How I do it: lateral supra-cerebellar infra-tentorial approach for P2-P3 junction cerebral aneurysms
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HOW I DO IT - VASCULAR NEUROSURGERY - ANEURYSM
How I do it: lateral supra-cerebellar infra-tentorial approach for P2-P3 junction cerebral aneurysms Michel W. Bojanowski 1
&
Gilles El Hage 1 & Chiraz Chaalala 1 & Philippe Mercier 2
Received: 31 May 2020 / Accepted: 2 September 2020 # Springer-Verlag GmbH Austria, part of Springer Nature 2020
Abstract Background P2-P3 junction aneurysms are challenging to treat surgically because of their frequent complex morphology and their location deep in close proximity to the midbrain. The sub-temporal route requires significant retraction of the temporal lobe in addition to potential injury to the vein of Labbe. We describe the technique for treating such aneurysms via a lateral supra-cerebellar infratentorial (LSCIT) approach, which eliminates manipulation of the temporal lobe. Method Cadaveric dissection provided comprehensive understanding of relevant anatomy. Intraoperative video shows clipping of the aneurysm using a LSCIT approach. Conclusion LSCIT approach allows safe clipping of P2-P3 aneurysms with minimal brain manipulation. Keywords Posterior cerebral artery aneurysm . Supra-cerebellar trans-tentorial approach . P2-P3 junction aneurysm . Subarachnoid hemorrhage . Cerebral aneurysm, clipping
Relevant surgical anatomy Posterior cerebral artery (PCA) aneurysms represent less than 2% of all cerebral aneurysms [4, 9]. Most are located in the proximal segment of the PCA, while about 10% are found distally near the P2-P3 junction [1, 3]. Most P2-P3 aneurysms are treated by endovascular means, but when treated surgically, the most common approach found in the literature is the sub-temporal route. However, this route requires a significant amount of retraction of the temporal lobe. Herein, we describe the surgical technique for clipping a P2-P3 junction aneurysm This article is part of the Topical Collection on Vascular Neurosurgery Aneurysm Electronic supplementary material The online version of this article (https://doi.org/10.1007/s00701-020-04566-5) contains supplementary material, which is available to authorized users. * Michel W. Bojanowski [email protected] 1
Division of Neurosurgery, Université de Montréal, University of Montreal Medical Center, 1051 Sanguinet street, Montreal, QC H2X 3E4, Canada
2
Laboratoire d’Anatomie, Faculté de Santé, Université d’Angers, 28 rue Roger Amsler, Angers 49045 Angers cedex 01, France
via a lateral supra-cerebellar infra-tentorial (LSCIT) approach (Fig. 1). A thorough knowledge of the relevant anatomy is essential (Fig. 2). The tentorial incisura is the opening in the tentorium which provides space for the brainstem and its surrounding structures. This space is divided into 3 spaces: anterior incisural space (AIS) in front of the brainstem, middle incisural space (MIS) lateral to the brainstem, and posterior incisural space (PIS) behind the brainstem [8, 10]. The PCA and the superior cerebellar artery (SCA) both pass through the AIS and MIS as they contour the midbrain, to continue towards the PIS. The
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