TUMORS OF THE FOURTH VENTRICLE

AND CEREBELLUM IN ADULTS

M. N. PAMIR

INTRODUCTION

The posterior fossa can harbor a diverse pathological spectrum of lesions. The
incidence of these lesions varies considerably with age. Intraaxial tumors in
this region can originate from the fourth ventricle, cerebellum and/or brain
stem. Although the vast majority of intra-axial posterior fossa tumors in
adults are metastatic in origin, other tumors and tumor like lesions may be
encountered in this region, especially in young adults. The management strat-
egy depends on the nature and localization of the lesion and preoperative ra-
diological diagnosis plays a very important role in choosing this strategy.
When surgery is indicated, cerebellar tumors can be approached with a me-
dian suboccipital craniectomy, unilateral posterior fossa craniectomy or lat-
eral suboccipital retromastoid approaches. The fourth ventricle tumors are
also approached with a posterior median craniotomy/craniectomy. After du-
ral opening, the fourth ventricle is exposed through the telovelotonsillar fis-
sure by cutting the tela choroidea or with a midline approach with vermian
splitting. The exposure of fourth ventricle tumors by splitting of the vermis
was first described by Dandy, who indicated that this can be performed with-
out serious complications. However, cerebellar mutism, as well as other neu-
rological sequelae. As an alternative technique to avoid vermian splitting,
Yaşargil described the median inferior suboccipital approach along the tonsil-
louveal sulcus to expose fourth ventricle lesions. Matsushima et al. reported
the use of cerebellomedullary fissure for a similar approach.

RATIONALE

The posterior fossa extends from the tentorium down to the foramen mag-
num and contains cerebellum, brainstem, fourth ventricle and the cranial
nerves. Intraaxial tumors of the posterior fossa arise from the cerebellum,
fourth ventricle or the brain stem.
The cerebellum makes up 10% of the total brain weight but contains
more than 50% of all neurons. Functionally, it performs regulatory functions
on different sets of input. The major function is adjustment of the output

Keywords: posterior fossa tumor, tumor in adults

M. N. PAMIR

for major descending pathways. Anatomically, the cerebellum has 3 surfaces

and it can be divided into midline and hemispheric structures. Posterior
approaches expose the posterior surfaces. Vermis is centrally located and
neighbors the tonsils at its inferior opening which is termed the vallecula.
Bilateral cerebellar cortices contain lobules and fissures, which correspond to
gyri and sulci of the cerebrum. Cerebellar corticotomy is performed parallel
to the folia and the shortest route to tumor is used to avoid injury to deep
nuclei and minimize iatrogenic injury. The deep white mater contains 3 sets
of nuclei: fastiigal, interposed and dentate. The horizontal fissure provides
the shortest route to the dentate nuclei and is used to evacuate hypertensive
cerebellar hemorrhages, which are most commonly localized to the dentate
nuclei. Lateral 1/2 cerebellar resection can be performed in emergency situa-
tions and this is usually well tolerated with transient hypotonia and ipsilat-
eral disdiachokinesia. Iatrogenic injury to the dentate nucleus, however,
results in more severe and commonly permanent limb ataxia, nystagmus, hy-
potonia and hyporeflexia. The fourth ventricle is located between cerebellum
and the brain stem and has a rhomboid shape. The cerebral aquaduct is lo-
cated in the most rostral point and in the most caudal point at the obex the
ventricle connects to the central spinal canal. Lateral recesses harbor the
foramina of Luschka, which are above the stria medullares and caudal to
flocculi, which open to the cerebellopontine angle. The upper 2/3 of the
rhomboid fossa is located in the pons, while the inferior 1/3 lies in medulla
oblongata. Within the rhomboid fossa several surface landmarks can be dif-
ferentiated such as the vertical central fissure, facial colliculi, stria medullares.
These anatomical structures are used to define the hypoglossal and vagal tri-
angles in planning of safe surgical entry zones to the brain stem. The poste-
rior wall consists of the superior medullary velum rostrally and inferior
medullary velum caudally, which are connected by the fastigium. Through a
posterior approach the telovelotonsillar fissure can be exposed in the cerebel-
lar vallecula and division of either the tela choroidea or the inferior medullar
velum leads the surgeon into the ventricular cavity. The posterior inferior
cerebellar artery (PICA) crosses through the telovelotonsillar fissure, is en-
countered and protected during surgical approaches.

DECISION-MAKING

1. CLINICAL PRESENTATION

Patients with posterior fossa tumors present to clinical attention either by

direct neuronal dysfunction or signs and symptoms of obstructive hydro-
cephalus. Obstructive hydrocephalus will present with increased intracranial
pressure (headache, nausea-vomiting, depression of mental status, and diplopia).
Midline cerebellar masses present with truncal and gait ataxia and cerebellar
hemispheric tumors result in limb ataxias, nystagmus, hypotonia and hypore-

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