Suboccipital transtentorial approach to remove a cerebellar cavernous malformation adjacent to cerebellomesencephalic fi
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HOW I DO IT - VASCULAR NEUROSURGERY - ARTERIOVENOUS MALFORMATION
Suboccipital transtentorial approach to remove a cerebellar cavernous malformation adjacent to cerebellomesencephalic fissure Peng Hu 1
&
Hong-Qi Zhang 1
Received: 1 March 2020 / Accepted: 11 May 2020 # Springer-Verlag GmbH Austria, part of Springer Nature 2020
Abstract Background Microsurgical removal of cerebral cavernous malformations (CCMs) at the region of cerebellomesencephalic fissure is technical challenging. Methods A 51-year-old gentleman complained severe vertigo and vomiting for 10 days before admission. The symptoms did not improve after medicine treatment. Neuroimaging studies in other hospital revealed a CCM and hematoma at the region of cerebellomesencephalic fissure invading both the left cerebellum and its peduncles. The CCM was successfully removed through a suboccipital transtentorial approach. The detailed surgical techniques were reported. Conclusion A suboccipital transtentorial approach could be used to remove CCMs at the region of cerebellomesencephalic fissure. Keywords Cerebral cavernous malformation . Suboccipital transtentorial approach . Cerebellomesencephalic fissure
Relevant surgical anatomy Cerebellomesencephalic fissure communicates quadrigeminal cistern superiorly and ambient cistern laterally [5]. The ventral wall of this fissure is composed of rostral surface of the middle cerebellar peduncle, dorsal surface of the superior cerebellar peduncle, and the lingula of vermis. Anterior surface of the culmen, central lobule, and quadrangular lobule, covered by the tentorium superiorly, contributes to the dorsal surface of the cerebellomesencephalic fissure. Cranial nerve IV arises in this fissure below the inferior colliculus and travels along the mesencephalon anteriorly to join the ambient cistern. Posterior cerebral artery, superior cerebellar artery, Rosenthal’s basal vein, and other tributaries of the vein of Galen pass through the cerebellomesencephalic fissure. This article is part of the Topical Collection on Vascular Neurosurgery Arteriovenous malformation Electronic supplementary material The online version of this article (https://doi.org/10.1007/s00701-020-04412-8) contains supplementary material, which is available to authorized users. * Peng Hu [email protected] 1
Neurosurgery, XuanWu Hospital, Capital Medical University, 45 # Changchun Street, Xicheng District, Beijing 100054, China
Description of the technique (see supplementary surgical video) Neuroimaging studies revealed that the CCM situated mainly at quadrangular lobule with invasion into both the superior and middle cerebellar peduncles (Fig. 1). After a careful decision-making according to the anatomy, a left suboccipital transtentorial approach was used to remove the CCM [3, 7] (Fig. 2). After general anesthesia, the patient was placed in a left three-quarter prone position with head turned slightly to the right side [2] (Fig. 3). The upper body was elevated. Intraoperative somatosensory and motor evoked potentials were applied. Neuro-n
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