The vertex is placed in the neutral position. the internal auditory canal. Particular attention is directed toward the relationship between the cochlea. This process of strategy development is important so as to limit potential morbidity to the pericavernous structures. The head is placed in the Mayfield three-pin headrest with the two-pin side on the side of the approach. All patients are given antibiotics perioperatively. These maneuvers are directed at providing a compliant brain. All bony prominences are well padded with foam. gently curving to end at the midline (Figure 2). within the hairline. electrocardiogram. Vancomycin is given to patients who have exhibited an allergy to penicillin and its derivatives. Several maneuvers are important in terms of managing the intracranial pressure during the procedure. Selected patients undergoing an anterior transpetrosal approach have a lumbar drain inserted for drainage of cerebrospinal fluid during retraction of the temporal lobe. which is the dependent side. All sensory modalities are tested and the intensity of sensation as compared to a normal area is graded using a 10-point scale. The galeocutaneous flap is then elevated. 8 the optic canal. as this is an operation where the surgeon is looking down onto the middle fossa and cavernous sinus areas. Operative Positioning THE EXTRADURAL FRONTOTEMPORAL TEMPOROPOLAR APPROACH Patients are administered general anesthesia via inhalation agents. Sequential compression boots are placed on the patient’s legs and the device is activated. I do not insert a drain. The corneal reflexes are tested with a cotton wisp. Patients with any sign of keratitis are referred to an ophthalmologist for consultation. and the anteromedial triangle via removal of the anterior clinoid process. are also administered intravenously at the time of cutting the cranial bone flap to initiate a diuresis. typically diphenylhydantoin at a dose of 10 mg/kg. incorporating galea. some patients require central venous access. Large tumors involving the entire cavernous sinus region will require a global strategy in order to optimize extradural bone removal (Figure 1J). Patients in whom the anterior transpetrosal approach is indicated will undergo imaging work-up supplemented by a fine-cut bone window computed tomography scan. All patients have a radial arterial line placed to monitor blood pressure. VOL. 10-20 mg. Preferably. for hemostasis. This study is also important in cases where frameless stereotaxis will be used as an adjunct. trigeminal nerve function is carefully tested and documented. Scalp clips are applied to the margins of the scalp. within the hairline. Dropping the vertex of the head in these procedures is not suggested. For a short period. The nerve monitor is utilized to assist with identifying the geniculate ganglion when located deep to the bone. When performing the anterior transpetrosal approach. In particular. This is important in terms of determining postoperative improvement in sensory function. over the root of the zygomatic process. facial nerve monitoring is a useful adjunct. The patient is placed supine on the operating table and the table is “couched. This is especially important in the older patient who may not tolerate any degree of temporal lobe retraction. A broad-spectrum cephalosporin is used in the majority of cases. although it will be retracted only sparingly and under the protection of the overlying dura. Medical clearance is obtained when warranted by any chronic medical conditions such as diabetes or hypertension. The head is turned approximately 45 degrees toward the opposite shoulder. and mannitol.

After removal of the flap. The craniotomy is roughly centered one third above and two thirds below the superior temporal line. The galea is separated from the pericranium medial to the superior temporal line. and is performed with a high-speed drill. The scalp is held with large blunt scalp hooks and rubber bands. taking care to preserve the supraorbital nerves with the galeal layer. The dura is elevated away at the anterior temporal margin with a dissector. This fascia is then elevated with the galeal layer. covered by the periosteum. The temporalis muscle is then elevated from the frontozygomatic recess and the temporal squama via subperiosteal dissection. The patient is positioned with the head turned approximately 45 degrees (A). The extradural frontotemporal temporopolar approach.DAY : EXTRADURAL APPROACHES FOR RESECTION OF TRIGEMINAL NEURINOMAS 99 A B Figure 2. The bone flap typically measures roughly 6 × 4 cm. The scalp incision and craniotomy are similar to that of a routine pterional-type approach (B). hemostasis is secured and the posterior dural margins are tacked up to the bone margin with fine suture. dissection over the temporalis muscle. The sphenoid ridge is reduced until a smooth contour of the superior and lateral orbit is created. This maneuver places the surgeon in the correct plane to separate the superficial and deep components of the temporal fat pad. the periosteum over the zygomatic arch is exposed. Burr holes are placed over the pterion and in the low temporal region. The dura is elevated away from the sphenoid ridge. This may be used later for dural repair or coverage of an opened air sinus. The muscle is held inferiorly and posteriorly using large blunt hooks. This will result in rotating the temporalis muscle and fascia inferiorly and posteriorly. which are protected when this maneuver is properly performed. flat access to the middle fossa. A vascularized pericranial flap is preserved. leaving bare temporalis fascia. At the superior temporal line. the fascia innominata (loose connective tissue between the temporalis fascia and the galea) is incised from its connection to the medial pericranium. incising along the margin of the scalp incision and the superior temporal line. This is done “cold” in order to avoid damage to the neural or vascular supply to the muscle. The periosteum is then elevated toward the temporalis muscle. Scalp elevation proceeds until the supraorbital and lateral orbital rims are exposed. and any remaining bone overhanging the middle fossa is rongeured away. The superficial fat pad layer contains the frontalis branches of the facial nerve. freeing the fascia of its anterior and inferior attachment. such as to leave a cuff of tissue for later reattachment. Inferiorly. Periosteum over the lateral orbital rim and zygomatic arch is incised next. The . The temporalis fascia is separated at the superior temporal line using a sharp instrument. clearing out the frontozygomatic recess and providing a wide. and self-retaining retractor blades are placed to hold it away (Figure 3). The flap is then raised via subperiosteal dissection and wrapped in moist gauze. The pericranial flap is held anterior with the scalp flap using large blunt scalp hooks. The frontotemporal craniotomy is then cut using a high-speed drill. the result will be superior cosmetic outcome without loss of muscle bulk and tone. Extradural removal of bone at the anterior and temporal base is the next step in the procedure.

. Figure 5. VOL. The defining maneuver of the extradural approach for neurinomas is separation of the lateral wall of the cavernous sinus. Elevation of the dura exposes the neural foramina at the middle fossa base and the superior orbital fissure.100 NEUROSURGICAL OPERATIVE ATLAS. 8 Figure 3. Tumor is exposed and resected utilizing the various entry corridors to the cavernous sinus. Figure 4.

the structures exposed via bone removal are tailored specifically to what is required by the anatomy of the individual lesion being treated (as outlined above in the Introduction). and foramen ovale. and the tragus of the ear located. The routes accessible by this approach are the anteromedial. Typically. cavernous sinus bleeding is not particularly problematic in these cases. usually exposed via the anterolateral or far lateral triangle. Sometimes. and the ganglion. the mobility of the patient’s neck should have been tested to determine the degree of resistance to turning the head 90 degrees. a straight incision with a small anterior curve is adequate.DAY : EXTRADURAL APPROACHES FOR RESECTION OF TRIGEMINAL NEURINOMAS 101 bone of the middle fossa is shaved down toward the periosteum forming the roof of the infratemporal fossa. This is the defining maneuver of the extradural approach to these tumors (Figure 4). In selected cases. Prior to turning the head. For most small lesions of the ganglion or V3 peripheral branch. trigeminal nerve fibers are spread and flattened over the capsule of the tumor. foramen rotundum. After opening the capsule. procedures in which an air sinus has been opened through the course of extradural bone removal will require adipose and fascial grafting for adequate closure. far lateral. This same maneuver is then performed in the various triangular entry corridors used. the cleavage plane between the temporal dura propria and periorbital fascia is separated using sharp dissection technique. superior. The monitor is useful in locating the position of the geniculate ganglion and confirming the integrity of the GSPN on the floor of the middle fossa. The head is placed in the Mayfield three-pin headrest with the two-pin side straddling the subocciput. through possible traction on the greater superficial petrosal nerve (GSPN). The choice depends upon the necessary size of the craniotomy. adipose and fascial grafts are not necessary. However. The temporalis fascia and muscle are then incised with unipolar cautery along the line of the Operative Positioning Procedure . the anterior clinoid process will be removed and the optic canal unroofed. Beginning at the superior orbital fissure. Scalp clips are applied to the wound edges for hemostasis. the anterolateral. generous internal debulking is performed. Usually. Usually. and lateral triangles will be the most frequently employed for ganglion tumors. lateral. Monitoring of the facial nerve is employed routinely in this procedure because of the risk to the facial nerve during dural elevation. Resection of the tumor now proceeds utilizing the various triangular entry corridors to the cavernous sinus. The bone flap is then reapproximated with stainless steel wire or titanium microplates for best cosmesis. foramen rotundum. The incision begins just anterior to the tragus of the ear at the inferior margin of the zygomatic root. the outer cavernous membrane) continues toward the incisural edge. The third important surface landmark for planning is the superior temporal line. leaving the outer cortical table intact where possible. The dura is further elevated toward the temporal base to expose the superior orbital fissure. the wound is closed. The scalp is incised straight superiorly. fibers of the trigeminal nerve are separated to expose the capsule. far lateral. first working within one triangular corridor. Two different incisions may be utilized for this approach. The primary goal of closure in this approach is r econstruction of the skull base. From this point of the procedure. especially an elderly patient. Separation of the dura propria from the connective tissue covering of the nerve (i. If significant resistance is encountered. This cleavage plane is developed and opened over V2. the lateral position is required so that no strain is placed upon the cervical spine. Additionally. near the midline. external landmarks are identified. bone must be removed over the superior orbital fissure. Any opened air sinus must be exenterated of its mucosa and packed with fat or muscle to prevent infection and mucocele formation. A retractor blade is placed over the temporal pole and pressure is directed in the posterior direction.. The single pin arm is placed within the hairline. At a minimum. In some cases.e. Wound Closure THE EXTRADURAL SUBTEMPORAL TRANSPETROSAL APPROACH The patient is positioned with the head in a lateral orientation (Figure 6). The root of the zygomatic process is palpated. The tumor and the cavernous sinus are exposed without opening the dura and exposing the underlying temporal lobe (Figure 5). a roll is placed under the shoulder to reduce strain on the neck and minimize the chances of vertebral artery occlusion. Any cavernous bleeding is controlled with Surgicel packing. Any openings made in the dura must be reconstructed in watertight fashion. the plane between the trigeminal nerve and tumor capsule is developed with sharp microdissectors. anterolateral. Usually. and foramen ovale. This can be adequately performed with sharp dissection techniques and the use of microring curettes. After tumor resection. Prior to scalp incision. posterolateral. V3. At this point of dissection. the tumor becomes readily evident. The tumor capsule is identified and opened. pushing tumor and capsule toward the primary entry corridor with soft cottonoid patties. curving slightly anteriorly as the superior temporal line is neared. the temporal tip bridging veins are left undisturbed. After internal debulking. Standard principles of tumor resection are used in these procedures. and medial.

centered two thirds anterior and one third posterior to the external auditory canal. 8 A B Figure 6. The key to this dissection is identification of the loose areolar layer of connective tissue. Again.102 NEUROSURGICAL OPERATIVE ATLAS. VOL. opening the appropriate dissection plane to split the components of the fat pad. it is important to free the muscle from the zygomatic root and pull it anteriorly to maximize exposure. To safely remove the bone of the petrous apex via the extradural route. removal of bone at the petrous apex may be necessary for full exposure and removal of the tumor. The muscle is cleared away from the root of the zygoma and pulled anteriorly. The dura is further elevated to expose the foramen ovale and V3. Initiating dural elevation posteriorly is important in terms of avoiding traction on the GSPN. The patient’s head is positioned laterally (A). splitting the superficial and deep components of the temporal fat pad in order to protect the frontalis branches of the facial nerve. beginning over the petrous ridge (Figure 7). The cleavage plane between the temporal dura propria and the connective tissue sheath over V3 is next identified and developed sharply. This requires an interfascial dissection. After applying scalp clips to the galeocutaneous margins. The artery is coagulated and divided. In some cases. A flat viewing angle across the floor is necessary in terms of limiting temporal lobe retraction. The extradural subtemporal transpetrosal approach. The dura propria is separated from V3 and the lateral portion of the gasserian ganglion. The dura is elevated from the middle fossa floor with a fine dissector. lying in the major petrosal groove. Elevation in the anterior direction separates the dura propria from the periosteum covering the GSPN. held by blunt scalp hooks. similar to the temporopolar approach (Figure 8). Two tapered self-retaining retractor blades are then placed on the dura over the temporal lobe. between the galea and the temporalis fascia. When a larger craniotomy is necessary. The dura is elevated medially until the lateral margin of the trigeminal impression is exposed. A temporal craniotomy is then cut. scalp incision. The temporalis fascia and muscle are then incised in the line of the scalp incision with unipolar cautery. Elevation continues anteriorly until the middle meningeal artery is exposed at the foramen spinosum. The temporalis muscle is held anterior and posterior with blunt scalp hooks. called the fascia innominata. a question mark-shaped incision is made (Figure 6). The craniotomy needs to measure no more than approximately 4 × 4 cm. The fascia innominata is elevated with the galea. A highspeed drill is then used to reduce any remaining bony overhang of the middle fossa floor. The muscle is then elevated via subperiosteal dissection from the temporal squama and elevated anteriorly. The incision extends superiorly to the level of the superior temporal line. The incision and craniotomy are shown (B). sequential dissection of the . the scalp is elevated from the temporalis fascia. This maneuver exposes the trigeminal fibers stretched over the tumor mass. which may lead to postoperative facial nerve dysfunction.

Elevation of the middle fossa dura exposes key landmarks of the middle fossa floor. .DAY : EXTRADURAL APPROACHES FOR RESECTION OF TRIGEMINAL NEURINOMAS 103 Figure 7. Figure 8. Petrous apex removal increases exposure into the posterior cavernous sinus. Separation of the dura propria from the outer cavernous membrane provides exposure of the posterolateral cavernous sinus. The exposure is now adequate for petrous apex removal. if indicated. Figure 9. down to the clivus and entrance of the sixth cranial nerve into Dorello’s canal.

This may also be described by the “premeatal” triangle. The tumor is then resected by utilizing the lateral triangular entry corridors to the cavernous sinus. Radical petrous apex removal is seldom required in these patients. This axis is roughly 60 degrees from either the GSPN or the superior semicircular canal. 2) the porus trigeminus. Of course. VOL. the bone between these two structures may then be quickly removed with the drill. Certainly. the geniculate ganglion. With the internal auditory canal and the petrous carotid exposed. defined by the carotid genu. This triangle is defined by the foramen ovale. The bone under the gasserian ganglion may also be removed by thinning with the drill followed by removal using a dissector. eye care is extremely important beginning at the time of presentation. COMPLICATIONS . Probably the most troublesome complication from removal of these tumors is keratitis suffered as a consequence of a diminished corneal reflex. My preferred method is placement of a pedicled temporalis muscle flap into the defect. Therefore. any operation in or around the cavernous sinus has the potential to injure the ocular motor nerves. Next. the seventh and eighth cranial nerves are especially at risk. posterolateral. Patients with pain as a presenting complaint are typically relieved. Because of the high risk of motor dysfunction. It is helpful to consider the key landmarks of the middle fossa floor as a guide to bone removal. This tends to heal very well due to the vascularized nature of the flap. The same principles apply as for the temporopolar approach. This approach is typically performed without any dural disruption. the rare patient with bilateral tumors is treated only on the side producing the bulk of symptoms. Careful dissection of the tumor capsule while limiting manipulation of these nerves is the key to reducing the chances of this complication. An alternative method is to place a free adipose graft in the defect. The cochlea may also be damaged during this drilling. Two methods for closure are possible. outlined above. and the approach must be tailored for the individual patient. These landmarks are: 1) the GSPN-V3 junction. Four landmarks outline the rhomboid-shaped volume of bone which may then be removed and which is devoid of neural or vascular structures. Most typical via this approach are the far lateral. although this is uncommon. The artery is followed laterally until the crossing point of the tensor tympani muscle is identified. medially situated ganglion tumors and those with peripheral lesions of V1 and V2. Diplopia may be a consequence of surgical resection. The seventh nerve in particular may be damaged via traction on the GSPN. This flap is taken from the posterior to the middle section of the temporalis muscle. Diplopia is also a frequent presenting complaint that may or may not be helped by surgery. 3) the arcuate eminence-petrous ridge junction. and posteromedial triangles. the seventh and eighth nerves are at risk during unroofing of the internal auditory canal. Many patients will have some resolution or a diminution of their hypesthesia. the intrapetrous carotid artery is exposed by unroofing the carotid canal in Glasscock’s triangle. A large number of patients suffer trigeminal motor dysfunction after resection. the cochlea.104 NEUROSURGICAL OPERATIVE ATLAS. damaging the nerve. Certain complications are common after resection of trigeminal neurinomas. The majority of this bone is vascular cancellous bone that can be easily drilled away. This circumstance requires exclusion of the subarachnoid space from communication with the middle fossa. this is harvested from the abdomen. When utilizing the extradural subtemporal transpetrosal approach. The cochlea resides in the volume of bone located under the geniculate ganglion. To begin. the posterior fossa subarachnoid space will come into communication with the extradural space as a consequence of tumor resection near the trigeminal root in Meckel’s cave. the internal auditory canal is unroofed. and the V3 origin. This is done by first drilling near the petrous ridge over the bisection axis of the angle between the GSPN and the arcuate eminence. which translates to the geniculate ganglion. the carotid artery. most patients will present with a diminished corneal reflex. It is easiest to begin drilling near V3. Avoidance of this structure is achieved by observing the anatomical relationship of the cochlea to the landmark structures. However. just anterior to the GSPN. practice in the cadaver laboratory and clinical experience are key factors in avoiding the cochlea during drilling. and the medial lip of the porus acusticus. Typically. and the trigeminal peripheral branches. whether it be hypesthesia or pain. 8 middle fossa floor is critical (Figure 9). This marks the genu of the petrous carotid artery. Elevating the dura posteriorly to anteriorly will reduce the chance of this complication. Most patients present with some dysfunction of the trigeminal nerve. Obliquely projecting this rhomboid-shaped complex through the bone toward the clivus delimits the volume of bone removed to the level of the inferior petrosal sinus. The bone flap is then replaced and the wound closed. deficits of the fifth cranial nerve may be expected in the early postoperative period. and 4) the junction of the axes of the GSPN and the arcuate eminence. Also. This is less common in patients with small. In some cases. The opposite side must be managed expectantly and may only be treatable by radiation therapy. between the internal auditory canal and the genu of the petrous carotid artery. Certainly. the oculomotor nerve. Other structures at risk from the high-speed drill are the optic nerve.

When successfully employed. tumors classified as ganglion or peripheral types may be treated through an entirely extradural approach. Such complex bone removal must be done carefully after sufficient training in the cadaver laboratory to reduce complications. Also.DAY : EXTRADURAL APPROACHES FOR RESECTION OF TRIGEMINAL NEURINOMAS 105 All structures are at risk both from direct damage by the burr and from the heat generated by using a diamond-tipped burr. In the vast majority of cases. CONCLUSIONS Trigeminal neurinomas are rare tumors treated pri- marily with surgical resection. . all drilling is performed with strict attention to maintaining a cool local environment with continuous irrigation. It should be kept in mind that each approach is tailored according to the individual anatomy of the tumor in terms of the necessary extradural bone removal. The two main extradural approaches for these tumors have been presented. these approaches result in a high rate of success with regard to tumor resection and resolution of symptoms.

.

progressively eroding the skull base. and sixth cranial nerve dysfunction. or the enlargement of exit foramen (such as the foramen rotundum or ovale) may be candidates for surgery since these tumors have a tendency to violate the dura and become intracranial. and extend to the extracranial branches on the face. extracranial lesions at the skull base without erosion of the skull base should be periodically followed.2% of all intracranial tumors. decreased sensation is more commonly reported than pain. and/or difficulty in chewing on the side where the tumor is located.D. M. PH. MARCOS TATAGIBA. signs and symptoms depend upon the direction of tumor growth. Although rare. Although 50% of intracranial trigeminal schwannomas arise from the trigeminal ganglion. Approximately 20% of trigeminal schwannomas arise from the fifth cranial nerve in the posterior fossa and present as a mass in the cerebellopontine angle. thus. It is estimated that 25% of trigeminal schwannomas have an hourglass type of extension above and below the tentorium. Patients with extracranial lesions and erosion of the skull base. asymptomatic. followed by the maxillary and mandibular divisions. Among the extracranial branches. seventh. Resection of these tumors may not be a technical challenge. However. Schwannomas arising from the trigeminal nerve are quite uncommon and represent only 0. Fifteen percent of patients with a middle fossa schwannoma may be asymptomatic. These tumors may appear as masses INTRODUCTION in the cavernous sinus with third. Although some patients experience facial pain. fourth. schwannomas can arise from any part of the trigeminal nerve. causing dysfunction of the fifth.SURGICAL MANAGEMENT OF TRIGEMINAL SCHWANNOMAS MADJID SAMII. or masses in the pterygopalatine and infratemporal fossae.D. Symptoms may consist of paresthesias. pain.D. the ophthalmic division is the most commonly involved. but significant morbidity can result from cerebrospinal fluid (CSF) leakage PATIENT SELECTION 107 . they are often accidentally discovered during work-up for sinus conditions or facial injury. patients presenting with small. However. as the tumor increases in size. including its origin in the posterior fossa.. M. numbness. RAMESH PITTI BABU. © 1999 The American Association of Neurological Surgeons Patients with intracranial lesions presenting with increased intracranial pressure (ICP) and neurological deficits are candidates for surgery. it can grow in a variety of ways depending on which branch is involved. nasopharyngeal masses. incidentally discovered.D. an increase in size or a change in the character of the lesion should alert the surgeon to a possible malignant transformation requiring surgery. Schwannomas of the ophthalmic division present with proptosis. or as para-pharyngeal masses. and eighth cranial nerves with or without cerebellar dysfunction. M. lesions arising from the maxillary or mandibular divisions can be quiescent for a long time. However.

5 mg/kg body weight) may be useful prior to laryngoscopy. such as sodium nitroprusside or nitroglycerine. commonly arising from the trigeminal ganglion. After intubation. a loading dose of 1 gm Dilantin is administered. electrocardiography. The PaCO2 is maintained in the range of 25 to 30 mm Hg. VOL. proximal to the ganglion. and capnography. On MR imaging. The availability of computed tomography (CT) and magnetic resonance (MR) imaging has made plain x-rays obsolete. Type D tumors arise from the extracranial branches of the fifth cranial nerve. but may not be tolerated by a patient with cardiovascular disease or hypertension. Induced hypotension may be required during surgery to reduce blood loss and the need for transfusion. In elderly patients presenting with intracranial lesions. the patient is given intravenous Solu-Medrol. Patients are placed in the supine position with the head fixed in a three-pin Mayfield head- Type A Tumors (The Frontotemporal Approach) . it may be one of the shorteracting benzodiazepines such as diazepam or midazolam.4% and anesthesia is sustained primarily with a narcotic infusion and nitrous oxide. These tumors may invade the cavernous sinus or extend into the orbit via the superior orbital fissure. The day prior to surgery. or hyperintense on T1-weighted images and significantly enhance after intravenous contrast. A short-acting opioid and ultrashort-acting intravenous anesthetic (generally thiopental or propofol) are used for induction.0-1. On CT. or where temporary occlusion of the carotid artery is required during tumor dissection. When premedication is used. which can result in increased ICP. or coughing. 8 if the floor is not repaired well. these lesions are hypo-. deliberate hypotension may be induced by increasing the level of isoflurane or by a direct-acting vasodilator. Anesthesia is generally maintained with a narcotic by infusion or intermittent dosage of nitrous oxide and isoflurane. These tumors are classified into four categories: Type A tumors are located entirely within the middle cranial fossa. In this case. Type B tumors are situated in the posterior fossa and arise from the root of the fifth cranial nerve. They arise either from the trigeminal ganglion or from one of the branches of the fifth cranial nerve prior to exiting the intracranial compartment. halogenated anesthetics cannot be used.and supratentorial extensions (hourglass type). The hypertensive response to pin fixation of the head may be minimized or eliminated by prior administration of an intravenous anesthetic. particularly in large tumors. the level of isoflurane is maintained at <0. Narcotics should be avoided because they tend to produce respiratory depression and/or nausea and vomiting. on call to the operating room. hypoxia. Evoked potential monitoring necessitates some modification of the anesthetic technique. The balloon occlusion test may be necessary in cases where the carotid artery needs to be sacrificed and a vein bypass graft is contemplated.108 NEUROSURGICAL OPERATIVE ATLAS. In addition. noninvasive blood pressure measurement. followed by a nondepolarizing muscle relaxant for intubation. for whom long hours of surgery cannot be undertaken for medical reasons. RADIOLOGICAL EVALUATION increase ICP. Capnography assesses the ICP level and is titrated to obtain optimal ICP control. All patients should be advised of the potential risks of deficits of the fifth cranial nerve following surgery. conventional cerebral angiography may be undertaken to better delineate the carotid artery and to study the venous anatomy with attention to the vein of Labbé and the sigmoid sinus. Intravenous lidocaine (1. such as in tumors arising from the ophthalmic division. particularly in tumors with infra. 250 mg every 6 hours.and infratentorial compartment in an hourglass manner and grow across the tentorial hiatus. iso-. A combination of these agents permits a smooth induction of anesthesia. Type C tumors occupy the supra. propofol and opioid (fentanyl or sufentanil) infusions are substituted and only nitrous oxide is used as an inhalant. The frontotemporal approach is best suited for type A tumors situated in the middle cranial fossa (Figure 2). the bladder is catheterized and 20% mannitol is administered intravenously (1 gm/kg body weight). hypercarbia. schwannomas appear isodense and enhance with contrast medium. which is continued postoperatively at 100 mg three times a day. Routine monitoring in the operating room consists of pulse oximetry. If just the sensory modalities are monitored. In highly vascular tumors. If motor evoked potentials and electromyography are also employed. thus avoiding hypertension. CT with bone windows is an excellent diagnostic tool by which to visualize the bony erosions at the skull base. MR angiography may be performed to visualize displacement of the major vessels. OPERATIVE TECHNIQUE Type A tumors are entirely confined to the middle cranial fossa (Figure 1). all of which may PREPARATION AND ANESTHESIA The surgical approach to a trigeminal schwannoma depends upon the location of the tumor. intratumoral debulking may be ideal to reduce the mass. Starting at midnight prior to surgery. A mean arterial pressure of 50-60 mm Hg is acceptable in a healthy individual. An arterial catheter and one or two largebore intravenous lines are inserted.

Note that the patient is well padded and secured and the head is maintained above the level of the heart. .SAMII ET AL : SURGICAL MANAGEMENT OF TRIGEMINAL SCHWANNOMAS 109 A B Figure 1. axial (A) and coronal (B) views. of the brain with gadolinium demonstrating tumor of the middle cranial fossa (type A tumor). Supine position used for resection of tumors via the frontotemporal approach. Figure 2. MR imaging.

Tumor has been exposed after widely splitting the sylvian fissure. Note the relationship of optic nerve and cerebral vessels to the tumor. Skin incision. VOL. Tumor resection via the frontotemporal approach (type A tumor) Figure 5. After interfacial dissection at the zygomatic process. fissure . Craniotomy and planned dural incision are shown. 8 Figure 3. Figure 6. Note that the lower part of the skin incision is within 1 cm of the ear to avoid injury to the facial nerve. Skin flap has been retracted.110 NEUROSURGICAL OPERATIVE ATLAS. the temporalis muscle and fascia are incised as a second layer. Figure 4.

We use a Jackson Pratt drain in the submuscular-galeal plane. the gasserian ganglion and the posterior cavernous sinus are carefully examined and exposed if necessary. the surface of the tumor is coagulated and cut. During bone removal. which are inside the arachnoid toward the pia around the brain. the tumor can be removed without causing undue damage to the fifth nerve. carotid artery. from it. the lateral decubitus position can be used. it is usually not necessary to cut the superior petrosal . since in massive tumors. including the posterior fossa dura (Figure 10). The head is elevated above the level of the heart. the mastoid air cells may be opened. the patient’s head is placed in a three-pin Mayfield headholder and is slowly positioned in the sitting position. It also helps to identify the arachnoid membrane around the tumor. Alternatively. microscopic magnification and illumination are used. a craniotomy flap exposing the posterior fossa with additional required drilling toward the sinuses can be accomplished. A cuff of fascia along the superior temporal line is left for later closure. these are packed with muscle at the end of surgery. The dura is then opened in a semicircular manner based on the floor. An ultrasonic aspirator is generously used to reduce the size of the tumor and thoroughly decompress it so that the surrounding structures. Otherwise. making the zygomatic eminence the highest point in the operating field. which is discontinued after 48 hours. a precordial Doppler ultrasound is used to detect air embolism and a central venous line with its tip at the junction of the superior vena cava and the right atrium is placed after intubation to aspirate the embolized air. minimizing rotation of the head. A frontal keyhole and another burr hole at the squamous portion of the temporal bone. incision and muscle dissection at the skull base is carefully done using a knife. Initially. just above the zygomatic root. exposing the cerebellopontine angle. Prior to tumor resection. exposing the tumor. Extradural drilling of the lesser wing of the sphenoid bone is accomplished. the brain is covered with a Penrose drain and cottonoids are placed over the brain. Once the tumor is removed. facilitating the venous drainage. in younger patients. Initially. Cerebellar retractors are later applied to retract the muscles that are supporting the bone. it is better to place two or three burr holes and gently separate the dura from the bone before the craniotomy flap is lifted. beginning at the zygoma and gently curving around the temporal line onto the frontal area. a second T-shaped cut is made vertically corresponding to the sylvian fissure (Figure 5). the dura is closed in a watertight fashion and the operation is completed in a routine manner. Progressive internal decompression helps identify the branches of the fifth cranial nerve as well. In elderly patients. Initially. avoiding injury to the blood vessels. Dural opening is carried out several millimeters away from and along the sinuses and then retracted with tack-up sutures. a malleable brain retractor is used on the surface of the cottonoids. Type B Tumors (Retromastoid Approach) Tumors situated in the posterior fossa (Type B) are approached via conventional retromastoid craniectomy (Figure 7). These tumors are approached with the patient in the semi-sitting or lounging position (Figure 8). All pressure points are well padded. elevating and turning the upper torso to the opposite side. On most occasions. Retraction of the frontal and temporal lobes is accomplished by the Greenberg retractor system. later. The head is tilted to the other side by 30 to 35 degrees and extended by 150 to 120 degrees. A single myocutaneous flap is elevated and retracted using fishhooks. all within the hairline (Figure 3). These tumors are extracerebral and subdural. Once the tumor is removed from the cavernous sinus. The skin incision is marked starting within 1 cm in front of the external auditory meatus. such as the carotid artery bifurcation and the third and fourth nerves on the medial aspect of the tumor near the tentorial margin. Beginning at this stage. Alternatively. The head is slightly turned to the ipsilateral side of the tumor. lest injury to the vertebral artery occur. bleeding that originates from the sinus is readily stopped by packing it with surgical cotton or Avitene. The muscles are cut using a knife or Bovie coagulator. to expose the dura covering the frontal and temporal lobes and the sylvian fissure. The sylvian fissure is split from medial to lateral. Initially. since the dura is stuck to the bone. are well visualized. and the sylvian vessels (Figure 6). brain relaxation is achieved by draining CSF through an opening of the cistern in the angle (Figure 11). exposing the frontal and temporal bones and centered on the pterion (Figure 4). A retromastoid skin incision is made from the superior nuchal line up to the base of the occiput (Figure 9).SAMII ET AL : SURGICAL MANAGEMENT OF TRIGEMINAL SCHWANNOMAS 111 holder.5-5 cm behind the external auditory canal and is converted into a 4-5 cm diameter craniectomy exposing the edge of the transverse and sigmoid sinus junction. A single burr hole is placed just below the Frankfurt horizontal plane and 4. At the conclusion of surgical resection. A shoulder roll is placed under the ipsilateral shoulder. remnants of the tumor may lurk that can cause recurrence if not removed. allowing the tumor’s interior to be exposed. no special anesthetic considerations are necessary. The cerebellum is then covered with cottonoids and retracted using a malleable brain retractor. making the base very flat. however. If the semi-sitting position is chosen. are placed before the craniotome is used. They have a well-defined capsule and often are not vascular.

8 A B Figure 7. of the head. without causing jugular vein compromise. Semi-sitting position commonly employed for resection of type B tumors. VOL. sagittal (A) and axial (B) views. MR imaging.112 NEUROSURGICAL OPERATIVE ATLAS. with mild flexion. Note the elevation of the legs and ipsilateral turning. Figure 8. . of the brain with gadolinium demonstrating tumor in the posterior fossa (type B tumor).

Once the cerebellum is retracted. the tumor is exposed in the cerebellopontine angle. Figure 11. Dura is tightly tacked up to the nearby soft tissue.SAMII ET AL : SURGICAL MANAGEMENT OF TRIGEMINAL SCHWANNOMAS 113 Resection of tumors situated in the posterior fossa (type B tumor) Figure 9. . Figure 10. maximizing the exposure. Note the relation of the superior cerebellar artery and the seventh and eighth nerve complex to the tumor. Craniectomy adequate to expose the edge of the transverse and sigmoid sinuses. Retromastoid skin incision. The dura is opened a few millimeters away from the sinuses.

the entire nerve is often splayed on the surface of the tumor. using electrophysiological monitoring. axial view. Routine closure of muscle and fascia is later achieved using 0-0 Vicryl sutures. is performed. and preserved. Figure 12. two additional burr holes are placed in the temporal area. push- . To achieve total tumor resection. the bone over the sigmoid sinus and the junction of the transverse sinus is drilled. the tumor lies above the seventh and eighth nerve complex.114 NEUROSURGICAL OPERATIVE ATLAS. Part of the transverse sinus closer to the midline is also drilled. the nerve is visualized after the displaced nerve fibers become compact. The extraarachnoidal dissection and debulking are performed by teasing with the help of two tumor-holding forceps and an ultrasonic aspirator. and skin closure with either staples or monofilament nylon. with progressive debulking using the ultrasonic aspirator. Before the tentorium is cut. pushed to the caudal aspect of the tumor. the fifth cranial nerve at the brainstem. both anatomically as well as physiologically. Once the tentorium is cut. in the supine position with the head turned. Enthusiastic separation from the brainstem using cottonoids is to be avoided. maintaining the integrity of the peritumoral arachnoid. VOL. Later. Once the cerebellopontine angle exposed.and Infratentorial Approach) shaped bone flap is then removed using a craniotome. Progressive intratumoral decompression with an ultrasonic aspirator is carried out. similar precautions and maneuvers are undertaken as mentioned in the previous section. The fourth cranial nerve and the posterior cerebral artery at the tentorial hiatus are protected while the retractors are applied. of the brain with gadolinium demonstrating tumor in both the posterior and middle fossa (ype C tumor). In the posterior fossa. It is advised not to simply coagulate and leave the sinus since it can open during the surgery and cause troublesome bleeding. by using a high-speed drill. as well as the tumor are observed. MR imaging. one on the cerebellum and another on the temporal lobe. a total mastoidectomy extending to the semicircular canals is accomplished. The skin incision is marked as shown in Figure 13. or in a strict lateral position. A helmet- Type C Tumors (Combined Pre-sigmoid Supra. thus exposing the subtemporal and suboccipital dura as well as the transverse and sigmoid sinuses. in a “7” shape around the ear. In large tumors. it may be necessary to sacrifice a few nerve fibers without any major neurological deficit. and can be preserved completely. but sacrificing the vein is not known to cause any deficits. The seventh and eighth cranial nerve complex (which has been pushed down) is identified. Initially. Patients with type C tumors are operated on using a combined pre-sigmoid supra. Subcutaneous closure with interrupted 3-0 Vicryl sutures. The skin is incised and reflected toward the ear. We believe that the sitting position is ideal for operating on these patients.000 lidocaine with epinephrine. the superior petrosal sinus is doubly heated using 2-0 silk ties. jugular compression is performed to test hemostasis. It is advisable to cut the tentorium in its posterior portion to prevent injury to the trochlear nerve. The mastoid air cells are packed with fibrin glue-soaked muscle to prevent CSF leak. Since these tumors arise from the sensory component. The last cut on the tentorium is made after identifying and isolating the fourth cranial nerve in the subarachnoid space with the assistance of a fine nerve hook. 8 vein. The area of skin incision is infiltrated with 1:100.and infratentorial approach (Figures 13-18). The pre-sigmoid dura is cut vertically and the subtemporal dura is incised horizontally along the base of the temporal fossa. This approach is done with the patient either in the semisitting position. the motor component is separately identified. As far as the sitting position is concerned. At this stage. and the temporal and suboccipital bones are exposed after raising a single musculoperiosteal flap. The entire dura from the sigmoid sinus to the semicircular canals is then exposed. and the dura is closed in a watertight fashion. Constant suction and irrigation help to clear the operative field. Once the tumor is completely removed. the tumor is exposed after placing two retractors.

Retromastoid skin incision is continued as a low temporal incision around the ear is used.SAMII ET AL : SURGICAL MANAGEMENT OF TRIGEMINAL SCHWANNOMAS 115 Figure 13. Dural incision as marked by the dotted line. exposing the dura in the retrosigmoid. The superior petrosal sinus needs to be ligated prior to the tentorial incision. The mastoidectomy. . and temporal areas. and temporal craniotomy are completed. Note the relationship of the superior petrosal sinus relative to the dotted line. Figure 14. suboccipital craniectomy. pre-sigmoid. Tumor resection via the combined pre-sigmoid supraand infratentorial approach (type C tumor) Figure 15.

116 NEUROSURGICAL OPERATIVE ATLAS. A thorough understanding of this information acquired by preoperative neuroimaging is very important for proper surgical planning. A standard interfacial dissection is carried out at the zygoma. and if the surgeon stays within the tumor and within the arachnoid. lumbar spinal drainage is used for a period of 3-5 days until the dura seals. The zygomatic osteotomy. With progressive decompression. the tumor lies in the pterygopalatine fossa. Peritumoral arachnoid separates the tumor from the important surrounding neurovascular structures. Gentle retraction of the temporal lobe and the cerebellum in the presigmoid area exposes the tumor. if it arises in the mandibular division. inadvertent injury to these structures is avoided. These tumors cause erosion of the foramen ovale or rotundum and extend intracranially. At the end of the procedure. Once they extend intracranially. the petrous bone is eroded and the petrous carotid artery becomes incorporated into the tumor. Type D tumors are primarily extracranial tumors with or without intracranial extension. and the seventh and eighth nerve complex. gently curving forward (Figure 21). Intratumoral decompression without disturbing the arachnoid will shrink the tumor and separate it from the seventh and eighth nerve complex. they may compress the temporal lobe. Large tumors in this area significantly compress the brainstem. often embedded into the dura yet never violating it. Type D tumors are resected using the subtemporal-infratemporal approach in collaboration with a faciomaxillary surgeon (Figure 19). blood vessels. The skin incision begins in front of the ear. If the tumor arises in the maxillary division. and extends to the temporal area. the tumor delivers itself and becomes separated from the brainstem. 8 Figure 16. lyophilized dura or temporalis fascia is used for duraplasty and fibrin glue is used to reinforce the suture line. the dura is approximated with an interrupted 4-0 Nurolon suture. just below the level of the zygoma. Careless peeling of the tumor from the brainstem before adequate decompression of the tumor should be avoided. ing it downward. and cranial nerves. the tumor occupies the subtemporal and infratemporal fossa. since there is always a layer of arachnoid at the interface. In the case of duraplasty. the fourth cranial nerve. including part Type D Tumors (Preauricular Subtemporal-Infratemporal Approach) . The myocutaneous flap and skin are closed in layers in the usual fashion. Tumor is exposed after the tentorium is cut. to the top of the superior temporal line. Residual tumor situated near the brainstem is managed after resecting the tumor from the posterior cerebral and superior cerebellar arteries. In the case of giant-sized tumors. If watertight closure cannot be achieved. Patients are operated on while in the supine position (Figure 20). VOL. or at least lies very densely adherent to the tumor. thus protecting the facial nerve branch traveling to the forehead (Figure 22).

showing the tumor exposed. . Intraoperative photograph showing the extent of craniectomy and mastoidectomy.SAMII ET AL : SURGICAL MANAGEMENT OF TRIGEMINAL SCHWANNOMAS 117 Figure 17. Intraoperative photograph axial view. Figure 18.

If retraction is difficult. is performed later (Figure 23). it is advisable to retract the temporal dura before the tumor is resected. After bipolar cauterizing. the facial nerve may need to be identified.118 NEUROSURGICAL OPERATIVE ATLAS. at the parotid fascia. an elective dural-arachnoidal incision is made to allow drainage of some CSF. Once the tumor in this area is identified. it is advisable to per form a craniectomy and expose the dura to avoid inadvertent dural and temporal lobe injury. it is progressively decompressed and resected. Note the generous padding of pressure points. as well as the adequate taping to secure the patient and position the legs above the level of the heart. Initially. the middle meningeal artery is carefully sectioned. of the frontal process. is carried out. Figure 20. The tumor borders are identified and its relation to the temporal dura defined. If there is radiographic evidence of compression on the temporal lobe. including the margins of the foramen ovale and spinosum. coronal view. 8 Figure 19. to avoid injury during tumor dissection. the mandibular division is followed from its extracranial course toward the middle fossa. identifying the mandibular division and the middle meningeal artery. If the tumor capsule is densely adherent to the dura and is difficult to sepa- . There is no need to perform an orbital osteotomy for tumors located in the pterygopalatine and infratemporal fossa area. VOL. Supine position used for resection. In large tumors. Even if the tumor is not compressing the temporal lobe. MR imaging. with gadolinium demonstrating extracranial tumor (type D tumor). A small low temporal craniotomy and craniectomy.

. the temporalis muscle has been separated from the zygomatic arch.SAMII ET AL : SURGICAL MANAGEMENT OF TRIGEMINAL SCHWANNOMAS 119 Tumor resection via the preauricular subtemporalinfratemporal approach (type D tumor) Figure 21. Figure 23. Skin incision. After interfacial dissection to preserve the frontal branch of the facial nerve. Zygomatic osteotomy and temporal craniotomy have been performed and the tumor is exposed. Note the relation of the tumor to the dura and the parotid gland. Note that the lower part of the skin incision is within 1 cm of the ear as well as below the zygomatic arch. Figure 22.

Intraorbital tumors are very well localized and can be removed without causing injury to the ocular muscles or nerves. which lies in the area. postoperative lumbar drainage is necessary for 3-5 days. extra space is created by dislocation of the mandible of the temporomandibular joint. The dura in the superior orbital fissure area is cut and continued to the periorbita. in rare cases. tapering doses of intravenous steroids and anticonvulsants. and prompt attention must be paid to repair it appropriately at that time. Once the tumor is resected. needs to be identified and preserved with great attention. such as infection. the dura is opened. If the approach described above does not give adequate exposure. Except in those with a spinal drain. Gold weights in the upper eyelid and temporary tarsorrhaphy are two of the best methods for protecting the eye. This is more useful in very large and malignant tumors and often is not necessary in routine schwannomas. and fibrin glue to prevent potential CSF leak. osteotomy and craniotomy are replaced and the wound is closed in layers in a routine fashion. To prevent life-threatening infection. Reoperation is not indicated unless there is significant compromise of the neural structures from the residual tumor. muscle. 8 rate. CSF leak. After removing the tumor. Dysfunction of the ophthalmic division can cause exposure keratitis and corneal ulceration. hemorrhage. COMPLICATIONS Postoperatively. Tumors that extend into the cavernous sinus are located primarily in the leaves of the lateral wall and can be completely removed after opening the lateral wall of the cavernous sinus. In tumors arising from the maxillary division. and other related problems. particularly in very large tumors eroded into the pterygopalatine fossa. Sometimes. Pneumatic compression boots are used for patients while in bed. follow-up MR imaging with and without gadolinium enhancement is performed. mobilization of the facial nerve (by detaching the pterygoid muscles to the coronoid process of the mandible and section of the ramus of the mandible) gives extra room. The skull base defects are repaired using fat. it is essential to recognize the entry into the paranasal sinuses during surgery. The optic nerve. patients undergoing surgery for trigeminal schwannomas are given intravenous antibiotics for a period of 72 hours. to prevent potential complications such as deep venous thrombosis. a transfacial-transmaxillary approach is necessary. VOL.120 NEUROSURGICAL OPERATIVE ATLAS. and the tumor completely excised. If there is no residual tumor. a frontotemporal craniotomy and orbitozygomatic osteotomy are performed with removal of the roof of the orbit and the superior orbital fissure. POSTOPERATIVE CARE AND FOLLOW-UP . the temporal lobe retracted. Other than routine complications of craniotomy. the involved dura is resected and duraplasty is later performed. the periorbita is closed with 0-0 Vicryl. and the craniotomy and osteotomy are closed with 0-0 Tevdek stitches. After 3 months. The remainder of the closure is carried out as usual. patients are mobilized out of bed as soon as possible. occasionally. MR imaging every year for 2 years and then every 5 years is suggested. In tumors arising from the ophthalmic division or tumors with intraorbital extension. In tumors with a tongue-like intracranial extension after extracranial tumor resection. Patients with small residual tumors are closely followed with MR imaging since these tumors grow very slowly. fifth nerve dysfunction is the most common complication associated with these operations. which need to be recognized and treated promptly.

Patients who present with either significant symp- PATIENT SELECTION 121 . placement of a small Silastic tube was then inserted to re-establish aeration. including the mucosal lining. As such. The mucosal hemorrhage that ensues sets the stage for a cycle of hemorrhage and inflammation ending in the formation and growth of a cholesterol granuloma. The cyclical pattern of hemorrhage and inflammation often leads to periodic worsening of symptoms rather than a steady progression. Patients with progressive symptoms or enlarging lesions obviously require treatment.S. OSSAMA AL-MEFTY. As it grows. In the past.. the recurrence rates following the procedure using these approaches have been reported in the literature to be as high as 60%. followed by obliteration of the cavity with vascularized tissue. While there is no pathognomonic symptom of a PACG. PACGs have usually been drained by otolaryngologists via either a transtemporal or a transsphenoidal route. The presenting signs and symptoms of PACG are largely dependent upon the size and extent of the lesion. Unfortunately.A. Smaller asymptomatic lesions may be discovered only during the evaluation of an unrelated complaint (e.. the progressive cycle will be arrested and no further treatment will be required. the time course of symptoms often gives a clue as to the diagnosis. M. F. which are etiologically and histologically distinct from PACGs. the patient may present with hearing loss and facial nerve dysfunction.SURGICAL MANAGEMENT OF CHOLESTEROL GRANULOMAS OF THE PETROUS APEX MARK B. M. With larger lesions. as in a neoplastic growth.D. The trigeminal and abducens nerves are particularly vulnerable because of their proximity to the petrous apex. with some pa- INTRODUCTION tients requiring multiple revisions. In a small subset of these patients. EISENBERG.D. many patients present either because of diplopia or facial numbness or pain. have been described less often and in many cases have been erroneously grouped with epidermoid tumors. Because the progression from hemorrhage to granuloma formation is an ongoing process. however. these lesions have varied clinical and radiographic characteristics depending upon their stage of formation. CLINICAL PRESENTATION © 1999 The American Association of Neurological Surgeons Small asymptomatic or minimally symptomatic lesions in a compliant patient may be safely followed with serial magnetic resonance imaging (MRI) studies. This obstruction leads to the development of negative pressures within the air cells. Petrous apex cholesterol granulomas (PACGs). Petrous apex cholesterol granulomas are the end result of chronic obstruction of normal aeration to the petrous air cells. causing mucosal engorgement.C. Cholesterol granulomas are benign expansile lesions most commonly found in either the middle ear or the mastoid region in association with some type of inflammatory ear disease. the PACG has a compressive effect upon the surrounding neurovascular structures.g. headache or dizziness). An alternative approach is complete excision of the lesion.

A computed tomography (CT) scan with bone window settings should also be obtained in order to evaluate the extent of erosion of the petrous apex and the temporal bone. This is followed by obliteration of the cavity with vascularized tissue in the form of a pedicled strip of temporalis muscle. It is important to drill the edge of the craniotomy flush with the middle fossa floor in order to avoid unnecessary temporal lobe r etraction (Figure 3). the patient may be positioned in the true lateral position with a subaxillary roll in place. may result in traction injury to the facial nerve via the geniculate ganglion. the patient must not receive muscle relaxants following induction and intubation. The patient is also maintained in a hypovolemic state and is hyperventilated. 8 toms (r egardless of lesion size) or large lesions (regardless of symptoms) will also require surgical intervention. and draped in a standard manner. an earphone is placed in each external auditory canal THE EXTENDED MIDDLE FOSSA APPROACH and scalp electrodes are inserted for monitoring of brainstem auditory evoked potentials. A limited temporal craniotomy abutting the floor of the middle fossa is performed. PREOPERATIVE PREPARATION Following the induction of general endotracheal anesthesia. Patients are therefore started on an anticonvulsant medication the night prior to surgery.and T2-weighted images with only meager peripheral enhancement (Figure 1). there is a small risk of postoperative seizures because of elevation of the temporal lobe. These maneuvers are important to maximize brain relaxation. the operating microscope is brought into the field and the remainder of the surgery is performed under the microscope. For cases in which intradural extension is suspected. The patient is positioned supine and the head is fixed in a three-pin head clamp. In addition. At the anterior third of the temporalis muscle. The temporal lobe is supported extradurally with a malleable retractor. thus maximizing venous drainage and brain relaxation. which allows complete removal of the granuloma and pseudocapsule. Small dural vessels traversing the middle fossa floor are easily controlled with either direct bipolar coagulation or bone . PREOPERATIVE EVALUATION The extended middle fossa approach is an extradural. the lateral thigh is also exposed and prepared. Because the r ecurrence rate for these types of procedures is relatively high. thus sparing the frontalis branches of the facial nerve. Because of frequent involvement of the sixth and eighth cranial nerves. Any involvement of the middle ear will also be readily seen on CT. Electrodes are then placed to allow for monitoring of somatosensory evoked potentials and facial nerve electromyography (EMG). The traditional mode of therapy involves a drainage procedure via either a transtemporal or transsphenoidal route. a lumbar drain is placed to allow cerebrospinal fluid (CSF) drainage during the extradural subtemporal dissection. this “classic” appearance may not be present. Therefore. The lumbar drain is opened and 30 to 50 cc of CSF is allowed to drain. MRI also provides information regarding the extent of the lesion and whether intradural extension is present. A preauricular curvilinear incision is made (Figure 2) and the scalp flap is elevated along the subgaleal plane. During the exposure. This is continued for 3 to 6 months following surgery. Care is taken to preserve the superficial temporal artery. The head of the bed should be elevated to bring the patient’s head above the level of the heart. The radiographic evaluation consists of an MRI with and without contrast enhancement in order to confirm the diagnosis. which runs along the floor of the middle fossa. subtemporal approach to the petrous apex. should the need for a fascial or fat graft arise. This allows downward displacement of the arch along with the temporalis muscle. Petrous apex cholesterol granulomas often display a highsignal characteristic on both T1. and extradural dissection is carried medially until the middle meningeal artery is identified at the foramen spinosum. prepped. The ipsilateral frontotemporal region is then shaved. At this point. Although the dissection is entirely extradural. This maneuver provides access along the middle fossa floor with <1 cm of temporal lobe elevation. excessive traction or manipulation on the greater superficial petrosal nerve. we have approached these lesions via an extended middle fossa approach. however. This complication has been minimized by continuously monitoring the facial nerve EMG.122 NEUROSURGICAL OPERATIVE ATLAS. The operating microscope is then balanced and brought over to the field to check that it will be in a comfortable operating position prior to draping. The zygomatic arch may then be safely dissected in a subperiosteal manner and sectioned at its most anterior and posterior ends. VOL. Alternatively. all patients should undergo a formal neuro-ophthalmological examination as well as an audiogram and monitoring of brainstem auditory evoked responses. No other special preparations or medications are required apart from the routine preoperative evaluation and preparation for surgery. the superficial layer of the deep temporal fascia is incised down to the muscle and reflected anteriorly with the scalp flap. The head is turned to bring the zygoma nearly horizontal. Depending on the age of the lesion. and a roll is placed under the ipsilateral shoulder to maintain the neck in a neutral position (Figure 2).

. Figure 3.EISENBERG AND AL-MEFTY : CHOLESTEROL GRANULOMAS OF THE PETROUS APEX 123 A B Figure 1.(A) and T2-weighted (B) MRIs. Note the high signal of the right petrous apex cholesterol granuloma. Axial T1. Figure 2. Note osteotomy of zygoma (asterisks). Temporal craniotomy flush with the middle fossa floor to avoid retraction of the temporal lobe. Patient positioning and scalp incision for an extended middle fossa approach to the petrous apex.

VOL. Surgeon’s view following extradural elevation of the temporal lobe and ligation of the middle meningeal artery (1).124 NEUROSURGICAL OPERATIVE ATLAS. 5 = cholesterol granuloma. 3 = V3. . 8 Figure 4. 2 = petrous portion of carotid artery. The emptied petrous apex cavity obliterated using a pedicled strip of temporalis muscle. Figure 5. 4 = greater and lesser petrosal nerves.

then close postoperative surveillance for a CSF leak is crucial. We therefore fashion a pedicled strip of temporalis muscle that can be used to obliterate the PACG cavity (Figure 5). It enables the surgeon to radically remove the granuloma and obliterate the cavity with vascularized tissue. efforts to stop the leak must be taken. The foramen ovale anteriorly and the greater superficial petrosal nerve (GSPN) medially are then identified. and granuloma formation. depending upon the size of the PACG. a portion of the remaining petrous apex must be removed with a high-speed drill in order to gain access to all areas of the cavity.. which in turn leads to a repeating cycle of mucosal engorgement. however. If this is necessary. This is prevented with careful intraoperative monitoring of facial nerve EMG. All patients receive antiseizure medication for 3 to 6 months. a diamond bit is used in order to minimize the chance of injuring any surrounding structures (e. This is most often done with a combination of microdissectors. Complications related to temporal lobe r etraction are minimized by combining a zygomatic osteotomy and drilling the temporal squama flush with the middle fossa floor. The GSPN is sharply dissected from its dural attachment and preserved. the dura or the internal carotid artery). . Maximal brain relaxation using a combination of hypovolemia.g. and the remainder of the flap is closed in standard fashion. in some cases. in which case the drain is usually left in place for 24 to 48 hours. combined with the vascularized temporalis flap and postoperative lumbar drainage. Often. there is a risk of postoperative seizures. extradural exposure of the petr ous apex. and smooth ring curettes. The authors thank Ron Tribell for his expert creation of the illustrations in this article. the GSPN must be divided to avoid traction injury to the facial nerve. the fluid is drained and the soft tissues. The lumbar drain is removed prior to the patient being reversed from anesthesia unless a dural repair was necessary. 3. This permits easy postoperative MRI follow-up. and. hyperventilation.EISENBERG AND AL-MEFTY : CHOLESTEROL GRANULOMAS OF THE PETROUS APEX 125 wax. hypovolemia. 4. If it should occur. The lesser superficial petrosal nerve may be seen lateral to the GSPN. Because this is an extradural approach. and antibiotics are maintained for 48 hours. The bone flap is returned and secured with titanium miniplates and screws. Further medially. with the muscle flap giving a consistently hypointense signal on T1-weighted images. patients are therefore maintained on antiseizure medication for 3 to 6 months. They are maintained on dexamethasone for 1-2 days followed by tapering doses. As mentioned above. shallow. which is then tapered off if the patient remains seizure-free. adequate brain relaxation is obtained using hyperventilation. are completely excised. bipolar forceps. POSTOPERATIVE COMPLICATIONS CONCLUSIONS 1. When using ring curettes. helps minimize the risk of a CSF leak in patients requiring a repair. including re-exploration. it is important to be sure that they are smooth in order to avoid inadvertent injury to the carotid artery. The use of either a fat or a fascial graft. Care must be taken in exposing this region because the bone over the carotid canal is often thin or even dehiscent. postoperative facial weakness is related to traction injury via the superficial petrosal nerve. Obliterating the resultant cavity with fat fragments makes follow-up MRI arduous because of the difficulty in distinguishing the signal intensities of fat versus postoperative fluid collections. the petrous portion of the internal carotid artery can be seen deep to the posterolateral border of the third division of the trigeminal nerve. and the foramen is packed with bone wax or oxidized cellulose. The extended middle fossa approach provides a safe. Patients are reversed from anesthesia in the operating room and observed overnight in either the neurosurgical intensive care unit or the recovery room. The middle meningeal artery is coagulated and sectioned sharply. Cholesterol granulomas of the petrous apex are distinct lesions resulting from blockage of the normal aeration of the petrous apex air cells. Ipsilateral facial nerve function is protected by attending to the greater superficial petrosal nerve and intraoperative EMG monitoring. hemorrhage. primary neurological complications are rare. Once the PACG is identified and entered. If a dural repair was necessary because of intradural extension of the granuloma. may be deviated superolaterally (Figure 4). No subgaleal drain is utilized. including the pseudocapsule. and CSF drainage. and CSF drainage has nearly eliminated temporal lobe-related problems. 2. Despite this.

.

The neurological morbidity and mortality associated with clinical bleeding from AOVMs in these regions can be significant.and T2-weighted images.” The natural history of untreated AOVMs in the brainstem. Many patients suffering episodic clinical deterioration secondary to hemorrhage from an AOVM were diagnosed as having multiple sclerosis or cerebral infarctions.D.and T2-weighted images represent subacute blood (extracellular methemoglobin). P H. The use of microinstrumentation and the neuromicroscope along with the aid of stereotaxis and electrophysiological monitoring have enabled neurosurgeons to safely resect many of these lesions.5% per year. M. due to the critical nature of structures affected by a single or recurrent hemorrhage. while other neurological deficits may result from edema or gliosis surrounding the AOVM. obscuring the characteristic mixed attenuation appearance. These lesions usually appear as well-demarcated areas of heterogenous signal intensity on both T1.SURGICAL MANAGEMENT OF ANGIOGRAPHICALLY OCCULT VASCULAR MALFORMATIONS OF THE BRAINSTEM. most of which were believed to be “unresectable. thalamus. STEVEN D.D.. with bleed rates ranging from 0. thalamus. this has come about largely as a result of improvements in micr osurgery and radiographic imaging. as well as the particular location. The volume of the hemorrhage. Data suggest that brainstem AOVMs presenting with clinical hemorrhage may rebleed at a higher rate of 4. CLINICAL PRESENTATION The radiographic appearance of AOVMs is quite characteristic. Resection of angiographically occult vascular malformations (AOVMs) of the brainstem. Occasionally. it was extremely difficult to diagnose the presence of AOVMs in these regions. surrounded by a peripheral rim of hypointensity that is more easily seen on the T2-weighted images. CHANG. and basal ganglia has only recently been possible. and basal ganglia. RADIOGRAPHIC APPEARANCE PATIENT SELECTION © 1999 The American Association of Neurological Surgeons Current indications for surgery include multiple. Acute hemorrhages usually yield new deficits. clinically symptomatic hemorrhages or a single large 127 . INTRODUCTION Angiographically occult vascular malformations typically become symptomatic following a hemorrhage. Given the critical functions of the brainstem.25% to 43% per year. Seizures (supratentorial AOVMs) and cranial nerve deficits (brainstem AOVMs) as well as generalized symptoms such as headache and nausea may be noted. a large subacute hemorrhage will dominate the MR appearance. while the peripheral rim of hypointensity represents hemosiderin and ferritin (chronic hemorrhage).5% to 21. Prior to the advent of magnetic resonance (MR) imaging. determine the type and severity of the neurological symptoms. THALAMUS. The high-attenuation areas on T1. AND BASAL GANGLIA GARY K. STEINBERG. thalamus. Small AOVMs may appear as a punctate region of low attenuation. and basal ganglia is variable and incompletely described.D. M. most hemorrhages in these regions are symptomatic.

facilitating easier dissection. resection more than several months after the last hemorrhage may be more difficult than procedures per formed in the subacute phase. T2-weighted images. infratentorial exposure is utilized. Patients undergo surgery while under normotensive conditions. the hematoma will organize. The patient is positioned laterally with the involved side down to allow gravity relaxation of the ipsilateral parietal-occipital mesial cortex (Figure 1B). AOVMs of the thalamus are exposed via a midline posterior parietal interhemispheric approach. depending on their precise size and location. transpetrosal approach if they present to the lateral or anterior surface of these structures. A 4-week delay from the most recent significant clinical hemorrhage allows for stabilization and possible improvement of the clinical condition. fibrose. Adequate relaxation is achieved thorough the use of ventricular or subarachnoid CSF drainage. Removal of subacute hematoma may also immediately improve the patient’s neurological condition by relieving pressure on normal neural pathways. The patient is positioned supine with a shoulder roll and the head is turned or operated in the lateral position. either transcallosal transventricular as the thalamic lesions. Midbrain or pontomesencephalic AOVMs are exposed via a subtemporal or a subtemporal. the AOVM can be approached safely. The patient is positioned laterally or supine with the head turned (Figure 1B). For AOVMs in the midline medulla or pons that present to the fourth ventricular surface. Others have used the supracerebellar. this hypothermic technique is safe. Under operative conditions of AOVM resection. The timing of surgery following the last clinical hemorrhage is important. PREOPERATIVE PREPARATION The patient is given general anesthesia with judicious Anesthetic Technique The surgical approach is chosen according to the site where the AOVM presents at the pial or ependymal surface. The T1-weighted MR image is best for assessing proximity to such an ependymal or pial surface. Spinal cerebrospinal fluid (CSF) drainage is not routinely utilized. because of fear of producing permanent contralateral hemiplegia. However. a midline suboccipital approach is utilized. Some of the midline pontomesencephalic AOVMs can also be approached via a midline suboccipital exposure if they present to the fourth ventricle or the cerebral aqueduct. but not to the fourth ventricular surface. Over several months’ time. We prefer the patient to be in a sitting position to allow easier positioning of the microscope (Figure 1C). a supracerebellar. Patients in the following categories are poor anesthetic risks and are excluded from surgical consideration: elderly patients. obscuring the well-demarcated dissection planes and making surgical removal more difficult. thalamic. and economical with excellent overall clinical outcomes. control of blood pressure.128 NEUROSURGICAL OPERATIVE ATLAS. but sometimes inferior to the splenium of the corpus callosum. and become surrounded by glial scarring. infratentorial approach with the patient in the Concorde position. Upon completion of the procedure and during emergence from anesthesia. Another advantage of operating in the subacute period is that the hematoma has already performed some of the dissection and. including first echo or second echo. since operative exposure through intact brainstem. AOVMs of the basal ganglia are exposed. those severely and chronically debilitated by neurological deficits. hypertension is controlled with oral antihypertensive medications. cause some “blooming” in the hemosiderin ring and a false sense of proximity to the pial or ventricular surface. This also provides time for acute hemorrhagic components to soften or liquefy. feasible. Thus. the far lateral suboccipital approach is employed. If the medullary or pontine AOVM is located laterally or anteriorly and presents to one of these pial surfaces. particularly during extubation. VOL. If the AOVM or its hemosiderin ring is immediately adjacent to such a surface. or transsylvian. dropping the core body and brain temperature to 33°-34°C by applying a cooling blanket. one can work through the clot cavity without entering normal parenchyma. or those with associated severe medical problems. with the patient positioned prone (Figure 1A). Operative Positioning and Exposure . If mesencephalic AOVMs are located in the tectal plate region. 8 hemorrhage associated with significant neurological deficit. after drainage or removal of this blood. It is also important to consider the location of the AOVM in relation to a ventricular or pial surface. Mild brain hypothermia is used. the patient’s blood pressure should be controlled to avoid any hypertensive episodes. This degree of mild brain hypothermia has been shown to provide excellent protection against experimental ischemic and traumatic cerebral injury. large AOVMs located in the basal ganglia or thalamus and adjacent to the posterior limb of the internal capsule can be successfully removed with good clinical outcomes. Prior to surgery. or basal ganglia structures usually results in unacceptable neurological consequences. An exception to this is the presence of deep lesions in the thalamus that can be stereotactically approached through the pulvinar region and microsurgically resected with good clinical results. usually transcallosal to the lateral ventricle. Patients with AOVMs located within the posterior limb of the internal capsule are also not good surgical candidates.

for lateral medullary or pontine AOVMs. AND BASAL GANGLIA 129 A B Figure 1. The cerebellar tonsils are retracted and the inferior midline vermis is sectioned to facilitate exposure to the floor of the fourth ventricle (Figure 2). Dissection of the AOVM is done using extreme caution to avoid . and bipolar coagulating forceps are used to cauterize any bleeding scalp vessels. 15 blade or electrocautery. Bone wax is used to control bleeding along the bone edges. leaving the hemosiderin-stained parenchyma intact (Figure 4). THALAMUS. 15 blade. For AOVMs in the midline medulla or pons that present to the fourth ventricular surface. The skin incision is made using a No. Gelfoam. It is critical to perform the dissection on the edge of the AOVM. Dissection is carried through the subcutaneous tissue. 10 blade. B. C. a sterile surgical scrub is performed and the incision site draped. for AOVMs in the midline medulla or pons that present to the fourth ventricular surface. the patient is positioned in the sitting position. and the bone is exposed. or cotton. C After general anesthesia is induced and the patient positioned. for tectal plate or posterior mesencephalic AOVMs. A.STEINBERG AND CHANG : AOVMS OF THE BRAINSTEM. and dural tack-up sutures are placed. A perforator and craniotome are used to perform the craniotomy. the patient is placed in the lateral position with head turned. A region of blue discoloration (hemorrhage) or hemosiderin indicates the location of the AOVM (Figure 3). the patient is placed in the prone position. Microsurgical resection is done under high-power magnification with very fine bipolar irrigating coagulation forceps and using low coagulation power. galea. and/or muscle using a No. a sub- OPERATIVE PROCEDURE occipital craniotomy (removing the foramen magnum but not the posterior arch of C1) is used. The dura is opened using dural forceps and a No. Hemostasis is achieved with small pieces of Surgicel.

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A
Figure 2. The prone position as viewed through microscope with surgeon at the top of the patient’s head. A, the floor of the fourth ventricle is exposed for medial medullary or pontine AOVMs, and a midline suboccipital approach is utilized. B, once the AOVM is localized, a gently placed small retractor blade may aid in exposure.

B

Figure 3. Intraoperative low-power photograph showing hemorrhagic discoloration where the AOVM presents to the ependymal surface of the fourth ventricle (arrow).

Figure 4. Intraoperative high-power photograph showing circumferential dissection around the AOVM, taking care to stay on the AOVM margin, thereby avoiding injury to surrounding brainstem parenchyma.

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excessive coagulation with spread of current to surrounding brain tissue. Occasionally, the smallest sized tapered retractor blade applied gently to the edge of the brainstem is used for exposure (Figure 2B). It is important to employ piecemeal removal of the AOVM if the parenchymal opening is smaller than the AOVM in order to avoid excessive retraction of normal parenchyma; however, it is essential to resect the entire AOVM, since any residual has a high chance of recurrence with rebleeding and enlar gement. It is also critically important to preserve any developmental venous anomaly (venous angioma) that is associated with the AOVM to avoid a venous infarction with subsequent neurological injury. For AOVMs located in the lateral or anterior medulla or pons, a far-lateral suboccipital approach is used. Meticulous drilling of bone up to the transverse and sigmoid sinuses maximizes exposure. Once the craniotomy is complete, the dura is opened while carefully preserving the transverse and sigmoid sinuses. Retractor blades are used to gently retract the cerebellum to expose the brainstem. Discoloration of the normal tissue indicates the AOVM location, and microsurgical resection proceeds as above. Cranial nerves and vascular branches of the basilar and vertebral artery are carefully avoided (Figure 5). AOVMs in the tectal plate or posterior mesencephalon are approached via a suboccipital craniotomy, and a supracerebellar, infratentorial exposure is most frequently used (Figure 6). This approach requires dissection (using bipolar electrocautery and small bore suction) of the superior cerebellar vermis and superior medullary velum. The precentral cerebellar vein may be sacrificed to improve exposure. Exposure is maximized using retractor blades to retract the cerebellar hemispheres. Care must be taken to avoid injury to the vein of Galen, the two draining veins of Rosenthal, and the straight sinus. Hemostasis is maintained at all times to reduce blood clots within the fourth ventricle in order to minimize postoperative hydrocephalus. Once the AOVM location is identified, microsurgical resection proceeds as described previously. Following the craniotomy, AOVMs of the thalamus are approached via a midline posterior interhemispheric transcallosal approach if the malformation is medial (Figure 7A). Retractor blades placed on the ipsilateral cortical hemisphere improve exposure (the dura maintains retraction of the contralateral hemisphere if the involved side faces down). The corpus callosum is identified, and a callosotomy performed using bipolar electrocautery forceps and small bore suction to achieve exposure to the third ventricle (Figure 7B). Hemostasis must be maintained at all times to ensure visibility while working in the ventricle. The AOVM is identified on the surface of the pos-

terior thalamus or, if not directly visible, located with the aid of stereotaxis. Microsurgical resection can be safely per formed within the pulvinar nucleus without any significant neurological deficit. Occasionally, the smallest sized tapered retractor blade applied gently to the edge of the thalamus is used to increase exposure. Care must be taken to avoid significant amounts of intraventricular blood to minimize the risk of postoperative hydrocephalus. Posteroinferior thalamic AOVMs may be difficult to reach via the above exposure, and are optimally approached through a transcallosal interhemispheric approach inferior to the splenium. Basal ganglia AOVMs are exposed via a transcallosal transventricular approach if they are medially located. For these lesions, the case proceeds as described above for the thalamic AOVMs. Lateral basal ganglia AOVMs are generally exposed via a transsylvian approach (Figure 8). Following completion of a temporal craniotomy, the dura is reflected and the sylvian fissure opened under the microscope to expose the insular cortex. Stereotaxis is useful in the approach to these lateral lesions, which generally do not come to a pial surface. Once the AOVM location is identified, bipolar electrocautery is used to dissect through a small portion of the insular surface directly overlying the AOVM. Small retractor blades may be gently placed to maximize exposure. Microdissection is performed similarly to thalamic lesions, using bipolar electrocautery forceps and gentle small bore suction. Perforating arteries from the middle cerebral artery traverse the insula and the basal ganglia, and should be avoided if they do not directly feed the AOVM.

Meticulous hemostasis is obtained in the resection bed of the AOVM, and a final inspection is performed to ensure that the entire AOVM has been completely removed. Transient induced hypertension can be used to test hemostasis. The resection bed is then lined with Surgicel. The dura is closed in the standard fashion using 4-0 nylon suture, and the bone replaced to complete the craniotomy. A subgaleal drain is attached to light suction for 12-24 hours. The scalp incision is closed in two layers, with approximation of galeal layer using 3-0 Dexon sutures and the skin with staples. A sterile head dressing is applied.

CLOSURE TECHNIQUES

Electrophysiological monitoring and mapping of brainstem motor nuclei are extremely valuable aids for the resection of AOVMs of the brainstem, thalamus, and basal ganglia, and will improve clinical results. Monitoring routinely consists of bilateral somatosensory evoked potentials, bilateral brainstem

MONITORING

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Figure 5. The far-lateral suboccipital approach to the anterolateral medulla or pons. Cranial nerves V (short arrow), VII/ VIII (long arrow), and IX, X, XI complex (arrowhead) are well visualized.

Figure 6. The infratentorial supracerebellar approach to tectal plate or posterior mesencephalic AOVMs. Gentle retraction on the cerebellum can sometimes facilitate exposure.

A

B

Figure 7. Thalamic and mesial basal ganglia AOVMs are approached via a midline interhemispheric approach (A) and a callosotomy is performed providing access to the lateral ventricle and thalamus or basal ganglia (B). Arrow indicates corpus callosum.

A

B

Figure 8. Lateral basal ganglia AOVMs are exposed via a transsylvian approach with gentle retraction of the frontal (A) and temporal (B) lobes.

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auditory evoked potentials, and, if appropriate, bilateral fifth, seventh, 11th, and 12th nerve motor function for brainstem surgery. Bilateral upper and lower somatosensory evoked potentials are used during resection of thalamic and basal ganglia AOVMs. Continuous monitoring of these sensory pathways and motor nuclei has allowed early detection of excessive retraction or manipulation of critical structures. Electrophysiological mapping of the brainstem fifth, seventh, and 12th nerve motor nuclei function, using tiny stimulating electrodes to localize these functions, has allowed more precise planning of safe trajectories through the floor of the fourth ventricle to approach AOVMs. A midline approach to the floor of the fourth ventricle should be avoided, if possible, since this risks causing bilateral internuclear ophthalmoplegia. Special precautions should also be taken to avoid the sixth/seventh cranial nerve complex.

while the subgaleal drain is in place. Postoperative anticonvulsants are utilized on a routine basis only if the patient presented with preoperative seizures.

Intraoperative stereotaxis helps localize portions of the deep AOVMs not presenting directly to the ventricular or pial surface. The CRW (Cosman-RobertsWells) frame was previously used, but was found to be somewhat cumbersome. The Radionics frameless Operating Arm System (OAS) was easier to use, although we now routinely employ the new Radionics Optical Tracking System (OTS) or the Elekta Viewscope, which obviate the need for any articulating arm system and maintain a precision of a few millimeters. This stereotactic approach has allowed better planning for the initial incision into the brainstem, thalamus, or basal ganglia, and also has helped confirm complete resection of all components of the larger AOVMs that may have irregular configurations.

STEREOTAXIS

The patient is monitored for 24 hours in an intensive care setting. Careful control of blood pressure through the judicious use of antihypertensive medication minimizes hemorrhage at the AOVM resection site. The subgaleal drain is removed on the first postoperative day. Antibiotics are routinely used only

POSTOPERATIVE CARE

The most devastating complication is perioperative recurrent hemorrhage which, fortunately, is extremely rare. This can be due either to lack of adequate hemostasis or failure to completely resect the AOVM and emphasizes the importance of removing the entire malformation, including any irregular extensions. MR scanning 3-6 months following surgery is generally reliable in confirming complete resection of the malformation, although hemosiderin staining will persist forever in the resection bed. There should be no evidence of persistent subacute hemorrhage in the form of methemoglobin. Other areas of postoperative morbidity can be related to manipulation, retraction, and edema of critical brain parenchyma surrounding these deep AOVMs. Transient internuclear ophthalmoplegia is common after a midline fourth ventricular approach, but usually resolves. Transient worsening of hemiparesis is associated with resection of some thalamic and basal ganglia AOVMs. Worsening of facial nerve function, sixth nerve paresis, appendicular ataxia, or gait is sometimes noted following resection of certain brainstem AOVMs. “Ondine’s curse” is a risk in patients with large medullary AOVMs. The far-lateral approach can sometimes be accompanied by transient lower cranial nerve palsies. Postoperative hydrocephalus is a known complication in patients with significant intraventricular blood, but this can be avoided with meticulous hemostasis throughout the procedure. A watertight dural closure minimizes the risk of CSF leaks and pseudomeningoceles. As with other craniotomies, postoperative meningitis and wound infections are rare, but well-described, events. Better clinical results are achieved in patients who are in good preoperative condition; however, patients in poor preoperative condition have been found to make remarkable recoveries.

COMPLICATIONS

D. INTRODUCTION © 1999 The American Association of Neurological Surgeons The most common tumors of the jugular foramen include neuromas of the lower cranial nerves and glomus jugulare tumors. and neuroradiologists. hypoglossal nerve. the location of feeding vessels. The anatomical complexity and functional importance of jugular foramen structures present a formidable challenge to the surgical removal of tumors in that region. The diagnosis of a glomus tumor should be anticipated prior to angiography so that simultaneous embolization may be performed if indicated (Figure 4B). representing the continuation of the sigmoid sinus and progressing to the internal jugular vein. and the spinal accessory nerves) also traverse the foramen. Less commonly presenting tumors include chordomas. Highresolution computed tomography (CT). delineates the destruction and erosion of the temporal bone and its relationship to the carotid artery. Neuromas are less of a surgical challenge since they are noninvasive and are generally localized to one nerve fascicle. middle ear. Additional venous drainage enters the jugular bulb via the inferior petrosal sinus. making them easily separable from the surrounding cranial nerves. hypoglossal canal. and the temporal components for hearing function. headneck surgeons. it is necessary for determining the degree of vascularity. M. and routes of venous drainage (Figure 4A).D. A detailed radiological workup is necessary for establishing the diagnosis and determining the anatomic extent of the tumor. When PATIENT SELECTION 135 . temporal bone structures. with and without bone windows. and a variety of carcinomas. in addition. Additional adjacent anatomical structures encountered during jugular foramen surgery include the facial nerve. IAN STORPER. semicircular canals. Angiography is useful for establishing the diagnosis of a glomus tumor. Optimal therapeutic outcomes are dependent upon the cooperation of a multidisciplinary team consisting of neurosurgeons. carotid artery. epidermoids. and arteries (Figure 3). Magnetic resonance imaging (MRI) with and without gadolinium enhancement is best for demonstrating the tumor and its relationship to adjacent structures (Figures 1 and 2).MANAGEMENT OF JUGULAR FORAMEN TUMORS JEFFREY BRUCE. The jugular foramen contains the jugular bulb. Glomus jugulare tumors require a much greater operative exposure than neuromas due to their highly vascular and locally invasive characteristics. The lower cranial nerves (the glossopharyngeal. A thorough understanding of the jugular foramen and its adjacent anatomy is essential for a successful surgical outcome. the vagus. M. otologists.

There is no simple formula for determining the risk-benefit ratios of surgery other than on an individual basis. Figure 3. the presence of catecholamines can lead to postoperative complications. appropriate. Nearly all symptomatic patients with jugular fora- men tumors are candidates for surgical resection. Contrast-enhanced coronal MRI demonstrating an enhancing mass in the jugular foramen and extending into the jugular vein. consideration must be given to the patient’s age and any underlying medical conditions that might contraindicate surgery. Figure 2.136 NEUROSURGICAL OPERATIVE ATLAS. which must also be evaluated within the context of the patient’s age and medical condition. VOL. Approximately 4% of glomus tumors secrete catecholamines. a carotid occlusion test may also be performed if the tumor involves the carotid artery and potential damage to the artery during surgery exists. Axial CT showing glomus tumor eroding the jugular foramen. Conserva- . however. Contrast-enhanced axial MRI demonstrating enhancing mass in the jugular foramen. In addition to the radiographic workup. 8 Figure 1. These operations are rarely emergencies and adequate time for complete diagnostic workups and thoughtful preparations can be made. Since many tumors grow slowly. an endocrine evaluation including a 24-hour urine collection to measure for catecholamines should be performed. More controversial are asymptomatic tumors. Complete hearing and swallowing evaluations and otoscopic examinations are also indicated. if not recognized.

The decision to radiate has important implications. The tracheostomy can be removed if the swallowing function is intact. The patient must be well prepared for the extensive surgery that is required. angiogram following embolization demonstrating marked reduction in vascularity. facial functions. consisting of brain stem auditory evoked responses as well as monitoring of the lower cranial nerves and facial nerve. it is best placed preoperatively. angiogram showing prominent vascularity of the glomus tumor. B. and speech must be anticipated. it may be necessary to stage the operation into two parts. The effectiveness of radiation therapy on a long-term basis is disputed. If radiation fails and surgery is ultimately necessary. unless intradural exploration is not likely to be per- Anesthetic Technique . there is significantly greater difficulty and morbidity associated with surgery. Most of the literature addressing alternatives to surgery is distorted by the lack of scientific methodology. swallowing. In most instances. functions such as hearing may need to be deliberately sacrificed as part of the resection. cranial nerve impairment is temporary. A. Routine broad-spectrum antibiotics are used. Tracheostomy. In certain instances where there is extensive tumor. Extensive tumors may require two separate embolizations. tive management is often desirable under these circumstances.BRUCE AND STORPER : MANAGEMENT OF JUGULAR FORAMEN TUMORS 137 A B Figure 4. Significant risks to hearing. performed prophylactically. it is generally used in conjunction with surgery rather than as a primary. even less is known about the long-term effects of radiosurgery. single therapeutic option. The selection of alternatives to surgery is also controversial. The timing of this is controversial but generally should be done within 24 to 72 hours of surgery. Patients must be prepared for the possibility of either a temporary or permanent tracheostomy. Patients must also be aware that because of the labor-intensive surgery involving the jugular foramen. Since a spinal drain is usually necessary to reduce postoperative cerebrospinal fluid (CSF) leakage. All patients with glomus tumors should undergo preoperative embolization (Figure 4). Electrophysiological monitoring is recommended. Embolization alone is thought to reduce the rate of growth of these tumors. however. Similarly. PREOPERATIVE PREPARATION There are no special general anesthesia considerations. may be preferable to risking postoperative aspiration pneumonia.

a flap is raised off the periosteum of the skull continuous with the sternocleidomastoid muscle. Skin Incision The scalp flap is retracted anteriorly. The parotid gland is sharply dissected off the tympanic and mastoid bones to the level of the posterior belly of the digastric muscle. The jugular vein and common carotid arteries are both tagged with a vessel loop. Dissection proceeds until the external auditory canal itself is removed. the temporomandibular joint must be drilled away on all sides. Smaller glomus tumors and noninvasive tumors such as neuromas generally require a less extensive exposure. The spinal accessory nerve is followed through the sternocleidomastoid muscle and up to the jugular foramen. As the surgeon’s experience increases. VOL. The facial nerve is carefully dissected adjacent to the styloid process and peeled off the parotid gland up to where it branches. The facial nerve is dissected and drilled away from its bony canal up to the level of the external genu (Figure 8). A threepoint head fixation device may be used to maintain the head position. The posterior external auditory canal wall is then ground to Koerner’s septum. enabling the mandible to be mobilized anteriorly. To accomplish this. although a simple cerebellar headrest is often preferable so that the head position may be moved as desired. As dissection proceeds anteriorly into the zygomatic route. A sandbag is placed underneath the ipsilateral shoulder. The incudostapedial joint and incus are removed from the middle ear. and the annulus are removed. the carotid artery. The spinal accessory and hypo- OPERATIVE PROCEDURE glossal nerves are identified and dissected above the bifurcation of the carotid artery. This can be performed using either loupes and a strong headlight or the operating microscope.138 formed. The facial nerve is also dissected free from the parotid gland. with exposure and control of the internal jugular vein. Drilling continues into the posterior cranial fossa to the retrosigmoid region. the descending segment of the facial nerve is visualized. NEUROSURGICAL OPERATIVE ATLAS. At this point. The vagus nerve is identified and followed along its path between the carotid artery and the internal jugular vein. A C-shaped posterior auricular incision is made extending anteriorly into the temporalis muscle and down along the anterior border of the sternocleidomastoid muscle. as well as to be able to mobilize the temporomandibular joint and perform temporal bone dissection. The temporal bone posterior to the facial nerve is drilled away down to the level of the jugular bulb. taking care to avoid the carotid artery lying just medial to it. The facial nerve is dissected from an inferior to superior direction until it is completely freed from the parotid gland. Operative Positioning A wide operative exposure of the petrous bone and neck is necessary for safe removal of jugular foramen tumors. with the flap remaining continuous with the fascia of the parotid gland. The internal carotid artery is dissected up toward the base of the skull after elevating the submandibular gland. The bony external auditory canal is drilled away circumferentially to the area of the facial recess. and the ninth through 12th cranial nerves up to the jugular foramen. however. The next phase is temporal bone dissection (Figure 7). the sigmoid sinus can be opened and packed with Surgicel or other suitable hemostatic agent. The entire sigmoid sinus is drilled away down to the jugular foramen as well as down to the occipital . and the jugular vein in the neck. the neck dissection is completed. If an individual is particularly large and of limited mobility. The septum is removed and the incus can be seen. the patient is placed supine with the head turned 90 degrees in the contralateral direction (Figure 5). This will provide the exposure necessary to the lower cranial nerves. this is not of major concern. facilitating head turning. The bone over the middle cranial fossa (tegmen) and the sigmoid sinus is exposed. The zygoma is then divided. 8 For optimal positioning. Inadequate exposure adds to the difficulty of the operation and may result in failure to completely remove the tumor. a lateral position may be needed. At any point. the carotid arteries. a decision can be made as to whether or not the petrous carotid artery needs to be mobilized. the size of the operative field may be reduced. Dissection continues until the facial nerve is completely mobilized distal to the lateral genu. Enough bone is removed to be able to mobilize the sigmoid sinus. The sternocleidomastoid muscle is retracted laterally and the internal jugular vein is identified and dissected from an inferior to superior direction. The parotid gland can then be removed in its entirety. Inferiorly. the tympanic malleus. Subplatysmal flaps are elevated in the neck until the parotid gland is visualized. The tympanic membrane. It is important to have control of the vessels proximally and distally as well as to identify the cranial nerves proximally and distally where the anatomy has not been disturbed by tumor (Figure 6). A high-speed drill with copious irrigation is used to begin the mastoidectomy. The tumor can often be seen by this point. The ear canal is transected at the bony-cartilaginous junction and is then oversewn. This is followed down to the stylomastoid foramen. leaving the temporalis muscle and fascia intact. At this point.

Photograph showing patient positioned supine with the head turned approximately 90 degrees. A C-shaped posterior auricular incision provides the exposure necessary to expose the temporal bone and lower cranial nerves in the neck.BRUCE AND STORPER : MANAGEMENT OF JUGULAR FORAMEN TUMORS 139 Figure 5. Smaller tumors can be removed with a smaller incision and less exposure. Figure 6. (Drawing courtesy of George Card) . Drawing demonstrating a postauricular incision.

140 NEUROSURGICAL OPERATIVE ATLAS. Operative photograph demonstrating facial nerve exposure after temporal bone drilling. (Drawing courtesy of George Card) facial nerve jugular bulb sigmoid sinus Figure 8. Drawing of the tumor in the jugular foramen after temporal bone drilling. 8 facial nerve external auditory canal tumor within jugular bulb sigmoid sinus Figure 7. . VOL.

Drawing showing the jugular foramen anatomy following tumor removal.BRUCE AND STORPER : MANAGEMENT OF JUGULAR FORAMEN TUMORS 141 facial nerve glossopharyngeal nerve carotid artery vagus nerve jugular vein accessory nerve sigmoid sinus (opened) Figure 9. (Drawing courtesy of George Card) Figure 10. . Operative photograph demonstrating closure with free fat graft overlying vascularized temporalis muscle flap that has been rotated into temporal bone defect.

The drain is clamped in between draining to avoid overdrainage. a medialization procedure or Teflon injection may be necessary. Continuous drainage is best avoided in favor of intermittent drainage of 12 to 15 cc of CSF every 2 hours. therefore. Watertight closure is accomplished by mobilizing a vascularized portion of the temporalis muscle and fascia and sewing it to the dural defect with a running suture. and hemostatic material such as Avitene placed into the tumor will control most bleeding. En bloc removal of the tumor is preferred. removal of the tumor begins. Fascia lata may be used if necessary. This puts the carotid artery at some risk and. The tumor can be internally debulked. The outer capsule is generally vascular. it is preferable to allow minor bleeding to continue rather than to risk cranial nerve damage from cautery. Once the cochlea is drilled away. because of the adjacent cranial nerves. VOL. this must be done with great care. Cautery may be used to reduce the capsule. CSF leakage can be a problem and is best prevented by the meticulous use of layered closure and a spinal drain. followed by staples for the skin. A subfascial drain is often helpful for at least the first 48 hours. although its benefit is questionable. the patient no longer has the capacity for hearing.142 NEUROSURGICAL OPERATIVE ATLAS. COMPLICATIONS . the dura may be opened adjacent to the internal auditory canal. The middle meningeal artery can also be ligated at this point. Drilling continues until the endolymphatic sac and semicircular canals are drilled away. most of which are transient. 8 condyle and hypoglossal canal. Following tumor removal. The facial nerve can be followed up to the geniculate ganglion and to the cerebellopontine angle. Fibrin glue may be used to reinforce this closure. The scalp flap is reapproximated with subgaleal sutures. there is always risk of catastrophic injury to the carotid artery which could result in a stroke. vascularized tissue is preferred. The eustachian tube is sealed using a piece of temporalis muscle. The petrous carotid artery can be identified and safely dissected away. A complete labyrinthectomy is often needed. although is often difficult to follow the nerves as they enter the canal. Following a labyrinthectomy. It is generally best to mobilize the sigmoid sinus and resect it down to the jugular foramen (Figure 9). the defect in the dura must be closed. The internal jugular vein will already have been ligated distally and following the jugular bulb through the foramen and down to the divided jugular vein is straightforward. infection is common. If there is significant vagus nerve palsy. piecemeal removal may be necessary depending on the size of the tumor. Dissection is continued anteriorly into the clivus and the bone overlying the Eustachian tube is removed. it is important to leave the capsule of the tumor intact to reduce bleeding in the operative field. Because of the length of the procedure and the potential for open space around the temporal bone. If there is a significant intradural component. CLOSURE Major complications include facial nerve and lower cranial nerve palsies. Generally. Tumor attachments to the carotid artery as well as the surrounding nerves may require sharp dissection. Following the extensive exposure. Although unusual. Throughout drilling. however. Once the tumor has been completely removed. Non-autologous materials should be avoided as they provide less capacity for watertight closure and carry a higher risk of infection. an interposition graft with the greater auricular nerve or a direct re-anastomosis may be performed. Venous back bleeding from the inferior petrosal sinus can be controlled with Avitene. The sternocleidomastoid muscle is reapproximated at its site of origin with interrupted sutures. even with embolization. Fat harvested from the thigh can be used to fill any open space from the temporal bone dissection (Figure 10). The temporomandibular joint is reapproximated with microplates. The cranial nerves can be identified proximally as they go into the jugular foramen. A spinal drain is left in place for approximately 5 days. but enough exposure must be maintained to have control of the artery should a tear occur. If there is obvious damage to the facial nerve during surgery. complete hemostasis is easier to obtain. however. it is important to have complete control of the vessel. the middle fossa dura is easily freed up.

the intracranial masses present with anosmia and signs and symptoms of raised intracranial pressure (ICP) or proptosis and visual defects once they invade the orbit. remains to be evaluated. Esthesioneuroblastomas are often slow-growing tumors and have a tendency to metastasize to regional lymph nodes and the lung. Management of these tumors is primarily surgical. either as primary treatment or as an adjuvant. No definite correlation between the histological grading of these tumors and the biological behavior INTRODUCTION is known. orbit. These tumors are locally aggressive and invade the paranasal sinuses. CT with bone algorithms shows the extent of bone destruction (Figure 1). Tumors with intracranial extension associated with cysts in the peritumoral area are often diagnostic of esthesioblastomas. distant metastases in the lung. these tumors are hypointense on T1-weighted images and enhance with contrast.D. Regional cervical metastases are known to occur in 10%-40% of cases. CT of the paranasal sinuses demonstrates the entire extent of the disease process. and MRI. are uncommon tumors constituting 3% of all intracranial neoplasms. the study helps plan reconstruction of the skull base. serves to detail the location and extent of submucosal spread of the tumor and define dural involvement (Figure 2). nasopharynx. and the destruction to the bone (Figure 3). rather it is the location and extent of the tumor at the time of the diagnosis that appear to bear a direct relation to the prognosis. liver. PERSKY. MARK S. M. the common findings are nasal obstruction and epistaxis. they produce neurological symptoms due to intracranial invasion. M. In MRI. Esthesioneuroblastomas. The disease may also begin with the signs of a brain tumor or meningitis. or the basicranium.D. the obstruction of paranasal sinus outlets. The differential diagnoses include hemangiopericytoma and olfactory groove meningioma. A three-dimensional CT with bone windows would show the defect in the skull base. The role of chemotherapy in the management. mediastinum. When present in the nasal cavity. They are derived from the neuroepithelial sensory cells of the olfactory mucosa.SURGICAL MANAGEMENT OF ESTHESIOBLASTOMAS RAMESH PITTI BABU. magnetic resonance angiography and/or RADIOLOGICAL EVALUATION 143 . with and without gadolinium enhancement. Although they have a certain degree of radiosensitivity. esthesioneuroblastomas tend to recur after radiotherapy. or olfactory neuroblastomas. However. even after a silent period lasting years. palate. In large tumors. bone. In 20% to 25% of cases. © 1999 The American Association of Neurological Surgeons Computed tomography (CT) and magnetic resonance imaging (MRI) are the two most valuable diagnostic tools in evaluating this disease. presenting as nasal masses. They usually arise in the nasal vault. and spleen occur in 8% of cases. In large tumors.

and Patient Selection PREOPERATIVE CONSIDERATIONS .144 NEUROSURGICAL OPERATIVE ATLAS. In selective cases. Clinical Evaluation. conventional cerebral angiography are necessary to determine the vascularity of the tumor and the displacement of the major intracranial vasculature. A B Figure 2. Coronal section of CT with bone algorithm demonstrating the extent of bone destruction caused by the esthesioneuroblastoma. However. These tumors Presentation. MRI with gadolinium enhancement in sagittal (A) and coronal (B) views verifies the location and submucosal spread of the tumor. the work-up should include a complete skeletal survey complemented with a bone scan to detect the metastatic spread to the skeleton. a second peak is noted in persons aged 10-20 years. Caucasians are more commonly affected than Blacks. Esthesioneuroblastoma most frequently occurs in patients 40-60 years of age. 8 Figure 1. VOL.

Stage C: Tumor extending beyond the nasal cavity into the orbit and/or the intracranial cavity. although all tumors respond to radiation. cervical lymph nodes. Figure 3. the initial evaluation is often done by an otolaryngologist. The term “cure” in these patients is to be used with caution because 50% of the patients who are survivors eventually succumb to recurrent or metastatic disease. However. Radical tumor dissection or any of its modifications followed by postoperative radiation is warranted for clinically evident neck metastases. or distant structures. however. as long as they are confined to the nasal cavity. either a direct endoscopic or open biopsy is necessary for the diagnosis prior to definitive surgery. we feel that in all stages (A. Currently. The Role of Biopsy OPERATIVE TECHNIQUE Esthesioneuroblastomas presenting at the anterior skull base pose a surgical challenge. radiation alone or radiation prior to surgery appears to yield less favorable results than Treatment Choice A correct preoperative diagnosis is crucial in lesions confined to the nasal cavity with either minimal or no intracranial extension. Some oncologists favor using radiotherapy as the sole treatment. further clarification is obtained by electron microscopy and immunohistochemical studies. melanoma. and aggressive inverting papilloma are some of the tumors considered in the differential diagnosis. The results of the biopsy help in planning for definitive treatment. plasmacytoma. B. Since local recurrence is as high as 60% in patients treated with radiotherapy followed by extracranial surgery. When large series are critically evaluated. lymphoma. Hemangiopericytoma. for Stage C tumor. Although between 19% and 47% of patients have neurological complications associated with the disease. they are managed via a combined craniofacial or rhino-neurosurgical approach. particularly in small intranasal tumors. except for a few episodes of epistaxis and nasal obstruction. is undertaken along with a routine general medical preoperative evaluation. only 7% have primary symptomatology referable to the nervous system. the approach is multidisciplinary and multimodality based. Stage B: Tumor in the nasal cavity with extension to one or more paranasal sinuses. undifferentiated squamous cell carcinoma. possibly in the lungs. surgery and radiation seem to offer a similar benefit. 70% have rhinological complaints. In Stages A and B craniofacial resection with postoperative radiation has been found to give the best tumor-free survival time. A thorough examination of the neck to rule out cervical lymphadenopathy or a work-up for distant metastases. as there is only a 12% recurrence. Radiological studies are warranted in patients with the above symptoms and clinical evidence of nasal polypoid masses (especially unilateral). embryonal rhabdomyosarcoma. and C) craniofacial resection is necessary. the tumor should be staged based on the classification proposed by Kaddish and coworkers (Figure 4): Stage A: Tumor confined to the nasal cavity. At times. Transnasal biopsy with the patient under local anesthesia is easily performed. oat cell carcinoma. the consensus is to perform a craniofacial resection with the addition of radiotherapy and chemotherapy (cyclophosphamide and vincristine) for distant metastases.BABU AND PERSKY : SURGICAL MANAGEMENT OF ESTHESIOBLASTOMAS 145 combined craniofacial surgery and postoperative radiation. are slow growing and remain asymptomatic for a long time. Coronal section of CT with contrast enhancement showing the full extent of the disease process as well as obstruction of the paranasal sinus outlets. For optimal treatment planning. it is a matter of debate whether radiotherapy prior to surgery or postoperatively (even in the absence of residual tumor) is useful. In larger tumors. Although routine hematoxylin-eosin staining is helpful in diagnosis. hence. Some surgeons advocate a form of . There is an ongoing debate as to the optimal method of treatment.

An arterial catheter and one or two large-bore intravenous lines are inserted. frontal (left) and lateral (right) views. Appropriate treatment planning follows staging.0-1. con- Preoperative Preparation and Anesthetic Considerations tinuous blood pressure measurement. which is continued after surgery at 100 mg three times a day. A = tumor confined to the nasal cavity. If sedation is desired. B = tumor in the nasal cavity extending to one or more paranasal sinuses. A short-acting opioid and ultrashort-acting intravenous anesthetic (generally thiopental or propofol) are used for induction. patients are given a loading dose of 1 gm Dilantin. VOL. Intravenous lidocaine. electrocardiography. A combination of these agents permits a smooth induction of anesthesia. The Kaddish tumor staging process. may be useful prior to laryngoscopy. Controlled hypotension may be desired during surgery to reduce blood loss and the need for .5 mg/kg body weight. Starting at midnight prior to surgery. one of the shorter-acting benzodiazepines such as diazepam or midazolam is administered on call to the operating room. thus avoiding hypertension. transfacial exposures such as lateral rhinotomy. followed by a nondepolarizing muscle relaxant for intubation. hypoxia. the patients are given 250 mg intravenous Solu-Medrol every 6 hours. and medial maxillectomy for tumors that do not extend intracranially or do not involve the cribriform plate. C = tumor extension beyond the nasal cavity into the intracranial compartment. Routine monitoring in the operating room consists of pulse oximetry. all of which may increase ICP. and coughing. a combined transfacial and transcranial approach is necessary because there is microscopic infiltration of the cribriform plate and olfactory bulbs. 8 Figure 4. hypercarbia. However. Narcotics should be avoided because of their tendency to produce respiratory depression and/or nausea and vomiting. assessing the extent of tumor.146 NEUROSURGICAL OPERATIVE ATLAS. ethmoidectomy. Capnography assesses the level of hyperventilation and is titrated to obtain optimal ICP control. which in turn can result in increased ICP. Anesthesia is generally maintained with a narcotic by infusion or by nitrous oxide and isoflurane. The PaCO 2 is maintained in the range of 25 to 30 mm Hg. The hypertensive response to pin fixation of the head may be minimized or eliminated by the prior administration of an intravenous anesthetic. even in small tumors. The day prior to surgery. 1. and capnography.

When the burr hole is made. it is safer to deal with the intracranial portion initially. The posterior edge of the cut skin is lifted with hooks. is stripped and reflected along with the skin up to the nasion. This technique could cause a tear of the dura and/or the superior sagittal sinus. cerebrospinal fluid (CSF) is not drained unless necessary for brain retraction during surgery. Special attention is paid while the burr hole is drilled near the frontal sinus. and use the side-cutting Midas Rex drill to complete the craniotomy. a tunneled lumbar drain is placed. The skin incisions (dotted lines) for resection of esthesioneuroblastomas. Skin Incision transfusion. Two burr holes are placed just above the supraorbital ridges on the lateral aspect (“keyholes”) and another burr hole is placed exactly in the midline just anterior to the coronal suture. One can also raise the bone flap in two pieces. The right quadrant of the abdomen is also prepped and draped for harvesting the fat graft at a later stage. The entire head and face up Patient Positioning Initially. any brain herniation through the skull base might cause injury to the brain parenchyma during the rhinological portion of surgery. A mean arterial pressure of 50 to 60 mm Hg is acceptable in a healthy individual. Using a #11 blade. the table padded. Prior to the Betadine prep. It is necessary to raise a low frontal bone flap but not a large one. deliberate hypotension may be induced by increasing the level of isoflurane or by a direct-acting vasodilator. separate the dura and sagittal sinus from the overlying bone. defining the tumor and protecting the brain. A high bicoronal skin incision within the hairline at least 13 cm from the root of the nose and a separate lateral rhinotomy incision are marked as shown in Figure 5. Instead. Figure 5. and subcutaneous dissection is carried out 2 to 3 inches behind the line of the incision. The first piece comes up almost to the midline. a low frontal craniotomy is performed using the Midas Rex drill. Thus obtained (at least 2 to 3 inches longer than the skin flap). the pericranium is later used to cover the anterior cranial fossa during the repair. In highly vascular tumors. including a high bicoronal incision behind the hairline (which is at least 13 cm from the root of the nose) as well as a separate lateral rhinotomy incision. but may not be tolerated by a patient with cardiovascular disease or hypertension. In the case of a large tumor. the pericranium is cut right to the bone. Prior to positioning the patient. a temporary tarsorrhaphy using 6-0 nylon is undertaken. The proposed line of incision is infiltrated with 1% lidocaine with epinephrine. The skin is incised and the bleeding skin edges are controlled with Raney clips. exposing both of the supraorbital ridges and held retracted until the end of surgery. it is better to drill the inner wall of the frontal sinus as well. All pressure points are well padded. and 20% mannitol is given intravenously (1 gm/kg body weight). After intubation. This long skin flap is necessary to obtain an adequate pericranial graft. the surgeon may decide to stop after penetrating the outer wall of the frontal sinus and use the Midas Rex drill to cut the bone. otherwise. Venodyne pneumatic compression boots are applied with their use continued into the postoperative period. the bladder is catheterized. The patient is then placed in the supine position. without any side-to-side tilt. then the superior sagittal sinus is sepa- Craniotomy and Supraorbital Osteotomy . The frontal sinuses entered in these exposures are obliterated and repaired at the end of the surgery to prevent potential CSF leak or the formation of mucoceles. The pericranium. along with the thin layer of fascia on the temporalis muscle (which is located superficial to the temporalis fascia). The head is slightly extended and fixed to the bed after securing it in a three-pin Mayfield headholder.BABU AND PERSKY : SURGICAL MANAGEMENT OF ESTHESIOBLASTOMAS 147 to the upper lip is thoroughly prepped with Betadine scrub and solution and draped. such as sodium nitroprusside or nitroglycerine.

later the second piece is removed from the other side. especially in large tumors (Figure 6). The sinus is divided between two 2-0 silk ligatures. VOL. Resection of Tumor . which occupy the anterior cranial fossa about equally from the midline. the rim of the foramen on either side is broken with a small osteotome and the nerve is released toward the orbit along with the periorbita which. After the frontal bone is removed. This exposes the falx and undersurface of the superior sagittal sinus. Prior to the osteotomy. in turn. will minimize the need for brain retraction. exposing the cribriform plate and the olfactory bulbs (Figure 7). After the craniotomy. is sharply separated from the inner surface of the orbit. at least on one side. a supraorbital osteotomy is performed. This is particularly necessary with large tumors. and two rubber dam cottonoid patties are applied on the surface of the brain next to the midline and retracted posteriorly. the supraorbital nerve is released from the notch using a Cottle elevator. This would avoid injury to the superior sagittal sinus and provide excellent cosmetic results.148 NEUROSURGICAL OPERATIVE ATLAS. 8 skin reflected supraorbital osteotomy craniotomy line of pericranial incision Figure 6. If the notch is converted into a foramen. bilateral supraorbital osteotomies are necessary. The frontal lobes are retracted back. rated from the bone. the addition of a supraorbital osteotomy. In giant tumors. Two horizontal incisions are made in the dura along the floor of the anterior cranial fossa up to the midline.

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intracranial tumor eye globe

anterior cranial fossa

frontal lobe retracted cranial nerve II Figure 7. The cribriform plate and the olfactory bulbs are exposed, while the frontal lobes are retracted back, just prior to tumor resection.

In extracranial tumors or tumors with minor intracranial extension, the olfactory nerve filaments should be microdissected and excised at the time of removal of the intranasal component of tumor. This should be done even in the absence of CT evidence of intracranial involvement, to prevent recurrence of the tumor, because of its origin from olfactory epithelium. After resection, a routine closure is undertaken. In medium-sized tumors, resection is carried out piecemeal. Pr ogressive intratumoral decompression and shrinkage of the tumor with bipolar coagulation under constant irrigation would separate the tumor from surrounding compressed brain and open the subarachnoid space. Once partial decompression is accomplished, the base of the tumor at the cribriform plate is managed. The ethmoidal feeding arteries are generally found in this area. They are cauterized and cut, and the intranasal part of the tumor is removed. In giant tumors, the dura is attached to the surface of the tumor; in order to obtain a satisfactory result, the dura (along with the tumor) is resected. Giant tumors could extend posteriorly and press upon the optic nerves and anterior cerebral artery complex. Progressive extra-arachnoidal debulking of the tumor would create a peritumoral space, avoid-

ing injury to the arachnoid toward the brain side. After tumor resection, it is important to resect the olfactory nerve filaments and bulbs.

If the tumor has extensively penetrated the skull base, then en bloc resection of the cribriform plate, the ethmoid sinuses, and a portion of the planum sphenoidale including both the olfactory bulbs with their filaments is attempted. En bloc resection can be achieved either by drilling at the tumor margins or through saw cuts. If saw cuts are preferred, cut at the glabella parallel to the anterior cranial fossa. A second cut just behind the cribriform plate approximately 2.5 cm from the root of the nose and two lateral cuts on either side of the cribriform plate will surround the tumor and avoid injury to the optic nerves. Occasionally, in patients with extensive tumors presenting with poor vision, unroofing the optic nerves from the chiasm to the orbital apex, either unilaterally or bilaterally with the resection of the entire planum between the nerves, is undertaken. The cut margins are examined to ensure that they are tumor free. Orbital exenteration is necessary only if the tumor extends beyond the periorbita into the orbit. We advised earlier to complete the intracranial

Resection of the Cribriform Plate and Planum

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portion of resection before the rhinosurgical portion; however, in massive tumors, it is easier and safer to have the otolaryngologist and the neurosurgeon work in concert so that the neurosurgeon, after protecting the frontal lobes with rubber dam cottonoid patties and placing retractor blades, should be able to push the tumor through the cribriform plate so that the otolaryngologist can remove it from below through the nose. Because these tumors are notorious for their recurrence, total gross surgical resection without causing undue complications should be the goal.

An incision is made from the inferior medial third of the eyebrow along the lateral nasal area and around the base of the ala nasi (Figure 5). The soft tissues are elevated in a subperiosteal plane to expose the nasal bone, the frontal process of the maxilla, and the maxillary process of the frontal bone. If wide exposure of the anterior superior nasal cavity is necessary, a lateral nasal osteotomy extending into the nasal cavity is performed. The nasal bone is replaced using miniplates at the end of the procedure. The medial orbit is then dissected in a subperiorbital fashion to the orbital apex. The medial canthal ligament is mobilized without disrupting it. The nasolacrimal duct is sharply transected and the anterior and posterior ethmoid arteries are bipolar cauterized and transected. Identification of the fronto-ethmoidal suture indicates the border between the anterior cranial fossa above and the ethmoid cavity below. A complete anterior and posterior ethmoidectomy and sphenoidectomy are done; the lacrimal bone and lamina papyracea are resected. Adequate tumor exposure is now obtained. Large tumors may require a medial maxillectomy. The medial third of the orbital floor can also be resected without need for subsequent reconstruction. The orbital roof is resected as necessary; this is safely per formed since the frontal lobe has been retracted via an intracranial approach.

Lateral Rhinotomy

second layer is the fat graft, and the third layer is the vascularized pericranial flap (Figure 8). The bony defect in the anterior cranial fossa could be left alone, but we advocate repairing the floor with a split-thickness bone graft obtained from the craniotomy flap. This would act as a bridge, preventing herniation of the frontal lobes and sagging of the soft tissue layers placed on the floor. However, some surgeons do repair it with a methylmethacrylate mold. A primarily watertight dural closure is not possible; hence, closure of the dura using either cadaver fascia lata or autologous temporalis fascia should be undertaken. To further achieve a tight seal, a fat graft obtained from the abdominal wall is placed on the floor over the bone graft. At this stage, the vascularized pericranial flap is separated from the skin and laid down on the floor over the fat graft. This flap is also tacked down with 4-0 Nurolon to the posterior end of the dura of the anterior cranial fossa. The suture lines and the tissue grafts are routinely sealed by fibrin glue. In reoperations or in the absence of a strong pericranium, the floor is covered with vascularized temporalis muscle; the free rectus abdominus flap hooked to the superficial temporal artery (with the help of a plastic surgeon) may be used. Postoperatively, a lumbar drain is routinely used for 5-7 days. Repair of the cribriform plate from the nose is accomplished using fat and full-thickness grafts of the skin and subcutaneous tissue placed on a gelatin sponge; keeping the raw surface upward toward the intracranial cavity and packing with iodoform gauze impregnated with bacitracin ointment gives the best results of repair. The nose is then sewn back in position.

RECONSTRUCTION AND REPAIR
Prior to reconstruction, the frontal sinus is repaired. Initially, it is cranialized and the mucosa is thoroughly removed. The interior of the sinus is then devascularized by cauterizing it with a Bovie coagulator and is filled with Gelfoam soaked with bacitracin powder. Later, a piece of muscle that has been harvested from the temporalis muscle is placed and glued down using fibrin glue. Lastly, the pericranial flap is turned to cover the sinus.

Repair of Frontal Sinus

Reconstruction of Anterior Cranial Fossa

After en bloc resection, the floor of the anterior cranial fossa is repaired. Three layers of grafting are used. The bottom-most layer is the bone graft, the

All patients are maintained on antibiotics, preferably 500 mg vancomycin every 6 hours and 80 mg tobramycin or gentamycin administered intravenously every 8 hours, until the drains and packing are removed. Alternatively, Unasyn can be used. If no drains are placed, antibiotics are given for a period of 48 hours. Patients are also continued on 100 mg Dilantin three times a day. Bed rest is required until the lumbar drain is removed, and the patient should be carefully monitored for any signs or symptoms of CSF leak through the nose. This potential problem is hopefully prevented via a lumbar drain for 5-7 days, after all layers of repair are stuck down and well healed. CSF, 50 to 60 cc every 8 hours, is drained. In rare instances, it is necessary to seal the leak via a transfacial, transsphenoidal approach by packing the sphenoid sinus. After the spinal drain is removed, the patient is mobilized. While on bed rest, the patient is given 5000 U heparin subcutaneously administered every 8 hours, beginning 72 hours after surgery. Nasal packing is removed on the 7th postoperative day.

POSTOPERATIVE CARE

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pericranial flap

fat graft

bone graft

Figure 8. Illustration demonstrating complete repair of the anterior cranial fossa, which is carried out after the en bloc resection. The bottom-most layer consists of the bone graft, the middle layer consists of the fat graft, and the top layer is the vascularized pericranial flap.

Operative complications include injury to the anterior cerebral artery complex and the optic nerves, especially when the tumors are large. Care is exercised during dissection of the posterior aspect of the tumor to avoid these structures. During tumor resection, one should not violate tumor-arachnoid interface. Bilateral frontal lobe damage, either due to excessive retraction or to inadvertent injury during tumor removal, may result in serious cognitive problems. Supraorbital osteotomy and good anesthetic brain relaxing technique would help to avoid these known complications. Other complications include meningitis secondary to CSF leak and the development of meningoencephalocele or mucoceles. As

COMPLICATIONS

mentioned earlier, all of these complications can be avoided by strict adherence to the repair, reconstruction principle, and postoperative care.

The 5-year survival rate ranges from 18% to 71%. Survival depends on the size of the tumor, intracranial extension, and lymph node involvement. In patients with Stage C disease, the 5-year survival is reported in the range of 60%, while with Stage A it is almost 100%. Postoperatively, these patients are carefully followed by CT or MRI about every 6 months. In suspicious cases, endonasal endoscopy is performed and any recurrence is appropriately managed by either surgery or adjuvant therapy.

FOLLOW UP, PROGNOSIS, AND SURVIVAL

SURGICAL TREATMENT OF BRAINSTEM GLIOMAS
MARK R. LEE, M.D., PH.D. MICHAEL COWAN, M.D.

Brainstem gliomas represent approximately 10% of pediatric brain tumors, but are rare in adults. As a group, these tumors have a poor prognosis and are associated with a 30% 5-year survival rate. However, it has become clear that brainstem gliomas are a heterogeneous group of tumors in regard to biological behavior and surgical accessibility. Certainly, some categories of brainstem gliomas possess a lowgrade pathology and have a better prognosis. In addition, with modern imaging and technical advances, many of these tumors represent surgical challenges that can be overcome. A very important tool in the surgical management of brainstem gliomas is magnetic resonance (MR) imaging. This makes it possible to identify the precise anatomical location of the neoplasm. In conjunction with the clinical picture, MR imaging allows one to know the pathology of the tumor with some degree of certainty. Thus, therapeutic decisions, including those regarding the surgical management of brainstem gliomas, can be made based on characteristic MR images.

INTRODUCTION

Patient selection is vital to the successful surgical treatment of brainstem gliomas. The most rewarding surgical outcomes will be in patients who harbor

PATIENT SELECTION

© 1999 The American Association of Neurological Surgeons

low-grade tumors that displace rather than infiltrate normal brainstem structures (Figure 1). In addition, patients who are most able to withstand the surgical manipulation of brainstem structures are those who have not yet been injured by their tumor; thus, surgery early in the disease course is preferable to surgery late in the disease course. There is a subgroup of patients with diffuse brainstem tumors in whom surgical intervention plays no role. These patients typically present with a very short history (a duration of weeks) of progressive cranial nerve palsies and gait ataxia. MR imaging reveals an expanded brainstem throughout, with diffuse infiltration by neoplastic cells as evidenced by a marked increase in signal on T2-weighted images of the pons and the medulla. Because these tumors diffusely infiltrate normal brainstem structures, resection of any portion of the tumor also involves removal of functional brainstem tissue. These tumors behave quite aggressively and the patient’s prognosis is dismal. The histology typically is anaplastic astrocytoma or glioblastoma multiforme. Focal brainstem tumors, on the other hand, are amenable to surgical resection, especially those with an exophytic component. Because these tumors are very slow-growing, patients typically present with a long history (years) of a mild cranial nerve palsy and occasionally with long-tract signs. MR imaging reveals a focal tumor that frequently enhances with gadolinium contrast. As noted above, the tumor often has a large exophytic component. The growth pattern of these tumors suggests that they respect anatomical boundaries and they remain restricted to the “compartment” of the brainstem from which they

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juvenile pilocytic astrocytoma. originated (e. The patient is typed and cross-matched for two units of packed red blood cells. and partial thromboplastin time are obtained. In addition. Not only does this provide for anatomic localization of the tumor and its relationship with normal structures. it also provides for a baseline study in which to judge the efficacy of the operation. in the medulla). can make these lesions amenable to complete surgical resection and possible cure. Patients receive 10 to 20 mg of dexamethasone intravenously every 6 hours starting at midnight before surgery. PREOPERATIVE PREPARATION Routine laboratory studies including a complete blood count with differential. Prophylactic antibiotics (usually a first-generation cephalosporin) are given the morning of surgery. early enough to obtain a therapeutic tissue level at the time of incision. Focal or exophytic brainstem gliomas typically displace and compress normal brainstem structures. at which time the clinical course may accelerate. An illustration of a partially exophytic focal medullary tumor. 8 Figure 1. prothrombin time..g. All patients should undergo preoperative MR scanning with contrast enhancement. The tumor displaces the lower cranial nerve motor nuclei anterior to the tumor rather than infiltrating normal brainstem structures. The patient’s hair is shampooed with antiseptic soap the night before surgery. It is unusual for patients with brainstem gliomas to suffer from hydrocephalus. or more rarely ganglioglioma. 10 to 20 mg of Pepcid (famotidine) is given intravenously at midnight. it may be worth a discussion with the anesthesiologists as to the merits of using an “armored” Anesthesia . The histology typically is low-grade astrocytoma.154 NEUROSURGICAL OPERATIVE ATLAS. This characteristic. VOL. OPERATIVE TECHNIQUE The patient is induced with intravenous Pentothal and intubated in the supine position. and therefore cerebrospinal fluid (CSF) diversion is rarely an issue. Although not essential. coupled with their low-grade pathology and slow growth. These tumors behave in a fairly indolent manner until they reach a critical mass.

We frequently use one to prevent the collapse of the endotracheal tube that occasionally occurs with aggressive flexion of the patient’s neck to obtain optimal suboccipital exposure during positioning. The nuchal muscles are dissected in a subperiosteal manner utilizing Bovie current on the suboccipital cranium and a combination of blunt and sharp dissection on the foramen magnum and the arch of C1. The hemodynamic instability usually self-corrects. Care is taken not to cross the midline occipital sinus or the usually present marginal sinus. the burr hole is enlarged with a curette and the dura is widely stripped with a #3 Penfield. The dura is again widely stripped at the foramen magnum with a #3 Penfield. The arms are tucked on the sides under the sheets. an incision is made from several centimeters Incision and Opening above the inion to the palpated spinous process of C2 or C3. In children under the age of 3 years. If a patient’s hair is too short to comb. an air-powered drill with an “acorn-shaped” bit is utilized. However. The lateral edges of the posterior rim of the foramen magnum are removed using rongeurs. Therefore. The patient is placed in a pinned headholder (either Mayfield or Sugita) and is turned to the prone position onto two gel chest rolls. and it is essential that the anesthesiologist be prepared for pharmacological intervention if necessary. a horseshoe-shaped headholder is used instead of a pinned headholder. The bone flap is elevated with a #3 Penfield. we do not advise the sitting position for brainstem glioma surgery. The fascia is cut on the midline with Bovie current and taken down to the cranium. and the spinous process of C2. There is no need for hyperventilation since early in the course of the procedure. After exposure of the dura. This gives excellent exposure of the suboccipital region (Figure 2A).LEE AND COWAN : SURGICAL TREATMENT OF BRAINSTEM GLIOMAS 155 endotracheal tube. It is not unusual to note wide fluctuations in blood pressure and heart rate during tumor dissection and removal.000 epinephrine. An intra-arterial line is placed to monitor blood pressure and blood gas levels. A bone flap is then created utilizing a craniotome. but plan for the incision in a midline part. Patients are generally maintained with inhalation anesthesia consisting of Forane and nitrous oxide. The . Supplemental intravenous fentanyl is also administered. Attention is then turned to the foramen magnum where the periosteum. Typically. allowing for the procedure to continue. It should be remembered that a “keel” of bone very commonly exists on the midline in the posterior fossa. bringing them laterally and then inferiorly and diagonally toward the foramen magnum to make a “heart-shaped” craniotomy (Figure 3). There is no need to expose the transverse sinus. attention is turned to the dural opening. Therefore. is cut widely utilizing a curette. two Ligaclips are placed across it on the midline. Typically. Bone cuts are made from the burr hole. the patient will become either hypertensive or bradycardic. tumor dissection and manipulation should be halted temporarily. If the marginal sinus is significant. Patients undergoing brainstem surgery require strict hemodynamic monitoring. and taken down to the pericranium of the occiput and the fascia of the nuchal muscles (Figure 2B). There is no need to perform further muscle dissection on C2 unless a laminectomy is required for resection of the cervical portion of some brainstem gliomas. In this case. the arch of C1. we will shave a small strip. The operating table is placed in reverse Trendelenburg position until the posterior neck and inion are parallel to the ground. A small dural opening is made with a #11 blade at one of the upper corners of the craniotomy. which melds into the outer leaf of dura of the posterior fossa. An alternative method of positioning patients for this operation is the sitting position. After the usual prep and drape. especially in younger children. The headholder is attached to the operating table with the neck moderately flexed and the chin pulled posteriorly. and the sinus is divided at the base of the two diagonals. If hemodynamic changes are encountered. The incision line is infiltrated with 0. but there are also major concerns regarding adequate cerebral perfusion during times of hemodynamic instability brought on during the tumor surgery. and violation of the dura could occur if care is not taken. when drilling one must be aware that the bone thickness will vary widely over the small area of the burr hole. Care must be taken when cutting down on the midline of the arch of C1 since this can be cartilaginous. Using Metzenbaum scissors. The posterior arch of C1 is not removed except in cases where the brainstem tumor extends into the cervical spinal cord. Unfortunately. Two Ligaclips are placed across the occipital sinus. care is taken to protect the eyes. A small amount of bleeding may be encountered at this point from the marginal sinus.5% lidocaine with 1:200. which can be easily controlled with Gelfoam soaked in thrombin. the cisterna magna is opened with release of CSF and resulting relaxation of the posterior fossa. This is repeated on the opposite side. After epidural hemostasis is obtained. An oval-shaped burr hole is then created on the midline just below the inion. the dural opening is continued diagonally to the midline at the craniocervical junction. not only is there a risk for air embolism. optimal exposure of the suboccipital region is difficult without a pinned headholder. Patient Positioning We typically do not shave the patient’s hair.

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A

B

Figure 2. A, patient positioning. The patient is placed in the prone position on two gel chest rolls. The head is fixed with a pinned head clamp and attached to the operating table with the neck moderately flexed; the chin is pulled posteriorly to give good exposure of the suboccipital region. B, a skin incision is made from several centimeters above the inion to the palpated spinous process of C2 or C3. The hair is not shown for illustrative purposes.

Figure 3. A suboccipital craniotomy. A high-speed drill is utilized to create an oval-shaped burr hole over the midline. One must be aware of the varying bone thickness because of the midline “keel.” After stripping the dura at the foramen magnum, two bone cuts are made, creating a “heart-shaped” craniotomy (dotted lines). Any remaining bone of the posterior foramen magnum is removed with rongeurs (also shown with dotted lines).

Figure 4. Dural opening. A “Y”-shaped dural opening is created. When cutting across the occipital and marginal sinus, Ligaclips may need to be placed to control bleeding. After cutting the dura, the superior and lateral flaps are sutured out of the field.

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dural opening is then completed, bringing a final limb inferiorly on the midline in the upper cervical region. The dural opening appears as a “Y” (Figure 4). The three corners are sutured and tacked laterally and superiorly. If not already violated during the dural opening, the cisterna magna should be opened at this time to allow for release of CSF and relaxation of the posterior fossa. The degree and method of magnification during the remainder of the operation depend on the individual surgeon. However, we elect to bring in the operating microscope at this time and perform the remainder of the operation under microscopic illumination.

To provide adequate exposure of the fourth ventricle, the inferior half of the vermis is split. Initially, the retractors from the system of choice (we use either the Sugita or Greenberg systems) are placed to split the tonsils and provide good exposure of the inferior vermis. The bipolar cautery is then utilized to coagulate the pia and veins on the surface of the vermis. The coagulated surface is then cut with microscissors. The corticectomy is created using bipolar coagulation and suction. With completely intrinsic brainstem tumors, the floor of the fourth ventricle is frequently elevated with partial or complete obliteration of the fourth ventricle. Therefore, care must be taken when removing tissue of the inferior vermis since the floor of the fourth ventricle can be inadvertently violated. To help guard against this, we typically split the vermis from a caudal to a cranial direction after retracting the cerebellar tonsils. This allows direct visualization of the dorsal surface of the upper cervical spinal cord, which can be followed to the obex, and the floor of the fourth ventricle as the vermis is split. With dorsally exophytic brainstem tumors, the tumor is usually encountered first, and the floor of the fourth ventricle will not be identified until the superior pole of the tumor has been breached.

Tumor Exposure

Tumor Resection

Focal intrinsic brainstem tumors are completely intra-axial; however, a portion of the tumor will usually have an abnormal-appearing layer of ependyma over it where it broaches the floor of the fourth ventricle. This can be readily identified. This area can be coagulated utilizing bipolarity and entered using suction, after which tissue is removed for pathological examination. An ultrasonic aspirator is then used for the majority of the tumor removal (Figure 5). These tumors are typically quite soft and suckable; therefore, it is advisable that the aspirator settings of low amplitude and suction be used. Typically, these lesions will displace brainstem nuclei either superiorly, laterally, or inferiorly (Figure 6). Although displaced,

the important nuclei will be intimately associated with the tumor margins, and, therefore, it is vitally important that tumor resection proceeds from the inside out (internal resection). Tumor margins are recognized by a change in the way the tumor tissue responds to suction. The area where there is little residual tumor becomes “floppy,” as if there remains a fragile capsule. The difference in tissue consistency between tumor and brainstem causes tumor tissue to pull away from brainstem tissue under light suction when there is little tumor bulk left at a specific margin. When this is encountered, the remainder of tumor removal should be accomplished with light suction and bipolar coagulation. Once white matter is encountered, tumor removal is complete at this margin (Figure 7). Significant bleeding is uncommon and is usually easily controlled. One should be loath to use bipolar coagulation in the tumor bed unless a specific bleeding vessel can be identified, since this can easily injure normal brainstem tissue. Usually, hemostasis is obtained with gentle, warm saline irrigation, and if necessary with application of microfibrillary collagen and thrombin. With dorsally exophytic brainstem tumors, the tumor bulk is outside the brainstem. In fact, when first reviewing imaging studies, it is common to believe that one is dealing with a cerebellar tumor until invasion of the brainstem via the floor of the fourth ventricle or the inferior and middle cerebellar peduncles is recognized. After opening the posterior fossa as described above, we usually perform a corticectomy of the inferior vermis or over the dome of the mass of exophytic tumor coming closest to the cerebellar cortex as defined by intraoperative ultrasound. Upon encountering the tumor, we take several specimens for pathological examination and then proceed with surgically defining the tumor. Lateral, inferior, and superior margins of the tumor must be identified and dissected from the surrounding cerebellar tissue prior to tumor debulking with the aspirator. Continuously alternating between defining tumor borders and removing tumor tissue allows one to safely proceed with tumor resection without risking inadvertent entry into the brainstem. Although these tumors can be very large, with adequate debulking, the superior pole of the tumor can be identified and the floor of the fourth ventricle visualized. At this point, it is prudent to place a cottonoid patty over the floor of the upper fourth ventricle to guard against injury to the facial colliculi and to block any blood from entering the aqueduct. Working over the dome of the debulked and more mobile tumor, the tumor can begin to be amputated at the level of the floor of the fourth ventricle, bringing this dissection inferiorly until the tumor has been completely mobilized and removed. This allows removal of the tumor tissue while maintaining the

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Figure 5. Tumor exposure and resection. A corticectomy is made with bipolar coagulation and suction, and the lower half of the vermis is split. Identifying the floor of the fourth ventricle is critical. Intrinsic tumors usually can be readily identified broaching the ventricular floor. After tumor samples are taken for pathology, an internal resection is performed, primarily utilizing the ultrasonic aspirator.

Figure 7. View of the floor of the fourth ventricle after tumor resection and hemostasis have been achieved.

Figure 6. An illustration of an intrinsic focal pontine tumor displacing the facial colliculi (abducens nuclei) inferiorly and laterally.

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orientation of the normal brainstem tissue. It is extremely important that the small amount of residual tumor tissue which may invade the brainstem is not chased below the level of the floor of the fourth ventricle, as this can lead to permanent injury of the motor nuclei of the lower cranial nerves.

At completion of the tumor resection, the tumor bed is irrigated with warm saline, and hemostasis is assured. The dura is closed with running 4-0 silk sutures, and the bone flap is secured with 2-0 silk sutures. A few 2-0 Vicryl sutures are placed in the muscle to decrease the amount of “dead” space, followed with interrupted 3-0 Vicryl sutures for the fascia and the galea or subcutaneous tissue. The skin is closed with a running 3-0 nylon suture. No drains are placed.

Closure

Patients with lesions restricted to the pons are extubated in the operating room. They are usually managed in the intensive care unit for about 24 hours. This is primarily for close observation and monitoring. At this point, they are most often fully responsive and able to assist in their own care; they are

POSTOPERATIVE MANAGEMENT

then transferred to the regular ward. Physical and occupational therapy is often begun on the third postoperative day to assist in their recovery. Dexamethasone is usually tapered over 7-10 days. Patients with lesions involving the medulla remain intubated for 72 hours. Sedation may be necessary to keep them comfortable. Continued intubation and ventilation is a precaution against the loss of respiratory drive suf fered by some patients 24 to 48 hours postoperatively. This is probably related to edema of the medulla and leads to hypoventilation, hypoxia, and hypercarbia. Patients who do well are transferred to the regular ward usually 24 hours after extubation. Physical and occupational therapy is begun at this time. If they have an adequate gag reflex, they are fed orally. If not, a nasal feeding tube is placed temporarily until it is no longer needed. Most patients recover their ability to swallow quickly and do not require a percutaneous gastrostomy tube. Patients are maintained on high-dose steroids (6 to 10 mg dexamethasone every 6 hours depending on their size) for 3 days, and then tapered over 7-10 days. Skin sutures are usually removed 7-10 days after surgery, and most patients are discharged at that time. Some patients may require inpatient rehabilitation and are usually transferred to an appropriate facility at that time.

Toronto. In 1939. whereas in older children. DORSALLY EXOPHYTIC BRAINSTEM TUMORS 161 . in writing about brainstem gliomas in 1975. brainstem tumors were diagnosed using air and contrast x-ray techniques. we encountered a small but distinct group of eight brainstem tumors that behaved in a significantly different fashion from the typical infiltrating brainstem glioma. Poole reported three cases of confirmed astrocytoma in the brainstem. Bailey et al described the treatment of brainstem gliomas as “a pessimistic chapter” in the history of neurosurgery. Magnetic resonance images (MRIs) and operative photographs are used in describing these tumors. these patients survived for long periods. F. including papilledema. In 1967.BRAINSTEM GLIOMAS HAROLD J. no progress had been achieved in this field. of these. Although these studies gave a very poor view of the brainstem. These patients were treated by uncapping the cyst. Traditionally. Lassiter et al described five patients with brainstem masses that were largely cystic and contained mural nodules.C. 20% are focal in the brainstem. Russell and Rubinstein stated that 77% of brainstem gliomas occur in patients less than 20 years of age. seven survived for 10 to 25 years after an operation that comprised either partial removal or biopsy and decompression. biopsy of the nodule. are frequently present. In 1968.R. These four types of brainstem gliomas are discussed below. In 1971. A long history of symptoms can usually be elicited. Olivecrona described 26 patients with tumors of the medulla. Poole ascribed this long-term survival to treatment including radiotherapy. Before the advent of modern neuroimaging. and postoperative radiotherapy. 50% are diffuse intrinsic tumors that start in the pons and spread throughout the brainstem. in which the lesions were intrinsically solid and cystic. © 1999 The American Association of Neurological Surgeons In 1980 at The Hospital For Sick Children. A review of brainstem gliomas has indicated that 20% are dorsally exophytic into the fourth ventricle. Brainstem gliomas are a relatively common tumor in children. symptoms frequently began early in childhood and sometimes during infancy. M. stated that during the previous 30 years. and 10% are located in the craniocervical junction. HOFFMAN. and in my own institution 29% of posterior fossa tumors were located in the brainstem. signs of raised intracranial pressure. Matson stated that 18. Koos and Miller found that 13% of the posterior fossa tumors they encountered were in the brainstem. they allowed neurosurgeons to recognize tumors in the brainstem and to operate on them. there were long-term survivors among these patients..D. In infants.(C) Brainstem gliomas have long been regarded as inoperable tumors. In these patients.7% of posterior fossa tumors were in the brainstem. Again. the history tends to be one of intractable vomiting and failure to thrive. No mention was made on whether these patients received radiotherapy. Vil- INTRODUCTION lani.S. all tumors involving the brainstem were considered infiltrative with diffuse gliomatous proliferation.

at autopsy. gangliogliomas. the brain- stem typically returns to a normal size. Adjunctive therapy. At autopsy. Dorsally exophytic brainstem tumors protrude into and largely fill the fourth ventricle (Figures 1 and 2). For a brief period the child responds positively. the vast majority of these tumors are solid and not cystic. In numerous instances. more rarely. despite aggressive therapy. DIFFUSE INTRINSIC ASTROCYTOMAS OF THE BRAINSTEM Intrinsic astrocytomas of the brainstem start in the pons and spread up into the midbrain and down into the medulla. Subtotal surgical excision has been extremely successful (Figure 3). Furthermore.162 NEUROSURGICAL OPERATIVE ATLAS. They mushroom down over the dorsal surface of the cervical spinal cord and typically enhance brightly with the administration of a contrast agent. including radiotherapy and chemotherapy. If the patient is treated with radiotherapy. . No treatment has been shown to be successful in enhancing the length of survival in children with this type of tumor. Patients with these diffuse intrinsic tumors rarely survive for more than 2 years. Initially. with nodular excrescences extending from the brainstem (Figure 4). the tumor shows no enhancement and enlarges the brainstem. Sagittal T1-weighted MRI showing a dorsally exophytic tumor. these tumors are revealed to be either malignant astrocytomas or glioblastoma multiforme (Figure 5). VOL. they typically present with cranial nerve palsies and long-tract signs. provides short-term relief for these patients. These tumors are typically low-grade astrocytomas or. but eventually the tumor returns and survival for more than 2 years is rare. Furthermore. 8 Figure 1. extensive leptomeningeal metastases are frequently present (Figure 6). surgeons have operated on these tumors with no effective long-term results. until MRI reveals the tumor to be enhancing.

operative view following resection of tumor. operative view of a dorsally exophytic astrocytoma. B.HOFFMAN : BRAINSTEM GLIOMAS 163 Figure 2. A. Operative view of a large dorsally exophytic tumor. . A B Figure 3.

Leptomeningeal metastases seen in a diffuse tumor in the pons. VOL. Figure 5. 8 Figure 4. . Sagittal T1-weighted MRI showing a diffuse tumor of the pons extending up into the midbrain and down into the medulla with nodular excrescences. Postmortem view of a diffuse tumor in the pons. Figure 6.164 NEUROSURGICAL OPERATIVE ATLAS.

A B Figure 7. In my experience. There is no need to resect these small indolent tectal gliomas. although they have been known to occur in the medulla. Focal tumors in the medulla are approached via an incision in the midline. producing hydrocephalus. if they bulge out laterally. they are approached usually via a midline incision in the floor of the fourth ventricle (Figure 13). . Focal tumors in the pons are rare. whereas 40% require adjunctive therapy because of recurrence. section the tentorium. which can then be debulked using an ultrasonic aspirator or a contact laser. They usually involve a portion of the tegmentum of the midbrain (Figures 7 to 10). A. They are most commonly located in the midbrain. However.HOFFMAN : BRAINSTEM GLIOMAS 165 FOCAL INTRINSIC BRAINSTEM ASTROCYTOMAS Focal intrinsic gliomas make up about 20% of brainstem gliomas. Small tectal tumors can be very indolent and typically close off the aqueduct. a horizontal incision is then made in the midbrain exposing the tumor. and then expose the side of the midbrain. it is important for the patient to maintain postoperative ventilation in the intensive care unit until it can be ascertained that breathing is effective and there is no evidence of CO2 retention. After resection. T1weighted MRIs of the patient at 8 years old. no additional therapy is necessary in 60% of patients. in rare instances. they can be approached from the external surface of the medulla (Figure 14). B. they can give rise to cranial nerve palsies and to long-tract signs. These tumors must be explored and debulked (Figure 11). one can resect a very large tectal glioma that mimics a pineal tumor. Frameless stereotaxis is essential in removing focal tumors of the brainstem (Figure 12). Focal tumors can occur in any location within the brainstem. computed tomography scans in an 8-month-old infant showing an enhancing tumor of the midbrain extending into the thalamus. I have found that one can elevate the temporal lobe. Depending on the location. In patients in whom resection is undertaken in the medulla. Six years later. hemiparesis has disappeared and there is very little tumor. they are located in the pons itself. They can be solid or cystic. Hydrocephalus can be treated with a third ventriculostomy or a ventriculoperitoneal shunt.

some enhancing tumor is still seen. 2. 3 months following resection of the tumor. axial T-1 weighted MRIs showing large enhancing tumor of the midbrain. . VOL. A.166 NEUROSURGICAL OPERATIVE ATLAS. B. C.5 years later. no residual tumor is seen. 8 A B C Figure 8.

frameless stereotaxy is used in removing the tumor. A and B. C.HOFFMAN : BRAINSTEM GLIOMAS 167 Figure 9. . little tumor remains. MRIs showing focal tumor filling the left midbrain. following resection. MRIs showing focal tumor in the midbrain with a cystic component in the fourth ventricle. A. operative view of the tumor. A B C A C B Figure 10. C. B.

T1-weighted MRIs showing a large tectal tumor. C. operative view showing the left colliculus filled with tumor. B. Frameless stereotaxy is used in resecting a focal tumor. 8 A C B Figure 11.168 NEUROSURGICAL OPERATIVE ATLAS. VOL. operative view after resection of the tumor. . A. Figure 12.

and craniocervical tumors are usually benign and surgical debulking is beneficial. Craniocervical brainstem gliomas arise in the upper cervical cord and extend into the medulla (Figures 15 to 17). CONCLUSION Figure 15. In patients with large tectal gliomas that can mimic a pineal tumor. Figure 14. Some of these tumors undergo involution. In patients with small tectal gliomas. CRANIOCERVICAL BRAINSTEM ASTROCYTOMAS Diffuse intrinsic brainstem tumors are malignant and patients do not benefit from surgical intervention. Laminotomy is a useful procedure if the tumor extends down into the spinal cord. focal intrinsic tumors.HOFFMAN : BRAINSTEM GLIOMAS 169 Figure 13. . These patients typically present with long-tract signs and may have lower cranial nerve signs as well. Resection is carried out rostrally to the level of the medulla. and the tumor is debulked using an ultrasonic aspirator. A midline laminotomy is made. only control of the hydrocephalus and observation are needed. MRIs showing a large enhancing tumor extending from the cervical cord and into the medulla. The use of motor and sensory evoked potentials is essential. Dorsally exophytic tumors. T1-weighted enhanced MRIs showing a focal tumor in the medulla with a cyst. and no adjuvant therapy is needed. where resection becomes more conservative. Axial T1-weighted MRIs showing a focal tumor in the pons. the glioma should be explored and resected.

8 Figure 16. B. MRI of a craniocervical tumor—the patient underwent biopsy and radiation at another institution. following resection and fusion of the spine. operative view of tumor extending into fourth ventricle. C .170 NEUROSURGICAL OPERATIVE ATLAS. C. Operative view of a craniocervical tumor. A B Figure 17. A. the child responded to treatment. VOL.

or the frontal lobe. The use of this approach avoids a transcortical incision.D. © 1999 The American Association of Neurological Surgeons The contralateral transcallosal approach can be used to expose several different types of lesions located laterally in or adjacent to the lateral ventricle. arteriovenous malformations (AVMs). the patient is supine. T raditional approaches to such lesions are transcortical. These lesions reach an ependymal surface laterally in the ventricular system. gravity retracts the hemisphere to open the interhemispheric fissure. Typically. lesions located in the dominant hemisphere can be resected without an interhemispheric dissection on that side. can be exposed via the contralateral transcallosal approach. AVMs located in the corpus callosum. LAWTON. such AVMs are fed by the pericallosal and choroidal arteries. INTRODUCTION We performed our first contralateral transcallosal approach in 1983 and recently published our results with 32 patients. in addition. the risks of sinus injury. including gliomas.THE CONTRALATERAL TRANSCALLOSAL APPROACH TO LESIONS IN OR ADJACENT TO THE LATERAL VENTRICLE MICHAEL T. and air embolism are increased. through the superior or middle temporal gyrus. choroid plexus/lateral ventricle. anteromedial thalamus. In older patients with more adherent dura. sinus occlusion. The contralateral transcallosal approach has many advantages compared to other routes. and posterior thalamus are well suited to this approach. The transcallosal approach is usually performed via an ipsilateral route with the patient supine and the midline of the head vertically oriented. Cavernous malformations located in the caudate nucleus.D. tumors in similar locations. Dissection proceeds through the ipsilateral interhemispheric fissure and the ipsilateral ventricle to reach the lesion. Finally. PATIENT SELECTION 171 . ROBERT F. Patient age can be a contraindication to this approach because the craniotomy flap crosses the superior sagittal sinus. and the nidus extends laterally. including cavernous malformations. Likewise. significant blood loss. The authors prefer a contralateral transcallosal approach. Lesions located laterally in or adjacent to the lateral ventricle can be difficult to surgically expose. and tumors. A more lateral angle of approach increases the surgical exposure and minimizes retraction of the medial hemisphere. The technique is safe and effective and warrants consideration for appropriate lesions. lateral ventricular wall. and dissection proceeds through the contralateral interhemispheric fissure and ipsilateral ventricle to reach the lesion. and thalamus are also well suited to this approach. and some craniopharyngiomas. choroid plexus papillomas. the midline of the head is oriented horizontally with the lesion on the upside. SPETZLER. intraventricular meningiomas. central neurocytomas. M. In this approach. the superior parietal lobule. M.

SURGICAL TECHNIQUE The dura is opened contralateral to the lesion with a C-shaped flap based along the superior sagittal sinus. The pericallosal arteries are separated. working between the veins bridging to the superior sagittal sinus. and a craniotomy is made with two thirds of the bone flap anterior and one third posterior to the coronal suture. the ventricles are extensively irrigated and filled with saline. A fishhook retraction system. If a dural breach is detected. 8 A B Figure 1. The head is turned to the right. A retractor is placed along the inferior free edge of the falx to expose the pericallosal arteries and corpus callosum. normal ventricular anatomy is identified (including the choroid plexus. This technique is particularly important in elderly patients with adherent or thin dura. helps to increase the anteroinferior exposure of the bone flap. with the first piece entirely over the down hemisphere and the second piece crossing the sinus to complete the craniotomy. The coronal suture is identified. the left shoulder is bolster ed. If not in- . The head is placed in a Mayfield headholder and turned so that the hemisphere contralateral to the lesion is down. the lesion is up. to avoid stenosis or occlusion of the superior sagittal sinus which would thereby promote sinus thrombosis and venous infarction. Gravity allows the contralateral (down) hemisphere to separate from the falx. and septal vein) and the appropriate ventricle is confirmed (Figures 5 and 6). and the sagittal midline is parallel to the floor (Figure 2). Every effort is made to preserve these bridging veins. The arachnoid membrane deep to the free edge of the falx is opened to expose the pericallosal arteries and corpus callosum. and care is exerted not to incise the skin on the forehead. crossing the superior sagittal sinus twice to expose the other side. With two pieces. The superior falx should not be resected aggressively. with the hooks pulling inferiorly on this limb of the incision. Important bridging veins must be protected (Figure 4A). The dural flap is tented superiorly to open the interhemispheric fissure.172 NEUROSURGICAL OPERATIVE ATLAS. which is then opened further by removing adhesions between the brain and falx. VOL. The lesion is then identified and treated. At the end of the procedure. Lateral (A) and superior (B) views of the patient positioned for a contralateral transcallosal approach to a left intraventricular lesion. the flap is taken in two pieces. The patient is placed in the supine position with bolsters under the shoulder ipsilateral to the lesion (Figure 1). The head is angled 45° upward (lateral neck flexion) to optimize the angle of view into the ventricle (Figure 3). thalamostriate vein. The incision site can be identified using an intraoperative navigational system or by retracting the ipsilateral pericallosal artery laterally and entering the ventricle beneath the artery’s normal location (Figure 4B). A Ushaped skin incision in the frontoparietal region creates a scalp flap that is based laterally on the contralateral side and crosses the midline to the other side. the dura and sagittal sinus can be carefully dissected off the inner table of skull after the first piece is removed under excellent visualization. and the corpus callosum is incised 2 cm to permit entry to the lateral ventricle ipsilateral to the lesion. Once inside the ventricle. Further exposure can be obtained by deepening the retractor so that its tip is in the ventricle retracting the corpus callosum. The anterior limb of the incision parallels the hairline. and the skin flap is based on the right. Great care must be exercised in crossing the sagittal sinus with the craniotome. eliminating the need for retraction. Its epidural position is established visually before the sinus is crossed by aiming a light into the cut of bone and irrigating enough to see intact dura.

the ipsilateral transcallosal approach (line A) requires retraction of the medial hemisphere to reach the lateral aspect of the lesion. and pulls the lesion into the surgeon’s view. Patient position and lesion location from the surgeon’s perspective. B. A. whereas the contralateral transcallosal approach (line B) requires no additional retraction. lesion in left lateral ventricle Figure 3.LAWTON AND SPETZLER : THE CONTRALATERAL TRANSCALLOSAL APPROACH TO LESIONS IN OR ADJACENT TO THE LATERAL VENTRICLE 173 A B Figure 2. gravity retracts the contralateral hemisphere. opens the interhemispheric fissure. .

the callosotomy is made beneath the pericallosal artery ipsilateral to the lesion in order to enter the appropriate ventricle. 8 A planned callosotomy dura falx superior sagittal sinus pericallosal arteries B falx midline corpus callosum section of corpus callosum pericallosal arteries midline corpus callosum (long striae) callosomarginal artery cingulate gyrus Figure 4. VOL. A. This bone work enables the dural flap to be tacked superiorly. The bone flap crosses the sagittal sinus twice to expose it completely. and the corpus callosum is in view at the depth of the exposure. permitting a view directly down the falx and the ability to open the interhemispheric fissure widely. B. . The fishhooks pull the scalp forward to increase exposure for the bone flap while keeping the incision off the forehead.174 NEUROSURGICAL OPERATIVE ATLAS. the interhemispheric dissection has been completed.

and the lesion is visualized. slit of lateral ventricle corpus callosum entire lateral ventricle visualized Figure 6. Deepening the tip of the retractor into the ventricle helps visualize the pathology better.LAWTON AND SPETZLER : THE CONTRALATERAL TRANSCALLOSAL APPROACH TO LESIONS IN OR ADJACENT TO THE LATERAL VENTRICLE 175 pericallosal artery corpus callosum cavernous malformation in caudate nucleus thalamostriate vein thalamus foramen of Monro septal vein septum pellucidum choroid plexus of the lateral ventricle fornix Figure 5. . The relationship between the lateral thalamostriate vein and the medial choroid plexus confirms entry into the appropriate ventricle. Sagittal view illustrating that all regions of the lateral ventricle are accessible via this exposure. depending upon the angle of approach. Note how gravity pulls the lesion down into the corridor of operative exposure.

the remaining 29 patients had left-sided lesions and were positioned with the right side down. and central neurocytomas) can also be accessed through this approach. a second-stage surgery was required. The corpus callosum may not be traversed. which also resolved completely. through the superior and middle temporal gyri and through the inferior (Van Wagenen) and superior parietal lobules). and Ehni. VOL. each associated with neurological sequelae. In four patients. Three patients had right-sided lesions.176 NEUROSURGICAL OPERATIVE ATLAS. including Long and Chou. He subsequently developed a Serratia ventriculitis. First. that most neurosurgeons use this approach rarely. 8 serted preoperatively. transcortical approaches traverse normal brain tissue. in the remainder. Only four patients required ventriculoperitoneal shunting. if at all.. Two other approaches for exposing ventricular lesions are the transcortical-transventricular approach and the transcallosal-transventricular approach. which can be particularly difficult to resect.. also have mentioned it. which may warrant more than occasional use. When not already present. patient outcome in terms of the Glasgow Outcome Scale score (GOS) was determined over a mean follow-up of 1. four had moderate disabilities (GOS 2). After resection of a left atrial meningioma. astrocytomas. one choroid plexus papilloma. The contralateral transcallosal approach is an excellent technique for dealing with laterally placed lesions in the lateral ventricles. including cavernous malformations. Two patients (6%) experienced permanent neurological morbidity. however. and two had severe disabilities (GOS 3). which resolved completely.6 years. More malignant tumors (e. however. benign tumors (two meningiomas. the posterior contralateral transcallosal approach was used. The contralateral transcallosal approach was used in lesions laterally in or adjacent to the lateral ventricle in 32 patients. Second. Fewer anatomical landmarks are present to guide the surgeon transcortically to the DISCUSSION . The modifications described here make this a safe and effective approach. and they were positioned with the left side down. but it has distinct disadvantages. thalamic AVMs may require treatment with stereotactic radiosurgery to the deep residual nidus. but the advantages of the contralateral approach apply as well to these lesions. cavernous malformations were resected completely in a single surgical stage. trapped ventricular horns. We are not the first to report the contralateral transcallosal approach. the falx was cut to increase exposure of the contralateral medial hemisphere. and one prolactinoma) were resected completely via the contralateral transcallosal approach. or obstruction of the foramen of Monro. In five patients. The transcortical approach is more direct with a short working distance to the lesion. With this approach.g. With the more superficial lesions. one patient developed a small thalamic infarction RESULTS with right-arm weakness. a ventriculostomy catheter is left in the ventricle at the end of the operation to clear residual blood that could obstruct the flow of cerebrospinal fluid. Twenty-six patients had a good recovery (GOS 1). Shucart and Stein. the craniotomy and interhemispheric approach are contralateral to the lesion and the transventricular approach is ipsilateral to the lesion. but their resection is typically subtotal. In six patients. Two (6%) of the 32 patients experienced transient neurological deficits. Other surgeons. transcortical approaches are more difficult to perform than the transcallosal approach. and tumors of all types. the falx often is cut inferiorly after the inferior sagittal sinus has been coagulated to enable a sharper angle across to the opposite side. Various trajectories through cortex have been described (e. There were no surgical deaths in this series. the foramen of Monro was enlarged by opening the choroidal fissure posteriorly to gain access to the third ventricle. with resultant right hemiparesis and expressive aphasia. a second patient developed left moderate hemiparesis. glioblastomas multiforme.g. AVMs. One patient with a central neurocytoma experienced postoperative intraventricular hemorrhage that required multiple ventriculostomies. At last examination. Choroidal and pericallosal AVMs can be resected completely via this approach. It seems. The other patient developed a venous infarction after resection of a left glioblastoma multiforme. After resection of a thalamic AVM. In one patient with a thalamic AVM. In four patients. increasing the risk of neurological deficits. and in two. The contralateral transcallosal approach is also used for lesions located laterally in the corpus callosum and the cingulate gyrus. The outcomes in this series demonstrate the utility of the contralateral transcallosal approach for treating a wide variety of lesions located laterally in or adjacent to the ventricle or in the interhemispheric fissure. AVMs were resected in a single stage. the standard anterior contralateral transcallosal approach was used. In two patients with left hypothalamic lesions. Machado de Almeida. ventricular catheters were inserted during the operation and left in place for several days. Ventriculostomy catheters were often indicated preoperatively due to hydrocephalus from intraventricular hemorrhage.

the lateral margin of the lesion can be reached only with excessive retraction. Because of this. Milhorat and Baldwin. The transcallosal approach does not traverse cortex but goes through the interhemispheric fissure and corpus callosum instead. a maneuver not easily accomplished through a more oblique transcortical approach. This horizontal position is easier on the surgeon’s hands. Finally. The exposure tends to be limited because of the inclination to minimize the extent of cortical incision. many studies have demonstrated that the transcallosal approach is well tolerated and produces no functional neurological deficits or postoperative seizures. The third ventricle can be exposed simply by enlarging the foramen of Monro. it is believed to be safer than the approach to a right-sided lesion from the left. The approach is particularly difficult when the ventricles are not dilated. Although added lateral exposure is gained regardless of the side of approach. This position also permits gravity to retract the downside hemisphere and open the interhemispheric fissure while the falx retracts the upside hemisphere. Illustrations reproduced with permission from Barrow Neurological Institute. The horizontal position necessitates a decision regarding laterality. The surgeon can use an instrument in each hand without obscuring the operative field. Most importantly. the approach to a left-sided lesion from the right spares the dominant hemisphere from retraction injury and the potential sacrifice of bridging veins. the contralateral transcallosal approach from the left can be used judiciously when the need for more lateral exposure offsets the additional risks of a left interhemispheric dissection. Increasingly.e. This problem. In addition to opening the interhemispheric fissure to facilitate the approach. This position works well for lesions located near the midline. and others to develop the transcallosal approach. exposure of laterally placed lesions in or adjacent to the lateral ventricle requires significant retraction of the hemisphere and risks injury to the parafalcine and cingulate gyri. However. Without this angle of approach.. Shucart and Stein. The contralateral transcallosal approach is ideal for left-sided lesions. This route has identifiable anatomical landmarks to guide the surgeon to the ventricle and enlarged ventricles are not a necessity. . In most cases. the head is positioned with the lesion side down (i. the advantages of this position are being recognized. Thus. right-sided lesions are approached with the right side down and left-sided lesions with the left side down). The contralateral transcallosal approach offers a better angle of approach that increases lateral exposure of the lesion and minimizes the retraction required on the medial hemisphere. has been mitigated by the advent of intraoperative navigational systems.LAWTON AND SPETZLER : THE CONTRALATERAL TRANSCALLOSAL APPROACH TO LESIONS IN OR ADJACENT TO THE LATERAL VENTRICLE 177 ventricle. gravity pulls the upside lesion medially into the surgeon’s view. however. We prefer to rotate the neck laterally to orient the midline horizontally. allowing the hands to work in the same plane rather than on top of each other. The limitations of the transcortical approach led Dandy. the transcortical approach can cause postoperative seizures. Most neurosurgeons position their patients supine or sitting with the head and neck in the neutral position and the sagittal midline oriented vertically.

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an inhalation anesthetic is ad- PREOPERATIVE EVALUATION AND PREPARATION 179 . and blood type and crossmatch. LARSON. however. Preoperative evaluation should include complete blood cell count. In patients with medical conditions that preclude surgery (e. KERRY R. the patient is intubated. M. Contraindications to this treatment include the presence of any intradural pathology that requires dural opening. M. as well as plugging of the obex to prevent syrinx expansion. Sagittal and axial T2-weighted images are important to visualize the CSF spaces ventral and dorsal to the cervicomedullary junction. Our treatment for patients with Chiari I malformation is based on the theory that posterior fossa decompression without duraplasty is adequate if CSF flow can be established. INTRODUCTION Children with Chiari I malformation are candidates for posterior fossa decompression. this procedure would be contraindicated until treatment is initiated. with or without cervical laminectomy. bleeding disorders or cardiac anomalies). Prior to being placed on the operating table.D. combined with duraplasty. Modifications of this treatment include fourth-ventricle-to-subarachnoid shunting to maintain free egress of cerebrospinal fluid (CSF). The treatment of patients with Chiari I malformation traditionally consists of posterior fossa decompression.. especially in patients with signs and symptoms suggestive of a syrinx.D. coagulation studies. electrolyte profile.D. We have adopted the use of intraoperative ultrasound to evaluate decompression of the foramen magnum and the need for duraplasty in children with Chiari I malformation. JEFFREY J. such as arachnoid scarring or sequestrations. CRONE. PATIENT SELECTION © 1999 The American Association of Neurological Surgeons Magnetic resonance imaging (MRI) of the craniocervical junction is obtained preoperatively to determine the extent of the Chiari I malformation. MRI of the spine is helpful to demonstrate the presence and extent of a syrinx.g. Ultrasound may be performed in such patients. M. intradural exploration is still required.POSTERIOR FOSSA DECOMPRESSION WITHOUT DURAL OPENING FOR THE TREATMENT OF CHIARI I MALFORMATION JONATHAN SHERMAN. However. Posterior fossa decompression has been developed to relieve impaction created by tonsillar herniation and to cause regression of symptoms. it is unclear whether the syrinx is in direct communication with the subarachnoid space.

9% NaCl. The surgeon stands at the patient’s left side. The shoulders are pulled down to expose the suboccipital region and the posterior cervical spine from C1 to C6. A 7-MHz transducer (actual head size 1. ministered. The assistant and the scrub nurse are on the patient’s right side. allowing the surgeon a clear view of the image while ultrasonography is performed. Prior to patient positioning. The head is placed on a Mayfield headrest or in three-point fixation. The ultrasound equipment is behind the assistant. cardiac monitor leads. 8 video monitor instrument table electrocautery assistant scrub nurse surgeon anesthesiologist video monitor x-ray view boxes Figure 1. which has been irrigated with 0. Superior view of the operating room layout during posterior fossa decompression. Sagittal and axial imaging of the cervicomedullary junction is obtained intraoperatively to evaluate the ade- In the surgical suite (Figure 1) the patient is positioned prone. intravenous access. and intravenous antibiotics are completely infused.2 × 2. VOL. quacy of decompression.2 cm) is introduced into the surgical bed. pulse oximetry. SPECIAL EQUIPMENT In addition to the standard surgical instrumentation needed for posterior fossa decompression. with the neck slightly flexed. intraoperative ultrasound equipment is necessary. SURGICAL SET-UP .180 NEUROSURGICAL OPERATIVE ATLAS. while the patient is prone. and an arterial line or a blood pressure cuff are placed.

Bone rongeurs are used to expose the posterior fossa and spinal dura. which is frequently found overlying the fourth ventricle and foramen of Magendie. less than 2 mm between the tonsils and dura (Figure 3B)) or if there is “pistoning. the surgeon thins the suboccipital bone. above the level of the foramen magnum to avoid opening the occipital sinus. In one patient. as well as to determine the long-term outcomes in patients in whom decompression is performed with and without dural opening. interrupted 3-0 Vicryl sutures. Movement of the tonsils is also assessed.e. Activity is increased progressively. This dural band. If the CSF spaces are small (i. which is carried laterally to the occipital condyles. must be incised to achieve decompression (Figure 2B). Ultrasound images are obtained to reveal the level of tonsillar herniation. An incision is made in the dura from the top of the bony decompression to the bottom. Intradural exploration and coagulation of the cerebellar tonsils elevate the tonsils above the level of the foramen magnum. intractable posterior headaches. The paraspinous musculature is reapproximated using widely spaced.” then duraplasty is performed using a graft of periosteum or dural substitute (Figure 3C). CONCLUSIONS . which consists of thickened dura and periosteum of the bony foramen magnum. pulsatile rostral-caudal movement of the tonsils with little anterior–posterior pulsation (Figure 3A)) is absent.SHERMAN ET AL : POSTERIOR FOSSA DECOMPRESSION WITHOUT DURAL OPENING FOR THE TREATMENT OF CHIARI I MALFORMATION 181 A midline skin incision is made from the inion to the level of C3. meningitis. Further studies are needed to assess the amount of CSF necessary for adequate decompression. After presenting with recurrent. as described. Avoiding duraplasty has decreased the incidence of postoperative complications. Using a high-speed drill. The band is divided with a #15-blade scalpel. The patient is discharged when dietary intake is adequate and he or she is ambulating well. An upper cervical laminectomy is performed to accommodate the extent of the descended cerebellar tonsils. the patient underwent duraplasty. After completing the bony decompression of the suboccipital and cervical canal. interrupted 3-0 Vicryl sutures. The dural opening is made lateral to the midline on one side. simple. The thickened band is then peeled away from the dura using forceps (Figure 2C). We have subsequently discontinued the practice of dural thinning and release the fibrous band only at the level of the foramen magnum. provides lateral decompression of the cervicomedullary junction. POSTOPERATIVE CARE Approximately 6 weeks after the operation. a portion of the cerebellar tonsil herniated through a small hole that occurred in the dura during dural thinning. a decrease in the size of the syrinx can be observed by 4 to 6 months postoperatively. repeat MRI at the appropriate spinal level is per formed to monitor the size. After adequate decompression is obtained. and arachnoiditis can be prevented when duraplasty is avoided. This caused infarction of the herniated portion of tonsil. but may also prove effective in adults. Release of an arachnoid membrane. To allow sufficient space inside the dura for adequate decompression. Frequently encountered complications such as CSF leakage. that foramen magnum obstruction by further tonsillar descent does not occur and to verify OPERATIVE PROCEDURE that no holes or defects were created in the dura. a graft is sewn in place using 5-0 Prolene sutures. Her symptoms resolved following this second procedure. The overlying cervical fascia is tightly closed. Bony decompression. Intraoperative ultrasound is a useful adjunct to evaluate adequate decompression by assessing the amount of CSF around the descended tonsils in the obstructed foramen magnum. We have used cine-MRI to assess CSF flow.e. The paraspinous fascia is dissected at the avascular linea albae and is retracted laterally to expose the occiput and the upper cervical laminae. the surgeon identifies a transverse dural band at the level of the cervicomedullary junction. The use of this procedure without duraplasty has been limited to the pediatric population. running a simple suture to obtain a watertight closure. Follow-up Care Most postoperative complications in posterior fossa decompression are a result of duraplasty. Complications We have found that posterior fossa decompression without duraplasty can adequately treat patients with Chiari I malformation. Sufficient decompression has been achieved if CSF can be identified dorsal to the tonsils and cervicomedullary junction by ultrasound on sagittal and axial views and if tonsillar “pistoning” (i. being careful that the underlying dura is not incised. The patient remains in a high-acuity care setting for 24 hours following surgery. a Valsalva maneuver is performed to ensure. In our experience. using simple. Ultrasonography is used to determine whether there is adequate CSF dorsal to the cervicomedullary junction and tonsils. The skin is closed in the usual fashion. MRI is performed to evaluate the CSF space around the tonsils and cervicomedullary junction.. Laminectomy is carried to the lateral aspect of the canal (Figure 2A). If the patient has an associated syrinx. hemorrhage. via ultrasonography.. is also performed.

thus providing further decompression of the foramen magnum. C. a right-angle dissector is inserted between the fibrous band and the dura. the posterior fossa and spinal dura are exposed following a suboccipital craniectomy and C1 laminectomy. B. Note the thickened transverse fibrous band at the level of the foramen magnum. 8 transverse sinus occipital sinus thickened transverse band B vertebral artery C1 laminectomy bulging tonsil C marginal sinus Figure 2. still compressing the dura and underlying tonsils and brainstem. VOL. the fibrous band is peeled from the dura after incision.182 A NEUROSURGICAL OPERATIVE ATLAS. A. . The fibrous band is then incised to prevent cutting the dura or marginal sinus.

Note the 2 mm of CSF space between the cerebellar tonsils and the dura posteriorly. A. in cases in which adequate decompression cannot be obtained without dural opening. Loss of this pistoning movement. ultrasonic image demonstrating adequate decompression of the foramen magnum. tonsil C . illustration of tonsillar pistoning (arrow) or the rostral-caudal movement of the tonsils that occurs in Chiari malformation during systole–diastole pulsations. combined with adequate CSF space between the tonsils and the dura. placement of a dural graft.SHERMAN ET AL : POSTERIOR FOSSA DECOMPRESSION WITHOUT DURAL OPENING FOR THE TREATMENT OF CHIARI I MALFORMATION 2 mm CSF space 183 B A confluence tonsillar pistoning diastole systole C2 fourth ventricle foramen of Magendie dural graft Figure 3. indicates sufficient decompression of the foramen magnum. and duraplasty are used to widen the foramen magnum. C. a midline dural incision. B.

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COMPUTED TOMOGRAPHY-ASSISTED PREFORMED PROSTHESIS FOR REPAIR OF CRANIAL DEFECTS MANUEL DUJOVNY. diagnostic and three-dimensional (3D) reconstruction computed tomography (CT) 3. RAYMOND EVENHOUSE. Trauma. SADLER. M.D. tumors. skull x-ray 2. INTRODUCTION Table 1 Causes of Cranial Defects Trauma Motor vehicle accidents Occupational accidents Urban violence Sports injuries War Neoplasia Meningioma involving the bone Eosinophilic granuloma Posterior fossa tumors Bone metastasis Infection Osteomyelitis Fungi Tuberculosis Miscellaneous Aneurysms Subdural hematoma Cranial decompression Cranial nerve neuralgias DIAGNOSTIC STUDIES 1. transcranial cerebral oximetry (TCCO) with orthostatic challenge (Figure 2A and B) 5.S. Table 1 lists common causes of bone defects. M. Many authors suggest that cranioplasty may have a therapeutic effect that broadens previous indications for the procedure. neuropsychiatric evaluation (exit interview and Cognistat) © 1999 The American Association of Neurological Surgeons 185 .D. electroencephalography (EEG) 6. diagnostic and phase-contrast magnetic resonance imaging (MRI) 4.D. and compression caused by brain edema are some of the reasons for removal of cranial bone (Figure 1).D. xenon-enhanced CT cerebral blood flow (CBF) (Figure 2C and D) 7. FADY T. PH. DEIRDRE MCCONATHY. M.S. infections. CELSO AGNER. LEWIS L. M. CHARBEL. B. Cranioplasty is among the oldest neurosurgical procedures.

A. precranioplasty 3D reconstruction of the skull in a patient with a large cranial defect secondary to trauma. C. VOL.186 NEUROSURGICAL OPERATIVE ATLAS. precranioplasty 3D reconstruction of the skull in a patient with a large convexity meningioma. D. 8 A B C D E F Figure 1. B. E. postcranioplasty 3D CT reconstruction in the same patient. F. precranioplasty 3D CT reconstruction of the same patient. postcranioplasty 3D reconstruction of the skull in the same patient. . Causes of cranial defects. precranioplasty plain CT in a patient with frontal sinusitis.

D. postcranioplasty TCCO with orthostatic challenge. Diagnostic tests in cranioplasty. showing generalized improvement of CBF after the surgical procedure.DUJOVNY ET AL : CT-ASSISTED PREFORMED PROSTHESIS FOR REPAIR OF CRANIAL DEFECTS 187 B C D Figure 2. postcranioplasty anatomical and quantitative Xe-CT CBF of the same patient. showing return to precranioplasty values in the same patient. . A. precranioplasty TCCO with orthostatic challenge. C. precranioplasty anatomical and quantitative Xenon-enhanced CT CBF study of a patient with a large cranial defect. B.

CA). 8 Table 2 Characteristics of a Good Cranioplasty • • • • • • • • structural integrity infection-resistant properties stability over time ease of fabrication precise fit minimal inflammation and graft-host reaction radioneutral for visualization material properties Table 3 Characteristics of a Good Implant Material • biocompatible • high-impact strength • Food and Drug Administration-approved and readily available • nonbiodegradable • non-exothermic during surgery • no toxic fumes and/or residues • MRI compatible The fabrication and surgical fitting of cranial implants by traditional methods is dependent on subjective skills and procedures. data processing. In the medical field. Table 4 lists the characteristics of implant materials used in stereolithography vs. The process involves the following steps: data acquisition (image acquisition. The first primitive demonstration of the technology was in 1984. VOL. Table 4 Comparison Between Intraoperative Molding and Stereolithography of Methylmethacrylate Intraoperative Molding Exothermic reaction Fume production Tissue reaction Graft-host reaction Operating time Hospital stay severe severe severe severe long long Stereolithography none none mild mild short short . and model building). SURGICAL RECONSTRUCTION Rapid prototyping is a term for several manufacturing processes that permit the creation of solid. implant fabrication. it was first applied for maxillofacial prosthetics in the late 1980s and was later used to design cranial implants in the middle 1990s. Several authors have claimed to be the first to adopt the technology for cranioplasty. producing in most cases a close but imperfect fit that necessitates revisions during the surgical placement of the implant. Results from our experience using computer-aided design and computer-aided manufacturing (CAD/ CAM) technology indicate that presurgical design and the fabrication of cranial implants using CT data from the patient results in a “near perfect” fit. Tables 2 and 3 list characteristics of a good cranioplasty and of a good implant material. Since its development. Stereolithography but its full development was not realized until a few years later. physical objects directly from a digital file or computer data. stereolithography has been applied to a wide range of objects. Stereolithography was first applied commercially in the automobile industry by Chrysler Motors in 1989. The specific rapid prototyping technology used in our procedure is stereolithography technology from 3D Systems (Valencia. A procedure for generating CAD/CAM files to manufacture cranial implants to repair intermediate and large-sized skull defects was developed in 1996 by the Department of Neurosurgery and researchers in the Biomedical Visualization Laboratory. those used in intraoperative molding. from archaeology and environmental science to physical and paleoanthropology.188 NEUROSURGICAL OPERATIVE ATLAS. School of Biomedical and Health Information Sciences at the University of Illinois at Chicago in collaboration with commercial design and rapid prototyping products. and implantation.

the second half of the mold can be made.DUJOVNY ET AL : CT-ASSISTED PREFORMED PROSTHESIS FOR REPAIR OF CRANIAL DEFECTS 189 IMPLANT DESIGN AND FABRICATION Data Acquisition Image Acquisition A 1-mm slice thickness CT scan is generated using a General Electric high-speed advantage CT scanner (GE Medical Systems. as necessary. The final model is an exact physical representation of the computer model of the patient’s skull and defect (Figure 3E). drained of excess polymer. are mathematical curves explicitly defining geometry. The vector maps are then connected to generate a surface model of the skull. After trimming and polishing. according to this sequence. a bed or platform in the vat of polymer to which the model is attached is lowered. The material is placed into the mold and clamped tightly (Figure 4D). MI). Ann Arbor. Following a prescribed cure time. To create an appr opriate output file for use in rapid prototyping. the clamps are removed and the solid methylmethacrylate implant is taken from the mold (Figure 4E). Initial Steps Modeling clay is applied to the plastic model of the patient’s defect. Dallas. flooding the surface of the developing model. The clamped mold is placed in a hot-water bath to slow cure. CA). TX or Materialise. The liquid polymer is converted to a solid by the energy of the laser beam. Milwaukee. Additional curing in an oven releases free monomers trapped in the implant. The physical model generated through stereolithography (Figure 4A) serves as a template for the manufacture of the final implant. the software positions the surface model in the optimal orientation for the “build cycle” in the machine and resamples the data into appropriate slice thicknesses for stereolithography. The image data protocol allows the data to be taken directly into software on the workstation for slice and volumetric viewing to verify the integrity of the database. Data Processing To construct a file suitable for driving the rapid prototyping (stereolithography) device. Casting the Implant The mold halves are separated and the wax is removed. several processing steps must be completed. WI) and imaged on the viewing console (Figure 3A-D). Inc. It is smoothed and contoured to represent the inner surface of the prosthesis/neurotissue boundary. where the tool path information is used to drive a computer-guided laser positioned over a vat of polymer. The pixel-to-vector map conversion establishes the geometry of each skull outline curve from the CT slice. Inc. The “resliced” data now represent a tool path to guide the stereolithography machine in creating the model. or transferred through the university’s data network to a graphics workstation (Silicon Graphics. Care is exercised in maintaining appropriate contour and thickness to assure the best cosmetic appearance following implantation of the custom prosthesis. Dental stone is poured into the Silastic mold to produce a solid base upon which the prosthesis is designed. Implant Fabrication . “Keys” are placed in the back piece of the mold so that the final two pieces can be perfectly realigned.. The edges of the inner and outer tables of cranium are identified and their contours converted from a pixel map representation to a vector map. Vector maps. slice-by-slice. the finished implant is sent to the operating suite for ethylene oxide gas sterilization. but each slice is manually checked and corrected. As each slice from the CAD file is traced by the laser beam. a solid plastic form is gradually created in the photocurable polymer.. The data are transferred to DAT or magnetic tape.. Model Building The computer file is imported into the stereolithography machine. Pixels and their volumetric equivalent “voxels” are image representations only and do not explicitly establish the geometry of the objects they represent. Pixel data from the CT slices must undergo segmentation to extract the skull information from the rest of the slice image data. leaving a negative space to receive the final implant material. A separator is applied to all exposed surfaces so that the two halves of the final mold will not bond together. pliable lump the consistency of warm butter. Inc. A medical-grade methylmethacrylate is mixed to form a soft. The Mold When the wax model is completed. Design of the Implant A dental grade wax is applied to the negative space representing the skull defect. The polymerization by the laser beam is repeated. Semiautomatic segmentation algorithms in the software initiate the segmentation scheme. The data can then be stored for later processing or imported directly into CAD/CAM software (Surgicad. using a drawing tool. A silicone rubber mold is made of this aggregated piece (Figure 4B). The finished model is removed from the vat. on the other hand. In this way.” only the portion of the skull immediately surrounding the defect is manufactured. Dental stone is poured onto the surface to an appropriate thickness and allowed to set until thoroughly hardened (Figure 4C). To save time and the cost of additional material and “buildtime. Mountain View. and submitted to a final curing stage using ultraviolet radiation.

D.190 NEUROSURGICAL OPERATIVE ATLAS. plain skull CT slice. A. final cranial prosthesis. computer-generated 3D model of the bone defect. B. E . precranioplasty 3D bone reconstruction. E. precranioplasty 3D soft tissue reconstruction. 8 A B D C Figure 3. C. VOL. Steps for using stereolithography in cranioplasty.

. stereolithographic model of the cranial defect.DUJOVNY ET AL : CT-ASSISTED PREFORMED PROSTHESIS FOR REPAIR OF CRANIAL DEFECTS 191 A B C D Figure 4. wax pattern or stone positive. A. C. D. positive clay model. B. mold in clamp. Steps in the prosthesis fabrication.

The implant is fixed in place and screwed with a minimum of three to four titanium plates and screws to effect immobilization of the prosthesis and restitution of the calvarium (Figure 5G).192 Implantation NEUROSURGICAL OPERATIVE ATLAS. B. or lateral position (Figure 5C). a spinal drain may be introduced to control increased postoperative intracranial pressure. and the incision made. as evidenced by EEG. and the patient is paralyzed with pancuronium. and mean arterial pressure are generally monitored intraoperatively. the skin incision replicates that used in the previous surgery. The flap is undermined and the dural attachments are released (Figure 5D and E). F. Seizure control. lateral view of the cranial defect. postoperative posterior view. if needed. the patient is draped in the standard fashion dictated by the cranial defect. D. C. Ventilatory control is established. Figure 5. Patient Postioning and Draping Positioning is predicated on the location of the bone defect. Electrocardiography. Operative Procedure The incision site is infiltrated with 1% lidocaine and epinephrine. Holes are drilled in the surrounding bone and implant with a Midas Rex high-power drill (Midas Rex. the patient is positioned in the appropriate supine. and normal preoperative psychiatric status need to be established in order to avoid major complications postoperatively. 8 Patient Selection Any patient with a large cranial defect (≥9 sq cm) or who has a cranial defect with a complex shape is a candidate for implantation (Figure 5A and B). graft rejection. General anesthesia is administered with isoflurane after intubation with an endotracheal tube. and Foley catheter placement. allergic reaction to the implant material. Infection of the surgical site. VOL. Accordingly. postoperative lateral view. gallium single photon emission CT (SPECT) is performed and an appropriate antimicrobial chemotherapy initiated. posterior view of the cranial defect. MA). and the skin is closed using staples (Figure 5H and I). If necessary. The implant is removed from the bacitracin bath in which it was preserved following the ethylene oxide sterilization (Figure 5F). arterial and venous lines. The decision to perform a cranioplasty may be influenced by tests for seizure control. G. After shaving and cleansing the surgical site. Contraindications Contraindictions of cranioplasty include infection of the skin or bone. Anesthesia and Monitoring Induction is performed with mesethlin and thiopental. and no clinical evidence of seizures. detail of the screwed titanium plates. are used for hemostasis. . prone. The surgical site is irrigated with bacitracin. arterial blood gases. Fort Worth. Dissection continues until the edges of the skull defect are visualized. Inc. opening of the skin and dissection of the musculocutaneous flap. or patients in poor clinical condition who may not withstand anesthesia and surgery well. Randolph. thin skin with compromised blood supply after radiotherapy. body temperature. hematoma formation. The subcutaneous/galea incision is closed with 0-0 interrupted inverted Dexon. the incision is closed in two layers. A. I. plasma drug levels. Preoperative Preparation In cases where there is concern about an active infection of the bone. liberation of adhesions. Cranioplasty as a secondary procedure is per formed only after r esolution of the basic pathological processes that led to its avoidance as a primary procedure. E. patients presenting with “sinking scalp” syndrome or the “syndrome of the trephined” may benefit from cranioplasty. pulse oximetry. Additionally. missing skin. After careful hemostasis of the periosteum and musculocutaneous flap. patient in prone position. Raney skin clips (Codman.. TX). Presurgical tests are important for establishing the intracranial hemodynamic environment. Implantation of the prosthesis. H. controlled mechanical ventilation. and carcinogenic potential are some of the general risks of the procedure. as well as knowledge of the neuropsychiatric status of the patient. Skin Incision To avoid postoperative healing that might compromise the flap. implant in bacitracin solution.

DUJOVNY ET AL : CT-ASSISTED PREFORMED PROSTHESIS FOR REPAIR OF CRANIAL DEFECTS 193 A B C Figure 5. I .

transcranial cerebral oximetry with orthostatic challenge. At that time. thereby decreasing patient risk in the form of reduced operating room time and better implant fit and function. 8 Hematoma. a 3D reconstruction of the skull is made from a 1-mm CT slice. infection. Computer-aided cranial implant design and fabrication procedures appear to provide a better quality product. and skin dehiscence may occur. a “near perfect” custom fit to the individual patient. neuropsychiatric analysis. xenon-enhanced CT. VOL. CONCLUSION . With the intention of early detection of any acute postoperative complication. and plasma anti-epileptic drug levels are measured. to assess the fit of the implant. Computer-aided preoperative implant manufacture methods yield cost savings as a result of reduced operating room time and shortened hospital stays for patients requiring implant surgery. within the first 24 hours. cerebrospinal fluid leak. seizures.194 COMPLICATIONS AND POSTOPERATIVE COURSE NEUROSURGICAL OPERATIVE ATLAS. Patients are generally sent home 1 day after surgery and return to the outpatient clinic 1 week later.

improvements in physiological localization techniques. The major advantage of DBS is its adjustable and reversible feature. stereotactic thalamotomy and posteroventral pallidotomy are the most commonly employed lesioning procedures for movement disorders.D. The improved patient safety and the striking benefits of DBS have expanded the possibilities of intervention into new targets. M. the irreversible nature of lesioning can result in significant morbidity. speech. The exact mechanism of DBS action is unknown. However. ANDRES M. Currently. gait difficulties. Currently the most common application of DBS is thalamic (ventralis intermedius (VIM)) stimulation for refractory tremor (essential tr emor. This chronic stimulation effectively mimics a lesion. particularly with bilateral procedures. 195 . lesioning has implicit limitations. One such target area of increasing attention is the subthalamic nucleus (STN). An increasingly utilized alternative mode of therapy is chronic electrical stimulation of specific intracranial structures. basal ganglia. motor. or white matter tracts. REZAI. In patients undergoing pallidotomy. allowing for maximal efficacy while minimizing complications.CHRONIC SUBTHALAMIC NUCLEUS STIMULATION FOR PARKINSON’S DISEASE ALI R.D. Parkinson’s disease. Lesioning offers a one-time benefit and is not adaptable to clinical changes or disease progression. but is reversible. prevailing theories implicate a depolarizing blockade or “jamming” of neurons and/ or axonal tracts resulting from high-frequency stimulation. and visual field deficits have been reported.D. and cognitive dysfunction. LOZANO. Additionally.D. Complications associated with thalamotomy include speech disturbances such as dysarthria. In the last several years. Despite being effective. PH. also called deep brain stimulation (DBS). M. Complication rates as high as INTRODUCTION © 1999 The American Association of Neurological Surgeons 60% have been reported with bilateral thalamotomy.. PH. Advances in anatomical and functional imaging. DBS involves the placement of multicontact electrodes in the thalamus. the wide availability of stereotactic systems. cerebellar) and pallidal stimulation for rigidity from Parkinson’s disease. there has been a renaissance in the neurosurgical management of patients with movement disorders. cerebellar signs. WILLIAM HUTCHISON. cognitive. and the realization of the limitations of medical therapy have all been instrumental in the resurgence of surgery for the treatment of movement disorders.

Indeed. at times. This baseline evaluation should consist of objective standardized parkinsonian scales incorporated into the Core As- .196 NEUROSURGICAL OPERATIVE ATLAS. The STN sends excitatory (glutamate) efferents to the output nuclei of the basal ganglia (i. Many also have dyskinesias and severe on-off fluctuations. The STN receives input from the motor cortex as well as inhibitory gamma-aminobutyric acid (GABA) input from the globus pallidus externus (GPe) via the “indirect” pathway. The overall results have been very encouraging and. posture. The overactive STN through its excitatory projections to the GPi/SNr causes hyperactivity in the basal ganglia output.e. reports from several centers have shown safety and efficacy of bilateral STN stimulation for Parkinson’s disease. VOL. It is not known if patients with secondary parkinsonism and the “Parkinson plus” syndrome are suitable candidates for STN stimulation. Although a logical target for intervention. Surgical candidates should not have a bleeding disorder or contraindications to general anesthesia. rigidity. however. The increased STN activity is believed to be secondary to the loss of inhibition from the GPe via the indirect pathway. and tremor).000 neurons and measures 10 mm (medial-lateral) × 8 mm (anterior-posterior) × 6 mm (dorsal-ventral). It should be noted that the selection process should be case specific. or chronic high-frequency electrical stimulation of the STN result in the resolution of motor dysfunction. and posteromedial to the pallidum and the internal capsule.” The overall effect in patients with Parkinson’s disease is overactive GPi/SNr nuclei with corresponding excessive inhibitory (GABA) efferents to the motor thalamus and the brain stem. These models have shown that the degeneration of the substantia nigra pars compacta (SNc) and the resultant dopamine deficient state lead to an overactivity of the STN and GPi/SNr.2. including the most resistant and disabling axial components of gait. The rationale for targeting the STN lies in its distinct anatomical connections to the basal ganglia and the brainstem (Figure 1). and balance. This hyperactive basal ganglia output is implicated in the generation of the ANATOMY AND PHYSIOLOGY OF THE SUBTHALAMIC NUCLEUS The indications for treating patients using STN stimulation are expanding and evolving. dopamine agonists. akinesia/bradykinesia. and primary motor cortex) as well as in the brainstem regions involved with the control of posture and gait. symptomatology of Parkinson’s disease causing abnormalities of the motor thalamus and its upstream projections (supplementary motor cortex. The STN comprises approximately 540. Additionally. Recently. dramatic. with a significant disability despite optimization of their medication regimen. It lies inferior to the thalamus.3. Other important considerations include living in close proximity to or having ready access to a center with expertise in DBS and having resources to deal with long-term hardware/system maintenance and associated complications. These studies have demonstrated that chronic high-frequency bilateral STN stimulation results in improvements in all of the cardinal motor manifestations of Parkinson’s disease (akinesia. and gait disturbance. 8 The STN plays a crucial modulatory role in influencing the basal ganglia projections to the motor thalamus and the brainstem. premotor cortex. the STN sends projections to the GPe and striatum as well as to brainstem nuclei such as the pedunculopontine nuclei. Additionally. Patients must be motivated and have sufficient cognitive functions and reserves to undergo an awake surgery requiring their active participation. postural instability.. STN DBS candidates typically will have bilateral. radiofrequency lesioning. At our center. a nucleus of importance for axial control and locomotion. bradykinesia. in MPTP-treated primates. the globus pallidus internus (GPi) and the substantia nigra pars reticulata (SNr)). rigidity. Patients considered for STN DBS must be examined by a movement disorder specialist and meet the clinical criteria for the diagnosis of idiopathic Parkinson’s disease. axial manifestations of Parkinson’s disease and are advanced in their disease. PATIENT SELECTION Preoperative Investigations All patients must be evaluated preoperatively in the “off” phase (approximately 12 hours without medication) as well as in the “on” phase (1 hour after the usual morning dose of medication). as patients in their 80s have successfully undergone DBS. Advanced age is not necessarily a contraindication for the procedure. superior to the substantia nigra. patients and family must be able to effectively use the stimulator and be willing to participate in frequent follow-up visits for detailed evaluation and adjustments of the stimulator. These include tremor. the association of the STN with hemiballismus has been worrisome. which has also lost its striatal inhibition via the “direct pathway. A patient with predominantly unilateral drug-induced dyskinesias may be a better candidate for pallidotomy than STN stimulation.6-tetrahydropyridine (MPTP) primate model of parkinsonism and studies in patients with Parkinson’s disease. The currently proposed models of basal ganglia function are based on work in the 1-methyl-4phenyl-1.

This causes a hyperactivity of the GPi/SNr secondary to loss of inhibition via the direct pathway and hyperactivity of the STN via loss of inhibition through the indirect pathway.25% bupivacaine and 2% lidocaine). basal ganglia. degeneration of the SNc results in the loss of dopaminergic input to the striatum. These output nuclei. This accentuates the pathophysiological findings seen with microelectrode recording and allows for optimal assessment of the intraoperative clinical improvements in patients with stimulation. The substantia nigra pars compacta (SNc) with its dopaminergic projections to the striatum is also not shown. STN. all patients should undergo a formal neuropsychological evaluation. in turn. Note the excitatory projection of the STN to the output nuclei of the basal ganglia: globus pallidus internus (GPi) and substantia nigra pars reticulata (SNr). and striatum. have inhibitory input to the motor thalamus as well as descending inhibitory input to the pedunculopontine (PPN) and the mesencephalic area (MEA) of the brainstem (believed to play an important role in axial control of posture and locomotion). In Parkinson’s disease. motor thalamus. Schematic diagram demonstrating the inhibitory (GABA.” whereas the GPi receives inhibitory projections from the striatum via the “direct pathway. blue arrows) and excitatory (glutamate. sessment Program for Intracerebral Transplantation (CAPIT). such as the Unified Parkinson’s Disease Rating Scale (UPDRS). the subthalamic nucleus (STN). red arrows) projections between the striatum. brainstem locomotion/gait centers. Additionally. and the Schwab and England disability scale. The PPN/MEA also have reciprocal ascending input to the Gpe. This can be performed in the operating room or in a . the patient should undergo the procedure in the “off” state.” Not all projections (including the cholinergic pathways) are demonstrated in this diagram. held overnight.REZAI ET AL : CHRONIC SUBTHALAMIC NUCLEUS STIMULATION FOR PARKINSON’S DISEASE 197 Figure 1. Frame Application and Stereotactic Imaging Whenever possible. GPi/SNr. thalamus. with all medications with- OPERATIVE TECHNIQUE Any one of several commercially available stereotactic frames can be applied under local anesthesia (1:1 mixture of 0. and cortical motor areas. the Hoehn and Yahr staging scale. The STN receives inhibitory input from the globus pallidus externus (GPe) via the “indirect pathway.

Ventriculography is not used in most centers as the currently available MRIs with high-resolution volumetric acquisitions obviate the need for this invasive technique. A subsequent volumetric scan is performed along the ACPC line providing coronal. When performing simultaneous bilateral STN procedures.5-tesla MRI magnet (General Electric. y. Physiological localization begins at this time. an identical sequence of steps is carried out on the opposite side. WI). in a cruciate fashion. Milwaukee. avoiding surface vessels. The procedure is performed with the patient under local anesthesia with 2% Xylocaine. and SNr/SNc in the midbrain. The surgeon also has the option of applying ear bars to assist in frame alignment. PC intercommissural line onto the digitized map at the sagittal laterality of interest. Surgical Procedure In our experience. we utilize the anatomical brain atlas method for targeting. the STN is located anterolateral to the red nucleus and posterior to the cerebral peduncle. an imaginary line from the external auditory meatus to the lateral canthus can approximate this AC-PC line. the patient is taken to the operating room and placed in a supine position. The pial surface is also coagulated and incised. with the head elevated approximately 30 degrees. MRI has a higher anatomical resolution than CT. The calculated AC and PC stereotactic coordinates are fed into a computer with a commercially available program containing digitized diagrams of sagittal brain sections from a standardized brain atlas (G Schaltenbrand. The frontal region is shaved and prepped in the standard fashion. find the ear bars to be uncomfortable. For direct targeting. After the initial image acquisition. y. The frame should be applied such that it is parallel to the anterior commissure (AC)-posterior commissure (PC) line. At the Toronto Hospital. Sole reliance on anatomical localization can be problematic because of the frequent discrepancy between the Physiological Target Localization . On MRI and/or axial CT slices. STN can be visualized on coronal T2-weighted MRI or various other sequences such as an inversion recovery sequence. GA) which can be attached to the skull with sharp pins or with carbon fiber pins inserted into holes drilled into the outer table of the skull. the stereotactic x. To correct for individual variations in the AC-PC distance. The stereotactic arc is then applied. The subsequently generated brain map is overlaid onto a millimeter grid ruled in stereotactic coordinates in the anteroposterior and dorsoventral scales with a corresponding diagram of the brain nuclei and tracts depicted in the chosen laterality (Figure 2). Raney clips are placed for hemostasis. however. Atlanta. W Wahren: Atlas for Stereotaxy of the Human Brain. this corresponding 12-mm sagittal map is shrunk or stretched and reformatted to the length of the intercommissural line for each specific patient. Fibrin glue is applied to minimize cerebrospinal fluid leaks and entry of air into the cranial cavity. At our institution. 8 procedure room adjacent to the imaging suite. On axial MRI. and axial images. Most patients. Any of the currently available image-correction algorithms or MRI-CT image fusion software can minimize these distortions. a burr hole is made anterior to the coronal suture. As a guideline. we use a Signa 1. After frame application. 2nd ed. Typically. The dura is coagulated and incised. we use the Leksell G frame (Elekta. the magnetic resonance imaging (MRI) or computed tomography (CT) localizer (fiducial box) is attached to the frame and the patient undergoes either CT or MRI for anatomical localization. zona incerta. physiological localization is mandatory for definitive target determination. A 5-cm linear or curvilinear incision is made 2. with the ultimate aim of correlating the anatomical and physiological findings. and a self-retaining retractor is applied. and the x. but is more prone to distortions in spatial accuracy. Intravenous prophylactic antibiotics are administered. We usually start with the laterality of 12 mm from the midline that corresponds to the plane with the maximum diameter of the STN in an anteroposterior direction. or 2) indirectly using a standardized anatomical atlas as a function of the AC and PC. The program transcribes the patient’s calculated AC- Anatomical Target Localization Subsequent to stereotactic CT/MRI image acquisition and anatomical target localization.5 cm lateral to the midline and centered anterior to the coronal suture. and z coordinates of the AC and PC are calculated using the MRI/CT console software program. Using a 14-mm diameter drill bit on a power drill. FOV 24 × 24. H2 fields of Forel. Inc. a midline sagittal slice is chosen to best identify the AC and the PC. STN. 1977). Images are acquired using a gradient echo sequence with a relaxation time of 43 msec and an excitation time of 13 msec (flip angle 450. A guide tube cannula with a blunt tip stylet is then introduced into the brain parenchyma to a point 10 mm proximal to the chosen target. Our final anatomical target is chosen at the center of the STN on this reformatted brain map. and z coordinates for the anatomical STN target are set. The sections are 1 mm thick and non-overlapping.198 NEUROSURGICAL OPERATIVE ATLAS. ventralis oralis posterior nuclei.. sagittal. Anatomical localization of the STN can be achieved in two ways: 1) direct targeting. ventralis oralis anterior. matrix 256 × 256). structures encountered in our trajectories include the anterior thalamic nuclei such as the nucleus reticularis. At our institution. VOL.

Rt = nucleus reticularis of the thalamus. Voa = ventralis oralis anterior. mcp = midcommissural point.REZAI ET AL : CHRONIC SUBTHALAMIC NUCLEUS STIMULATION FOR PARKINSON’S DISEASE 199 Figure 2. Vop = ventralis oralis posterior. The + in the center of the subthalamic nucleus (STN) represents the chosen anatomical target. ZI = zona incerta. Vim = ventralis intermedius. A 12-mm sagittal map of the Schaltenbrand and Wahren Atlas reformatted to an actual AC-PC distance of a patient and ruled in stereotactic coordinates for the Leksell frame. IC = internal capsule. A typical trajectory of the microelectrode through various nuclei is depicted. Each gradation is 1 mm. Hpth = hypothalamus. . H2 = fields of Forel. This point is annotated as 0 on the trajectory. SNr = substantia nigra pars reticulata.

and 100-µsec pulse width) through the tips of the electrode. As an adjunct to microelectrode recording.and multi-unit neuronal recordings is amplified. the lower the threshold of stimulation. microelectrode stimulation is performed by passing electrical current of 0. or the ventralis oralis posterior.200 NEUROSURGICAL OPERATIVE ATLAS. the zona incerta can be a relatively quiet region. filtered. 8 expected location and actual position of the stereotactic targets. superior (zona incerta. In Parkinson’s disease patients in the “off’ state. which is also a relatively quiet region. Macroelectrode stimulation is rapid and requires minimal equipment. nucleus reticularis. less frequently. three or four trajectories (anterior. reproducible. Trajectories are made by removing the guide tube assembly and moving the arc in the desired direction in increments of 2-3 mm. displayed on an oscilloscope. we have recorded large-amplitude regular-firing or. The other major cell type is a nonbursting but irregular firing cell. This is the thalamic fasciculus (H1 fields of Forel). The microelectrodes are made of Parylene-C insulated tungsten electrodes plated with gold and platinum. These cells usually have a firing rate of 15 to 25 spikes/second but the bursts can reach firing rates up to 300 or 400 spikes/second. Tip lengths range from 15 to 40 µm with impedance of 0. Ventral to the zona incerta is the lenticular fasciculus (H2 fields of Forel) containing pallidofugal fibers. and the ventralis oralis anterior and posterior). the ventralis oralis anterior. Thus the relative size and shape of the action potential is visualized. which guides the surgeon in determining the most optimal location for final electrode implantation. We rely exclusively on microelectrode recording and stimulation for STN localization. dorsal (zona incerta). which contains pallidofugal fibers with very few cells. The ultimate goal of physiological localization is to identify the STN. and fed to an audio monitor. Occasionally. The zona incerta is a thin strip of gray matter below this fiber tract with a variable recording pattern. whereas stimulation is done every 1-2 mm. and the firing frequency of individual neurons determined.5 MOhm. The electrical signal derived from single. the opposite side usually requires one or two trajectories because of the brain symmetry. The recording is typically performed continuously. STN neurons have an irregular firing pattern with a mean rate of 37 Hz (range 25 to 45 Hz). Alternatively. The microelectrode is housed in its own guide tube. and lateral) are made for physiological localization. and ventral (SNr) must be localized (Figure 2). These have firing rates ranging from 15 to 25 spikes/second and may be cells of the nucleus reticularis. A manual hydraulic microdrive is used to advance the microelectrode in submillimeter steps beyond the most distal aspect of the cannula into the brain parenchyma (typically 10 mm superficial to the chosen anatomical STN target (Figure 2)). 300 Hz. As the microelectrode passes ventrally to the anterior thalamic nuclei. provide exquisite physiological identification of receptive fields and neuronal firing patterns via direct measures of individual single-unit neuronal activity and are able to distinguish somatodendritic from axonal activity. With simultaneous bilateral pr ocedures. Physiological corroboration can be achieved with microelectrode recording and stimulation and/or macrostimulation. The ventral aspect of the STN may also have movement-related neurons. The clinical stimulation responses are correlated with electrical thresholds to further determine the proximity to a given location. Microelectrodes provide precise mapping information. PHYSIOLOGICAL LOCALIZATION OF SPECIFIC STRUCTURES Anterior Thalamic Nuclei: Nucleus Reticularis.1 to 100 µA (1-second train. however. In order to accomplish this. In a typical STN case. Zona Incerta and Fields of Forel As the microelectrode enters the STN. These characteristic bursting cells have also been described in other thalamic regions as well as in r ecordings from laboratory animals. an increase in background noise is detected reflective of a region of increased cellular density. but in our experience these are more prevalent in the dorsal regions. Micr oelectrodes. The characteristic frequencies of cellular activity encountered in each of these structures are shown in Figure 3.” which has a slow firing rate interposed by characteristic rapid bursts of activity. VOL. it has low spatial resolution and is not able to record neurons and to discriminate between axons and neurons. medial.2 to 0. audio monitoring of neuronal activity is achieved. posterior. struc- tures anterior (internal capsule). which is the same length as the larger guide tube described above. Ventralis Oralis Anterior and Posterior There are two characteristic types of neurons observed in the anterior thalamic nuclei. and should be actively sought during the recording. One type is called a “bursting cell. burst-firing neurons from this region in the range of 25 to 45 spikes/second. These movement-related responses are clear. a relatively quiet region is encountered. the closer the proximity to the area of interest. The cellular activity in the dorsal portion of the STN can be modulated by active and/or passive movements of limbs. A window discriminator is used to determine the discharge frequency of the recorded units. Usually. Subthalamic Nucleus . However.

General principles guiding the final implantation of the electrode involve placement of the electrode at a region allowing for maximal clinical response while minimizing the undesired side effects. The characteristic physiological findings of microelectrode recording and stimulation are summarized in Table 1. contralateral muscle contraction can be observed. axons of the internal capsule are encountered and. Microstimulation (particularly in the medial regions of the SNr) can result in ocular Substantia Nigra Pars Reticulata and Pars Compacta deviation due to current spread to the oculomotor nerve fascicles. Graph showing the mean neuronal firing frequencies (spikes/second) of neurons encountered in trajectories traversing the anterior thalamus. presumably from current spread to the medial lemniscus. ventralis oralis anterior. The substantia nigra pars reticulata and pars compacta lie ventral and posterior to the STN and are characterized by cells with a regular pattern of firing with higher rates than the STN (mean 71 Hz. Occasionally. cells can be found that respond to saccades. range 60 to 80 Hz). STN. In the patient with clinically apparent tremor. This assists in the selection of the optimum location for implantation of the DBS electrode. occasional bursting cells can be encountered in the STN. In addition to tremor cells. The anterior thalamic nuclei consist of the nucleus reticularis. “tremor cells”) can be observed. The physiological information derived from the corresponding microelectrode recording (receptive fields) and microelectrode stimulation (projected field) along each tract/trajectory is annotated on the corresponding stereotactic brain maps. The ideal location for the placement of the electrode is in the trajectory.e. paresthesias can be reported. Microstimulation can occasionally result in the patient experiencing paresthesias. but with less prevalence than in the anterior thalamic nuclei. and SNr. In more anterior and lateral trajectories. cells with spontaneous discharge rates synchronous with the tremor (i. Occasionally. AnTh-B = anterior thalamic cells with bursting characteristics. allowing simultaneous visualization and correlation of the physiological and anatomical findings (Figure 4).REZAI ET AL : CHRONIC SUBTHALAMIC NUCLEUS STIMULATION FOR PARKINSON’S DISEASE 201 Figure 3. and ventralis oralis posterior. presumably from current spread to the posteriorly located medial lemniscus. Microstimulation can result in tremor reduction or tremor arrest.. which is traversing the midportion of the IMPLANTATION OF THE DBS ELECTRODE . AnTh-NB = anterior thalamic cells with no bursting activity. with microstimulation.

paresthesias. Finally. VOL. Inc.5 mm in length. 8 Table 1 Characteristic Physiological Findings Using Microelectrode Recording and Stimulation Structure Thalamic nuclei: reticularis. and z coordinates of the determined target are set on the frame. separated from the other pole by an insulated distance of 1. the x.27 mm. The diameter of the electrode is 1. To confirm the position and trajectory of the actual DBS electrode. the same procedure is . thus providing maximal programming possibilities. MN). This arrangement allows for the contacts/poles to be within the STN. depending on the model (Figure 5). which is a good prognostic sign that clinically verifies the target. depending on the model.5 mm. the DBS electrode is inserted under fluoroscopic guidance to the target and the cannula is removed (Figure 6). An additional plastic burr-hole cap further locks the DBS lead into the burr hole ring. Subsequently. ventral oralis anterior and posterior Zona incerta Subthalamic nucleus Microelectrode Recording Bursting cells Microelectrode Stimulation No clinical effect Sparse cells (bursting) Irregular firing pattern Mean rate (37 Hz) Range (25-45 Hz) Movement responsive Neurons Tremor cells No clinical effect Tremor arrest Paresthesias‡ Contralateral muscle contraction* Subtantia nigra: pars reticulata pars compacta Regular firing pattern Ocular deviation† Mean rate (71 Hz) Paresthesias‡ Range (60-80 Hz) Saccade and movement responsive Neurons ‡Paresthesias are most likely due to current spread to the medial lemniscus. This maneuver is designed to prevent lead migration. 60 msec). At this time. (Minneapolis. A stylet-coupled cannula (1. the use of intraoperative x-ray or fluoroscopy is mandatory. y.202 NEUROSURGICAL OPERATIVE ATLAS. *Contralateral muscle contraction secondary to current spread to the internal capsule. For simultaneous bilateral STN electrode implantation. Each pole/contact is made of cylindrical platinum/iridium alloy and is 1.6 mm in diameter) is inserted to the target under fluoroscopic guidance and verification. ≥120 Hz. or ocular deviation) are persistent at low thresholds (<2 V. †Ocular deviation secondary to stimulation of third cranial nerve. final fluoroscopic imaging is performed for verification. This assembly device stabilizes and secures the DBS electrode and the cannula. A lead holder assembly (Medtronic) is attached to the frame. If adverse effects (motor contraction. which was a significant problem in the past. This is accomplished via a beam orthogonal to the stereotactic frame. The mere introduction of the cannula/ DBS lead causes the patient to exhibit dyskinesias and choreiform movements. At this time. At this time. the electrode may be repositioned to a more favorable site according to the anatomical/physiological map.5 mm or 0. The patient is tested at the most proximal and distal pole combinations for therapeutic and adverse effects. the stylet is removed and the DBS electrode is anchored to the burr-hole ring (a plastic ring designed to fit the 14-mm burr hole) by wedging the electrode into one of its two grooves. STN with the most distal lead being placed in the most ventral portion of the STN. The DBS electrode we currently use is a quadripolar electrode (Figure 5) supplied by Medtronic. intraoperative test stimulation is performed by attaching the proximal portion of the DBS lead to a hand-held pulse generator device (Screener). and the entire electrode length can be 28 or 40 cm.

Each gradation is 1 mm. The corresponding frequencies are shown. Microelectrode recording findings of three trajectories superimposed on the 12-mm lateral sagittal brain map are used for initial anatomical targeting as shown in Figure 2. hfd = high frequency discharge >80 Hz. red P = paresthesias experienced with microstimulation in the distal lower extremity. . Black circles represent single unit cellular recordings.REZAI ET AL : CHRONIC SUBTHALAMIC NUCLEUS STIMULATION FOR PARKINSON’S DISEASE 203 Figure 4. red dots = neurons responsive to passive and active movements of areas depicted by red circles. BC = cells with characteristic bursting activity. hpth = hypothalamus. Solid bars = quiet regions with sparse neurons. most likely due to current spread to the medial lemniscus.

5 mm in length and 1. left) or 0. The electrode is introduced from a precoronal burr hole and directed posteriorly and ventrally. separated from the other pole by an insulated distance of 1. which has been withdrawn proximally.204 NEUROSURGICAL OPERATIVE ATLAS. which is also the center of the stereotactic ring. right). . Each pole/contact is made of cylindrical platinum/iridium alloy and is 1. Intraoperative stereotactic radiograph of the DBS electrode at the target. 8 Figure 5.27 mm in diameter. The black circle represents the target. VOL.5 mm (Model 3389. (Courtesy of Medtronic) Figure 6. Note the appearance of the four contacts/poles and the cannula. The position of the electrode is monitored via fluoroscopy. The quadripolar DBS electrode.5 mm (Model 3387.

A 5-cm horizontal incision is made below the clavicle and a subcutaneous pocket is made for placing the generator. one can proceed directly to the implantation of the pulse generator. The distal end of this extension is connected to the IPG device. negative. After DBS implantation. The patient is positioned in a similar fashion as for a ventriculoperitoneal shunt. intraoperative test stimulation. and continuous or cycling stimulation. 2. An electrode extension wire is passed retrograde from the infraclavicular opening to the scalp. The implantable pulse generator (IPG) device (Itrel II. the proximal portion of the extension wire is connected to the proximal portion of the DBS lead by tightening the four screws. The quadripolar DBS electrode is also shown. 1. and securing of the DBS electrode. frequency. Finally.REZAI ET AL : CHRONIC SUBTHALAMIC NUCLEUS STIMULATION FOR PARKINSON’S DISEASE 205 Figure 7. the DBS lead can be connected to a percutaneous extension for prolonged testing and obtaining imaging studies prior to permanent internalization with the pulse generator. The implantable pulse generator (Itrel II) unit is powered by a lithium battery and fully programmable via telemetry. Alternatively. pulse width. placed supine with the head turned toward the opposite side. The mode of stimulation can be unipolar. Figure 9 demonstrates the final position of the DBS electrodes with postoperative MRI. DEEP BRAIN STIMULATION PROGRAMMING The goal of DBS programming is to provide the best clinical response with minimal or no side effects. The pulse generator is sutured to the pectoralis fascia to prevent migration. bipolar. The direction of current is from cathode (–) to anode . amplitude. with a shoulder roll on the ipsilateral side. We routinely implant bilateral STN stimulators simultaneously. Medtronic) is powered by a lithium battery and is fully programmable via telemetry (Figure 7). This stage of the procedure should be carried out with the patient under general anesthesia as it requires a tunneling procedure that can cause significant discomfort and anxiety. Alternatively. Each of the four poles/contacts (designated as 0. a two-layered standard wound closure is performed (Figure 8). Intravenous prophylactic antibiotics are administered. or off. DBS programming is achieved via a telemetry device capable of adjusting parameters such as the choice of poles. mode of stimulation. (Courtesy of Medtronic) repeated on the opposite side. or multipolar. The scalp opening is connected to the infraclavicular opening using a tunnel- PULSE GENERATOR IMPLANTATION ing device similar to a shunt passer (provided by Medtronic). the opposite side can be implanted at a later time. Similarly. A plastic cover/ sheath is place over the connector and sutured at both ends to keep fluids out and maintain contact point isolation. at the cranial opening. or 3) can be positive.

This process can consume much A B Figure 9. . The pulse width (duration of pulses) is commonly 60-90 µsec. a pulse generator can be expected to last 3 or 4 years. The determination of the optimal selection parameters. Each time a setting is changed. After this period. The life expectancy of the pulse generator varies depending on the parameter and duration of stimulation. The patient also has the capability to turn the stimulator off and on with a hand-held magnet. Choosing the optimal stimulation parameters can be a complex task and can require hours of programming. stimulation parameters usually remain stable. The amplitude of stimulation can range from 0. Like thalamic (VIM) stimulation for tremor. axial (A) and sagittal (B) views. however. 8 Figure 8. and the case of the IPG device serves as the ground for unipolar stimulation.206 NEUROSURGICAL OPERATIVE ATLAS. connectors. VOL. effective STN stimulation is best achieved using a high frequency (≥120 Hz). is individualized. the patient must be assessed objectively and subjectively in a systematic and consistent fashion. Composite photograph showing the overall configuration/positioning of the implanted bilateral DBS electrodes. The multiple combination of stimulation settings is particularly advantageous as it allows the best clinical response to be achieved with the fewest side effects. demonstrating the final position of the DBS electrodes. In general. The frequency (number of pulses/second) can go as high as 185 Hz with the currently available models. Most stimulation parameter adjustments are made in the initial 1-3 months after implantation. and pulse generators.5 V for STN). Postoperative T1-weighted MRI. (+) in bipolar stimulation.1 to 10 V (usually 2 to 3.

bilateral. The additional small risk of pneumocephalus is minimized by sealing the dural opening with fibrin glue. programming can require significant time and resource expenditures. Important issues to take into consideration in the initial decision-making process include the cost of a bilateral system and the long-term system maintenance (including equipment-related complications and battery replacement). hardware. disconnection. rigidity (60%). CONCLUSION . the overall improvement of total UPDRS motor scores was 47% and L-dopa-induced dyskinesias were reduced by 76% with total drug dosage being decreased by 40%. Transient hemiballism has also been observed with stimulation. They can also exhibit movement-related activity and/or activity in synchrony with the tremor. and stimulation can occur. particularly with bilateral STN stimulation. DBS not only prevents undesired side effects. but most commonly in older individuals. A center dedicated to this endeavor must be carefully planned and have adequate resources for the long term. The reversible and adjustable features of DBS technology have permitted its application to the STN in the patient with advanced. which occurs on the order of 1%-3%. while those with tremor-dominant Parkinson’s disease require less programming. Another consideration is the proximity of the patient or ready access to a center with expertise in the management of DBS. Microelectrode stimulation is less useful for STN localization. The complications associated with STN DBS can be categorized as those related to the surgical procedure. Other complications CLINICAL OUTCOME AND COMPLICATIONS have involved neuropsychiatric changes with subtle memory deficits. In the “on” state. including tremor (82%). as well as reduction in the use of drugs by 40%-50%. because of its overactivity and its projections to the basal ganglia output nuclei (GPi/SNr). Additionally. Finally. These studies have documented striking improvements in parkinsonian symptoms. The complications of the surgical procedure are similar to those seen following other stereotactic DBS or lesioning procedures. In our own series of patients who have undergone chronic high-frequency bilateral STN stimulation. all of which can be alleviated by adjusting stimulation settings. akinesia (62%). patients must be willing and have the ability to cooperate with the extensive evaluation and prolonged programming that may be necessary to reach the optimal settings. and equipment failure. There have been several recent reports of follow-up with chronic high-frequency bilateral STN stimulation. and technical/equipment. followed by akinesia/bradykinesia and rigidity. The STN is an ideal target in patients with Parkinson’s disease. and medically refractory Parkinson’s disease. and personality changes. The stimulation-induced side effects include apraxia of eyelid opening. and gait and postural instability (51%). Patients with advanced disease and axial symptomatology require more frequent adjustments and careful clinical evaluation. there is approximately a 5% chance of infection that is most often superficial. PRACTICAL CONSIDERATIONS The reversible and adjustable features of DBS technology have allowed its application to the STN. skin erosion.REZAI ET AL : CHRONIC SUBTHALAMIC NUCLEUS STIMULATION FOR PARKINSON’S DISEASE 207 time and resources. stimulation. paresthesias. Additionally. Although complications related to the procedure. diplopia. we have observed total UPDRS motor score improvements in the medication “off” state of 63%. Single cell microelectrode r ecording technology can precisely and reproducibly localize the STN. The potential hardware-related complications are on the order of 1%-3% and include electrode migration. the overall marked benefits obtained by these disabled patients outweigh the adverse effects. STN neurons have an irregular firing pattern with a firing rate in the range of 25-45 Hz. There have also been significant impr ovements in dyskinesias and on/off motor fluctuations. but also can be adaptable as the symptoms change or the disease progresses. Transient complications such as intraoperative and postoperative confusion and agitation have also been seen (up to 2 weeks). An experienced team with available resources is required to achieve these goals most efficiently and effectively. breakage. as well as significant improvements in gait. word finding and concentration difficulties. In patients with advanced Parkinson’s disease. and involuntary movements such as chorea. The most serious complication inherent to any intracranial stereotactic procedure is that of intracranial hemorrhage. Improvements in overall “off” state UPDRS motor scores have been 60% or greater with the most striking improvement in tremor. bilateral STN DBS results in a definitive improvement in all of the cardinal motor manifestations of Parkinson’s disease.

.

The percutaneous approach utilizing the endoscope extends the knowledge that we have acquired over the past 50 years. M. Patients usually have not responded to conservative therapy. This approach dates to 1951. Conservative therapy persists for a period of not less than 6 weeks nor longer than 18 weeks. dermatomal pain. Orthopedic and neurological surgeons have had at their disposal a variety of surgical techniques to approach the lumbar disc since it was first approached in 1934. At the conclusion of the conservative therapy phase. Patients with a clear-cut single-level root symptom ideally present with MRI evidence for focal disc pathology.D. Minimally incisional spine surgery is undergoing a revolution at the current time. Kambin has pioneered and extensively devel- INTRODUCTION oped instruments for targeted posterior fragmentectomy. Patients with a history of lumbar root symptomatology of either myotomal loss. PARVIZ KAMBIN. the “open” pr ocedure is one of the most common techniques for alleviating pain in this area and remains a procedure commonly performed by orthopedic and neurological surgeons. we have seen advances in anesthetic techniques. can be a part of the armamentarium of all spine surgeons. patients should undergo imaging studies.D. Kambin described the technical aspects of the operation as we shall describe it in this chapter. The evolution of these techniques has revolved around the need to remove the offending material and reduce the patient’s pain. and consists of land. or/and sensory loss are candidates. and scope of the instruments available to the surgeon. In some instances. diversity. CASEY. extent. the further development of instrumentation has made this technique one that. magnetic resonance imaging (MRI) of the spine affords the most comprehensive view as to the origin. © 1999 The American Association of Neurological Surgeons Patients are selected for arthroscopic microlumbar discectomy as they would be for any discectomy approach. Since that time. disc pathology may be combined with a minimum of anterior bony disease causing a mini- PATIENT SELECTION 209 . while preserving neurological function. Over the last decade. Although fraught with complications.D. M. and contributing factors of compressive nerve root pathology. MARC CHANG. herein called arthroscopic microlumbar discectomy. In 1982.ARTHROSCOPIC MICROLUMBAR DISCECTOMY KENNETH F. when Hope described an anterior retroperitoneal approach to the disc space. with the appropriate training. coupled with technical advances in the size. Hijikata expanded this approach when he described the percutaneous technique. In 1975. Patients who present with motor loss or other acute neurological syndromes can certainly be evaluated and treated more promptly as the situation dictates. With those advances have come radically different attitudes toward the possibilities of minimally incisional surgery. M. At the current time.or water-based exercises for flexion/extension of the spine.

UT) to ensure proper positioning and readily readable x-ray images. some patients ANESTHETIC TECHNIQUE AND PREOPERATIVE PREPARATION Patient positioning commences with the patient being requested to turn prone on a radiolucent operating frame (Kambin Frame. Kalamazoo. patients are advised of the possibility of conversion to an open procedure should the pathology so dictate. and a combination of bony and epidural pathology should be counseled as to the limited nature of biopsy in resection possible through the scope. Bladder catheterization is not generally employed. This can be determined by a simple measurement from the lateral aspect of the disc space to the skin entry point described in this article. is intravenous conscious sedation. however. VOL. that is not the subject of this review. Northstar Medical. or additional other bony pathology would not be candidates for this lateral extracanalicular approach.or retrolisthesis is a relative contraindication to the procedure. In some cases. Patients whose imaging studies reveal extensive lateral recess stenosis. the use of spinal anesthetics or general anesthesia is necessary for the successful completion of the procedure. adequate padding is required over the lower extremities. within the canal space. patients whose anatomical size would preclude the instrument use are also not candidates. become obvious candidates for general anesthesia when their level of anxiety and/or their previous experience with conscious sedation so dictates to the anesthesiologist. symptomatology was relieved in 87%). This is best accomplished using computed tomography (CT) at the symptomatic level. 2) failure to relieve symptomatology (seen in 13% of our patients. Single preoperative doses are employed. including 1 gm Ancef administered intravenously within 1 hour of incision. patients who cannot comfortably be positioned in the prone position due to orthopedic or soft-tissue deformity of the lower extremities are not candidates. occurs most often on Day 5 following the procedure. 50 µg fentanyl injected into the annular fibers will afford and extend relief. while relying predominantly on midazolam or propofol.210 NEUROSURGICAL OPERATIVE ATLAS. the occasional patient complains of pain at the time of manipulation of the annular fibers. some patients presenting with penicillin allergies are given 120 mg gentamycin intravenously when renal function is appropriate. we utilize the biplanar fluoroscopic x-ray device (OEC Medical Systems. PA). We have found that the topical use of fentanyl applied via cottonoid patty to the annular fibers has been helpful. Occasionally. Antibiotics are also administered as part of the preoperative preparation. The anesthetic technique used is determined by the surgical team. The anesthesia of choice. which allows for the straightening of lumbar lordosis and gentle positioning and cushioning of the chest and hips (Figure 1). In addition. In addition. Stryker Instruments. and 3) transient worsening of symptomatology (seen in 2% to 4% of patients). local instability such as antero. The surgeon has the option of standing on the side of the patient ipsilateral or contralateral to the pathology. At the time of counseling for endoscopic surgery. Preoperatively. Intravenous conscious sedation utilizing fentanyl and midazolam and/or propofol has enjoyed large acceptance in the institutions in which we currently practice this surgery. The fibular head can inadvertently be trapped under the operating table belt. The fluoroscopic arm is best positioned opposite the side that the surgeon stands to allow for ease of use during the operation with a minimum of movement in the area of the field. especially if the patient is large and the apparent volume of distribution makes the administration of conscious sedation more challenging. This worsening takes the form of dysesthesia occurring frequently along the anterior aspect of the calf or thigh. Salt Lake City. we have found intravenous ketamine to be useful. focal bilateral stenosis. However. Patients with tumors in the foramen. 8 mum of lateral recess stenosis. To avoid the complication of strap pressure. The risks and complications of arthroscopic microlumbar discectomy include those experienced in the open procedure: 1) infection (seen in 1% to 3% of patients in the current series). The preoperative selection of the patients is neither age nor sex limited. Despite adequate intravenous sedation for the initial steps of the procedure described here. and the C-arm device to the left. In some patients. Philadelphia. and has been self-limited in most patients. however. completing a 90-degree arc from the foot of the patient to the point opposite the surgeon. The camera tower (Stryker Systems. We usually allow the camera device to be positioned at the foot of the patient. PATIENT POSITIONING . the x-ray fluoroscopic television immediately to the surgeon’s left of the camera tower. The arms are brought up alongside the patient’s head and the legs are flexed over two pillows. However. Also not feasible for removal due to limitations with the equipment is disc material that has migrated the equivalent of one disc space level above or below the index. During preoperative counseling. Dysesthesia is described as burning in nature. There have been no neurovascular complications to date. MI) and additional arthroscopic materials including the printing device are best positioned at the foot of the patient in clear view of the surgeon.

g. the drape should extend at least 12 cm off the midline. The instruments used are the Smith and Nephew arthroscopic surgical system and Kambin surgical set (Memphis.). We use a Sony color video printer to record the pr ocedure. and the angle of the C-arm is adjusted so that the OPERATIVE TECHNIQUE disc space is seen straight ahead after the appropriate disc level has been selected. Laterally. Line drawing of a patient in the prone position. TN) (Figure 2). This facilitates manipulation of the biplanar fluoroscope during the procedure. Minneapolis. The preparation is augmented by a shower curtain-type drape (Ioban 2 patient isolation system 6617.” Laterally. for example.CASEY ET AL : ARTHROSCOPIC MICROLUMBAR DISCECTOMY 211 Figure 1. The Kambin arthroscopic microlumbar discectomy instruments. “L4-5. the skin entry point 9 to 11 cm from each midline is marked and the entry point is selected (usually 9 cm) and infiltrated at the skin level using 0. MN) to cover the entire operative field. A 22-gauge spinal needle measuring 18 cm is introduced at the skin entry point at an angle of 35-45 . Figure 2. Betadine or alcohol) supplemented with an Ioban drape (3M Corp. The muscles are infiltrated as well with lidocaine. three disc levels above and below the target level. The pictures are useful for review and teaching purposes.. The C-arm is ideally positioned in the anteroposterior (AP) plane at the start of the procedure.. A line is drawn on the skin utilizing a marking pen to indicate the level selected and identified. The camera equipment is a Dyonics Surgical System (Andover.5% lidocaine without epinephrine. The electrocautery device and suction are positioned at the head or foot of the patient to facilitate C-arm movement and to avoid the lines crossing the patient during x-ray evaluation. 3M Corp. MA). Skin preparation is accomplished utilizing surface agents (e.

the 9 o’clock rostrally.5 cm to allow docking or firmly seating it in the annular fibers. The scope allows for inspection of the annulus. the needle will lie just at the inferior margin of the disc space at the level selected (Figure 4). Following successful needle placement. This confirms the position of the cannula over the disc space. The preoperative imaging study. whether CT or MRI. which carries the potential to traverse the peritoneal space prior to entering the retroperitoneal muscles. The biplanar C-arm is utilized to demonstrate placement of the cannulated obturator at the lateral aspect of the bipedicular line and at the posterior margin of the disc space. the 3 o’clock caudally. the height of the crest will obstruct the approach. The zero-degree forward-looking endoscope can be introduced through the suction cap. a #15 scalpel blade is used to incise the skin and subcutaneous fascia. the needle stylet is removed and a small metal wire is placed in the center barrel of the needle into the disc space. and psoas major muscles. As the needle is introduced and penetrates the sacrospinalis. Control of flow is accomplished in the field with the usual stopcocks. The needle has entered the triangular working zone when the tip of the needle seen in the AP projection lies at the lateral margin of the bipedicular line formed by the ipsilateral outer margin of the pedical above and below the disc space selected. Straight trephines 3 and 5 mm in diameter are introduced through the universal access cannula and twisted until they penetrate the annulus. We soak the 1-cm cottonoid patty in 50 µg fentanyl and apply it directly to the annulus. The cannulated obturator is introduced over the stylet through the muscle layers until within 1-2 cm of the annulus. The annulus can then be cleaned utilizing a cottonoid patty introduced into the universal access cannula and moved around the end of the cannula with either the back of the obturator twirled between the fingertips or a small grasping forceps to place the patty against the annulus and wipe off some of the fat. At this point. VOL. with the 12 o’clock position posteriorly or dorsally on the patient. The universal access cannula is now introduced over the end of the obturated cannula. Occasionally. the access cannula can be gently advanced 0. In the lateral view. This allows for . the edge of the annulus can often be assessed by tapping against the obturated cannula and feeling a sense of steady pressure. The stylet is removed while approaching the annulus to avoid inadvertently pinning or trapping the nerve root in the triangular working zone. This emphasis distinguishes the angle normally employed during a biopsy when simple triangulation of the lateral edge of the disc space is appropriate. which then springs back against the thumb. The pattern of annular fibers and fat can be visualized to distinguish the annulus from the periosteum of the bone above and below (Figure 5). The biplanar fluoroscopic C-arm images are most helpful in avoiding incorrect needle positioning when seen in true orthogonal relationship.or 3-L bag of saline positioned at the edge of the operative field. 8 degrees. It will become apparent that to remain parallel with the endplates. and the 6 o’clock ventrally as viewed from the end of the access cannula. Needle geometry is also important so as to avoid too lateral an entry. At this point. The biplanar C-arm can be utilized to demonstrate the level of visualization. inferiorly by the proximal plate of the inferior vertebrae. it is gently rotated to allow the bevel to carry the needle through a straight line toward the target level. may be utilized to determine the exact angle of entry as measured from the triangular working zone to the point of entry on the skin. At this point. The goal of the lateral projection is to maintain the plane of the needle parallel with one of the endplates in the disc space. Irrigation is provided via a 1. confirmed by biplanar fluoroscopy. A technical note regarding the L5-S1 disc space: This disc space is best approached by imaging the sharp angle of the endplates in the lateral view and projecting that point to the skin. and posteriorly by the proximal articular process of the lower lumbar segment. thereby avoiding inadvertent injury. Needle geometry is important so as to avoid too steep an entry angle which would project the surgeon past the disc space and into the retroperitoneal structures or too shallow an angle which would project posteriorly behind the lamina and other spinal structures. Prior to the application of the local anesthetic. the needle entry point may come to lie at the level of the L4-5 disc space as seen in the AP projection. The triangular working zone (Figure 3) is the annular entry port through a posterolateral approach that is formed anteriorly by the descending spinal nerve from the level above. the cottonoid patty can be used to introduce the fentanyl at the level of the annulus.212 NEUROSURGICAL OPERATIVE ATLAS. quadratus lumborum. This will allow the safe docking and entry of the instruments into the disc space. Once the 5-mm trephine has been introduced. We find it helpful to move the scope to visualize the exiting root. it is helpful to use a spinal needle to check each of the four quadrants in the universal access cannula. Preoperative evaluation of the imaging studies will also identify the position of the iliac crest relative to the disc space. The biplanar fluoroscopic arm can be utilized to check the progress of the needle. After inspection of the annulus. leaving it in place for 1 minute. The operation then proceeds by attaching the suction cap to the access cannula. The annulus can be infiltrated during these maneuvers as well with 25 µg fentanyl or 1-2 ml 1% lidocaine without epinephrine. A high crest as seen on CT or MRI will force a more cephalad entry point for successful cannulation of the disc space.

Figure 4. . viewed axially (upper) and sagittally (lower). Drawing of the triangular working zone. Radiographs in anteroposterior (left) and lateral (right) projections showing the needle position.CASEY ET AL : ARTHROSCOPIC MICROLUMBAR DISCECTOMY 213 Figure 3.

within the disc space. We find hand stabilization to be superior. When a biportal exposure is utilized. especially for the initial cases. The shaver has a forward and reverse foot pedal and is provided with constant irrigation via a universal access cannula. the universal access cannula can be disengaged and moved somewhat more posteriorly along the edge of the annulus. stylet. which allows for simultaneous as well as metachronous visualization. similar steps are followed to this point with the introduction of the needle. The deflecting forceps are used to move more posteriorly in the disc space. On many occasions. scope.214 NEUROSURGICAL OPERATIVE ATLAS. allowing the dura to be inspected (Figure 8). it can be removed utilizing the various forceps in the instrument set. After completing the operation. one starts with the straight forceps to evacuate material directly in the path of the approach..and 30-degree scopes can be reintroduced as needed during the shaving process to inspect the posterior-most elements. subligamentous. Commonly. paramedial. Surgitron Corp. In the sagittal view. the extraligamentous material is at the level of the disc space or either above or below the disc space. access cannula. are particularly advantageous to remove as the extracanalicular approach of the scope brings the surgeon down directly on the offending pathology. avoiding the most dorsal portion of the disc space at the level of the root). A zero-degree endoscope can be introduced for visualization of the intradiscal material (Figure 6). or extraforaminal location moving from medial to lateral in any given disc space.e. Enough disc material is removed to enable room to introduce the shaver. then reduce or turn off the suction to allow a column of water for visualization and magnification. as opposed to the amorphous nuclear material. Caution should be taken to engage the drive motor for the shaver only when it is fully engaged in the disc space. allowing for visualization of the lateral end of the foraminal contents. 8 stability at the annular fibers as well as at the operator’s hand at the skin level. in the latter category. inspection of the annular surface allows for confirmation of the extent of removal of the protruding disc material and subsequent decompression of the nerve root visualized immediately rostral to the disc space. Another alternative technique utilizes the oval cannula with an external diameter of 9 mm. Alternatively. the material can be interannular. The shaver is utilized in a 270-degree arc which excludes the posterior 90 degrees running roughly between 10 o’clock and 2 o’clock positions in the clock face previously described (i. disc material that has penetrated the posterior longitudinal ligament and/or annular fibers can be retrieved. These fibers are oriented in parallel. The monopolar coagulation wire can be applied with the working channel scope and performed under direct vision (Ellman Wire. During this phase. Bleeding occasionally occurs in the venous elements lateral to the annulus and can be controlled with gentle irrigation.or 30degree endoscope through one portal and the shaver through another portal and observe the function and motion of the shaver and other grasping instruments (Figure 7). Once the presence of disc material has been confirmed through a zero-degree endoscope. a small locking cap can be placed over the cannula. on occasion. Alternatively. However. A suction trap is used to collect disc material as it is removed. through a unilateral approach. We have found a useful classification regimen that identifies disc material in the axial and sagittal planes as visualized on MRI. Fragments that are totally extraforaminal. it is possible to introduce a zero. When introducing the scope. or extraligamentous and. a working scope with a central channel can be introduced to allow simultaneous visualization of the removal of disc material. We have found that the initial inspection of the disc space and the subsequent inspection at the end are best accomplished with the zero-degree scope when moving along the annulus exterior to the disc space. or the utilization of a monopolar coagulation wire. Traversing the edge of the cannula with the shaver engaged can cause neural elements to be drawn toward the shaver. photos can be taken through the endoscope and the steps of the operation documented as well as providing a teaching file. This maneuver enables inspection of the posterior margin of the triangular working zone and. Disc removal continues posteriorly with the angle-edged instruments until elements of the posterior longitudinal ligament are identified. and disc space evacuation. disc material can occur in a medial. Disc fragments that have migrated beyond the confines of the posterior ligament and/or migrated within the epidural space are going to present the greatest challenge in the early phases of . this also allows for inspection of and removal of fragments that are in a paraforaminal location. Via the arthroscope photographic towers.). In the axial plane. obturated cannula. VOL. Suction is attached to the shaver head itself. Once disc removal is judged to be adequate. the 30-degree and 70-degree endoscopes allow for visualization especially along the posterior margin of the disc space at the level of the expected pathology. removal of small bony elements from the vertebral body that may impinge on the lateral aspect of the foramen. The extent of fragment removal and subsequent disc removal is obviously determined by the operating surgeon. it is useful to briefly irrigate to clear material and occasional blood products in the access cannula. the so-called lateral disc. foraminal. trephines. During routine disc removal. Zero. the application of Surgicel through the scope apparatus.

Disc material viewed through an endoscope. The posterior longitudinal ligament and the dura are visible at left.CASEY ET AL : ARTHROSCOPIC MICROLUMBAR DISCECTOMY 215 Figure 5. Figure 6. . Endoscopic view of grasping forceps. Figure 8. Figure 7. The annulus as seen through an endoscope.

Postoperatively. and recurrent disc disease have been associated with reduced incidence of successful outcomes. The instruments have limitations as to the degree of posterior reach that they enjoy. often using 3 L of normal saline. a successful outcome has been seen in approximately 87% of patients. a single nonabsorbable suture is placed at the skin line. a small Hemovac drain can be placed directly through the universal access cannula and removed in 6-8 hours. the access cannula is removed. Occasionally. Removal of these disc fragments should not be attempted until a surgeon’s learning curve justifies that approach. clinical signs and symptoms dictate the degree of success. other factors. patients present with possible residual symptomatology POSTOPERATIVE FOLLOW-UP or symptomatology that can be attributed to other structural abnormalities. In addition. Irrigation is continued throughout the procedure. litigation. In the current series. resumption of a more normal canal configuration along the posterior margin of the vertebral body. however. . We have looked at the percent of canal clearance in these patients and demonstrated a high degree of correlation with successful canal clearance and subsequent clinical outcome. when there is evidence of mild venous oozing near the root at the end of the procedure. including the presence of workers’ compensation. residual air in the previous area of disc protrusion. 8 acquiring the skill of arthroscopic microdiscectomy. We have not seen any systemic changes or local nerve root problems using this irrigation regimen. On occasion. and removal of the laterally placed disc herniation can be clearly visualized. As with many procedures in this region. exploration through the annulus and posterior ligaments into that epidural space increases the possibility of inadvertent dural injury and subsequent cerebrospinal fluid egress. the patient is then taken to the recovery room. We evaluated the usefulness of immediate postoperative imaging in this series of patients. no canalicular dissection. We found that MRI and CT examinations are both quite sensitive to the removal of offending disc material in the canal space. VOL. advantages include a smaller incision. and a single SteriStrip bandage is placed on the skin. When the preoperative studies are compared to the studies obtained in the first 12-24 hours after surgery. and minimal disc space collapse as indicated by long-term follow-up. In most patients.216 NEUROSURGICAL OPERATIVE ATLAS. Although the procedure has many similarities to open disc surgery.

D. pCO2 42-45 mm Hg. particularly lesions that are large or midline in location. RUSSELL W. Involvement of the cord can produce paraparesis or sensory disturbances that are generally subacute or chronic in nature. surgery can be planned on an elective basis to allow thorough evaluation of the preoperative pulmonary and cardiac status. Symptomatic thoracic disc herniations are unusual. with careful patient selection morbidity and mortality rates using transthoracic discectomy are not unreasonably high. Generally. M.D. We have performed the procedure in patients up to 70 years old with underlying coronary disease. urgent or emergent surgery is mandatory when there is rapid loss of lower extremity function. the following results are associated with significantly higher pul- PREOPERATIVE IMAGING AND PLANNING 217 . however. Perot and Munro. including the elderly. and persons who smoke do represent higher risk groups. Pulmonary function should be assessed with an arterial blood gas and spirometry. This is now a standard and very useful procedure for treating thoracic intervertebral disc disease. pCO2 <42 mm Hg and O2 saturation >92%. Values out of these ranges place the patient at a much higher surgical risk. and in 1969. certain patients. The abysmal results following laminectomy for herniated thoracic disks have led surgeons to seek novel approaches for this problem. Thoracic spine x-rays are useful to provide identifying landmarks for proper intraoperative localization. and later Ransohoff and colleagues described the transthoracic removal of herniated discs. INTRODUCTION © 1999 The American Association of Neurological Surgeons Precise preoperative imaging is key in the surgical planning for herniated thoracic disc. or O 2 saturation 90%92% would be considered borderline acceptable. The typical presentation involves radicular pain. Given the risks of this type of surgery. those with chronic obstructive pulmonary disease. Myelopathy is an indication for surgery.EXCISION OF HERNIATED THORACIC DISC VIA THE TRANSTHORACIC APPROACH MARY LOUISE HLAVIN. However. Value ranges of pO2 60-80 mm Hg. HARDY. Although a seemingly formidable surgery.25%-0. Magnetic resonance imaging (MRI) (preferably) or computed tomography myelography must clearly define the level of the offending disc. A satisfactory arterial blood gas value includes a pO2 >90 mm Hg. although sudden paraplegia can be seen. M. It is estimated that 0. On spirometry. However. The use of thoracotomy to treat spinal disease originated with the treatment of spinal tuberculosis or Pott’s disease.75 % of clinically apparent discs will occur in this region and most frequently present between T8 and T11. which can either be acute or chronic. nonsurgical options such as use of anti-inflammatory drugs or nerve blocks should be considered in patients with pain alone and no neurological deficit.

possibly requiring a median sternotomy. FEV1/FVC <35% or forced expiratory flow of 25%-75% (FEF25%-75%) <1 liter/ second. To reach the extreme levels of the thoracic spine. FEV1 (forced expiratory volume at 1 second) less than 1. the arch and great vessels may be of concern.5 liters. although at the superior aspect. monary complications: forced vital capacity (FVC) <1. VOL.0 liter. Using the posterolateral thoracotomy approach described here. therefore. Some surgeons prefer using a left-sided thoracotomy to provide access because of greater ease in dealing with the aorta than the venous structures on the right. (An intravenous dipyridamole-thallium scan may be obtained in a patient unable to exercise.218 NEUROSURGICAL OPERATIVE ATLAS. and L1 vertebrae must include managing the diaphragm. or heart failure. Cardiac evaluation should be directed by the patient’s internist or cardiologist and may include a treadmill test in asymptomatic individuals between ages 45 and 60 years or a thallium exercise scan in patients aged over 60 or with a history of myocardial infarction. carries a much greater risk for perioperative cardiovascular complications. T12. with excellent visualization of the anterior and lateral portions of the disc space as well as the spinal canal. 8 Figure 1. which usually enters on the left side in the region of the thoracolum- Surgical Approach .) All patients should refrain from smoking for at least 2 weeks before surgery and those with underlying lung disease should have their pulmonary status optimized with bronchodilators or treatment of any chronic bronchitis or bronchial edema. The thoracolumbar junction is obscured by the diaphragm. Premorbid cardiac disease. specialized techniques must be utilized. Other surgeons prefer to use a right-sided approach because of concern of injuring the artery of Adamkiewicz. congestive heart failure. T1-weighted non-contrasted MRI demonstrating a large right-sided. techniques to expose the T11. laterally herniated disc at the T10-11 level which resulted in sudden paraplegia. A right-sided thoracotomy was used to removed the fragment. The uppermost thoracic vertebrae can be approached via either a posterior transthoracic technique elevating and retracting the scapulae or by an anterior route. the fourth to the 10th thoracic verte- OPERATIVE TECHNIQUE Selecting the side of the surgical approach for a thoracotomy is largely a matter of preference. angina. including a history of angina. brae are easily accessible. or even diabetes.

The patient is secured in a lateral position with the chest centered over the break in the table to facilitate opening the interspace during surgery. the break can be returned to neutral to facilitate closure. bar junction. As with other procedures. At completion. perioperative antibiotics are given. the liver is more difficult to retract. On the other hand. side view. Spinal cord monitoring with somatosensory evoked potentials may be helpful. although the infor mation provided is clearly limited and injury to the anterior spinal cord can occur without significant changes in the signal. The course of a typical incision is shown (dotted lines). Care must be taken to protect the axillary and peroneal areas as well. The chest should be positioned over the break in the operating table so that it may be flexed during surgery to open the interspace and thus improve working room. a lateralizing disc. Should instrumentation be required.HLAVIN AND HARDY : EXCISION OF HERNIATED THORACIC DISC VIA THE TRANSTHORACIC APPROACH 219 A B Figure 2. The use of a double lumen-cuffed endotracheal tube (e. such as a Anesthesia As shown in Figure 2. The axilla is supported and protected with a roll while the legs are cushioned with pillows. Some patients may require more invasive central venous pressure or Swan-Ganz cardiac monitoring. can dictate the route of choice. as shown in Figure 1 (or other pathology). Patient positioning and incision. making a left-sided approach more desirable. The lower leg is bent while the upper leg is kept Patient Postioning . Carlens tube) permits deflating the exposed lung out of the way should additional room for retraction be necessary. bronchial blocker. In most cases. and again a right-sided approach is preferred by some. A beanbag device or sand bags padded in towels can be used to maintain this position. the patient is placed in a lateral position for surgery. as long as the support is radiolucent to allow intraoperative x-ray localization. Other methods can be used to separate lung ventilation if necessary. B. Other considerations include coexistent lung pathology..g. however. injury to the aorta is of concern. A urinary catheter is placed. rotated slightly forward so that the chest contents will tend to fall away from the spine with gravity. Surgery is carried out with a general anesthetic technique utilizing at least two large-bore intravenous access (16 gauge) catheters and arterial blood gas monitoring. Perioperative steroids may be used in cases with significant cord compression. when working at the lower portions of the thoracic spine. A beanbag device or padded sand bags (not shown) can support the patient. Clearly. which might dictate opening a particular side of the chest. surgeon facing the patient. surgeon’s view from above. approach from either side can be used. A.

the head of the T9 rib articulates with the body of T8 and T9 at the posterolateral aspect of the offending disc space. a plain spine x-ray should be obtained. Bovie cautery is used for hemostasis and division of the musculofascial layers. a portion of the rib numbered by the vertebral body superior to the offending intervertebral disc can be removed. the intercostal muscles may be split additionally to enable further separation of the intercostal space. It is important to remember to work away from the spinal cord. the rib to be resected may be cut out with a rib cutter. it is best to remove the rib numbered by the vertebrae superior to the disc space. then stripped from the superficial surface using a Cobb or other periosteal elevator. The upper arm is supported with pillows and bent at about a 90-degree angle to rotate it out of the field. (Thus. as shown in Figure 3.220 NEUROSURGICAL OPERATIVE ATLAS. The annulus of the offending disc is incised anteriorly and the disc space is grossly evacuated using a combination of pituitary ronguers and curettes. Flexion of the operating table at this juncture may be used as a maneu- . At this point. In the thoracic spine. After protecting the ribs with cotton tape. the operative microscope is brought into place. 8 extended. A wide ribbon retractor or sweetheart retractor may be used to accomplish this. dividing as posteriorly as possible. For example. The segmental vessels should be identified and ligated using 3-0 silk ties in order to provide adequate bony exposure. which includes the trapezius and rhomboid muscles medially and the latissimus dorsi and serratus anterior muscles deeper and extending anteriorly. The pleura is grasped with smooth forceps and opened using scissors (Figure 4B). The bottom of the concavity approximates the mid portion of the body. The counts should agree before a resection is performed. To obtain optimal exposure and working room. an important landmark. Care should be taken to identify and save the neurovascular bundles that travel along the inferior border of each rib. which then enables identification of the pedicle. Thereafter. An open-sided rectangular incision is then made in the parietal pleura. where it extends to approximately halfway between the spinous process and the medial portion of the scapula. however. At this point. For a standard thoracotomy. After clearing off the undersurface of the rib with a curette. the T8 rib is removed laterally to gain access to the T8-9 space. the incision curves toward the sternum. close to the costovertebral angle. as this provides exposure and working room. the incision is typically centered over the rib. extending from the mid portion of the vertebral bodies above and below the affected disc space and extending laterally at either end (Figure 6). Large vessels should be ligated and divided. The pleura is then dissected carefully from the vertebral body and reflected laterally. The nipple is a marker for the fourth interspace. that the head of the rib overlies the pedicle and occasionally needs to be removed to obtain adequate exposure of the thecal sac (Figure 7). thereby exposing the intervertebral vessels as well as the sympathetic chain. In young patients. Alternatively.) This compensates for the angulation of the ribs inferiorly across the anterior aspect of the vertebral body and facilitates working inferiorly rather than superiorly. Judicious placement of the ribbon under the Finochietto retractor can eliminate the need for manual retraction. The skin incision is made initially with a scalpel. Running with the segmental artery and vein are the intercostal nerves. The intercostal nerve can be traced to the neural foramina of interest. In some instances. the vertebral bodies and other anatomic structures should be visible through the parietal pleura (Figure 5). One accurate way to count ribs is to place one’s hand inside the pleural cavity and count down from the top and then up from the bottom. The patient may be tilted slightly toward the surgeon to allow for a better view. although not routinely. as shown in Figure 3. It is important to remember. The patient is secured well to the operating table with 3-inch tape to enable safe rotation during the procedure. The intervertebral discs can be both visualized and palpated as the prominent bulging areas of the vertebral column while the intervening concavities represent the vertebral bodies. it is important to remember that any particular rib articulates with the posterior/superior margin of the vertebral body with which it shares a number. a “pigtail” rib stripper can be used to dissect off the remaining periosteum and elevate the rib out of its bed (Figure 4A). VOL.) At this point. intercostal ligaments may be reasonably supple such that use of a rib spreader will provide adequate retraction and exposure. Radiographic confirmation of the proper disc space before proceeding is crucial at this point. The periosteum of the rib to be resected is incised with the Bovie cautery. Anteriorly. This initial debulking is crucial prior to any attempts to remove the extruded fragment compressing the neural elements. As depicted in Figure 2. Should an attempt be made to preserve the rib. The lung may be covered with a moist lap pad and retracted out of the way. the incision should follow the rib and curve slightly cephalad posteriorly. it may be necessary to drill off a portion of the pedicle as well. a self-retaining (Finochietto) retractor is placed in the pleural cavity and opened. which potentially may be removed. Alternatively. (Some surgeons prefer ligating the neurovascular bundle with 2-0 or Operative Procedure 3-0 silk ties because it is believed to eliminate stretch injury to the nerve that has been implicated in postoperative pain syndrome.

after bony resection. . In addition. Rib resection and pleural opening. A. posterior view. the now-exposed rib bed and pleura are grasped with forceps and divided. the T8 rib has been removed laterally to provide working room. The head has been removed to gain access to the T8-9 disc space.HLAVIN AND HARDY : EXCISION OF HERNIATED THORACIC DISC VIA THE TRANSTHORACIC APPROACH 221 1 2 3 4 5 6 Figure 3. B. The head of the T9 rib articulates with the bodies of T8 and T9 at the posterolateral aspect of the offending disc space. 1 2 3 4 5 6 7 8 7 8 9 9 10 11 12 12 10 11 A B Figure 4. the rib to be resected. Anatomic diagram of the rib cage. has been cleared off with periosteal elevators and the underside dissected free to allow insertion of a pigtail rib stripper. This picture depicts the articulation of the ribs with their respective bodies and interspaces and demonstrates the bony resection that would be used for a T8-9 herniated disc through a left-sided approach. still lying in its bed.

nerves Figure 5. A. 8 CAUDAL lung trachea esophagus diaphragm azygous vein greater splanchnic nerve sympathetic trunk A aorta CAUDAL lung CEPHALAD diaphragm esophagus B intercostal arteries. B. The dashed line indicates the window opening through the pleura (left-sided approach). right-sided view. Pleural incision. . left-sided view. veins. VOL. Figure 6.222 CEPHALAD NEUROSURGICAL OPERATIVE ATLAS. Intrathoracic anatomy.

segmental vessels ligated.HLAVIN AND HARDY : EXCISION OF HERNIATED THORACIC DISC VIA THE TRANSTHORACIC APPROACH 223 Figure 7. large osteophytes or calcified ligament can require more extensive bony removal of the bodies and pedicle to visualize the thecal sac and ensure adequate decompression. anatomic diagram demonstrating extent of final bony removal. The dashed line indicates where the rib was removed. A. B. Additional bone is being drilled off the superior and inferior endplates to widen working room. the annulus has been incised and the disc space preliminarily emptied using long pituitary ronguers and curettes. C. Bony resection and disc removal. . The parietal pleura has been reflected. A B C Figure 8. Removal of the rib head. and the head of the rib drilled off.

Return of the operating table to a flat position facilitates wound closure. An extensive bony removal must be weighed against the risk for postoperative kyphotic deformity from collapse. hemorrhage. A typical vertebral bony resection is shown in transverse section in Figure 8C. A running absorbable stitch is used for the individual muscular layers. Alternatively. this should be sealed with a muscle or fascia graft and fibrin glue and a lumbar drain placed for several days postoperatively to avoid a CSF fistula. An ample bony decompression to provide working room without retracting the cord as well as always working away from the cord will help decrease risk of damage. manipulation around the spinal cord poses a threat for neurological injury. post-thoracotomy pain. An immediate postoperative chest film as well as daily chest xrays should be obtained to confirm resolution of any pneumothorax. Should there be suspicion of a rent. It is subsequently removed when drainage has subsided and no air leaks are present. The parietal pleura is reapproximated using interrupted absorbable sutures of either chromic catgut or 3-0 Vicryl sutures. Any calcified posterior longitudinal ligament or fibrotic annulus should be resected either with Kerrison ronguers or by forcing the material into the interspace and removing it.224 NEUROSURGICAL OPERATIVE ATLAS. paraplegia. Careful patient selection and preoperative cardiopulmonary assessment with judicious perioperative monitoring will help minimize morbidity and mortality from this procedure. chest tube is attached to an underwater suction drainage. A rib approximator is used to initially place 0-0 Nurolon stitches around the ribs. Clearly. COMPLICATIONS AND AVOIDANCE . Should a significant bony defect be present. VOL. infection. At completion. or kyphotic deformity. Care must be taken to watch for a CSF leak at the end of the procedure. with inspection under a Valsalva maneuver. cerebrospinal fluid (CSF)-pleural fistula. palpation of the dura with a No. The WOUND CLOSURE Risks of surgery include death. The skin can be stapled or closed with an absorbable subcuticular stitch such as 4-0 Vicryl sutures. a disc space spreader may be placed into the interspace. An apical dependent chest tube is externalized through a stab wound and the chest is then closed serially in layers. Additional exposure of the dura may be obtained by resecting the head of the rib abutting the intervertebral disc space and r emoving the superior portion of the pedicle (Figure 8B). 4 Penfield should be performed to confirm adequate decompression. Drilling off a small portion of both the superior and inferior endplates as well as the vertebral body enlarges the exposure and provides access to the herniated fragments (Figure 8A). 8 ver to open the disc space. placement of a bone graft can reduce the risk of long-term angulation.

In patients who present with symptoms of spinal claudication. is essential. corpectomies. The deformity may present in many forms. or combined) and the area over which the surgery needs to be performed to stabilize the spine in the corrected coronal and sagittal planes. EUGENE PENNISI. anterior instrumentation techniques. When all conservative means have failed and the patient’s symptoms suggest that surgery is the most appropriate option. degenerative disc disease is the cause. Ultimately. bracing. This. give sufficient relief to obviate the need to con- INTRODUCTION © 1999 The American Association of Neurological Surgeons sider surgery. along with epidural steroid injections and nerve root blocks. may temporize through a period of symptom exacerbation or. and aerobic conditioning programs may be of use. Failure to achieve a balanced correction. PH. success will result from the appropriate realignment of the structural elements in both the coronal and sagittal projections and through decompression of stenotic levels to eliminate the effects of nerve root traction and spinal stenosis. For patients with minimal symptoms. an aerobic conditioning program may be of benefit. as well as the underlying pathology. and to anticipate changes in the remaining discs above and below will lead to long-term failure. in some fortunate patients. it is impossible to correctly determine the surgical technique most appropriate (whether anterior. M. The onset of adult degenerative scoliosis is rarely seen in patients younger than age 40. The appropriate application of these techniques in a well thought-out manner is necessary for the successful surgical treatment of these patients. observation may be sufficient. In the vast majority of adults with severe spinal deformity. O’BRIEN. As with all spinal disease. Unlike adolescent idiopathic scoliosis. M. pedicle screw placement. patient selection and a clear understanding of the structural pathology are the two most important factors in the successful surgical treatment of this disease. In those in whom the symptoms are back pain alone. Once believed to be stable in comparison to adolescent idiopathic disease. 225 .D. the first course of treatment is conservative. An understanding of the peculiarities of each unique curve.. posterior lumbar intradiscal fusion. Other techniques include derotation for correcting coronal deformities and restoring lordosis.D. The surgical treatments are really the sequential application of standard anterior and posterior spinal techniques. LOWERY. GARY L. a course of nonsteroidal anti-inflammatory medications. A.A. These include anterior lumbar intradiscal fusion. either idiopathic. Followed over 5 to 10 years. posterior. It is not possible to predict the natural history of untreated adult spinal deformity.D. long-term studies have shown that these deformities progress anywhere from at least 1° to 3° per year. bracing probably has less of a role in the elderly. and osteotomies. to address each abnormality at each level. or the result of a post-surgical imbalance with induced deformity either above or below the index fusion area. these deformities can result in a crippling disability. degenerative. M. Without a clear understanding of the unique segmental abnormalities in each deformity.SURGICAL MANAGEMENT OF ADVANCED DEGENERATIVE DISEASE OF THE LUMBAR SPINE WITH MULTIPLANAR DEFORMITY MICHAEL F.

Patients with significant upper lumbar and lower thoracic abnormalities may have unsightly rotational prominences that are an integral part of the patient’s dissatisfaction. When a patient presents with neurological deficits secondary to spinal stenosis and nerve root compression. In addition. serious complications can be associated with this. Specific positioning schemes may depend to a large degree on anticipated intraoperative repositioning (i. Whichever technique is used. Because the myelographic dye clearly and accurately outlines the neural space. In patients who have undergone previous surgery and implantation of stainless steel instrumentation. The patient is placed in the supine position with a bolster over the apex of the kyphosis. if the thoracic prominence is a cosmetic issue. particularly during large corrective deformity surgeries. VOL. ANESTHETIC TECHNIQUE For the most part. some form of preoperative enteral alimentation or hyperalimentation may be necessary to optimize the patient for the surgical challenge. adequate decompres- OPERATIVE POSITIONING . a precise and detailed representation of the extent of neural element compression can be obtained. Pulmonary function is decreased for several months following thoracoplasty. long-cassette right and left lateral side-bending films in the supine position and pushprone and extension films over a bolster are necessary to assess the structural components of the curve. In addition. these patients should be monitored with intra-arterial lines and central venous access lines.” Computed tomography (CT) myelography may be a more useful study for investigation of intracanal pathology in the severely stenotic and/or severely deformed spine. the level and the extent of the compressive pathology need to be delineated. total lymphocyte count. Cosmetic issues are also important. and pre-albumin. allowing the torso to fall backward under the effect of gravity. In addition. If there is a possibility of anterior transthoracic surgery. In a similar manner. In the elderly population. A chief concern in this population of patients is general nutrition. can result in blindness if direct ocular pressure is not applied. the possibility of poor vascular access. closing or opening osteotomy sites) and maintenance of lumbar lordosis. this is often a useful study.. If the patient has a significant and unacceptable lumbar prominence. structural grafting and fixation both anteriorly and posteriorly are warranted to ensure adequate fusion. with the pelvis stabilized by an assistant and the surgeon pressing on the deformity to attempt to create a radiographic picture of the maximum possible correction. magnetic resonance imaging (MRI) is useful to ascertain the intracanal pathology. however. hypotensive anesthesia.e. Preoperative laboratory investigations should include total albumin. CT discography is an excellent way to investigate both the morphology and the clinical condition of the disc. transferrin. and large fluid shifts. Normotensive anesthesia may be more appropriate in these extensive procedures. MRI gives valuable supplemental information about the lower lumbar discs and the possibility of avoiding fusion to the sacrum. These should include long-standing anteroposterior and lateral scoliosis films. Push-prone films are done with the patient in the prone position. both an anterior and a posterior approach will be needed for the correction of these deformities. Discography is useful for delineating the optimal operative levels. In patients with reduced serum PREOPERATIVE PREPARATIONS protein. Blood loss can be offset by preoperatively donated autologous blood and the use of a cell saver. consideration should to be given to an anterior multilevel discectomy and intradiscal fusion to help decrease this rotational deformity. a full pulmonary and cardiac workup should be performed. It is. it also approximates the response of the compensatory curves to this correction. In mild curves. This helps maintain some degree of flexibility and provides a stress relief point for the spinal instrumentation. Bolster films are particularly useful when considering the flexibility of a kyphotic segment and its ability to be corrected.226 NEUROSURGICAL OPERATIVE ATLAS. Many adequate positioning techniques have been described. Although hypotensive anesthesia is a possibility. consideration may be given to a thoracoplasty in combination with the deformity surgery. It is important that every attempt be made to spare lower lumbar segments in particular. However. a factor that should be considered preoperatively in patients with pulmonary dysfunction. including curve segment flexibility and the ability of the spine in the potentially uninstrumented segments to fall within the stable zone after operative connection. Because of the severe nature of the deformity and the poor fusion rates expected in this population. This will usually give a good indication as to the ability of the kyphosis to be corrected with instrumentation alone. unusual in a population of aging patients to have MRI “normal discs. Because of lengthy surgical time. in some instances the deformity may be addressed exclusively anteriorly or posteriorly. stroke. Not only does this help assess the flexibility of the main curve. severe hypotensive anesthesia can result in myocardial infarction. 8 The most important portions of the radiological workup are the plain x-rays. and multisystem failure including the renal and hepatic systems.

this is often identified as a slight asymmetric collapse without obvious SURGICAL GOALS rotation at the involved disc space. Foraminal stenosis due to hypertrophic facets. the patient frequently presents with radicular symptoms.. These symptoms typically result from either standard foraminal or central stenosis due to collapse of the disc space anteriorly and overgrowth of the facet joints with redundant ligamentum flavum posteriorly (Figure 1). The goal of surgery is to decompress where appropriate.O’BRIEN ET AL : DEGENERATIVE DISEASE OF THE LUMBAR SPINE WITH MULTIPLANAR DEFORMITY 227 ©Neill BioMedical Art Co. there is compression on the cauda .” Early in the course of the disease. and stabilize the spine until fusion occurs. The primary dysfunction in patients with this pathology is the asymmetric collapse of the degenerating lumbar intervertebral disc. restore spinal balance. reconstruct the deficient disc(s). sion of the abdominal contents must be achieved to reduce intraoperative bleeding. This asymmetric collapse increases until there is near complete loss of unilateral disc height in the coronal plane. The hallmark of the disease is lateral listheses or “rotatory subluxations. 1999 Figure 1. This is followed by a lateral shift of the superior vertebral body on the inferior vertebral body and evidence of rotation as identified by using Nash/Moe observations for pedicle position. At this point. Characteristically.

In the vast majority of cases. When the deformity is supple or unstable. Finally. although correcting large. It is not uncommon at the level of the rotatory subluxation to also have a sagittal plane spondylolisthesis in addition to a loss of lordosis (see Figure 3). consideration should first be given to instrumentation. This may be performed retroperitoneally or via Pfannenstiel’s incision (Figure 10). In the osteoporotic spine. which typically corresponds to at least one rotatory subluxation. Combined Anterior/Posterior Approach OPERATIVE PROCEDURE The determination as to whether to proceed anteriorly. concerns associated with the posterior approach have to do with improperly or poorly placed instrumentation. Realignment in such cases may often be achieved via a posterior osteotomy in which the lamina and facet are removed. Instrumentation used both anteriorly and posteriorly is common to less complicated surgeries and is used in multiple combinations to achieve the desired correction in complicated deformities. The osteotomy is then closed and stabilized under compression instrumentation (Figure 7). Once released. At this level. 8 equina secondary to the loss of overall central canal diameter associated with rotatory subluxation (Figure 2). This may be performed via an anterior or posterior approach. Contraindications for surgical treatment in these patients often center more around the medical conditions of the elderly and presence of osteoporosis than around specific difficulties with the procedure. but the risk of serious neurological injury should not be neglected. Anterior instrumentation at multiple levels typically requires a lateral approach and may be best suited to a patient positioned in the right or left lateral decubitus position and an extensile flank incision (Figure 11). even rigid constructs may be inadequate due to the poor osseous purchase of the metallic implants. Posterior osteotomies. posterolateral fusion. Another unique mechanism for the onset of radicular symptoms in this pathology is nerve root traction secondary to the rotatory translation of the pedicles. This safeguards against uncontrolled intraoperative bleeding and avulsion of these vessels from the iliac vein. . In this technique. The major considerations during an anterior approach are predominantly anatomic and center on the safe dissection of the vascular structures. both the rotatory subluxations and the spondylolistheses can involve multiple levels. or both needs to be assessed on a case-by-case basis. posteriorly. The curves range from subtle. if the deformity is rigid. This allows the development of the retroperitoneal space and provides for a straight lateral approach to the spine. and efficient placement of biomechanically correct posterior instrumentation can be accomplished. operative positioning. While it is most common to have only one such obvious level of instability. The segmental vessels are more easily located and controlled. Their safe placement is certainly within the realm of possibilities for the accomplished spine surgeon. The standard posterior approach for spinal cases is used (Figure 5). causing nerve root stretching as the roots exit the neural foramen (Figure 3). Special care must be taken not to injure the dura and the neural elements secondary to impertinent penetration into the canal. Insufficient or suboptimal biomechanical placement of instrumentation can result in failure. Pedicle screws are an excellent means of segmental fixation in the posterior lumbar spine (Figure 8). including the facets. Additionally. especially at L4 and below. fusion. the inferior facets of the superior vertebra and the lamina and the superior facets of the inferior vertebra are removed (Figure 6). part.228 NEUROSURGICAL OPERATIVE ATLAS. Anterior instrumentation is particularly helpful in substantially decreasing coronal plane deformities and in stabilizing the spine after corpectomy. and instrumentation frequently require supplementary intradiscal grafting in order to fully address discal pathology and secure a solid fusion. VOL. is performed to heal the osteotomy site. adequate exposure of the anterior spine requires immobilization of the great vessels at the aortic bifurcation and safe identification and ligation of the often prominent and numerous recurrent lumbar veins. the appropriate posterior osteotomies. Intradiscal fusion of L5-S1 is often needed to restore spinal balance and to reconstruct a deficient disc that is placed under increased shear and torsional loads (Figure 9). anterior instrumentation may be sufficient for reconstruction. For the most Posterior Approach Anterior Approach In certain instances. This usually implies a posterior approach with realignment and instrumentation first. the apex of the degenerative scoliosis is at the L3-4 disc level. stiff curves can be a formidable undertaking. an anterior release of the remaining structures most responsible for resisting rotation may be required in order to achieve correction. The type of anterior approach used depends on the individual patient’s anatomy that needs to be accessed and the type of instrumentation to be used during surgery. tight radius deformities confined to the upper and middle lumbar spine to fairly large curves involving the lower thoracic and upper lumbar spine as the primary curve and fractional or compensatory curve in the lower lumbar spine which returns the spine to the pelvis (Figure 4).

©Neill BioMedical Art Co. Loss of overall central canal diameter in rotational deformity. Lateral view showing spondylolisthesis and loss of lordosis. 1999 . Figure 4.O’BRIEN ET AL : DEGENERATIVE DISEASE OF THE LUMBAR SPINE WITH MULTIPLANAR DEFORMITY 229 Figure 2. Anteroposterior view showing primary and fractional curve. Figure 3. Note the nerve root stretching around the pedicle at L3..

and sharp dissection should be limited to intradiscal dissection. There must be adequate time for monitoring during dissection techniques using electrocautery and when probing pedicles and placing pedicle screws. the use of monitored pedicle probes and pedicle screw stimulation should be considered during the placement of pedicle screws. For electrophysiological monitoring to be truly effective. Significant preoperative planning is necessary to be sure that each technique is applied in a sound and planned order so as to achieve the goals of surgery with minimum blood loss and minimum operative time. a wake-up test should be considered as the MONITORING . electrophysiological monitoring is necessary.. Patient positioning for a standard posterior approach. Care must be taken to mobilize all structures anterior to the periosteum over the sacral promontory (L5-S1 disc space) using blunt dissection. particularly when large changes are anticipated in the overall coronal and sagittal alignment. It is obvious that multiple procedures performed in the same patient increase the risk of infection and other complications. there needs to be cooperation between the electrophysiologist and the anesthesiologist. In the event that electrophysiological monitoring is equivocal or suggests an intraoperative concern. they also need to be considered when performing corpectomies and during placement of transvertebral body screws with bicortical purchase. VOL. the ureter. 1999 Figure 5. The anterior and posterior reconstruction techniques used in these complicated procedures are not significantly different than the techniques used in simpler degenerative procedures. In addition. It is optimal to have both somatosensory evoked potential and motor evoked potential monitoring available. the lumbar plexus. the electrophysiologist needs to be familiar with sophisticated techniques that involve monitoring both nerve roots via EMG and monitoring of motor and sensory tracts.230 NEUROSURGICAL OPERATIVE ATLAS. Other anatomic structures that need to be carefully identified and considered include the hypogastric plexus. and of course the spinal cord and cauda equina. To ensure the greatest safety for the neural elements. 8 ©Neill BioMedical Art Co. Also affecting the usefulness of the electrophysiological monitoring is the willingness of the surgeon to cooperate with the electrophysiologist. the ilioinguinal and genitofemoral nerves. Failure to consider these vessels during these procedures can result in significant bleeding that is difficult to control since the vessels in question are on the opposite side of the vertebral body. Cautery should not be used on this anterior soft tissue. As with all types of deformity surgery. They merely represent the sequential application of various techniques to address the numerous problems in these complicated deformities.

Figure 8. Posterior osteotomy. 1999 . ©Neill BioMedical Art Co.O’BRIEN ET AL : DEGENERATIVE DISEASE OF THE LUMBAR SPINE WITH MULTIPLANAR DEFORMITY 231 Figure 6. Stabilization of the lumbar and lumbosacral spine using Texas Scottish Rite Hospital instrumentation.. Pedicle screws placed for fixation in the posterior lumbar spine. Figure 7.

.232 NEUROSURGICAL OPERATIVE ATLAS. 8 Figure 9. Pfannenstiel’s incision. Total discectomy in preparation for intradiscal fusion in a combined anterior/posterior approach. ©Neill BioMedical Art Co. VOL.. 1999 Figure 10.

Frequently. Intraoperative decisions can be anticipated and alternative solutions developed. Although a high-speed burr near the dural sac may appear somewhat dangerous. myocardial infarction. and rongeurs which have a tendency to slip off hard bone and may not be able to be applied to the osseous structures in a convenient manner. especially for the motor tracts. can substitute for careful preoperative planning. it is probably much less dangerous than dull osteotomes. High-speed burrs. resulting in more safely performed complex operations. careful preoperative planning is critical..O’BRIEN ET AL : DEGENERATIVE DISEASE OF THE LUMBAR SPINE WITH MULTIPLANAR DEFORMITY 233 ©Neill BioMedical Art Co. great care is necessary while using these tools near the neural elements. Intraoperative fluoroscopy also helps to ascertain the coronal alignment of pedicle screws since the head of the image machine can As described above. INTRAOPERATIVE RADIOGRAPHY Intraoperative imaging is most important in cases involving severe deformities in which large changes in patient positioning in either the frontal or the sagittal projection are anticipated. Large transfusion volumes may result in disseminated intravascular coagulation or adult respiratory distress syndrome. No intraoperative imaging techniques. Overzealous manipulation of vascular structures may result in intimal injuries leading to either local thrombosis or the propagation of thrombi with resulting stroke. In addition. complications in this group of patients concern the metabolic consequences of surgery. or pulmonary embolism. Other solutions and a worse-case scenario option must be detailed. SPECIALIZED INSTRUMENTATION actually be manipulated in such a way as to show the screw in a “bulls eye” position in the pedicle. however. To prevent these complications. Extensile flank incision for an anterior approach. anatomic or instrumentation problems can be avoided by careful preoperative planning and meticulous technique. COMPLICATIONS . These challenging cases are certainly not the forum to practice using this instrumentation. In spite of this. 1999 Figure 11. which provide both high torque and high speed. The optimal surgical goal cannot be achieved in all cases. large-volume fluid shifts may result in multisystem failures. Kerrisons. are extremely helpful when performing complicated osteotomies and decompressions around the neural elements. gold standard for intact neurological functioning.

.

the curved dorsal cortical vertebral body margin may disorient the surgeon. the parietal and visceral pleura shield the lung from the forces of retraction. Dorsolateral approaches such as the costotransversectomy and the lateral extracavitary provide exposure that barely extends to the midline.C. aorta. M. more secure operative field reduces the risk of untoward intraoperative events and facilitates achievement of the surgical objective.M. no treatment is indicated. SCHWARTZ. In the case of a cerebrospinal fluid (CSF) leak. which affords improved visualization of the spinal canal unobstructed by the rib head. avoiding entry of the pleural cavity. The retropleural approach also allows a smaller incision and minimizes soft tissue dissection. M. Finally. These approaches also require sacrifice of the intercostal nerve and risk possible occlusion of the radiculomedullary artery. A shorter.).THE RETROPLEURAL APPROACH TO THE THORACIC AND THORACOLUMBAR SPINE THEODORE H. the transthoracic approach requires placement of a spinal drain as well as a chest tube on water seal. especially if inadequate bony dissection has been performed. In the 235 . initial canal identification and complete canal decompression is more easily and confidently achieved. significant retraction of the unprotected lung is avoided. For the retropleural approach. McCORMICK. The approach also provides both lateral canal exposure through the resected pedicle bed and adjacent foramen as well as a direct line of vision that is anterior to the ventral canal floor. or vena cava. PAUL C. post-thoracotomy pain syndrome lasting at least 6 months was reported in 9. this has not been the experience of the senior author (P. which may lessen postoperative pain and shorten the patient’s hospital stay. The retropleural approach offers several advantages over the alternative transthoracic ventral approach. The retropleural approach also uses a less oblique angle. further ventral visualization may require extensive muscle mobilization and bloody transforaminal dissection. One advantage of a ventral appr oach to the spinal cord is the ability to visualize significant ventral pathology that extends past the midline of the involved vertebral body. Thus. Postoperative pulmonary complications are minimized and placement of a chest tube is usually not required. While some authors report a higher incidence of pleural effusion in the retro- INTRODUCTION © 1999 The American Association of Neurological Surgeons pleural approach. The retropleural approach provides the shortest direct route to the ventral thoracic and thoracolumbar spine and spinal canal. Some authors find that pleural adhesions encountered in adult patients make retropleural dissection difficult. bleeding from the extensive ventral epidural thoracic venous plexus is easier to control from a less oblique angle.D.D. In one large series.2% of patients undergoing the transthoracic approach. During the transthoracic approach. In the retropleural approach. Since a shorter segment of the chest cavity must be traversed to reach the spine through the opening.

or significant neurological deficits are generally considered operative lesions. Likewise.236 NEUROSURGICAL OPERATIVE ATLAS. (Reproduced from McCormick PC: Retropleural approach to the thoracic and thoracolumbar spine. A ventral approach is also useful in posttraumatic kyphosis in the setting of increasing deformity. and physiotherapy. anteroposterior radiograph following r etropleural corpectomy and reconstruction demonstrating lateral titanium plate and autologous rib/femoral head allograft bone graft. Neurologically intact patients with minimal canal compromise and an intact dorsal column can usually be managed conservatively with bracing. however. The retropleural approach is most appropriate for localized (two or fewer vertebral segments) pathology of the ventral thoracic and thoracolumbar spine between T3 and L1. computed tomography scan demonstrating L2 flexion/compression fracture with retropulsion of bone fragment into the spinal canal. minor lacerations of the pleura are easily r epaired. Adequate reduction and fusion. Fractures with a greater than 40% loss of body height. bed rest. The traumatic lesion most suitable to the retropleural approach is the burst fracture. usually require ventral instrumentation or prolonged postoperative recumbency. greater than 50% canal compr omise. Traumatic fractures and posttraumatic kyphoses occur frequently in the thoracolumbar spine and are often amenable to surgical correction via the retropleural approach. major kyphotic deformity. If the pleurae are significantly compromised. 1995. 8 A B C Figure 1. with permission) authors’ opinion. VOL. kyphosis greater than 30 degrees. A. B. or persistent or progressive neurological deficits since dorsal fusion alone is usually not sufficient. If there is dorsal stability. neurological improvement and significant pain relief are achieved in a majority of these patients approached ventrally. lateral radiograph following retropleural corpectomy and reconstruction. then dorsal spinal fusion may be required in . pa- INDICATIONS tients with complete loss of neurological function below the level of injury for more than 48 hours will usually not improve following operative decompression but may require surgical stabilization for rehabilitation. however. the approach can easily be modified into a transthoracic approach. intractable pain. C. Neurosurgery 37:908-914. If there is a question of compromised posterior stability. in which there is failure of the anterior and middle columns due to compression loading (Figure 1).

SCHWARTZ AND McCORMICK : RETROPLEURAL APPROACH TO THE THORACIC AND THORACOLUMBAR SPINE 237 Figure 2. Neurosurgery 37:908-914. For these lesions. The upper arm is rested on a pillow. a lumbar epidural catheter can be placed for perioperative morphine installation. The side of the approach is determined primarily by the level and location of the pathology. Artist’s drawing depicting patient positioning. and a dorsolateral or separate dorsal and ventral approaches may be more appropriate. All bony prominences and subcutaneously coursing peripheral nerves are well padded. Air-compression boots are used to prevent deep vein thrombosis. a 12-cm skin incision extending from the posterior axillary line to a point 4 cm lateral to the posterior midline is made over the rib at the level of the lesion (Figure 2). 1995. Anterior decompression and stabilization also have the long-term benefit of minimizing progressive deformity. which markedly diminishes postoperative pain. The lower leg is flexed at the hip and knee to stabilize the patient. instability and kyphosis during or following radiation therapy. a skin incision is made in line with the T9 rib. A double lumen endotracheal tube is requested for lesions above T6. A Foley catheter is placed and preoperative antibiotics are routinely administered. Operative Positioning Following appropriate venous and arterial line access. Suction aspiration of the beanbag secures the position. and patients with a known radio-resistant tumor such as melanoma or hypernephroma or Pott’s disease. for example. Disc herniations in the thoracic region are also easily decompressed via the retropleural approach. The skin incision must be altered for upper thoracic (T3-4) lesions. which cannot be adequately removed via the transpedicular or costotransversectomy approach. lack of tissue diagnosis. Laminectomy alone is often contraindicated in these situations and carries a risk of neurological deterioration. racic levels. with permission) addition to ventral fusion. which will be removed. For a T8-9 disc herniation. Significant ventral compression from primary and metastatic tumors to the vertebral body or infections of the spine can also be appropriately managed via the retropleural approach. Posterolateral approaches are more appropriate for lesions involving three-column dysfunction or greater than three segments of involvement. While forward flexion of the upper arm and shoulder rotates the scapula superolaterally to expose the T5 and T6 ribs. midthoracic (B). (Reproduced from McCormick PC: Retropleural approach to the thoracic and thoracolumbar spine. Thoracolumbar lesions should be centered over the kidney break or flexion joint of the operating table to improve the operative exposure. Skin incisions for upper thoracic (A). Indications for the ventral approach include progressive neurological deficit. even at upper tho- PREOPERATIVE PREPARATIONS AND ANESTHETIC TECHNIQUE For lesions between T5 and T10. The patient is turned to a lateral position on a beanbag with a small roll placed under the dependent axilla (Figure 2). the T3-4 ribs remain under its cover. The increased exposure is particularly useful for calcified discs. and thoracolumbar (C) levels are shown. Routine induction and intubation are then accomplished. a “hockey-stick” Skin Incision .

The endothoracic fascia is analogous to the transversalis fascia which lines the abdominal cavity. VOL. Vertebral body corpectomy requires removal of an additional rib head for adequate exposure. The intercostal artery and vein are divided between sutures. which lines the entire thoracic cavity. In the author’s experience.238 NEUROSURGICAL OPERATIVE ATLAS. A well-defined tissue layer is identified in the bed of the resected rib segment. costotransverse. The parietal pleura is dissected widely off the undersurface of the endothoracic fascia with Kitner (peanut) clamps. the periosteum and endothoracic fascia are incised and elevated off the vertebral body. 8 incision. The parietal pleura maintains its attachment to the inner chest wall through this layer. This rib segment is removed (Figure 3A). the trapezius or rhomboid muscles) to the ribs. The fascia and the vertebral body periosteum OPERATIVE PROCEDURE are elevated in either direction away from the disc space. The pleura is dissected proximally to expose the vertebral column. The margins of the pedicle are defined sharply with curettes and nerve hooks. Small pleural tears are repaired with suture. Bone bleeding may be intermittently controlled with smeared wax at the end of a Kitner clamp. a subperiosteal detachment of the intercostal muscles over an 8-10 cm rib segment is performed. which is probed with a dissector. much the same way in which the peritoneum is freed from the transversalis fascia of the abdominal wall during a retroperitoneal exposure (Figure 4). Deflation of the lung with a double-lumen tube is not critical but does facilitate lung retraction at the upper thoracic levels (above T6). This is the endothoracic fascia. The endothoracic fascia is opened over the remaining proximal rib segment with cautery. The adherent endplates. The thoracic sympathetic chain. The intercostal vessels that run transversely at the midvertebral body level are preserved within this reflected tissue. The detached scapula is rotated superiorly to expose the appropriate rib. Occasionally. muscle fibers of the inconstant subcostal muscle may be identified within this fascia in the rib bed. A tablemounted malleable blade maintains lung retraction.5 cm from the lateral vertebral body margin. remains in place. This provides access to the lateral spinal canal. The bony vertebral body dissection can now be completed posteriorly with knowledge of the canal’s location.. and azygous veins are contained against the thoracic wall and vertebral bodies within this fascial layer. For a T7 corpectomy. Once the dorsal cortical margin has been sufficiently thinned.e. The ligament is gently probed with a nerve hook for identification and delivery of these fragments away from the spinal cord. The incision is carried down through the scapular muscle attachments (i. The endothoracic fascia is sharply incised in line with the rib bed (Figure 3B). Following disc exposure and intercostal vessel ligation. thoracic duct. Proximal ligation of the intercostal artery can be safely performed because abundant muscular and osseous anastomoses will distally reconstitute the occluded vessel and maintain spinal cord blood flow. Generous bony removal facilitates and assures adequate canal decompression. is per formed (Figure 2). the endothoracic fascia over the disc space is incised. troughs are drilled into the adjacent vertebral bodies and the harvested rib is placed as an interbody strut graft (Figure 6B). A high-speed drill removes the adjacent endplates and extends the dissection into the adjacent vertebral bodies. This divides the sympathetic chain which descends on the vertebral column just anterior to the rib head insertion (Figure 5A). A self-retaining crank retractor on the adjacent ribs widens the exposure. This opening should be maintained back to the dorsal cortical margin. The disc space is incised and evacuated with curettes and rongeurs (Figure 5B). Once adequate decompression has been achieved. the calcified thoracic disc is often suspended within this layer and is not as commonly intradural as the literature suggests. The pedicle is also removed with the drill and Kerrison rongeurs (Figure 6A). resection of the T8 rib head provides exposure of the T7-8 disc space and adjacent T8 vertebral body and pedicle (Figure 7). The approach to the thoracolumbar junction is discussed separately. The endothoracic fascia is continuous with the inner periosteum of the rib and the thoracic vertebral bodies. for example. and cortex are pushed down into the corpectomy defect. The discs are incised and curetted as previously described. a reverse-angled curette sharply divides the posterior longitudinal ligament. The potential space between the parietal pleura and the endothoracic fascia may contain a small amount of loose areolar tissue. This invariably results in epidural venous bleeding so it must be completed quickly. The depth of decompression should be 3 to 3. After confirmation of the correct vertebral level.5 cm on either side of the disc space. The corpectomy should extend about 1. Bipolar cautery forceps may be passed on either side of the vessels from the lateral canal entrance for effective coagulation of the ventral epidural vessels. which has been exposed through the T7 rib bed. and stellate ligaments are sharply divided and the rib head is disarticulated from the vertebral body (Figure 4b). close to the midline. Note that the most proximal 4 cm of rib. The softtissue attachments. For thoracic disc removal. intercostal vessels and nerves. Both line their respective visceral cavities and are reflected over the diaphragm as its fascia. which is attached to the transverse process and vertebral body. annulus. The corpectomy is completed . The thin dorsal layer of the posterior longitudinal ligament usually remains. which parallels the medial and inferior scapular borders.

The pleura is bluntly freed and retracted (a) from the undersurface of the endothoracic fascia to widely expose the posterior thoracic wall and vertebral bodies. The pleura has been bluntly freed from its inner surface and remains intact.SCHWARTZ AND McCORMICK : RETROPLEURAL APPROACH TO THE THORACIC AND THORACOLUMBAR SPINE 239 A B Figure 3. the endothoracic fascia is opened in line with the resected rib bed. Neurosurgery 37:908-914. B. (Reproduced from McCormick PC: Retropleural approach to the thoracic and thoracolumbar spine. with permission) Figure 4. Incision and subperiosteal elevation of the endothoracic fascia then continue proximally over the rib head (c). The endothoracic fascia remains densely adherent to the posterior thoracic wall and vertebral column. the disc space. (Reproduced from McCormick PC: Retropleural approach to the thoracic and thoracolumbar spine. and adjacent vertebral bodies. Neurosurgery 37:908-914. 1995. with permission) . an 8-10 cm rib segment is removed following subperiosteal dissection. A. 1995. The neurovascular bundle (b) has been partially mobilized from its underlying fascia to improve visualization.

Neurosurgery 37:908-914. A B Figure 6. B. VOL. with permission) . a high-speed drill is utilized for removal of adjacent endplates and pedicle. B. 1995. the disc space is evacuated using curettes and rongeurs. 8 A B Figure 5. the harvested rib is placed as an interbody strut graft. A. (Figure 6A reproduced from McCormick PC: Retropleural approach to the thoracic and thoracolumbar spine. the sympathetic chain is divided and the disc space sharply incised.240 NEUROSURGICAL OPERATIVE ATLAS. A.

it is opened.SCHWARTZ AND McCORMICK : RETROPLEURAL APPROACH TO THE THORACIC AND THORACOLUMBAR SPINE 241 A B Figure 7. The retropleural approach must be modified at the thoracolumbar junction (T11-L1) because of the diaphragm and the greater caudal angulation of the ribs. Approximation of the adjacent ribs with suture reduces the chest wall deformity associated with rib resection. The endothoracic fascia is reflected over the diaphragm and tightly applied to its surface. Table-mounted malleable blades provide retraction. This may substantially increase postoperative pain. a 12-14 cm skin incision is made over the T10 rib from the posterior axillary line to 4 cm off the midline (Figure 2). and a high-speed drill. may need to be elevated. The subcostal nerve can be seen running laterally beneath the lateral arcuate ligament on the quadratus lumborum surface. adjacent disc. The incision is carried down through the subcutaneous tissue and muscles to the T10 rib with cautery. and T12 pedicle. reconstruction is performed following adequate spinal canal decompression. The remainder of the wound is closed in layers. The pleura is then carefully inspected. Appropriate reconstruction is then performed. The costophrenic pleural reflection may also be seen. Following decompression and stabilization. which attaches to the T12 vertebral body. Part of the psoas muscle. with permission) using rongeurs. The proximal 4 cm of the T12 rib. the pleural surface of the diaphragm is depressed and detached from the inner surface of the T11 and T12 ribs with sharp periosteal dissectors. In these cases. incision and removal of discs both superior and inferior to the involved body. A 10-cm segment of exposed rib is cleaned circumferentially and removed. for example. A. The detachment is easily continued medially to elevate the arcuate ligaments off the quadratus and psoas muscles. and proximal ligation of the intercostal vessels (a) at the affected level. This immediately unites the retroperitoneum with the retropleural space. B. adequate exposure for corpectomy requires the removal of two proximal rib segments. including the rib head. This completes the exposure of the T12 vertebral body. the skin incision and rib resection are performed two levels rostral to the pathological segment. The initial exposure is tight because of the diaphragm attachment to the ribs. Neurosurgery 37:908-914. Caudally. The pleural surface of the diaphragm is identified. curettes. 1995. the arcuate ligaments are reattached to the psoas and quadratus muscles with suture. Disc incision or corpectomy is performed utilizing the principles previously outlined. Division of the ipsilateral crus completes the diaphragm mobilization. (Figure 7B reproduced from McCormick PC: Retropleural approach to the thoracic and thoracolumbar spine. In the case of a T12 vertebral body exposure. is removed. Care is taken not to ensnare the intercostal nerves with suture during closure. A chest tube should be placed if any pleural tears are identified. If the lateral endothoracic fascia is present in the rib bed. Closure .

1) Pneumothorax can be avoided by repairing any pleural tears with sutures or staples under positive pressure ventilation. 2) CSF leak is prevented by visualizing the dura early in the operation. This can be achieved by identifying and removing the pedicle to expose the lateral canal.242 COMPLICATIONS NEUROSURGICAL OPERATIVE ATLAS. 6) Carefully ligate the intercostal neurovascular bundle if performing corpectomy. or if air remains in the intrapleural space at the conclusion of the procedure. Do not use this approach above T3. Also. 4) Spinal cord infarction can be avoided by not using cautery in the foramen. 3) Horner’s syndrome can be avoided by preserving the sympathetic chain in the upper thoracic region if possible. 8 The following are commonly seen complications and suggestions for avoiding them. . a chest tube should be placed. In the face of large tears. Preserve the intercostal neurovascular bundle if only removing disc. 7) Pleural effusion can be avoided with selective placement of a chest tube or even a Hemovac drain in the retropleural space in cases where hemostasis is not totally secure due to persistent oozing from epidural veins or bone to prevent significant retropleural fluid collection. VOL. 5) Intercostal neuralgia is minimized by not suturing the intercostal nerve during rib approximation. This may be prevented by passing suture through holes drilled in the caudal rib. avoid crushing the neurovascular bundle against rib with crank retractors.

e. the traversing nerve root is much more commonly affected (i. Lateral herniation occurs more frequently at higher lumbar spine levels.D. the nerve root and ganglion are displaced cranially and/ or dorsally and are compressed against the lower edge of the upper pedicle. PH.. M. and extraforaminal disc. The straightleg raising test is usually positive if the L5 nerve root 243 . A superolateral migration of disc material occurs in most cases of lateral lumbar disc herniation. the L4-5 disc is affected in 40% of cases and the L3-4 level in 37%. Lateral disc herniations generally occur in older patients and at higher interspace levels than routine (intracanalicular) herniations. Because of the anatomical relationships of the neural foramen.D. such as lateral recess stenosis. Downward migration of a fragment is prevented by the lower pedicle. SR. an L4-5 disc herniation compresses the L4 root). extreme lateral disc. Central and paracentral disc herniations involve the L4-5 or L5-S1 levels in 95% of reported cases. Before the widespread use of computed tomography (CT) and magnetic resonance imaging (MRI) permitted an accurate diagnosis. including herniation of the foramen. patients with a herniated lateral disc often complain of radiating pain and sensory changes in the medial or anterior thigh.D.D.SURGICAL TREATMENT OF LATERAL LUMBAR HERNIATED DISCS GIUSEPPE LANZINO. M. In contrast.. Quadriceps weakness and reduced or absent patellar reflexes are common findings on neurological examination. A further differentiation can be made of a lateral disc herniation between a foraminal lateral disc herniation (when the disc material is primarily located in the intervertebral foramen) and a far lateral herniation (when the herniated disc is mainly situated extraforaminally and the nerve is compressed in its paraspinal course). far lateral disc. Lateral disc herniation has been denoted by a variety of terms. This superior migration has important surgical implications because disc fragment removal is frequently possible without compromising the facet joint. Lateral disc herniation is defined here as herniated disc material predominantly located lateral to the midportion of the intervertebral foramen.. posterior lateral disc.e. The surgical approach is significantly influenced by the location of the disc herniation relative to the intervertebral foramen (foraminal vs. JOHN A. which often overlies the intervertebral disc space. In surgical series. This is compared to an intracanalicular disc herniation when the disc lies in the midline (central) or out to the midportion of the intervertebral foramen (paracentral). with most intracanalicular disc herniations. is present. CHRISTOPHER I. an L4-5 disc herniation compresses the L5 root). M.. lateral disc herniations were difficult to visualize and were often missed on routine myelography. the incidence DEFINITION AND DIAGNOSIS © 1999 The American Association of Neurological Surgeons of lateral disc herniation ranges from 4% to 12% of all herniated lumbar discs. Since the L3 and L4 nerve roots are commonly involved. JANE. far lateral) and whether any associated intracanalicular pathology. SHAFFREY. which results in compression of the exiting nerve root at the level of the foramen (i.

Familiarity with the relevant anatomy is of utmost importance to fully understanding the surgical approach to lumbar lateral disc herniation. high-resolution CT and MRI will display lateral disc herniation when present. Signs of lateral disc herniation on MRI and/or CT studies include the presence of disc density or disc signal material at the level of or lateral to the neural foramen. careful analysis of the intervertebral foramen on the axial and sagittal images is warranted despite either the normal appearance of the central and paracentral disc or cases with associated pathology. The early phase of conservative therapy includes pharmacological pain relief (generally with nonsteroidal anti-inflammatory agents) and a reduction of activities such as heavy lifting. prolonged sitting. The intervertebral foramina are three-dimensional canals bordered anteriorly by the more cephalad vertebral body and the intervertebral disc and posteriorly by the pars interarticularis of the vertebral body above (Figures 1 and 2). Surgery is performed only when the patient’s pain is persistent and disabling following a complete 6. We frequently use CT myelography as a complementary study for patients with lateral disc herniation. The femoral stretch test is usually positive when there is involvement of the L3 and L4 nerve roots. Optimally. Figure 1.to 8-week course of conservative treatment. displacement or obliteration of perineural fat. conservative management is recommended as a first-line treatment for the patient with a lateral disc herniation. Other treatment modalities such as physical therapy and selective perineu- PATIENT SELECTION ral infiltration with steroid solution may be considered in selected patients.244 NEUROSURGICAL OPERATIVE ATLAS. thincut axial CT improves the diagnostic accuracy by showing whether the disc fragment is in continuity with the intervertebral disc and whether it encroaches on the nerve root just inside or lateral to the intervertebral foramen. Lateral herniation can occur as an isolated condition or in association with other forms of spinal degenerative disease. We believe that CT myelography continues to have a significant role in the diagnosis and management of lateral herniation because it permits a better evaluation of associated lateral recess and spinal stenosis. is sometimes present if the compressed nerve root is L4. VOL. especially in older patients in whom lateral disc herniation often occurs. To avoid overlooking this source of neural compromise. Illustration showing the anatomical relationships of the neural foramen and the far lateral space at different levels of the lumbar spine. symptoms resolve with time and no additional therapy is needed. Prolonged bed rest is not indicated and is usually counterproductive. In addition. Unless a severe neurological deficit is present. and nerve root or ganglion compression/displacement. Frequently. 8 is involved. and is usually absent when the disc involves the L3 root. In fact. the addition of high-resolution. The cranial vertebral body may constitute more of the anterior border of the foramen than the intervertebral disc. The superior margin is delimited by the inferior aspect of the pedicle of the upper ANATOMICAL CONSIDERATIONS . this may be caused by the involvement of the very sensitive posterior root ganglion. and demonstrating the relationship of the disc herniation to the isthmus laminae and transverse process. CT myelography defines the bony anatomy better than MRI and improves preoperative planning by enhancing visualization of the orientation and location of the facet joints. Myelography alone has little value in the identification of far lateral disc herniation. disabling pain more often than patients with an intracanalicular herniation. or strenuous exercise for several weeks. this diagnostic test is often negative since the nerve compression usually occurs outside the nerve root subarachnoid space. It has been suggested that patients with a lateral herniated disc may experience lasting.

(Reproduced from Chenelle AG. The lateral and most inferior portions of the inferior facet of the superior lamina are removed for an extension outlined by the dotted line. Lanzino G. Crockard HA: A posterolateral microsurgical approach to extreme-lateral lumbar disc herniation. with permission) posterior primary ramus ventral nerve root Figure 3. the ligamentum flavum is opened and a small hemilaminectomy is performed on the lamina of L3. (Reproduced from O’Brien MF. Peterson D. 1996. et al: Treatment of far lateral discs by an approach lateral to the facet joint. J Neurosurg 83:636-640. Techn Neurosurg 2:249-253. Representation of the normal anatomy. Transverse section illustrating the neurovascular anatomy and the direction of the surgical exposure obtained via an intertransverse route. 1995. Inset.LANZINO ET AL : SURGICAL TREATMENT OF LATERAL LUMBAR HERNIATED DISCS 245 partial facetectomy L4 superior facet Inset Figure 2. Shaffrey CI. with permission) .

246 NEUROSURGICAL OPERATIVE ATLAS. 8 vertebra. the transverse process. the distance between the inferior margin of the upper transverse process and the superior boundary of the facet joint averages 10 mm. Because of the usual superior migration of the lateral disc herniation. The lumbar spinal anatomy is a major consideration in determining the appropriate approach to a lateral disc herniation. while the inferior margin is circumscribed by the superior aspect of the pedicle of the lower vertebral body. and ligament). with lateral retraction of the paraspinal muscles past the facet joints to expose the isthmus of the lamina and the proximal transverse processes. intertransverse muscle. There is also a progressive decrease in the cephalocaudal dimension of the operative window because of diminished distance between the inferior border of the transverse process of L4. Lateral to the foramen is the far lateral space. However. and the superior one fourth of the facet joint is needed to achieve satisfactory exposure. especially at L5-S1 (Figure 1). in cases with significant spinal or lateral recess stenosis. The width of the isthmus lamina is small so that the lateral disc herniation at these levels frequently lies lateral to the isthmus. but rarely is more than a small resection of the superior aspect of the facet needed. at the L4-5 and L5-S1 levels the operative exposure decreases in size because the pedicles originate more obliquely. passes between the pars interarticularis and the intertransverse muscle and ligaments. resection of the lateral aspect of the isthmus. and inferiorly by the apophyseal joint of the articular facet. a prominent accessory process may be present. a midline approach. Significant compromise of the facet joint should be avoided when possible. a few millimeters of the isthmus need to be removed to identify the nerve root. the inferior aspect of the superior transverse process and accessory process. These branches include: 1) a branch to the undersurface of the transverse process. laterally and slightly anterior to the posterolateral margin of the disc. The dorsal root ganglion is found within the intervertebral foramen just medial to the lateral border of the pars interarticularis. and then through a gap between the medial free edge of the intertransverse ligament and the lateral free edge of the ligamentum flavum (Figures 3 and 8). anteriorly by the cranial vertebral body and disc covered by the annulus fibrosus. The posterior primary ramus travels in a caudal and dorsal direction. SURGICAL CONSIDERATIONS Lateral disc herniation presents a particular problem surgically because the disc fragment and disc space . and the facet joints substantially overlie the intervertebral disc space. partial or complete facetectomy is occasionally required to adequately decompress the nerve root. From a surgical point of view. 3) a laterally directed branch that enters the space between the multifidus and longissimus muscles. the isthmus laminae are substantially wider. VOL. the superior and lateral aspects of the facet joint and the transverse process at the L4-5 level. especially at the L5-S1 level. 2) a dorsally directed branch in the waist of the pars interarticularis. an exposure through a paramedian incision permits a more direct approach and reduces the need for significant bone resection. and the superior and lateral aspects of the facet joint and of the sacrum at L5-S1. The nerve root enters the foramen and far lateral space medially and superiorly. and. and the disc fragment (following removal of the lateral extension of the ligamentum flavum. The L4-5 and L5-S1 facet joints may overlap the intervertebral disc space significantly. allows for enough exposure of the lateral portion of the intervertebral foramen. The entrance and exit to the foramen are the medial and lateral margins of adjacent pedicles. when present. At these levels the facet joint partially or completely covers the intervertebral disc. the ganglion. In the upper lumbar spine (L1-2 to L3-4). the operative approach to the far lateral space is limited dorsally by the isthmus laminae (defined as the lateral margin of the interarticular portion of the lamina). Often at L4-5 and always at L5-S1. adjacent to the pedicle of the superior vertebra. and 5) a branch accompanying the lateral branch of the posterior primary ramus (Figures 3 and 8). The nerve divides into the posterior primary ramus and the ventral nerve root immediately distal to the dorsal root ganglion. This space is bordered medially by the foramen. and posteriorly by the lateral fibers of the ligamentum flavum. superiorly by the inferior margin of the cranial pedicle. Conversely. then crosses the disc space extraforaminally. laterally by the intertransverse ligament. The relationships among these structures vary significantly at different levels and the operative exposure to the lateral space becomes progressively smaller in the lower lumbar spine. Frequently. These anatomical considerations strongly affect the microsurgical approach to an extraforaminal disc herniation. by a prominent accessory process. 4) a branch into the midlateral aspect of the erector spinae muscles. The lumbar segmental artery travels through the space defined medially by the emerging nerve root and laterally by fibers of the intertransverse ligament and divides into five recognizable branches. or when severe facet tropism is present. The ventral root crosses the disc space obliquely and passes in close proximity to the lateral aspect of the caudal pedicle. From L1-2 to L3-4. the lower one fourth of the superior pedicle. the pedicles arise vertically from the dorsal aspect of the vertebral bodies.

4% and the incidence of back pain is substantially higher. and the facet joint capsules are identified. and 5) a hemilaminectomy with foraminotomy (more recently. Specific attention should be given to the bony structures in the intertransverse process region.000 epinephrine. familiarity with the operative anatomy. significant lateral recess or foraminal stenosis. For far lateral disc herniations. allowing greater exposure than the midline approaches. a midline skin incision of 6 to 10 cm is made slightly superior to the disc space of interest (Figure 4A). This technique spares the majority of the facet joint and reaches the disc through the interval between the inferior aspect of the superior transverse process and the superior border of the inferior facet joint. This multiplicity of surgical approaches underscores the difficulty in achieving adequate exposure without potentially destabilizing the spine in the course of treating these herniations. Consequences include predisposition to fracture as the patient regains full activity. The proximal aspect of the transverse processes.A. is somewhat unfamiliar to most neurosurgeons and it is not possible to directly address any intracanalicular pathology. care must be taken not to make the isthmus overly thin after resection of the lateral aspect of the isthmus lamina. Nevertheless. and the ability to address pathology within the spinal canal. 4) a retroperitoneal approach. and spinal instability. Coexisting pathology within the canal should be defined and the operative approach tailored to address all significant pathology. After the administration of perioperative antibiotics and steroids and infiltration of the skin and paraspinal muscles with 0.I. We believe that most disc herniations within the intervertebral foramen at the L2-3 and L34 levels can be reached via a hemilaminectomy approach (J. the risk of spinal instability ranges between 1. a midline approach with a partial resection of the isthmus laminae). In cases where the facet joint has been significantly compromised. We routinely use an operating microscope for bone resection and disc fragment removal to allow adequate magnification and proper illumination. If required. An intraoperative lateral radiograph is then taken to confirm the level of the dissection.6% and 2. Electrocautery and a periosteal elevator are used to subperiosteally dissect the paraspinal muscles away from the spinous processes and lamina. Care is taken to preserve the facet joint capsules during the exposure. The paraspinal muscles are retracted just past the lateral border of the facet joint and a self-retaining retractor is inserted to maintain retraction (Figure 5). which is opened in a curvilinear fashion away from the insertion on the spinous process. We have gradually modified our surgical approach.LANZINO ET AL : SURGICAL TREATMENT OF LATERAL LUMBAR HERNIATED DISCS 247 are often hidden either under or lateral to the facet joint. however. The anatomy involved. 2) a muscle-splitting paraspinal operation with lateral dissection between the transverse pr ocesses. and paramedian splitting of the paraspinal muscles. or synovial cyst formation may require incomplete or total facetectomy. simultaneous fusion may be considered. isolated disc hernia- tions truly lateral to the facet joint from L1-2 to L3-4 can be very effectively undertaken via a midline approach lateral to the isthmus lamina without hemilaminectomy. Dissection is carried down to the level of the thoracolumbar fascia. only a very small portion of the isthmus usually needs to be resected.S.).25% bupivacaine with 1: 200. the isthmus lamina. Significant coexisting pathology such as severe facet joint arthritis. placing greater emphasis on maintaining the integrity of the facet joint. If more than 50% of the facet joint is removed. Midline Approach With or Without Hemilaminectomy . This approach can be effectively performed in cases of extraforaminal lateral disc herniation at any level and is frequently the procedure of choice for cases of foraminal or extraforaminal disc herniation at the L4-5 or L5-S1 levels. This flap is retracted past the midline. Removing either the entire medial or lateral half of the facet joint results in total facet joint compromise. The midline approach with several modifications is favored by many surgeons because of the ease of dissection. This lateral approach provides more direct visualization of the disc fragment and permits reduced bone excision and muscle retraction. back pain. exploration of the intraspinal compartment can be performed through a partial hemilaminectomy for removal of any additional disc fragments or treatment of associated lumbar or lateral recess stenosis (present in 20% to 72% of the cases). Anatomical variations for each patient should be analyzed on both plain radiographs and imaging studies to help determine the optimal approach. Several surgical approaches to this area have been described: 1) a unilateral facetectomy through a midline incision. especially at lower lumbar levels. The paramedian muscle-splitting approach allows a lateral exposure either through the longissimus-iliocostalis interval or via a muscle-splitting approach through the iliocostalis muscle.) or by an approach lateral to the isthmus lamina with resection of a portion of the isthmus (C. The different approaches described can be divided in two broad categories: midline hemilaminectomy. By preserving the facet joint.J. a blunt marker placed lateral to the isthmus gives a good indication of position and facilitates orientation. the risk of instability and postoperative pain is substantially reduced. If a simultaneous partial hemilaminectomy is planned. 3) a partial hemilaminectomy with partial or complete facetectomy.

the foramen can be explored from inside and outside the canal using a blunt nerve hook (Figure 7B). it can be difficult to enter the intervertebral disc space via this approach. A small portion of the lateral section of the superior facet of the inferior vertebral body can be removed without compromising the facet joint (Figure 2 inset). A neurovascular band can be felt obliquely crossing the vertical muscle fibers and is followed ventromedially to the pedicle-transverse process junction (Figure 8A).248 NEUROSURGICAL OPERATIVE ATLAS. the ganglion. Most lateral disc herniations are sequestered frag- Intertransverse Approach . This exposes the nerve root of interest. usually 8 to 10 cm in length. Bipolar coagulation of bleeding vessels should be performed with good visualization of the vessel to avoid thermal trauma to the dorsal The patient is placed in the prone position on a spinal frame. When these steps have been followed carefully. and then investing deep fascia. The intertransversarii muscles and the intertransverse ligament can now be sharply removed from the transverse process of the superior vertebral body. Careful dissection of the tissue planes will separate the neurovascular structures from the disc fragment. root ganglion. and the ventral root. The transverse process is then palpated and access is gained in a 30-degree line to the horizontal by longitudinally splitting fibers of the iliocostalis muscle (Figure 3). when removed. fat grafts are placed over the extraforaminal and intraspinal defects. the inferior aspect of the superior transverse process and accessory process. which can be removed with pituitary microrongeurs without bone resection (Figure 8B). and the superior one fourth of the facet joint. A vertical incision. A spinal needle is inserted in the midline in the interspace of interest and an intraoperative x-ray is obtained to confirm the correct level. This method usually provides adequate access to remove the disc herniation. The skin and the paraspinal muscles are anesthetized with 0.000 epinephrine. The muscle is separated by blunt dissection. If there is associated intraspinal herniation and/or stenosis. The operative microscope is then brought into position and the pedicle-transverse process junction is identified. exposes the origin of the posterior primary ramus. 8 B A Figure 4. A selfretaining retractor is inserted to maintain exposure. fat. the ligamentum flavum is opened more medially and a small hemilaminectomy is performed laterally on the superior lamina (Figure 2 inset). the laminectomy can be enlarged to complete the intraspinal portion of the procedure (Figures 6 and 7A). If exposure within the spinal canal is anticipated. A straight incision is made along the midline for the medial hemilaminectomy approach (A) or 10 cm from the midline at the level of interest for the intertransverse process approach (B). Brisk bleeding can occur from the lumbar segmental artery and its branches if they are inadvertently compromised. Care is taken to maintain the integrity of the isthmus lamina. is made 10 cm from the midline (Figure 4B) through skin. if required. At the end of the procedure. Adjacent to the intervertebral foramen is often a “plug” of fat which.25% bupivacaine with 1:200. and handheld retractors are placed. the lower one fourth of the superior pedicle. The intertransverse fascia and the lateral extension of the ligamentum flavum are removed only when drilling and bony resection are completed because the dorsal root ganglion is vulnerable to thermal or mechanical trauma. The amount of aggressive disc removal from within the disc space has been reduced as we have observed that removal of the free fragment is all that is required for symptomatic relief in most cases. The amount of bone resection required is frequently less with upper lumbar levels than with lower levels. To ensure complete decompression of the nerve root once the discectomy is completed. VOL. The herniated lateral disc can then be removed with little nerve root retraction. At the middle and lower lumbar levels. and ruptured disc material is usually seen inferior to the nerve root. this approach allows for a relatively avascular exposure. A microdrill is used to remove a small portion of the isthmus and.

et al: Treatment of far lateral discs by an approach lateral to the facet joint. A. Shaf frey CI. Lanzino G. the paraspinal muscles are dissected using a periosteal elevator and retracted laterally.LANZINO ET AL : SURGICAL TREATMENT OF LATERAL LUMBAR HERNIATED DISCS 249 Figure 5. with permission) A dural sac traversing nerve root B Figure 6. After incising the lumbosacral fascia in a curvilinear fashion. B. the intertransverse muscle is sharply removed and the lateral herniated disc overlying the nerve root is visualized. (Reproduced from Chenelle AG. et al: Treatment of far lateral discs by an approach lateral to the facet joint. Lanzino G. with permission) . the disc is removed. Techn Neurosurg 2:249-253. Shaffrey CI. 1996. (Reproduced from Chenelle AG. Techn Neurosurg 2:249-253. 1996.

Crockard HA: A posterolateral microsurgical approach to extreme-lateral lumbar disc herniation. 8 herniated disc exiting nerve root A B Figure 7. Peterson D. with permission) medial intertransverse muscle medial branch of the posterior primary ramus extreme lateral disc herniation lateral branch of the posterior primary ramus A transverse process terminal branch of the segmental artery ventral nerve root dorsal root ganglion B Figure 8. decompressing the nerve root. B. Lanzino G. with permission) . J Neurosurg 83:636-640. A. the hemilaminectomy is extended and the disc removed working on both sides of the foramen.250 intertransverse muscle NEUROSURGICAL OPERATIVE ATLAS. Shaffrey CI. (Reproduced from O’Brien MF. if the herniated disc extends medially to the neural foramen. Techn Neuro surg 2:249-253. 1995. the microscopic view obtained by the intertransverse route. after microdissection. A. (Reproduced from Chenelle AG. a blunt nerve hook is inserted in the neural foramen to verify that no disc fragments are left behind. et al: Treatment of far lateral discs by an approach lateral to the facet joint. B. the disc can be removed. VOL. 1996.

intraforaminal and far lateral disc herniations are diagnosed more frequently. or intracanalicular pathology is present at other levels. This technique. The amount of resection of the isthmus lamina and facet joint decreases as surgeons’ familiarity with this approach increases.LANZINO ET AL : SURGICAL TREATMENT OF LATERAL LUMBAR HERNIATED DISCS 251 ments. foraminal stenosis. the anatomical relationships often make an intertransverse approach more convenient. Lateral herniated discs pose particular surgical problems because the disc is either behind or lateral to the facet joint and it is difficult to treat using a standard lumbar hemilaminectomy without significantly compromising the facet joint. CONCLUSIONS we recommend a midline approach with resection of a small portion of the isthmus lamina that spares the majority of the facet joint. With the availability and routine use of CT and MRI. When a more medial exposure is required. the annulus can be incised and fine rongeurs used to remove the degenerated disc material. After discectomy. The midline approach allows for easy exploration of the intraspinal compartment through a hemilaminectomy when medial extension of the lateral disc fragment. If a diffuse disc bulge is present. . The paramedian intertransverse technique is less familiar to many neurosurgeons and requires a new surgical orientation. especially at the lower lumbar levels. allows removal of the disc with minimal bone resection and damage to the soft tissues and offers a more direct avenue to far lateral disc herniations. For some L4-5 and most L5-S1 far lateral disc herniations. lumbar stenosis. No drains are necessary and the patient is mobilized a few hours after the surgical procedure. In cases of L1-2 or L3-4 lateral disc herniations. the split muscle comes together and sutures are confined to the deep fascia and superficial layers. however. This technique is easy to learn and the anatomy involved is familiar to neurosurgeons. Each technique has its advantages and disadvantages. the lateral margin of the isthmus lamina or facet joint can be removed without jeopardizing facet integrity.

.

Unlike previously described approaches to the cervicothoracic junction. Whereas anterior cervical plate and screw constructs can be used for the fixation of this region in the absence of severe kyphotic angulation. primarily affecting the T3 and T4 levels. GOKASLAN. In patients who have significant spinal cord compromise at the time of presentation. WALSH.“TRAP DOOR” EXPOSURE OF THE CERVICOTHORACIC JUNCTION ZIYA L.D. additional posterior instrumentation is usually recommended for those who have significant spinal deformity. and neither of the approaches described above would be optimal for exposure of this region. INTRODUCTION © 1999 The American Association of Neurological Surgeons The main indication for this surgical procedure is an anteriorly located pathology resulting in spinal cord compression due to retropulsed bone or disc fragments and/or tumor mass or kyphotic angulation. on the other hand. The standard anterolateral cervical approach combined with a median sternotomy provides satisfactory exposure of the cervicothoracic junction from C7 through the T2-3 junction. either by using polymethylmethacrylate or a bone graft after the removal of a vertebra. but also to the entire ventral cervical spinal column. surgical intervention is usually per formed within 12 to 24 hours of diagnosis. Although the anterior weight-bearing spinal column can be effectively reconstructed. The “trap door” exposure described by Nazzaro and coworkers in 1994 is a combination of the anterolateral cervical approach. median sternotomy. the placement of supplemental anterior instrumentation is difficult to achieve due to the lack of appropriately designed upper thoracic spinal fixation devices. is mostly hidden behind the great vessels. Primary and metastatic tumors may both involve the upper thoracic spine.D. which is located at the apex of the chest pyramid and offers little room for maneuvering instruments. M. however. M. In patients with traumatic injuries. it also spares the sternoclavicular junction and does not require transection of the clavicle. The T3 through T4 region. as well as to the mid and upper thoracic spine. and occasionally trauma affects this region of the spinal column. computed tomography (CT) can provide important additional details of bony anatomy and is very helpful in deter- PATIENT SELECTION 253 . and anterolateral thoracotomy and is the most suitable intervention for gaining access not only to the T3 and T4 vertebral bodies anteriorly. whereas a high posterolateral thoracotomy allows access to the thoracic spine up to the T3-4 disc space. one may elect to postpone surgery until other concomitant injuries are dealt with and the patient is stabilized medically. Whereas magnetic resonance imaging (MRI) is preferred for evaluating the cervicothoracic junction and upper thoracic spine in most patients. GARRETT L.

the left common carotid artery (origin). where this cut is connected laterally to the previously made thoracotomy incision. the mammary artery is identified and may need to be ligated and transected to permit further retraction of the chest wall. the patient should undergo placement of a large-bore intravenous catheter. depending upon the patient’s cardiopulmonary reserve. Attention is then directed toward the carotid sheath. dissection is carried further down to the prevertebral fasciae. the right subclavian artery is identified and the vagus nerve is traced down to the takeoff of the right recurrent laryngeal nerve. During this stage of exposure. running longitudinally over the anterior cervical spinal column off the midline. the dura and the right T3 nerve root are seen. especially in those in whom a left-sided recurrent laryngeal nerve dysfunction is already suspected. 8 mining the nature of compressive pathology (i.254 NEUROSURGICAL OPERATIVE ATLAS. The neck platysma is then incised. both the omohyoid muscle and middle thyroid vessels may need to be ligated and transected to gain access to the lower cervical spine. which are in the surgical field. and the left brachiocephalic vein. The anesthesiologist is then instructed to selectively deflate the right lung. PREOPERATIVE PREPARATION ANESTHETIC TECHNIQUE The use of inhalation anesthetics should be minimized in order allow somatosensory evoked potential (SSEP) monitoring for assessment of spinal cord function during surgery. In addition. Second-generation cephalosporins are routinely administered preoperatively for prophylaxis. The patient is positioned as described in Figure 2A. The anterior cervical spinal column is visualized through the space between the carotid artery and the tracheoesophageal viscera. and T3 and T4 vertebrectomies have been completed. At this stage. where it curves laterally and follows the fourth interspace. and a plane is established between the carotid sheath (laterally) and the tracheoesophageal viscera (medially) using blunt dissection. whereas the right recurrent laryngeal nerve (shown exaggerated to demonstrate its entire course and relationship to the subclavian artery and tracheoesophageal structures) is retracted ventrally and medially. Through the vertebrectomy defect. the aorta. OPERATIVE POSITIONING OPERATIVE PROCEDURE The skin incision’s path and the location of critical cuts through the chest wall that are needed to expose the important anatomical structures are illustrated in Figure 1 (with inset). Subsequently. A chest spreader is placed to open the sternum in the midline and to retract the anterior chest wall superolaterally (Figure 2C). Anterolateral chest wall is retracted superolaterally. and the take-off of the right common carotid artery are shown. as shown in the intraoperative photograph (Figure 2A). The sheath is opened and the vagus nerve identified (Figure 2D). This is particularly important if one is contemplating the use of radiation therapy as the primary mode of treatment. thereby avoiding the right internal jugular and right subclavian veins. The intravascular volume status is monitored with either a central line or a Swan-Ganz catheter. This exposure is carried out through the right side. Artist’s depiction of the “trap door” exposure. where the longus colli muscles are visualized bilaterally. because these surgical procedures may require a significant amount of blood volume replacement during the vertebrectomy pr ocedure. This catheter is placed in a femoral or left subclavian vein. the innominate artery. the right subclavian artery. Retractors in the upper cervical region and over the sternal angle allow visualization of all important anatomical structures in the midline. tumor mass effect).e. the presence of retropulsed bone fragment(s) vs. Also visible are the transected azygos vein. The incision extends along the anterior border of the sternocleidomastoid muscle down to the sternal notch. In addition to the routine monitoring needed for general anesthesia. because the right recurrent laryngeal nerve is at considerable risk during the exposure. a sternal saw is used to transect the sternum in the midline down to the fourth intercostal space (Figure 2B). Just distal to that. Next. VOL. The right carotid artery and right vagus nerve are pulled laterally.. which loops Figure 1. A plane is established at this point between the manubrium and the underlying vascular structures. so that the chest cavity can be entered without injuring the lung underneath. the superior vena cava. an appropriate preoperative laryngoscopic examination is usually needed to rule out vocal cord paralysis. In the chest cavity. . Isolated lesions involving the spine but not the lung can be addressed in patients with marginal pulmonary function. From there the incision is carried down the midline and over the sternum to the fourth intercostal space. The innominate artery is then located under the sternal notch and is dissected free laterally up to the take-off of the right carotid artery. Rib heads have been removed.

GOKASLAN AND WALSH : “TRAP DOOR” EXPOSURE OF THE CERVICOTHORACIC JUNCTION 255 right internal jugular vein sternocleidomastoid muscle esophagus right vagus nerve right recurrent laryngeal nerve cervical spine trachea innominate artery left brachiocephalic vein right common carotid artery sternum T5 superior vena cava aorta azygos T3 nerve root right brachiocephalic vein dura right atrium lung right ventricle Figure 1. .

256 NEUROSURGICAL OPERATIVE ATLAS. VOL. 8 right vagus nerve right common carotid artery right recurrent laryngeal nerve innominate artery left brachiocephalic vein superior vena cava A aorta right phrenic nerve D right brachiocephalic vein right lung heart B E C F .

r econstruction of the spinal column is performed. Also seen are the DeBakey forceps. right innominate artery. Intraoperative photographs of the patient presented as an illustrative case. the vertebrectomy is carried out using the standard landmarks. the disc space between the vertebrae above and below is identified. close-up view of the posterior chest wall and the upper thoracic spine. F. Parietal pleura has been resected over the spine inferiorly. as well as the brachiocephalic vein. Also seen is the right recurrent laryngeal nerve. This vein is dissected free of the surrounding areolar tissue and is ligated. down to the T5-6 disc space. Visualized structures include the right common carotid artery. Either transaxial illumination with headlights and loupe magnification or an operating microscope can be used during this part of the procedure. D. transfixed. The azygos vein usually crosses the T4-5 disc space from a lateral to a medial direction in joining the superior vena cava. decompressed dura can be observed. The cervical plate extends from T1 to T5 and has vertebral body screws located at the T1 and T5 levels. and then the annulus is incised using a #15 blade. The lower cervical dissection has been completed. depending upon the number of levels of ver- Reconstruction Figure 2. and aorta. right vagus nerve. allowing them to be dissected free of the vertebral bodies and to be retracted more laterally. close-up view. Lateral to the plate. However. the use of a sternal saw following cervical dissection and completion of the anterolateral thoracotomy. The anterolateral parietal pleura. The low cervical exposure present at this point allows insertion of the screws into the vertebral bodies anteriorly at the T2 level. The azygos vein. from which it is carried to the fourth intercostal space over the sternum in the midline.GOKASLAN AND WALSH : “TRAP DOOR” EXPOSURE OF THE CERVICOTHORACIC JUNCTION 257 under this vessel. After the thoracic level has been confirmed. the disc material is removed using curettes of various sizes and Leksell rongeurs. Bipolar electrocautery is used for hemostasis. T3 and T4 are mostly hidden from view behind the great vessels. apical. and the right lung has been selectively deflated. In patients with tumors. usually with a small upward-angled curette. as well as the pericardium (more medially). A. all the anatomical structures of importance. Also visible is a double-lumen endotracheal tube that allows selective ventilation of the lungs during surgery. The surgeon’s hand is retracting the right lung to show the thoracic spinal column. following the space between the fourth and fifth ribs. in trauma patients. which is hidden from view under the plate. and a vessel loop is placed around it for identification. This provides exposure of the upper thoracic spine. After completion of the reconstruction. allowing further medial retraction of mediastinal pleura. A fibular strut graft or a tibial allograft can also be used for reconstruction of the anterior weight-bearing spinal column. an ultrasonic aspirator is often useful for breaking down and aspirating the tumor in a piecemeal fashion. After the recurrent laryngeal nerve has been identified and properly protected. The incision follows the anterior border of the sternocleidomastoid muscle down to the sternal notch. autologous bone from the iliac crest is preferred. These vessels are doubly ligated with 20 silk ties. and innominate arteries. In the case of tumor resection. pericardium. usually at the T1-T2/3 junction. Subsequently. the position of the patient and planned skin incision prior to draping. The incision is then curved laterally. The T2 through T4 vertebrectomy has been completed. whereas the lower aspect of the plate can be carried down to T5 or even further. and transected. and posterior chest wall pleurae covers the anterior and anterolateral surface of the T3 and T4 vertebral bodies. at the T5 level. which loops around the right subclavian artery and enters the tracheoesophageal groove. is retracted superolaterally. B. showing the transition from the lower cervical region to the chest cavity. either with an intraoperative x-ray or by visual inspection. crossing the C7T1 vertebral region. blunt dissection is used to obtain further exposure of the cervicothoracic junction. if needed. . After completion of the vertebrectomy. right brachiocephalic vein. This nerve is then traced more medially to where it enters the tracheoesophageal groove. Usually. The junction of the mediastinal. The surgeon’s hand is retracting the tracheoesophageal viscera medially. The patient’s head is turned to the left and his neck is slightly extended by placing a roll between the scapulae. right subclavian arteries (origin). has been ligated and transected. which is covered by parietal pleura extending from the mediastinum. vessel loops are placed around the carotid. and transected. The arms are tucked in at the sides and padded. it is opened and removed. polymethylmethacrylate is used. which crosses the field at the T4-5 level. close-up view showing the final construct. The pleura is incised over the spinal column and is dissected off the spine (Figure 2E). clipped. After the posterior longitudinal ligament is exposed. Also visualized are the right lung and the right brachiocephalic vein. the placement of anterior instrumentation can usually be carried out using a cervical plate and screw construct (Figure 2F). which have been passed from the lower cervical region into the chest cavity through an opening in the apical pleura. Further dissection at this stage also allows visualization of the thymus. and the anterior spinal column has been reconstructed with polymethylmethacrylate. E. A high-speed diamond-tipped burr is typically used to remove the vertebral body down to the level of the posterior longitudinal ligament. along with the chest wall. At this point it is possible to visualize the segmental vessels at the T3 or T4 levels and. Similarly. C. subclavian.

8 tebrectomy performed during the procedure. Other structures at risk include the carotid artery. Blunt dissection allows protection of the tracheoesophageal structures medially and the carotid artery more laterally. the great vessels. After completion of the instrumentation. If the surgeon believes the potential exists for a continuous CSF leak. In addition. as soon as the thoracic output has fallen below 150 cc in 24 hours or when there is no significant pneumothorax on the follow-up chest x-ray). during the exposure. as well as complications related to the thoracotomy procedure. the subclavian and vertebral arteries (as they are dissected out). Both the sternal incision and the anterolateral thoracotomy incision can be closed using either staples or a subcuticular running suture.. a barium swallow study should be obtained to confirm that the perforation has sealed. the esophagus and trachea. Unfortunately.e. injuries to these structures can be dealt with more easily if the thoracic surgical exposure has already been completed. fistula. two chest tubes are usually placed. However. and the rib cage is closed using 2-0 Vicryl pericostal interrupted sutures. The diagnosis can be confirmed with an esophagogram. as well as to avoid placing it in traction. The sternum is closed using interrupted 5-gauge stainless steel wires. more medially. If cer ebrospinal fluid (CSF) is visualized during surgery. Specialized Instrumentation During the procedure. Therefore. The neck incision is closed at the platysmal layer using 3-0 Vicryl running sutures. The peristernal fascia and the subcutaneous layer are closed with 1-0 and 2-0 Vicryl sutures. Subsequently. the right lung is re-expanded. the chest tubes that are routinely placed to prevent postoperative hemo. The wound should be drained and the patient placed on nasogastric drainage for at least 7 to 10 days. the innominate artery. Closure Techniques Throughout the procedure. as well as by intravenous pressure or Swan-Ganz catheter readings. and the skin is closed using a subcuticular 4-0 Vicryl running suture. In the chest cavity. an ultrasonic aspirator is very helpful for removing tumor tissue. If needed. in the majority of the cases. At this point. this would require postoperative lumbar CSF drainage. one should remove chest tubes as quickly as possible (i.or pneumothorax would also contribute to a CSF leak by creating a negative pressure. respectively. and. exposure of the lower cervical spine is achieved in a standard fashion by mobilizing the longus colli muscles bilaterally. a vascularized intercostal muscle flap can be used to plug the dural opening.258 NEUROSURGICAL OPERATIVE ATLAS. However. and the brachiocephalic vein can potentially be injured during the dissection. The neural structure at highest risk is the recurrent laryngeal nerve. In this situation. Monitoring COMPLICATIONS Complications of the “trap-door” exposure of the cervicothoracic junction procedure are those typical of anterolateral cervical exposure. Esophagoscopy or CT scanning . the vagus nerve. VOL. The subcutaneous layer in the cervical region is approximated using 3-0 Vicryl inverted interrupted sutures. Esophageal laceration can also occur. the subclavian artery. Should a dural tear occur during the vertebrectomy procedure. in the presence of an intraoperative CSF leak. The presence of crepitus in the neck or of mediastinal air on a chest x-ray should strongly suggest the possibility of an esophageal perforation. or mediastinitis. the important vascular and neural structures are protected and are in view at all times. Again. If the laceration of the esophagus is recognized intraoperatively. Following irrigation of the chest cavity. either as a result of sharp dissection or from the sharp teeth of the cervical retractors. injury to the esophagus is not recognized at the time of surgery and presents later as a local infection. and great attention should be paid to preserve this structure completely. although this test is not always positive. placement of a postoperative lumbar drain for CSF drainage for 4 to 5 days following the operation is almost always required. especially with metal retractors. Both tubes are brought out through the anterolateral chest wall along the anterior axillary line at the T8-9 level. SSEP monitoring is r outinely used to assess the spinal cord function. as they could potentially compress the recurrent laryngeal nerve. its primary repair is extremely difficult. The ribs are brought together with a rib approximator. one can usually place a piece of muscle or fascia lata over the dura along with Gelfoam and fibrin glue. usually with a vascularized muscle graft (as described above) and postoperative CSF drainage. At no time during this procedure should metal retractors be used. an additional drain can be placed in the cervical incision and brought out of the operative field through a separate stab wound incision. A CSF leak occurring postoperatively in spite of these precautions may require reoperation and repair of the dural tear. it should undergo primary repair. and the patient is kept at bed rest. one located posteriorly and the other more anteriorly. A diamond-tipped burr is used exclusively for the removal of the vertebral body because it does not snag either the dura (during the exposure of the thecal sac) or the other soft tissue structur es around the exposed area. generalized sepsis. Fluid volume replacement is determined by the blood loss observed during the procedure.

Occasionally. followed by insertion of posterior instrumentation with titanium rods. Artifacts visible posterior to the thecal sac are the result of previously placed cervicothoracic instrumentation consisting of hooks. His neurological examination was unremarkable. The treatment of a delayed perforation consists of nasogastric drainage. and reexploration of the incision. and Wisconsin wires. he presented with recurrent tumor around the methylmethacrylate construct that was placed during the initial procedure. because the esophagus can sometimes get caught in the drill burr. depending upon the need for the graft in maintaining spinal stability. resulting in esophageal per- foration. Postoperative MRI of the patient in Figure 2 showing the T2 through T4 vertebrectomy.GOKASLAN AND WALSH : “TRAP DOOR” EXPOSURE OF THE CERVICOTHORACIC JUNCTION 259 following an esophagogram may also demonstrate perforation. Once found. Preoperative MRI of the patient in Figure 2. Also. In addition. and the patient treated with antibiotics and nasogastric drainage. The patient had already undergone a transpedicular T3 vertebrectomy for metastatic renal cell cancer. and Wisconsin wires. In order to avoid injury to the esophagus. Epidural tumor extended rostrally and caudally behind the T2 and T4 vertebral bodies. attention should be paid to make sure that the esophagus or the other soft tissue structures are not protruding into the field between the retractors during the use of the power drill. hooks. Either replacement or removal of the graft may be indicated. if possible. a displaced graft can perforate the esophagus. resulting in myelopathy. the methylmethacrylate construct extending from T1 to T5. antibiotics. as described previously. the longus colli muscles should be freed enough both rostrally and caudally that the sharp teeth of the self-retaining retractors can be safely placed under them without being likely to dislodge during the procedure. Figure 4. The esophageal perforation should be repaired. rods. MRI revealed a T3 vertebral body metastasis involving primarily the left pedicle as well as radiographic spinal cord ILLUSTRATIVE CASE Figure 3. A 27-year-old white man with a history of renal cell carcinoma presented with a 3-month history of progressively worsening interscapular pain. thereby necessitating re-exploration. a defect can be repaired. one should minimize the use of sharp dissection below the level of the superficial cervical fascia. Six months later. and the cervical locking plate/screw fixation. .

hooks and Wisconsin wires.260 NEUROSURGICAL OPERATIVE ATLAS. The patient underwent a T3-4 laminectomy. VOL. Postoperatively. the patient’s myelopathy resolved (Figures 4 and 5). reconstruction with methylmethacrylate. Also seen is the initially placed posterior cervicothoracic fixation including rods. At 1year follow-up review. and had posterior cervicothoracic instrumentation and fusion (C4-T8). hooks. a transpedicular T3 vertebrectomy. Figure 5. Titanium rods. and Wisconsin wires were used initially for posterior fixation. In this patient. surgery was followed by local radiation therapy. 8 and nerve root compression. the construct consists of methylmethacrylate (which replaces the T2-4 vertebral bodies) and a cervical locking plate (with screws) extending from T1 through T5. as described in this chapter and figures. Postoperative anteroposterior (left) and lateral (right) x-rays of the patient in Figure 2 showing that anteriorly. He returned 4 months later with left T3 radiculopathy. extending behind the T2 and T4 vertebral bodies. The patient did well following surgery and was placed on chemotherapy. the decision was made to proceed with a “trap door” surgical exposure and to per form a T2-4 vertebrectomy and an anterior reconstruction with instrumentation. the patient was fully ambulatory with no symptoms. . MRI (Figure 3) showed recurrent tumor posterior to the methylmethacrylate con- struct. At this point. A neurological examination revealed myelopathy.

The direct or suture repair may be performed using an epineurial. INTRODUCTION © 1999 The American Association of Neurological Surgeons Nerves may be generally divided into four basic patterns of intraneural architecture. an understanding of the connective tissue layers as well as the fascicular anatomy of a nerve is important. in close association with Schwann cells and the basement membrane that surrounds Schwann cells.A. M. particularly the perineurium. From a practical viewpoint. For example. 261 . Methods of peripheral nerve repair fall under two basic categories: direct repair (neurorrhaphy). The axons are contained within fascicles. the ulnar nerve is polyfascicular as it comes off the brachial plexus and then generally becomes organized into four fascicles at the level of the elbow.A.D. A. repair of the peripheral nerve is in order. The connective tissue.SC. the motor branch in the hand is monofascicular.A. the distal axon undergoes Wallerian degeneration. There is an external epineurium and an internal epineurium.C.S. and bridge procedures in which autologous nerve grafts are most commonly utilized. The polyfascicular pattern exists either with fascicles grouped together or with a more diffuse (ungrouped) arrangement throughout the cross section of the nerve. there is more connective tissue in the nerve where it crosses the joint.C..SC. The internal epineurium demarcates fascicles and groups of fascicles within the nerve.N. an external epineurial sheath surrounds each peripheral nerve and is composed of connective tissue and longitudinal blood vessels.(C) MARGOT MACKAY. In the absence of effective spontaneous regeneration. Attempted regeneration from the proximal axon may or may not be successful. B. M...R. The fascicular nature of a nerve changes as it extends from proximal to distal in the extremity. from 25% to 85%. Following a nerve injury resulting in axotomy. the endoneural basal lamina. a grouped fascicular. F. throughout the cross section of the nerve. which contains a diagram of the peripheral nerve architecture and its components. finally. the smallest component of nerve that can be repaired is the fascicle. It is also the layer that can take and hold a suture.” Most nerves contain many fascicles of varying sizes and are termed polyfascicular. As seen in Figure 1. Each individual fascicle is surrounded by perineurium. is the source of the main tensile strength to the nerve. based on their fascicular structure (Figure 1).S. or various combinations of these methods. In general. To appreciate the suture repair of a peripheral nerve. These fascicles are further segregated into motor and sensory groupings at the level of the wrist and. depending primarily on local and certain systemic factors.M.” while those containing a few or a discrete number of fascicles are “oligofascicular. a fascicular. Nerves containing one large fascicle are termed “monofascicular. The proportion of connective tissue within the nerve varies considerably.PERIPHERAL NERVE SUTURE TECHNIQUES RAJIV MIDHA.

It also provides viable Schwann cells. It must be stressed at the outset that a peripheral nerve repair is not a type of cellular repair. VOL. They also undergo rapid revascularization. with emphasis on the connective tissue layers of the nerve (i. the graft provides an endoneural tube network available to be exploited by regenerating axons from the proximal host nerve stump. 8 FASCICULAR PATTERNS IN PERIPHERAL NERVES monofasicular oligofascicular polyfasicular grouped ungrouped (diffuse) PERIPHERAL NERVE COMPOSITION external epineurium internal epineurium fascicle perineurium endoneurium nerve fiber Figure 1. Note that a nerve graft functions as a conduit whose axons are destined to undergo degeneration as soon as it is removed from its harvest site. Schematic diagram of peripheral nerve architecture and composition. The anatomical composition. so that axons from the proximal stump can regenerate into endoneural tubes within the distal nerve stump and. The small-caliber nerves. when sutured in a series of parallel segments. small-caliber cutaneous nerves are most commonly used as graft material.. are in close proximity to tissue fluid and are therefore nourished. be led to end organs to restore function. perineurium. and polyfascicular (grouped and ungrouped). Thus. as long as the caliber of the nerve graft is not too large. The appropriate anatomical environment is then provided. . hence.e. and endoneurium) are illustrated. but is actually a repair done at the level of the connective tissue to coapt a healthy proximal nerve to a healthy distal nerve stump.262 NEUROSURGICAL OPERATIVE ATLAS. epineurium (external and internal). and thus remain viable. For this reason. oligofascicular. The patterns of fascicular structure of peripheral nerve are illustrated: monofascicular.

Thus. In general. In these situations. the patient is allowed gradual and progressive range of motion supervised by an appropriately instructed physiotherapist.g. a direct repair is appropriate. the elbow joint for upper extremity and the knee joint for lower extremity) may be appropriate. The author prefers the use of general anesthesia and does not use tourniquets for these procedures. Special attention to draping of the limb or a different limb for procuring nerve grafts is also required. as attempting to oppose or graft scarred proximal and distal stumps is a major cause of nerve repair failure. In clean lacerating injuries. If this can be performed without suture distraction. since these injuries are also explored weeks to months following trauma. The surgeon identifies normal nerve proximal and distal to the zone of injury. tethering forces to adjacent surrounding fascial and subcutaneous tissue are removed. a direct repair is appropriate. proximal and distal mobilization of the nerve for considerable distances should be performed. Appropriate positioning of the limb. In all situations. I place bulky dressings (but not splints) around the incision area and leave in place for 2 weeks as a reminder to the patient to avoid excessive motion. so that postoperative mobilization occurs without risk of distraction at the suture line. However. the gross anatomical details of the injury are identified. however.. a graft repair must be performed. Nerve repairs performed with a joint in slight flexion (e. there is considerable scar formation and distortion of tissue. allowing short gap lengths to be overcome. and then works toward the area of injury. This step is critical. the area of exposure may be relatively small. the area of injured nerve is circumferentially exposed. As advocated by Kline. should be avoided. 8-0. given at the induction of anesthesia. such as the ulnar nerve at the elbow. necessitating a wide exposure. using a fresh blade. The surgeon must be prepared to expose the nerve well proximal and distal to the area of injury. allowing a considerable length to be obtained (Figure 3). To control bleeding from the nerve ends. Indeed. intraoperative nerve action potential studies dictate an external neurolysis only if evidence of spontaneous regeneration (the presence of a nerve action potential studies) is found (Figure 2). If the gap is short and the two ends can be brought together without undue tension. In certain situations. However. 8-0 and more rarely 9-0 sutures are utilized for proximal repairs such as brachial plexus elements and 10-0 sutures are utilized for more distal repairs and fascicular coaptations. With the aid of an operating microscope. should be used. Direct end-to-end repair is possible in the majority of clean lacerating injuries and in cases of delayed repair when the two ends can be brought together without tension. The author uses magnification with the operating microscope (others may prefer loupes) for all repairs. the surgeon then cuts across the center of the neuroma. Indispensable tools include microinstruments with fine tips (such as jeweler’s forceps) and fine-tipped microsuture needle drivers. This type of adequate debridement invariably leaves some degree of gap between the proximal and the distal stump. On the other hand. padding of pressure points. Using sharp dissection techniques. Healthy fascicular tissue is recognized when the epineurium retracts slightly and the endoneurium appears to “pout” or mushroom out of the fascicles (because of positive endoneural pressure). determined by the caliber of the nerve undergoing repair. One can therefore avoid prolonged limb immobilization.MIDHA AND MACKAY : PERIPHERAL NERVE SUTURE TECHNIQUES 263 A detailed knowledge of the gross anatomy of the extremities and peripheral nerves is imperative before undertaking nerve exploration and repair. Excessive flexion of joints. Brachial plexus repairs are protected with a shoulder immobilizer or sling for 3 weeks. if the ends are under considerable tension and the suture line appears to tear out. Since the nerve may need to be stimulated intraoperatively to evoke muscle contractions. Thereafter. Commonly. the extremity will need to be splinted in this position for 2-3 weeks postoperatively and then gradually mobilized with physiotherapy. Small segments of the nerve are sliced in perfect cross section. One good way to determine the GENERAL PRINCIPLES OF NERVE EXPLORATION AND REPAIR degree of tension present at the suture line is to bring the ends together using the stay epineurial sutures. The isolation of the nerve itself should be performed using sharp dissection. most nerve repairs should be performed with the extremity in a state of near-maximal extension. the lack of evidence of spontaneous regeneration (the absence of a nerve action potential studies) dictates resection of the neuroma and appropriate repair. minor oozing is often halted by simple DIRECT REPAIR . 9-0. only a short-acting paralyzing agent. until a healthy fascicular pattern is identified both at the proximal and at the distal stump (Figure 2C and D). the nerve may be transposed. or 10-0 monofilament nylon microsutures are utilized. Under the operating microscope. Under most circumstances for extremity nerve repairs. and wide draping are essential. most injuries leave the nerve in continuity. Several techniques are available to bring the proximal and distal stumps closer together and allow a direct repair to be performed. The placement of lateral stay sutures using 6-0 monofilament (as illustrated in Figure 2A and B) helps maintain the topographical alignment of the nerve.

264 NEUROSURGICAL OPERATIVE ATLAS. VOL. . 8 A B C D Figure 2.

(Figure 2C reproduced courtesy of Dr. schematic diagram demonstrating progressive sectioning until a grossly normal fascicular pattern is observed. the ulnar nerve undergoes anterior transposition. An injury gap of the ulnar nerve just distal to the elbow is used as an example. A. operative photomicrograph demonstrating sequential sectioning of the neuroma under microscopic magnification to obtain a fascicular pattern. C and D: sectioning technique used to debride the neuroma in continuity until all scarring has been removed and a fresh fascicular pattern is observed at the nerve stump. Drawing demonstrating techniques available to gain length to allow direct repair of nerve ends without tension. In addition to slight flexion of the elbow joint. Figure 2. A and B: surgical management of a neuroma in continuity. The nerve appears attenuated at the site of the neuroma. These two maneuvers relax the nerve. B. Alan Van Beek) . and permit tension-free direct repair. D. drawing of a neuroma prepared for resection and debridement. There was no demonstrable evidence of regeneration across the deep peroneal branch (no return of clinical function and absence of a nerve action potential across the neuroma). C. with 6-0 stay sutures placed proximal and distal to the neuroma. overcoming the gap. encircled with the Penrose drain) conducted a nerve action potential and underwent neurolysis. The superficial peroneal nerve (in the upper part of photograph. operative photomicrograph illustrating injury to the peroneal nerve just proximal to the head of the fibula.MIDHA AND MACKAY : PERIPHERAL NERVE SUTURE TECHNIQUES 265 Figure 3. Stay or lateral stay sutures are positioned to orient and topographically align the nerve. The site of the initial nerve section is across the middle of the neuroma (solid line in center).

Neurorrhaphy is performed using 8-0 to 10-0 nonabsorbable nylon sutures.. grouped fascicular. It is critical to avoid tying the knot under too great a tension. digital) nerves and diffusely grouped polyfascicular (most proximal limb and plexus element) nerves. Achieving appropriate nerve alignment can be aided by inspecting for longitudinal blood vessels in the epineurium as well as attending to fascicular alignment. The goal is to obtain good coaptation of proximal and distal fascicular anatomy. 8 Figure 4. until the final repair is achieved (inset). These repairs are most appropriate for monofascicular (e. This distance is then divided in half and two further sutures are positioned.g. Epineurial suture repair technique. Epineurial suture repair has been a traditional method of nerve coaptation. However. as this will cause overriding or an accordion effect on the fascicles or. pressure with cottonoids. Sutures are placed with the needle passed through the internal and external epineurium from both stumps to approximate the nerve ends. Simplistically. more substantial bleeding from small epineurial vessels should be controlled using small amounts of bipolar current delivered via fine-tipped jeweler’s forceps. in fact. Lateral stay sutures and vascular landmarks are used to maintain topographic alignment. without tension and with appropriate rotational alignment of both stumps. . pouting out of a fascicle from the epineurial repair site. The two initial sutures are placed 180 degrees apart from each other (Figure 4). The use of lateral stay sutures (Figure 2) also aids this process. The use of a microirrigator for saline flushes enhances visibility and further aids the performance of the nerve repair. Direct repair techniques include epineurial. and fascicular repairs. thus defeating the purpose of suturing. Excess sutures may result in additional scarring and are to be avoided. VOL. four to eight sutures suffice for approximating the proximal and distal stumps in a tension-free manner. Freshening of the two nerve ends to debride the nerve and re- Epineurial Repair move scar tissue is therefore critical. The indications and use of each of these techniques are described here. this method achieves continuity of the connective tissue from the proximal to the distal stumps. in the majority of cases.266 NEUROSURGICAL OPERATIVE ATLAS. The number of epineurial sutures required varies. A small bite of the internal and external epineurium (being careful to avoid perineurium) is taken from both stumps and the suture is tied using only mild to moderate tension (Figure 4).

a portion of the nerve that is clearly regenerating (by clinical and electrical criteria) is preserved in continuity using external and internal neurolysis techniques. Microsutures are placed through the interfascicular epineurial tissue. each surrounded by a variable amount of internal epineurium. such as the elbow-to-wrist segments of the ulnar and median nerves. More distal extremity nerves.. the grouped fascicular technique is especially indicated in situations where an easily identifiable part of the cross section of the nerve supplies sensory function. preventing overriding of fascicles.MIDHA AND MACKAY : PERIPHERAL NERVE SUTURE TECHNIQUES 267 Figure 5. while another portion of the nerve supplies motor function. Another indication is the nerve injury requiring a split repair. under the operating microscope. avoiding perineurium and allowing coaptation of fascicular groups from the proximal to distal stumps. Debridement is followed by careful analysis. As in the epineurial repair method.g. avoiding perineurium and allowing coaptation of fascicular groups from the proximal to the distal stump (Figure 5). In this situation. A grouped fascicular repair technique is a potentially more accurate method than epineurial repair. experimental and clinical studies have not shown a clear advantage of one technique over the other. are examples of nerves that merit this type of repair. The sutures are tied using mild to moderate tension. the proximal and distal stumps can be matched. branching of nerve just proximal and distal to the injury site). Grouped fascicular repair technique. a disadvantage of epineurial repair is the inability to precisely match the appropriate proximal and distal fascicles. while the groups of fascicles that are clearly neur otemetic Grouped Fascicular Repair undergo repair. the nerve ends are matched by resecting damaged tissue. Once groups of fascicles are adequately matched. Theoretically. with the external epineurium dissected away (Figure 5). . Groups of fascicles may vary from two to several. and other spatial landmarks (e. the longitudinal blood supply. However. 8-0 or 9-0 microsutures are placed through the interfascicular epineurial tissue. Interfascicular dissection is then performed within the internal epineurium to draw out groups of fascicles (Figure 5). of the anatomical cross sectional appearance of the nerve stump. Using the cross sectional appearance. For practical purposes.

Jack Tupper) A B Figure 7. placed in the perineurium. David Kline and from Dubuisson A. Note that in the graft undergoing suturing. B. three sutures. are used to coapt individual or groups of two or three fascicles to each other. 1992 with permission) . Note that each fascicular repair requires two or. Fascicular repair. Kline D: Neurol Clin North Am 10:935-951. VOL. schematic drawing of interpositional grafts being sutured to the host nerve. The interfascicular technique is used to repair individual graft segments to groups of fascicles from the host proximal and distal stumps. operative photograph showing the completed repair of posterior tibial nerve injury with four interposed sural nerve grafts. 8 A B Figure 6. (Figure 7B reproduced courtesy of Dr. the needle bites of the graft and host stumps allow widening (or “fishmouthing”) of the cross sectional area of the graft to allow complete coverage of the host stump. at most. fine 10-0 nylon microsutures. A. A. an acutely lacerated nerve has its fascicular configuration dissected out. (Figure 6B reproduced courtesy of Dr. B.268 NEUROSURGICAL OPERATIVE ATLAS. Graft repair of the peripheral nerve. with topographical relationships used to align proximal and distal fascicles.

As much as possible. Sutures. using epineurial and interfascicular epineurial techniques (Figures 5 and 7). In the minority of situations. Again. a nerve graft should be about 10% longer than the existing nerve gap. the median and the ulnar nerve at the wrist). is helpful. Also. are required for each nerve graft at each coaptation site. when dealing with proximal nerves and nerve elements such as the brachial plexus.MIDHA AND MACKAY : PERIPHERAL NERVE SUTURE TECHNIQUES 269 In rare situations. specific fascicular anatomy is possible. occasionally. nerve grafting is generally performed with the extremity in full extension. only two or three sutures should be used in this situation. are positioned and passed through the epineurium of the nerve graft and then through the interfascicular epineurium of the host stump. many direct nerve repair techniques are a combination of epineurial and group fascicular repairs. sural) and upper extremities.g. Fascicular Repair The surgical technique of nerve grafting is similar in many ways to that of direct nerve repair. spatial alignment of fascicles allows the best possible matching. (Donor nerves that are available for nerve grafting and methods for procuring these are discussed in the next volume of the atlas. When preparing the proximal and distal stumps. repaired primarily where individual motor and sensory fascicles can be defined. This must be taken into consideration when harvesting the donor nerve. more precise anatomical matching with regard to group fascicular and. This allows for the most precise repair possible. when direct repair cannot be performed without undue tension. Thus. approximately 180 degrees apart. placed circumferentially around the nerve at approximately equal distances. individual injured fascicles from the proximal and distal stumps may be specifically repaired to each other. The fascicular repair can then be strengthened by repairing loose epineurial sutures of the surrounding nerve and grouped fascicle repairs of the remaining nerve elements. the fascicular repair of a specific nerve component may be required. When the caliber of the host nerve stump undergoing GRAFT REPAIR grafting is the same dimension as the nerve graft. In this sense. In general. The nerve graft is then sewn in place to the proximal group of fascicles. an understanding of the gross anatomy and the branching pattern of the nerve. nerve grafting must be undertaken.. a slightly larger segment than the gap is needed. The majority of autologous nerve grafts are cutaneous nerves of the lower (e. defeats exact matching. a specific fascicular repair may be indicated. allowing capture of the maximum number of regenerating axons. In general. An example of where this repair would be appropriate is a clean lacerating injury of the median or ulnar nerve at the wrist. Several segments of nerve graft will therefore be needed to allow coverage of the entire cross sectional surface of the host nerve stumps. The suture is placed through the perineurium of the proximal and distal stumps with careful avoidance of the internal endoneural contents (Figure 6). as they will result in lateral bulging and herniation of endoneural contents. Therefore. and occasionally three or four sutures. A corollary to this is that when nerve grafting is performed. where groups of fibers are exchanged among fascicles in a longitudinal manner. the purpose is to attain tension-free coaptation of the proximal and the distal stumps. From a simplistic viewpoint. The use of a given technique or combinations will depend on the specific nerve injury encountered and the underlying specific fascicular pattern. It is important to re-inspect all proximal and distal coaptation sites at the completion of the repair to ensure that no graft ends became disconnected while others were being sutured in place. the cross sectional area of the host nerve stump will be several folds larger than the diameter of the nerve graft. Another example is a partial injury across a portion of the cross section of the nerve. As Sunderland has shown. The end of the graft segment then covers as much of the fascicular area of the host nerve stump as possible. the grafts are aligned in orientation so that groups of proximal fascicles will be directed to appropriate groups of distal fascicles. Here. the plexiform nature of the more proximal nerve elements. Typically. the surgeon should be adept in all of the techniques described here. For each nerve treated. there must be no tension at the proximal and distal repair sites to prevent postoperative distraction. Tight suture ties should be avoided. The diameter of the group of fascicles should approximate that of the cutaneous nerve graft obtained. spreading the cross section of the graft in a fish-mouth configuration (Figure 7). . as well as knowledge of interfascicular anatomy.g. with the exception that there are two suture lines. The nerve graft segments are sutured to the distal group of fascicles in a similar manner.) It is imperative to harvest the maximum amount of nerve graft material available. In the most distal nerves (e. This repair requires the use of high magnification and fine 10-0 nylon microsutures swaged on a 75-µm needle. the interfascicular and external epineurial tissue must be dissected away to allow groups of fascicles (or fingers) to be created at each stump (Figure 7). The graft repair technique is similar to the various repair methods already outlined. two sutures. Frequently..

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