Stereotactic posterior midline approach under direct microscopic view for biopsy of medulla oblongata tumors: technical
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HOW I DO IT - FUNCTIONAL NEUROSURGERY - OTHER
Stereotactic posterior midline approach under direct microscopic view for biopsy of medulla oblongata tumors: technical considerations Janine-Ai Schlaeppi 1
&
Lukas Andereggen 2 & Andreas Nowacki 1 & Claudio Pollo 1
Received: 1 April 2020 / Accepted: 30 September 2020 # The Author(s) 2020
Abstract Background Open and stereotactic transfrontal or transcerebellar approaches have been used to biopsy brainstem lesions. Method In this report, a stereotactic posterior and midline approach to the distal medulla oblongata under microscopic view is described. The potential advantages and limitations are discussed, especially bilateral damage of the X nerve nuclei. Conclusion This approach should be considered for biopsy of distal and posterior lesions. We strongly recommend the use of direct microscopic view to identify the medullary vessels, confirm the midline entry point, and avoid potential shift of the medulla. Further experience is needed to confirm safety and success rate of this approach. Keywords Stereotactic biopsy . Medulla oblongata . Brain stem . Glioma
Relevant surgical anatomy Stereotactic biopsy of the medulla oblongata is a rare procedure and remains challenging. The lower the lesion is located in the brainstem, the greater is the risk and severity of associated complications [1]. Because of the distal and posterior location of the lesion, a transcerebellar approach would not This article is part of the Topical Collection on Functional Neurosurgery - Other Electronic supplementary material The online version of this article (https://doi.org/10.1007/s00701-020-04600-6) contains supplementary material, which is available to authorized users. * Janine-Ai Schlaeppi [email protected] Lukas Andereggen [email protected] Andreas Nowacki [email protected] Claudio Pollo [email protected] 1
Department of Neurosurgery, Bern University Hospital, Inselgruppe AG, Freiburgstrasse 8, 3010 Bern, Switzerland
2
Department of Neurosurgery, Kantonsspital Aarau, Tellstrasse 8, 5001 Aarau, Switzerland
have been possible. A stereotactic posterior approach through the midline allows for the shortest trajectory through the brainstem. The stereotactic conditions provide the highest precision in reaching the target point through a precisely defined trajectory. The craniocaudal level of the entry point in the brainstem is crucial as the position of the X cranial nerve nuclei is located immediately parasagittal in the upper part of the medulla oblongata. According to the Schaltenbrand and Wahren stereotactic atlas [3], the caudal extension of the X nuclei is 33 mm below the zero point, set at the pontomesencephalic junction. Since the lesion was located in the lower part of the medulla oblongata in this case, our entry point was located 43 mm under the referential (Fig. 1) and was considered safe with this respect. The other relevant anatomical challenge is to ensure that the entry point is accurately located at the midline to avoid injury of posterior fibe
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