CONCEPTS, INNOVATIONS AND TECHNIQUES

CONCEPTS, INNOVATIONS AND TECHNIQUES

Contralateral Interhemispheric Approach to

Deep-Seated Cavernous Malformations: Surgical
Considerations and Clinical Outcomes in 31
Consecutive Cases
Hasan A. Zaidi, MD
Shakeel A. Chowdhry, MD
Peter Nakaji, MD
Adib A. Abla, MD
Robert F. Spetzler, MD
Division of Neurological Surgery, Barrow
Neurological Institute, St. Joseph’s Hospi-
tal and Medical Center, Phoenix, Arizona
Correspondence:
Robert F. Spetzler, MD,
c/o Neuroscience Publications;
Barrow Neurological Institute,
St. Joseph’s Hospital and Medical Center,
350 W Thomas Rd,
Phoenix, AZ 85013.
E-mail: Neuropub@dignityhealth.org
Received, December 31, 2013.
Accepted, February 16, 2014.
Published Online, March 10, 2014.
Copyright © 2014 by the
Congress of Neurological Surgeons.
BACKGROUND: Deep-seated periventricular cavernous malformations of the basal
ganglia or thalamus can be approached via an interhemispheric craniotomy.
OBJECTIVE: To determine surgical efficacy and clinical outcomes of the contralateral
interhemispheric approach.
METHODS: Retrospective chart review was performed on patients undergoing an
interhemispheric approach for the resection of deep-seated cavernous malformation by
the senior author (R.F.S.) between 2005 and 2013. Demographic data and clinical out-
comes were reviewed. Pre- and postoperative imaging were analyzed for lesion loca-
tion, size, associated venous anomaly, proximity to ventricle, and presence of residual.
RESULTS: Twenty-one patients underwent a contralateral interhemispheric-transventricular
approach, 7 patients had a contralateral interhemispheric-transcingulate approach and
3 patients had a contralateral interhemispheric-transchoroidal approach. Mean age was
40.1 years, and the majority were female (58.1%). Mean maximum cavernoma diameter
was 1.97 cm, and 43.8% reached the surface of the ventricle. Average follow-up was
8.9 months, with complete resection achieved in 96.8% of patients. At last follow-up,
61.3% of patients remained stable and 29.0% had improved. Of the patients, 6.5%
experienced transient weakness that resolved at last follow-up, and 1 patient (3.2%) had
short-term memory problems. There were no surgical mortalities.
CONCLUSION: The contralateral interhemispheric approach is a safe, clinically well
tolerated, and surgically efficacious approach to deep-seated cavernomas.
KEY WORDS: Cavernomas, Cavernous malformations, Contralateral, Interhemispheric

Neurosurgery 75:80–86, 2014 DOI: 10.1227/NEU.0000000000000339 www.neurosurgery-online.com

D
eep-seated cavernous malformations can
be accessed via either a transcortical or an
interhemispheric approach. The trans-
cortical approach has several disadvantages, the
most important of which includes transection of
normal cortex and subcortical white matter dur-
ing access that confers a higher chance of new
clinical deficits and seizures.1,2 Additionally, the
transcortical approach affords few anatomic
landmarks to help the surgeon calibrate the
approach.3 Conversely, the interhemispheric
approach results in the transection of a compar-
ABBREVIATIONS: EVD, external ventricular drain;
POD, postoperative day
atively small amount of normal brain tissue.4
Partial transection of either the corpus callosum or
the cingulate gyrus is clinically well tolerated, and
access to the ventricular system provides reliable
visual cues to help guide the surgeon to the
target.5-7 In 1996, we described our experience
with 32 cases by using the contralateral approach
for various lesions, with the head rotated so that
the falx is oriented parallel to the floor and the
lesion on the upside of the surgical view in order
to take advantage of gravity to retract the
ipsilateral hemisphere.3 This positioning results
in a more angled approach to the surgical target
with better visualization of the lateral edge of the
lesion, an area that would otherwise require either
significant brain retraction or blind dissection if

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accessed traditionally. Since our report, many authors have
advocated the use of this technique and have shown its efficacy
in the resection of various pathologies.8-11 Despite its growing
popularity within the neurosurgical community, reported clinical
outcomes for contralateral approaches for lesions such as deep-
seated cavernous malformations have been limited to small case
series or case reports.3,9,12 Few objective data on the surgical
outcomes of this procedure and its long-term complications are
available in the neurosurgical literature. We report here our
experience with contralateral interhemispheric approaches to deep-
seated cavernous malformations that, to the best of our knowledge,
represents the largest single-surgeon series in the world.
METHODS
We performed a retrospective review of all patients who underwent
a supratentorial craniotomy for microsurgical resection of a cavernous
malformation at Barrow Neurological Institute (Phoenix, Arizona)
between 2005 and 2013 by the senior surgeon (R.F.S.). Radiological
imaging, operative reports, in-hospital records, and clinical visits were
analyzed to identify those patients who had undergone a contralateral
interhemispheric procedure. We identified basic demographic data and
radiological findings, including largest axial diameter, presence of
a developmental venous anomaly, proximity to an ependymal surface,
anatomic location, and extent of resection. Pre- and postoperative
modified Rankin Scale score and modified Rankin Scale score at last
follow-up were obtained, and operative reports were carefully reviewed to
document the use of fixed retractors and intraoperative evidence of
residual disease. All clinical follow-up was performed by the primary
surgeon and documented by clinical fellows. Clinical notes and patient
correspondence were used to identify any long-term deficits or the need
for a second surgery.
Patient Selection and Surgical Approach
All patients with deep-seated cavernous malformations were evaluated
with a preoperative magnetic resonance imaging (MRI). Lesions that are
closer to the midline typically require less retraction in order to view the
lateral aspect of the resection cavity and are best accessed by using an
ipsilateral interhemispheric approach. Conversely, eccentric lesions
necessitate more retraction using the traditional approach, with increased
risk of retraction-related injuries and the chance for residual disease. For
this reason, these lesions were best accessed via the contralateral
interhemispheric approach. We examined the preoperative imaging to
identify the location where these lesions approached the cortical or
ependymal surface. Using the 2-point method previously described by
our group,13,14 we determined the shortest linear distance to the
cavernous malformation that avoids important deep nuclei or white
matter tracts to decide on the transcallosal vs transcingulate approach.
Patients are positioned supine. The shoulder of the dependent
hemisphere is supported with a large bolster, and the head and the
operating table are turned to align the sagittal sinus plane parallel to the
floor. We take great care not to maximally rotate the neck to prevent
jugular vein compression. For young patients with a supple neck,
moderate neck rotation combined with lateral planing of the operating
room table provides sufficient rotation to align the falx parallel to the
ground without much venous outflow obstruction. However, with
older patients or obese patients with a short neck, we have found that
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CONTRALATERAL INTERHEMISPHERIC APPROACH TO CAVERNOMAS
a park-bench position seems to work better. The hemisphere containing
the lesion of interest is placed on the upside of the surgical field. The head
is fixed in a Mayfield 3-pin head holder, and the neck is flexed 45° laterally
toward the side of the pathology with respect to the floor in order to
maximize retraction by gravity and to provide a comfortable surgical
approach for the surgeon. This position not only takes advantage of
gravity to retract the dependent hemisphere, but also provides a level
operative exposure to maximize the surgeon’s visualization and hand
coordination. After a straight coronal incision is made, a craniotomy is
performed two-thirds in front and one-third behind the coronal suture,
crossing the midline approximately 2 cm above and 4 to 5 cm below the
sagittal sinus. In more recent years, strict adherence to the two-third/one-
third rule is emphasized less, because the use of neuronavigation helps
tailor the appropriate premotor craniotomy to provide the appropriate
trajectory. The dura is opened adjacent to the craniotomy below the
sinus and is then fixed tautly to the superior craniotomy edge with
tacking sutures along the inferior edge of the sinus. The dura is fixed with
sufficient tension that the sinus is maximally displaced superiorly. The
arachnoid dissection is performed in the usual fashion, separating the 2
hemispheres. We typically perform a small craniotomy, but angle the
microscope anteriorly and posteriorly underneath the craniotomy in
order to perform a wide arachnoid dissection along with maximal
cerebrospinal fluid (CSF) drainage to allow the hemisphere to sag. All
efforts are made to preserve bridging veins in order to avoid venous
ischemic complications. With this alone, we have found enough sag of
the hemisphere, obviating the need for a preoperative lumbar drain.
Gravity retracts the dependent hemisphere, exposing the corpus
callosum. With the use of neuronavigation, an ideal trajectory is
identified, and either the cingulate gyrus or corpus callosum (depending
on the location of the lesion) is entered into the contralateral lateral
ventricle. Careful attention is paid to discern the orientation of the
thalamostriate and septal veins in order to confirm entry into the correct
lateral ventricle. Often, opening the septum pellucidum will allow for
a less restricted operative view. If the lesion approaches the ependymal
surface on preoperative imaging, the operative bed is analyzed carefully to
identify hemosiderin staining, and the lesion is entered with careful
attention to minimize traction on or destruction of normal surrounding
tissue. The previously described 2-point method is used to determine the
ideal entry point into the lesion.15 The choroidal fissure is split if the
lesion is deep in the third ventricle. When opening the choroidal fissure,
the senior author (as opposed to the recommendation of most textbooks)
prefers opening it lateral to the choroid plexus as a protective buffer to
the fornix.
RESULTS
Between 2005 and 2013, the senior author (R.F.S.) performed
34 interhemispheric craniotomies for microsurgical resection of
supratentorial cavernous malformation. Of the 34 total inter-
hemispheric approaches for cavernomas, only 3 (8.9%) of these
lesions were deemed medial enough for a purely ipsilateral
interhemispheric approach. Most of the lesions (91.2%) in our
cohort were far eccentric, where we felt the lateral aspect of the
resection cavity would be best visualized via a contralateral
approach (Table 1). Among patients undergoing a contralateral
approach, 7 (22.6%) required a transcingulate approach and 3
(9.7%) required splitting of the choroidal fissure (Table 1). The
mean patient age of this cohort was 40.1 years, with a slight
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ZAIDI ET AL

TABLE 1. Approach and Side of Deep-Seated Cavernomas TABLE 3. Preoperative Imaging Findingsa
Approach No. Patients DVA, % 25.8
Anterior contralateral interhemispheric 30 Maximum diameter (average), cm 1.97
Posterior contralateral interhemispheric 1 Reached ventricular surface, % 43.8
Transcingulate 7 Location, %
Transchoroidal 3 Caudate/putamen 32.2
Side of lesion Thalamus 25.8
Right 11 Frontal/parietal 19.4
Left 20 Adjacent to third ventricle 16.1
Corpus callosum 6.5
a
DVA, developmental venous anomaly.

female predominance (58.1%) (Table 2). Presenting symptoms

included headaches (21.1%), intraventricular or intraparenchy- corners within the surgical resection cavity. Rather, dynamic
mal hemorrhage (13.2%), and seizures (13.2%); a small subset intermittent retraction by opening the bipolar to mobilize brain
was found incidentally (18.4%) (Table 2). tissue out of the surgical field as needed allowed for better
The majority of cavernomas were located on the left side (64.5%) visualization of deeper structures and afforded the surgeon more
(Table 1) and had a mean maximum diameter of 1.97 cm. freedom to dissect deeper lesions.
A minority of these lesions reached the ventricular surface (43.8%) Special attention was paid toward hemostasis to prevent blood
and nearly 25.8% were associated with a developmental venous products and particulates from entering the lateral ventricles to
anomaly seen on preoperative imaging, a ratio consistent with obviate the need for future CSF diversion surgery. In cases where we
previously reported data.16-18 However, all cavernous malforma- felt that blood products and tissue particulates during dissection
tions were found to be associated with veins at the time of their were higher than expected, we elected to place an external
surgical resection. Lesions were most commonly located in the ventricular drain (EVD) (54.8%) tracking through the approach
caudate/putamen (32.2%), thalamus (25.8%), frontal/parietal cavity into the lateral ventricles; after standard institutional weaning
(19.4%), or adjacent to the third ventricle (16.1%) (Table 3). protocols, the EVD was typically removed on postoperative day
Fixed retractors were used in only 12.9% of cases, because (POD) 1 or 2 (Table 4). Only 2 (6.5%) patients eventually
positioning and judicious arachnoid dissection facilitated visual- required a ventriculoperitoneal shunt because of symptomatic
ization of pertinent structures. When used, the retractor was ventriculomegaly and elevated pressures after EVD closure. Of
routinely placed against the falx to elevate the hemisphere on the these, 1 patient had a shunt placed at an outside facility as
upside of the surgical field to gain better exposure, and no a temporizing measure owing to obstructive hydrocephalus from
retractors were placed on the hemisphere on the downside of the hemorrhage of a third ventricular cavernoma. This shunt was
surgical field. We found that placing retractors were often
cumbersome, limited the visualization of deeper structures in the
surgical field, and drastically limited mobility to look around TABLE 4. Surgical Outcomes and mRS Score at Last Follow-upa
Surgical Outcomes %
Average follow-up, mo 8.9
Complete resection 96.8
TABLE 2. Patient Characteristics and Presenting Symptomsa Intraoperative EVD 54.8
Falx cut 16.1
Mean age, y 40.1 Retractors used 12.9
Sex, No. of patients VP shunt 6.5
Male 13 Reoperationb 9.7
Female 18 Mortality 0
Initial symptoms, % mRS score
Headaches 21.1 Stable 61.3
Incidental 18.4 Improved 29
Hemiparesthesia 15.8 Transient weakness 6.5
Seizures 13.2 Long-term deficitsc 3.2
Hemiparesis 13.2
a
IVH/IPH 13.2 mRS, modified Rankin Scale; EVD, external ventricular drain; VP,
Memory loss/confusion 5.3 ventriculoperitoneal.
b
One patient required reoperation for residual cavernoma, 1 patient for hematoma
within resection cavity, and 1 patient for ventriculoperitoneal shunt placement.
a c
IVH, intraventricular hemorrhage; IPH, intraparenchymal hemorrhage. One patient developed short-term memory deficits.

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 CONTRALATERAL INTERHEMISPHERIC APPROACH TO CAVERNOMAS

FIGURE 1. Modified Rankin Scale (mRS) scores for patients undergoing

a contralateral interhemispheric approach at preoperative, postoperative, and last
follow-up (f/u). No patient scored a 4, 5, or 6 at any time point. Used with
permission from Barrow Neurological Institute.

externalized during the definitive resection, but demonstrated

persistently elevated intracranial pressures after EVD closure,
necessitating reinsertion of the shunt.
Complete resection on initial surgery was successful in 30 of 31
patients (96.8%) (Table 4). Three patients required reoperation,
including 1 patient who required definitive resection of residual
disease 2 years later. One patient’s neurological status initially
declined after surgery; some minor blood products were noted in
the resection cavity on postoperative imaging. She underwent
a reoperation for removal of this residual blood when the results
of her examination did not return to baseline on POD 1, but she
was noted to have little pressure from the residual hemorrhagic
products on intraoperative inspection. She subsequently returned
to her baseline 3 days after her initial procedure. Another patient
initially tolerated an EVD wean protocol, but presented 4 weeks FIGURE 2. A, illustration showing the positioning of head such that the falx is
later with ventriculomegaly, necessitating placement of a ventri- parallel to the ground, and the neck is flexed 45 to 60° toward the side of the
culoperitoneal shunt. lesion. B, the resultant surgical corridor provided by this positioning. Used with
There were no operative mortalities in our series, with an average permission from Barrow Neurological Institute.
follow-up of 8.9 months (Table 4). Overall, 9 patients (29%)
improved, 19 patients (61.3%) remained stable after surgery, 2
patients (6.5%) had a transient decline, and 1 patient (3.2%) had approach was used, only a few small case series exist that report
a permanent deficit (Figure 1, Table 4). Among the patients who outcomes.9,11 In this article, we report our surgical results for 31
experienced a transient decline, all returned to their preoperative consecutive patients with deep-seated cavernous malformations
neurological baseline by POD 3. The patient who experienced that were resected through a contralateral interhemispheric
a permanent neurological deficit had a third ventricular/thalamic approach by a single surgeon, and have demonstrated its utility,
cavernous malformation, which was resected via a transchoroidal safety, and efficacy.
approach, and developed minor but detectable temporary short- The transcortical transventricular approach remains popular for
term memory deficits at last follow-up (Table 4). the resection of periventricular lesions.1,2,20 It affords a linear
approach to pathology in this region, but necessitates destruction
DISCUSSION of normal brain tissue, which increases the risk of postoperative
deficits, particularly for lesions located adjacent to critical
Deep-seated cavernous malformations are challenging lesions functional tissue such as the basal ganglia or internal capsule.
that historically have been treated through a myriad of approaches. Additionally, several reports indicate a higher incidence of
The contralateral interhemispheric craniotomy is a powerful seizures in patients who have undergone a transcortical approach.
approach for many different surgical pathologies, including Finally, this approach is critically dependent on image-guided
tumors, cysts, cavernomas, and arteriovenous malformations.3,19 neuronavigation, because there are few distinguishable anatomic
Despite a large number of accounts in which this surgical landmarks to act as waypoints to direct the neurosurgeon to the

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ZAIDI ET AL

FIGURE 3. A 27-year-old woman who presented with new-onset paresthesias and headaches. A, preoperative coronal T1-weighted magnetic resonance (MR) imaging with
gadolinium enhancement demonstrates a left-sided thalamic mass. B, axial T2-weighted MR image demonstrating a thalamic cavernous malformation with intralesional
hemorrhage. C, intraoperative photograph of a similar case showing a contralateral interhemispheric craniotomy that was tailored by using neuronavigation to achieve the ideal
trajectory while avoiding draining veins and eloquent territory. The right hemisphere is to the bottom; the left hemisphere is to the top of the image. D, photograph showing
visualization of the corpus callosum and the pericallosal vessels with a small callosotomy being performed. E, the choroidal fissure was opened, and lighted bipolars forceps were
used to enter the cavernoma. F, postoperative axial T2-weighted MR image showing complete resection of the cavernoma with minor blood products in the cavity. Used with
permission from Barrow Neurological Institute.

lesion. It is therefore subject to the limitations and inherent error
within navigation systems, which may result in greater cortical and
white matter transection than anticipated, particularly for small
lesions. The interhemispheric-transcallosal/cingulate gyrus approach
takes advantage of the interhemispheric fissure, allowing deep access
and requiring only a small amount of normal tissue resection.
Transection of a small portion of the corpus callosum or cingulate
gyrus is well tolerated by patients.21 This approach allows the
neurosurgeon to use direct visualization of reliable anatomic
landmarks to verify the accuracy of image guidance.
Traditionally, the interhemispheric craniotomy is performed
with the head in a neutral position. Proponents of this approach
argue that neutral head positioning permits intuitive awareness of
the midline at all times, facilitating safer manipulation of brain
tissue when accessing deep-seated lesions.4,22 However, this
positioning necessitates the use of bilateral, fixed brain retractors,
which may increase the risk for ischemic and hemorrhagic
complications from prolonged compression of brain tissue.23
We prefer to place the head in a lateral position, such that the
falx is aligned parallel to the ground, and, with the head extended
approximately 45 to 60° with respect to the floor, to allow the
exposed hemisphere to be retracted by gravity, which in turn allows
the lesion in the contralateral hemisphere to “hang” into the
surgical field. Using this methodology, we have utilized brain
retractors in just 12.9% of cases. When we did use retraction, the
retractor was always placed on the falx to avoid direct retraction of the
exposed brain tissue and the attendant ischemic complications.
Because our eyes are level, a horizontal exposure allows better
visualization. Additionally, this approach is ergonomically more
attractive because it allows the surgeon’s hands to rest side-by-side
when dissecting through the cingulate gyrus or the corpus callosum
rather than on top of one another as is required in the traditional
vertical exposure. This arrangement reduces surgeon fatigue and
allows for more delicate dissection during a prolonged case (Figure 2).
This approach is not without risk: injury to venous structures
during retraction (albeit intermittent) can predispose patients to

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venous infarcts. Such an insult to the contralateral, unaffected
hemisphere can potentially be catastrophic. For right-sided lesions,
where the approach necessitates a left-sided hemispheric dissec-
tion, fixed retractors should rarely be used and special attention
needs to be paid to minimize venous sacrifice. We spend
a considerable amount of time after positioning the patient and
registering the neuronavigation to plan the incision and contour
the craniotomy above a region devoid of midline bridging veins as
determined on wand, in order to reduce potential injury to these
structures.
Although the lesion of interest is usually ipsilateral to the
interhemispheric corridor, an ipsilateral approach is ideal for
lesions located purely in the midline. For more laterally located
lesions, the ipsilateral approach requires significantly more
retraction than the contralateral approach. In our series, the
majority of patients with supratentorial cavernous malformations
(31 of 34, 91.2%) were treated with by the use of the contralateral
approach to the cavernoma (Figure 3). The 3 lesions that were
resected by using the ipsilateral approach were closer to the
midline. Several advantages were obvious in the contralateral
approach, because it afforded better visualization with minimal or
no retraction. In our series, this approach has allowed complete
resection of cavernomas in 96.8% of cases.
Limitations
Our article is subject to all the limitations and biases inherent in
a retrospective review. Although the clinical evaluation was con-
ducted by the primary surgeon and fellows, documentation errors
and lack of formal neurocognitive evaluation can potentially
underreport deficits not obvious on gross physical examination.
Additionally, because this is a single-surgeon series, the clinical results
cannot be extrapolated to other surgeons and/or institutions, but
serve only as an assessment of feasibility and safety of the procedure.
CONCLUSION
The contralateral interhemispheric exposure is an attractive,
reliable, and efficacious approach. As we have shown in this series,
the largest of its kind reported to date, this approach results in
acceptable surgical morbidity (3.2%) with excellent efficacy
(96.8%) and no mortality.
Disclosure
The authors have no personal, financial, or institutional interest in any of the
drugs, materials, or devices described in this article.
REFERENCES
1. Konovalov AN, Gorelyshev SK. Surgical treatment of anterior third ventricle
tumours. Acta Neurochir (Wien). 1992;118(1-2):33-39.
2. Rhoton AL Jr, Yamamoto I, Peace DA. Microsurgery of the third ventricle: Part 2.
Operative approaches. Neurosurgery. 1981;8(3):357-373.
3. Lawton MT, Golfinos JG, Spetzler RF. The contralateral transcallosal approach:
experience with 32 patients. Neurosurgery. 1996;39(4):729-734.
4. Bellotti C, Pappada G, Sani R, Oliveri G, Stangalino C. The transcallosal approach
for lesions affecting the lateral and third ventricles. Surgical considerations and
results in a series of 42 cases. Acta Neurochir (Wien). 1991;111(3-4):103-107.
NEUROSURGERY
Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited
CONTRALATERAL INTERHEMISPHERIC APPROACH TO CAVERNOMAS
5. Dandy WE. Diagnosis, localization and removal of tumors of the third ventricle.
Bull John Hopkins Hosp. 1922;33:188-189.
6. Dandy WE. Benign Tumors in the Tumors in the Third Ventricle of the Brain:
Diagnosis and Treatment. Springfield: Charles C. Thomas; 1933.
7. Stein BM. Third ventricular tumors. Clin Neurosurg. 1980;27:315-331.
8. Zhu W, Xie T, Zhang X, et al. A solution to meningiomas at the trigone of the
lateral ventricle using a contralateral transfalcine approach. World Neurosurg. 2013;
80(1-2):167-172.
9. Davies J, Tawk RG, Lawton MT. The contralateral transcingulate approach:
operative technique and results with vascular lesions. Neurosurgery. 2012;71
(1 suppl operative):4-13.
10. Fronda C, Miller D, Kappus C, Bertalanffy H, Sure U. The benefit of image
guidance for the contralateral interhemispheric approach to the lateral ventricle.
Clin Neurol Neurosurg. 2008;110(6):580-586.
11. Rodríguez-Hernández A, Lawton MT. Contralateral transcallosal approach to
basal ganglia cavernous malformation: 3-dimensional operative video. Neurosurgery.
2013;72(2 suppl operative):ons182.
12. Abla AA, Spetzler RF, Albuquerque FC. Trans-striatocapsular contralateral
interhemispheric resection of anterior inferior basal ganglia cavernous malforma-
tion. World Neurosurg. 2013;80(6):e397-e399.
13. Abla AA, Lekovic GP, Turner JD, de Oliveira JG, Porter R, Spetzler RF. Advances
in the treatment and outcome of brainstem cavernous malformation surgery:
a single-center case series of 300 surgically treated patients. Neurosurgery. 2011;68
(2):403-414.
14. Brown AP, Thompson BG, Spetzler RF. The two-point method: Evaluating brain
stem lesions. BNI Q. 1996;12(1):20-24.
15. Abla AA, Turner JD, Mitha AP, Lekovic G, Spetzler RF. Surgical approaches to
brainstem cavernous malformations. Neurosurg Focus. 2010;29(3):E8.
16. Rigamonti D, Johnson PC, Spetzler RF, Hadley MN, Drayer BP. Cavernous
malformations and capillary telangiectasia: a spectrum within a single pathological
entity. Neurosurgery. 1991;28(1):60-64.
17. Rigamonti D, Spetzler RF, Drayer BP, et al. Appearance of venous malformations
on magnetic resonance imaging. J Neurosurg. 1988;69(4):535-539.
18. Rigamonti D, Hadley MN, Drayer BP, et al. Cerebral cavernous malformations.
Incidence and familial occurrence. N Engl J Med. 1988;319(6):343-347.
19. Goel A. Transfalcine approach to a contralateral hemispheric tumour. Acta
Neurochir (Wien). 1995;135(3-4):210-212.
20. Waga S, Shimosaka S, Kojima T. Arteriovenous malformations of the lateral
ventricle. J Neurosurg. 1985;63(2):185-192.
21. Winston KR, Cavazzuti V, Arkins T. Absence of Neurological and behavioral
abnormalities after anterior transcallosal operation for third ventricular lesions.
Neurosurgery. 1979;4(5):386-393.
22. Shucart WA, Stein BM. Transcallosal approach to the anterior ventricular system.
Neurosurgery. 1978;3(3):339-343.
23. Spetzler RF, Sanai N. The quiet revolution: retractorless surgery for complex
vascular and skull base lesions. J Neurosurg. 2012;116(2):291-300.
COMMENTS
T
he contralateral transfalcine approach for cerebral lesions was first
described by us in 1995.1 We used the approach to resect paren-
chymal brain lesions that included gliomas and brain abscesses. The
advantages of the approach included retraction of the unaffected or
normal brain rather than edematous brain and the possibility of ob-
taining a rather direct angle to approach the tumor. We subsequently
described the possible advantages of the transfalcine approach to arte-
riovenous malformations located in the interhemispheric region.2
However, over the years, we have observed that the transfalcine approach
is only rarely necessary. We observed that the interhemispheric corridor
can sometimes be quite restrictive and narrow. The angle of inclination
necessary to expose the contralateral hemisphere lesion can be rather
acute, and the distance of the lesion from the surface can be prohibitively
long. The need to retract the normal cerebral hemisphere to widely
expose the lesion and the possibility of damage to brain on the unaffected
side severely limits the usage of the approach.
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The authors approach deep-seated periventricular or thalamic cav-
ernomas by the contralateral interhemispheric approach. The authors find
the angle of approach to the lesion more direct in comparison with an
ipsilateral interhemispheric approach. The authors have collected a large
series of such cases where they find the feasibility of the approach. Peri-
ventricular and thalamic region cavernomas are by themselves relatively
rare and to identify a series of 31 cases suitable for a contralateral approach
is commendable. The comfort level that they have with the approach is
obvious from the fact that they used this surgical approach in 31 of 35 cases
with periventricular cavernomas.
Contralateral interhemispheric approach needs precise and meticulous
microneurosurgical techniques. The authors have identified that micro-
dissection techniques that drain CSF from relatively thin subarachnoid
spaces in the interhemispheric region can lead to relaxation of the brain,
and the use of retractors can be entirely avoided. However, it must be
remembered that damage to bridging veins and related consequences are
rare but are possible even in the modern day neurosurgery. Such a com-
plication on the unaffected side, in the presence of symptoms related to the
lesion on the ipsilateral side, can be a devastating complication. The au-
thors needed to place external ventricular drains in a significant number of
cases. Intraoperative lumbar CSF drainage can be a useful and probably
a better option to relax the brain.
The distance of the periventricular lesion from the contralateral side
approach in comparison with an ipsilateral approach can be longer by a few
but critically long millimeters. Retraction and sectioning of the falx and
dealing with veins and arteries in the region can be significant surgical
tasks. My personal observation is that the retraction of brain on the
ipsilateral side to approach the lesion may not only reduce the surgical
distance but can also provide a similar surgical view. I do believe that the
contralateral side interhemispheric approach can be used as a surgical
option on a rare occasion, but to keep it as a preferred approach for per-
iventricular cavernomas is a bit far-fetched.
Atul Goel
Mumbai, India
1. Goel A. Transfalcine approach to contralateral hemispheric tumor. Acta Neurochir
(Wien). 1995;135(3-4):210-212.
2. Goel A. Bilateral parafalcine approach for arteriovenous malformations located in
the interhemispheric fissure. In: Kobayashi S, Goel A, Hongo K, eds. Neurosurgery of
Complex Tumours and Vascular Lesions. New York, NY: Churchill Livingstone;
1997. pp. 143.
T
he report is a single-surgeon series and includes 34 operations of 31
patients with deep-seated cavernous malformations (CMs). The article
deals with a rare condition in a rather rare location.1 However, microsurgery
in this region represents an important frontier in neurosurgery.2
It has a standard format with a retrospective review of patients’ charts
and scans. As with any retrospective study, it is limited by the quality of
the patient chart entries, frequently done by junior staff or trainees and
most often not in a standardized manner, with some commendable
exceptions.3 Furthermore, by being a single-surgeon series, the data
cannot necessarily be extrapolated to other neurosurgeons or centers.
However, the report is very thorough and well-presented. The surgical
technique is nicely described and illustrated. The potential surgical
complications are addressed. The authors are to be congratulated on their
results with a low permanent surgical morbidity (3.2%), good efficacy
86 | VOLUME 75 | NUMBER 1 | JULY 2014
Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited
(96.8% complete resections), and no mortality in a cohort of patients with
mean CM size of 2 cm. This compares well with other series from expert
cavernoma surgeons.4-9
A discussion regarding the outcome measures would be welcome, as
mRS is quite a crude and rather insensitive test with regard to the finer
neurological deficits that could occur after surgery in this region. The same
holds true for neurological deficits; we have all experienced that a “neu-
rosurgically intact patient” may have quite profound neurocognitive or
neuro-ophthalmological deficits not detected by the neurosurgeon.
Last, I particularly welcome this thorough description of the contra-
lateral interhemispheric approach with the head in a lateral position as I
have found it most useful.10 This positioning allows the exposed
hemisphere to be retracted only by gravity, or “Newton’s retractor,”
contributing to the “quiet revolution” of retractorless surgery.11 Fur-
thermore, the positioning is more ergonomic than the traditional vertical
head position, because it allows the surgeon’s hands to rest side-by-side
rather than one hand on top of another.12 The callosotomy itself is only
12 to 15 mm13 and is generally well-tolerated. However, whenever I find
myself this deep in the brain, electrophysiological monitoring is most
helpful.14
Torstein Ragnar Meling
Oslo, Norway
1. Bradac O, Majovsky M, de Lacy P, Benes V. Surgery of brainstem cavernous
malformations. Acta Neurochir (Wien). 2013;155(11):2079-2083.
2. Gross BA, Batjer HH, Awad IA, Bendok BR, Du R. Brainstem cavernous
malformations: 1390 surgical cases from the literature. World Neurosurg. 2013;
80(1-2):89-93.
3. Schwartz C, Grillhösl A, Schichor C, et al. Symptomatic cavernous malformations
of the brainstem: functional outcome after microsurgical resection. J Neurol. 2013;
260(11):2815-2822.
4. Abla AA, Lekovic GP, Turner JD, de Oliveira JG, Porter R, Spetzler RF. Advances
in the treatment and outcome of brainstem cavernous malformation surgery:
a single-center case series of 300 surgically treated patients. Neurosurgery. 2011;
68(2):403-414.
5. Mai JC, Ramanathan D, Kim LJ, Sekhar LN. Surgical resection of cavernous
malformations of the brainstem: evolution of a minimally invasive technique.
World Neurosurg. 2013;79(5-6):691-703.
6. Pandey P, Westbroek EM, Gooderham PA, Steinberg GK. Cavernous malforma-
tion of brainstem, thalamus, and Basal Ganglia: a series of 176 patients.
Neurosurgery. 2013;72(4):573-589.
7. Dukatz T, Sarnthein J, Sitter H, et al. Quality of life after brainstem cavernoma
surgery in 71 patients. Neurosurgery. 2011;69(3):689-695.
8. Hauck EF, Barnett SL, White JA, Samson D. Symptomatic brainstem cavernomas.
Neurosurgery. 2009;64(1):61-70.
9. Li D, Zhang J, Hao S, et al. Surgical treatment and long-term outcomes of
thalamic cavernous malformations. World Neurosurg. 2013;79(5-6):704-713.
10. Meling TR. The anterior transcallosal- transchoroidal approach in mesencephalic
cavernous malformations. Proceedings of the 5th International Neurosurgical
Winter Congress (INWC) 2013, Chamonix, 10-16 February 2013.
11. Spetzler RF, Sanai N. The quiet revolution: retractorless surgery for complex
vascular and skull base lesions. J Neurosurg. 2012;116(2):291-300.
12. Rodríguez-Hernández A, Lawton MT. Contralateral transcallosal approach to
Basal Ganglia cavernous malformation: 3-dimensional operative video. Neuro-
surgery. 2013;72(2 suppl operative):ons182.
13. Ulm AJ, Russo A, Albanese E, et al. Limitations of the transcallosal transchoroidal
approach to the third ventricle. J Neurosurg. 2009;111(3):600-609.
14. Sarnthein J, Bozinov O, Melone AG, Bertalanffy H. Motor-evoked potentials
(MEP) during brainstem surgery to preserve corticospinal function. Acta Neurochir
(Wien). 2011;153(9):1753-1759.
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