Safe corridors for brain stem surgery
Brainstem is highly complex structure containing various
cranial nerve nuclei, ascending and descending tracts,
making it one of most difficult structure to access and
operate.
Median sulcus
Sulcus limitans - motor nuclei are medial
sensory nuclei are lateral
Median eminence – facial colliculus, hypoglossal triangle
vagal triangle and area postrema.
straie medullaris – cochlear fibres of VIII nerve
Approach to brainstem
Schematic drawing illustrating the
most common surgical approaches
used for different areas of the
brainstem.
Neurosurg Focus 29 (3):E9, 2010
Choice of approach
Location of lesion
Area to which lesion come close to pial surface
Clinical status of patient
Comfort of individual surgeon
If lesion abutting pial surface then direct access to lesion.
The 2-point method was used as an objective means to
choose the surgical approach
One point is placed in the center of the lesion, and a
second point is placed either where the lesion comes
closest to a pial surface or at the safest entry point into the
brainstem.
Brown AP, Thompson BG, Spetzler RF. The two-point method: evaluating brain
stem lesions. BNI Q. 1996;12(1):20-24.
MLSOC
Planned approach for ventral lesions
Ventral/ lateral
rostral to cranial nerve V Transsylvian / subtemporal
Between lower nerve and Presigmoid / retrosigmoid
cranial nerve V
Caudal to lower group Far lateral
CHEN ET AL - Surgical Strategies in Treating Brainstem Cavernous Malformations NEUROSURGERY
VOLUME 68 | NUMBER 3 | MARCH 2011 ,
Dorsal
Midbrain Suboccipital transtentorial/ supracerebllar
infratentorial
Floor of fourth ventricle Transcerebellomedullary fissure
Medulla intertonsior
CHEN ET AL - Surgical Strategies in Treating Brainstem Cavernous Malformations NEUROSURGERY
VOLUME 68 | NUMBER 3 | MARCH 2011 ,
Surgically treatable lesion present on dorsal part of
brainstem are easily approachable than ventral part of
brainstem.
Pons
Ponto-mesencephalic sulcus to ponto-medullary sulcus
Trigeminal nerve defines limit of pons proper medially
and middle cerebellar peduncle laterally.
MCP
Pons
Ventral and ventro-lateral pons approached by
Retro sigmoid approach
Pre sigmoid approach
Trans petrosal approach
Safe entry zone for ventro lateral pons
Peritrigeminal safe entry zone in the ventrolateral pons . - between
emergence of fifth and seventh nerve . Area is located medially to fifth and
lateral to pyramidal tract.
Peri trigeminal area - transverse fibers are directed
horizontally or slightly obliquely so myelotomy should be
in horizontal direction.
Surgical window –
Horizontal – 4.64mm ( 3.8 – 5.6 mm)
Vertical - 11.2 mm (9.5- 13.1mm)
Structure dysfunction
Pontine nuclei C/L hemiataxia
Corticospinal tract C/L UMN weakness
Middle cerebellar Ipsilateral
peduncle hemiataxia
Trigeminal nerve Loss of sensation
(motor /sensory over face and
nulcei) weakness of muscle
of mastication
Medial lemniscus Loss of posterior
column sensation
MLF INO
Dorsal pons
Upper part (2/3) of floor of fourth ventricle
Dorsal pons approached by
telo-velar trans cerebellar medullary fissure
transvermian
1 cm longitudinal
incision from edge
cerebellar peduncle
and 5mm lateral to
median sulcus
Length of incision –
7mm
Brainstem retracted
– laterally and
rostrally
Kyoshima K,Kobayashi S et al.A study of safe entry zones via the floor of the fourth ventricle for brain-stem lesions.
Report of three cases. JNS 1993
Suprafacial triangle
position relative to Structure Symptoms
surgery
Lateral SCP , trigeminal nuclei Hemiataxia ,
sensorimpairment of face
medial MLF Gaze palsy , nystagmus
Rostral SCP , 3rd and 4 th nuclei Hemiataxia, 3rd and 4th
and nerve palsy
Caudal Nucleus of 6th nerve 6th nerve palsy
PPRF Lateral gaze palsy
Facial nerve Facial nerve palsy
Ventral Medial lemniscus Ataxia, depth perception
Lateral spinothalamic tract impairment , analgesia
Corticospinal tract Motor impairment
Infra facial triangle
1cm longitudinal
incision above
striae medullaris
and 5 mm lateral ot
median sulcus
Brainstem can be
retracted laterally
only.
Kyoshima K,Kobayashi S et al.A study of safe entry zones via the floor of the fourth ventricle for brain-stem lesions.
Report of three cases. JNS 1993
Infra facial Triangle
Position relative to surgery Structure Symptoms
Lateral Facial nerve (deeper) Facial nerve palsy
Vestibular nerve Nystagmus
Medial MLF Nystagmus
Rostral Nucleus of 6th nerve Abducens palsy
PPRF Lateral gaze palsy
VII nerve Facial nerve palsy
Caudal Nuclei of lower cranial nerve Swallowing impairment ,
dysarthria
Ventral Medial lemniscus Ataxia, depth perception
impairment
Lateral spinothalamic tract Analgesia
Corticospinal tract Motor impairment
Ventral medulla
Approached by
far lateral approach
Safe corridors -
at level of retro olivary sulcus
between cranial nerve 12 and C1 at level of
anterolateral sulcus
No evidence that isolated lesion of olivary body causes
permenant deficits.
Retro –olivary area is safest approachable area over
anterolateral brainstem.
Surgical window –
cranio-caudal - 13.5 mm
transverse - 7 mm
antero-dorsal - 2.5mm
Structure dysfunction
pyramid UMN weakness
Inferior olivary nucleus Tremor and ? Cerebllar
sign
Nucleus ambigus Ipsilateral paralysis of
palate , pharynx, larynx,
Hypoglossal nucleus Tongue weakness
Dorsal medulla
Approach by MLSOC
Safe corridors –
Posterior median fissure
Posterior intermediate sulcus
posterior lateral sulcus
Posterior median fissure –
below obex ,between nucleus of
gracile fasciculus
posterior intermediate sulcus –
between gracile and cuneate fascile
Posterior lateral sulcus - between cuneate fascile
medially and spinal trigeminal tract and
nucleus laterally
Midbrain
Superior limit - optic tract
Inferior limit - pontomesencephalic sulcus
Cerebral peduncle
Tegmentum
Tectum
Lateral mesencephalic sulcus - limits between ventro-
lateral midbrain and posterior midbrain.
Posterior midbrain – quadrigeminal plate and superior and
inferior colliculi.
Midbrain
Approached by ( for central midbrain)
pterional craniotomy (trans sylvian approach)
FOZ craniotomy
Ventro lateral midbrain
Approach by
Transsylvian route
subtemporal – transtentorial
subtemporal - transpetrosal
safe entry zone is lateral mesencephalic sulcus (LMS)
Lateral mesencephalic sulcus -
minimum working distance – 4.9 mm
maximum working distance – 11.7 mm
mean +- SD - 8.2 +- 1.76 mm
MICROSURGICAL ANATOMY OF THE SAFE ENTRY ZONES ON THE ANTEROLATERAL BRAINSTEM
RELATED TO SURGICAL APPROACHES TO CAVERNOUS MALFORMATIONS
VOLUME 62 | OPERATIVE NEUROSURGERY 1 | MARCH 2008 |
Structure Dysfunction
Crus cerebri C/L UMN weakness
Substantia nigra Parkinsonism
Medial lemnisucs C/L hemianesthesia of
trunk and extermity
MLF INO
Red nucleus C/L Ataxia and tremors
Approach to posterior midbrain
Supra cerebellar infratentorial approach
median - MLSOC
lateral - Paramedian SOC
exterme lateral - RMSOC
Safe entry zone for posterior midbrain
Supracollicular area
Infracollicular area
Structure Dysfunction
Superior colliculus Pupillary disturbance, gaze palsy
Inferior colliculus Difficulty in localizing sound in space
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