Download PDF
J Neurol Surg A Cent Eur Neurosurg 2021; 82(03): 248-256
DOI: 10.1055/s-0040-1719107
Original Article

Endoscope-Assisted Neuroportal Transcerebellar Approach to the Fourth Ventricle: An Anatomical Study

Martina Piloni
1   Department of Neurosurgery and Gamma Knife Radiosurgery, Vita-Salute San Raffaele University and IRCCS San Raffaele Scientific Institute, Milan, Italy
,
Filippo Gagliardi
1   Department of Neurosurgery and Gamma Knife Radiosurgery, Vita-Salute San Raffaele University and IRCCS San Raffaele Scientific Institute, Milan, Italy
,
Michele Bailo
1   Department of Neurosurgery and Gamma Knife Radiosurgery, Vita-Salute San Raffaele University and IRCCS San Raffaele Scientific Institute, Milan, Italy
,
Lina R. Barzaghi
1   Department of Neurosurgery and Gamma Knife Radiosurgery, Vita-Salute San Raffaele University and IRCCS San Raffaele Scientific Institute, Milan, Italy
,
Anthony J. Caputy
2   Department of Neurological Surgery, The George Washington University, Washington, District of Columbia, United States
,
Pietro Mortini
1   Department of Neurosurgery and Gamma Knife Radiosurgery, Vita-Salute San Raffaele University and IRCCS San Raffaele Scientific Institute, Milan, Italy
› Author Affiliations
› Further Information
    Permissions and Reprints

Abstract

Background and Study Aims Minimally invasive approaches to deep-seated lesions still represent a fundamental issue in modern neurosurgery. Tubular retractors allow to enhance the operability of intraventricular lesions, minimizing the risk of damages to brain parenchyma. Increasing interest for portal devices has been mainly focused on supratentorial pathologies, while transportal approaches in the posterior cranial fossa have been rarely described. In the present study, the authors aimed to investigate the surgical exposure and operability obtained with a microsurgical neuroportal transcerebellar approach targeting the fourth ventricle, assisted by endoscopic exploration.

Material and Methods Six cadaveric specimens were provided for anatomical microsurgical dissection and Vycor ViewSite Brain Access System was used as tubular retractor. Surgical feasibility of the neuroportal transcerebellar approach was demonstrated through a definable and measurable parameter, the operability score.

Results The neuroport provided a surgical corridor away from eloquent structures to target the whole fourth ventricle cavity, preventing injury to cerebellar nuclei and white matter pathways and, potentially, minimizing the risk of surgical morbidity. Maximal operability was reached in the pontomedullary junction and medullary area of the ventricular floor. Transportal endoscopic assistance contributed to a further extension of surgical exposure in blind spots, corresponding to the ipsilateral lateral recess, the uppermost part of the fourth ventricle, and the obex.

Conclusion The neuroportal transcerebellar approach represents a viable alternative route to the fourth ventricle, avoiding vermian splitting or subarachnoid dissection of the cerebellomedullary cistern. Endoscopic assistance enhances the exposure of the surgical field and accomplishes a valid instrument for intraventricular orientation to ease microsurgical procedures.

Keywords

Cerebellum - dentate nucleus - fourth ventricle - neuroport - tubular retractor

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with 1964 Helsinki Declaration and its later amendments or comparable ethical standards.


Informed Consent

Informed consent was obtained from all individual participants included in the study.




Publication History

Received: 01 April 2020

Accepted: 08 June 2020

Article published online:
09 March 2021

© 2021. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • References

  • 1 Matsushima T, Inoue T, Inamura T, Natori Y, Ikezaki K, Fukui M. Transcerebellomedullary fissure approach with special reference to methods of dissecting the fissure. J Neurosurg 2001; 94 (02) 257-264
    CrossrefPubMedGoogle Scholar
  • 2 Mussi AC, Matushita H, Andrade FG, Rhoton AL. Surgical approaches to IV ventricle: anatomical study. Childs Nerv Syst 2015; 31 (10) 1807-1814
    CrossrefPubMedGoogle Scholar
  • 3 Tanriover N, Ulm AJ, Rhoton Jr AL, Yasuda A. Comparison of the transvermian and telovelar approaches to the fourth ventricle. J Neurosurg 2004; 101 (03) 484-498
    CrossrefPubMedGoogle Scholar
  • 4 Akakin A, Peris-Celda M, Kilic T, Seker A, Gutierrez-Martin A, Rhoton Jr A. The dentate nucleus and its projection system in the human cerebellum: the dentate nucleus microsurgical anatomical study. Neurosurgery 2014; 74 (04) 401-424 , discussion 424–425
    CrossrefPubMedGoogle Scholar
  • 5 Rekate HL, Grubb RL, Aram DM, Hahn JF, Ratcheson RA. Muteness of cerebellar origin. Arch Neurol 1985; 42 (07) 697-698
    CrossrefPubMedGoogle Scholar
  • 6 van Baarsen K, Kleinnijenhuis M, Konert T, van Cappellen van Walsum AM, Grotenhuis A. Tractography demonstrates dentate-rubro-thalamic tract disruption in an adult with cerebellar mutism. Cerebellum 2013; 12 (05) 617-622
    CrossrefPubMedGoogle Scholar
  • 7 van Baarsen KM, Grotenhuis JA. The anatomical substrate of cerebellar mutism. Med Hypotheses 2014; 82 (06) 774-780
    CrossrefPubMedGoogle Scholar
  • 8 Albin MS, Bunegin L. The insidiousness of brain retractor pressure: another “smoking gun”?. Anesth Analg 2003; 96 (01) 306 , author reply 306–307
    CrossrefPubMedGoogle Scholar
  • 9 Donaghy RM, Numoto M, Wallman LJ, Flanagan ME. Pressure measurement beneath retractors for protection of delicate tissues. Am J Surg 1972; 123 (04) 429-431
    CrossrefPubMedGoogle Scholar
  • 10 Rosenørn J, Diemer N. The risk of cerebral damage during graded brain retractor pressure in the rat. J Neurosurg 1985; 63 (04) 608-611
    CrossrefPubMedGoogle Scholar
  • 11 Rosenørn J, Diemer NH. Reduction of regional cerebral blood flow during brain retraction pressure in the rat. J Neurosurg 1982; 56 (06) 826-829
    CrossrefPubMedGoogle Scholar
  • 12 Xu W, Mellergård P, Ungerstedt U, Nordström CH. Local changes in cerebral energy metabolism due to brain retraction during routine neurosurgical procedures. Acta Neurochir (Wien) 2002; 144 (07) 679-683
    CrossrefPubMedGoogle Scholar
  • 13 Zhong J, Dujovny M, Perlin AR, Perez-Arjona E, Park HK, Diaz FG. Brain retraction injury. Neurol Res 2003; 25 (08) 831-838
    CrossrefPubMedGoogle Scholar
  • 14 Cohen-Gadol AA. Minitubular transcortical microsurgical approach for gross total resection of third ventricular colloid cysts: technique and assessment. World Neurosurg 2013; 79 (01) 207 e07-207 e10
    PubMedGoogle Scholar
  • 15 Eichberg DG, Buttrick SS, Sharaf JM. et al. Use of tubular retractor for resection of colloid cysts: single surgeon experience and review of the literature. Oper Neurosurg (Hagerstown) 2019; 16 (05) 571-579
    CrossrefPubMedGoogle Scholar
  • 16 Eliyas JK, Glynn R, Kulwin CG. et al. Minimally invasive transsulcal resection of intraventricular and periventricular lesions through a tubular retractor system: multicentric experience and results. World Neurosurg 2016; 90: 556-564
    CrossrefPubMedGoogle Scholar
  • 17 Gagliardi F, Piloni M, Bailo M. et al. Anatomic study on neuroendoportal transcortical approach to lateral ventricles. World Neurosurg 2019; 131: e255-e264
    CrossrefPubMedGoogle Scholar
  • 18 Herrera SR, Shin JH, Chan M, Kouloumberis P, Goellner E, Slavin KV. Use of transparent plastic tubular retractor in surgery for deep brain lesions: a case series. Surg Technol Int 2010; 19: 47-50
    PubMedGoogle Scholar
  • 19 Matsumoto Y, Kurozumi K, Shimazu Y, Ichikawa T, Date I. Endoscope-assisted resection of cavernous angioma at the foramen of Monro: a case report. Springerplus 2016; 5 (01) 1820
    CrossrefPubMedGoogle Scholar
  • 20 Raza SM, Recinos PF, Avendano J, Adams H, Jallo GI, Quinones-Hinojosa A. Minimally invasive trans-portal resection of deep intracranial lesions. Minim Invasive Neurosurg 2011; 54 (01) 5-11
    Article in Thieme ConnectPubMedGoogle Scholar
  • 21 Shoakazemi A, Evins AI, Burrell JC, Stieg PE, Bernardo A. A 3D endoscopic transtubular transcallosal approach to the third ventricle. J Neurosurg 2015; 122 (03) 564-573
    CrossrefPubMedGoogle Scholar
  • 22 Jamshidi AO, Priddy B, Beer-Furlan A, Prevedello DM. Infradentate approach to the fourth ventricle. Oper Neurosurg (Hagerstown) 2019; 16 (02) 167-178
    CrossrefPubMedGoogle Scholar
  • 23 Bergsneider M. Endoscopic removal of cysticercal cysts within the fourth ventricle. Technical note. J Neurosurg 1999; 91 (02) 340-345
    Google Scholar
  • 24 Hamada H, Hayashi N, Endo S, Kurimoto M, Hirashima Y, Takaku A. Endoscopic aqueductal plasty via the fourth ventricle through the cerebellar hemisphere under navigating system guidance--technical note. Neurol Med Chir (Tokyo) 1999; 39 (13) 950-952 , discussion 952–954
    CrossrefPubMedGoogle Scholar
  • 25 Longatti P, Basaldella L, Feletti A, Fiorindi A, Billeci D. Endoscopic navigation of the fourth ventricle. Technical note and preliminary experience. Neurosurg Focus 2005; 19 (06) E12
    CrossrefPubMedGoogle Scholar
  • 26 Longatti P, Fiorindi A, Feletti A, D'Avella D, Martinuzzi A. Endoscopic anatomy of the fourth ventricle. J Neurosurg 2008; 109 (03) 530-535
    Google Scholar
  • 27 Matula C, Reinprecht A, Roessler K, Tschabitscher M, Koos WT. Endoscopic exploration of the IVth ventricle. Minim Invasive Neurosurg 1996; 39 (03) 86-92
    Article in Thieme ConnectPubMedGoogle Scholar
  • 28 Toyota S, Taki T, Oshino S. et al. A neuroendoscopic approach to the aqueduct via the fourth ventricle combined with suboccipital craniectomy. Minim Invasive Neurosurg 2004; 47 (05) 312-315
    Article in Thieme ConnectPubMedGoogle Scholar
  • 29 Gagliardi F, Boari N, Roberti F, Caputy AJ, Mortini P. Operability score: an innovative tool for quantitative assessment of operability in comparative studies on surgical anatomy. J Craniomaxillofac Surg 2014; 42 (06) 1000-1004
    CrossrefPubMedGoogle Scholar
  • 30 Chau AM, Gagliardi F, Smith A. et al. The paramedian supracerebellar transtentorial approach to the posterior fusiform gyrus. Acta Neurochir (Wien) 2016; 158 (11) 2149-2154
    CrossrefPubMedGoogle Scholar
  • 31 Gagliardi F, Boari N, Roberti F. et al. Extradural subtemporal transzygomatic approach to the clival and paraclival region with endoscopic assist. J Craniofac Surg 2012; 23 (05) 1468-1475
    CrossrefPubMedGoogle Scholar
  • 32 Gagliardi F, Donofrio CA, Spina A. et al. Endoscope-assisted transmaxillosphenoidal approach to the sellar and parasellar regions: an anatomic study. World Neurosurg 2016; 95: 246-252
    CrossrefPubMedGoogle Scholar
  • 33 Gagliardi F, Piloni M, Bailo M. et al. Comparative anatomical study on the role of zygomatic osteotomy in the extradural subtemporal approach to the clival region, when less is more. Surg Radiol Anat 2020; 42 (05) 567-575
    CrossrefPubMedGoogle Scholar
  • 34 Spina A, Gagliardi F, Abarca-Olivas J. et al. Endonasal endoscopic and transoral approaches to the craniovertebral junction and the clival region: a comparative anatomical study. World Neurosurg 2019; 132: e116-e123
    CrossrefPubMedGoogle Scholar
  • 35 Spina A, Gagliardi F, Bailo M, Boari N, Caputy AJ, Mortini P. Comparative anatomical study on operability in surgical approaches to the anterior part of the third ventricle. World Neurosurg 2016; 95: 457-463
    CrossrefPubMedGoogle Scholar
  • 36 Deshmukh VR, Figueiredo EG, Deshmukh P, Crawford NR, Preul MC, Spetzler RF. Quantification and comparison of telovelar and transvermian approaches to the fourth ventricle. Neurosurgery 2006; 58 (04) (Suppl. 02) ONS-202-ONS-206 , discussion ONS-206–ONS-207
    CrossrefPubMedGoogle Scholar
  • 37 Ghali MGZ. Telovelar surgical approach. Neurosurg Rev 2019; (e-pub ahead of print) DOI: 10.1007/s10143-019-01190-5.
    CrossrefPubMedGoogle Scholar
  • 38 Tomasello F, Conti A, Cardali S, La Torre D, Angileri FF. Telovelar approach to fourth ventricle tumors: highlights and limitations. World Neurosurg 2015; 83 (06) 1141-1147
    CrossrefPubMedGoogle Scholar
  • 39 Gao JH, Parsons LM, Bower JM, Xiong J, Li J, Fox PT. Cerebellum implicated in sensory acquisition and discrimination rather than motor control. Science 1996; 272 (5261): 545-547
    CrossrefPubMedGoogle Scholar
  • 40 Lawrenson C, Bares M, Kamondi A. et al. The mystery of the cerebellum: clues from experimental and clinical observations. Cerebellum Ataxias 2018; 5: 8
    CrossrefPubMedGoogle Scholar
  • 41 O'Halloran CJ, Kinsella GJ, Storey E. The cerebellum and neuropsychological functioning: a critical review. J Clin Exp Neuropsychol 2012; 34 (01) 35-56
    CrossrefPubMedGoogle Scholar
  • 42 Schmahmann JD. The role of the cerebellum in cognition and emotion: personal reflections since 1982 on the dysmetria of thought hypothesis, and its historical evolution from theory to therapy. Neuropsychol Rev 2010; 20 (03) 236-260
    CrossrefPubMedGoogle Scholar
  • 43 Law N, Greenberg M, Bouffet E. et al. Clinical and neuroanatomical predictors of cerebellar mutism syndrome. Neuro-oncol 2012; 14 (10) 1294-1303
    CrossrefPubMedGoogle Scholar
  • 44 Ramos A, Chaddad-Neto F, Dória-Netto HL, Campos-Filho JM, Oliveira E. Cerebellar anatomy as applied to cerebellar microsurgical resections. Arq Neuropsiquiatr 2012; 70 (06) 441-446
    CrossrefPubMedGoogle Scholar
  • 45 Rhoton Jr AL. Cerebellum and fourth ventricle. Neurosurgery 2000; 47 (3, Suppl): S7-S27
    CrossrefPubMedGoogle Scholar
  • 46 Cobourn K, Marayati F, Tsering D. et al. Cerebellar mutism syndrome: current approaches to minimize risk for CMS. Childs Nerv Syst 2020; 36 (06) 1171-1179
    CrossrefPubMedGoogle Scholar
  • 47 Dailey AT, McKhann II GM, Berger MS. The pathophysiology of oral pharyngeal apraxia and mutism following posterior fossa tumor resection in children. J Neurosurg 1995; 83 (03) 467-475
    CrossrefPubMedGoogle Scholar
  • 48 Erşahin Y. Is splitting of the vermis responsible for cerebellar mutism?. Pediatr Neurosurg 1998; 28 (06) 328
    CrossrefPubMedGoogle Scholar
  • 49 Frassanito P, Massimi L. Cerebellar mutism: review of the literature. Childs Nerv Syst 2011; 27 (06) 867-868
    CrossrefPubMedGoogle Scholar
  • 50 Gudrunardottir T, Sehested A, Juhler M, Schmiegelow K. Cerebellar mutism: review of the literature. Childs Nerv Syst 2011; 27 (03) 355-363
    CrossrefPubMedGoogle Scholar
  • 51 Küpeli S, Yalçın B, Bilginer B, Akalan N, Haksal P, Büyükpamukçu M. Posterior fossa syndrome after posterior fossa surgery in children with brain tumors. Pediatr Blood Cancer 2011; 56 (02) 206-210
    CrossrefPubMedGoogle Scholar
  • 52 Mariën P, De Smet HJ, Wijgerde E, Verhoeven J, Crols R, De Deyn PP. Posterior fossa syndrome in adults: a new case and comprehensive survey of the literature. Cortex 2013; 49 (01) 284-300
    CrossrefPubMedGoogle Scholar
  • 53 Morris EB, Phillips NS, Laningham FH. et al. Proximal dentatothalamocortical tract involvement in posterior fossa syndrome. Brain 2009; 132 (Pt 11): 3087-3095
    CrossrefPubMedGoogle Scholar
  • 54 Matsushima T, Fukui M, Inoue T, Natori Y, Baba T, Fujii K. Microsurgical and magnetic resonance imaging anatomy of the cerebello-medullary fissure and its application during fourth ventricle surgery. Neurosurgery 1992; 30 (03) 325-330
    CrossrefPubMedGoogle Scholar
  • 55 Abdou MS, Cohen AR. Endoscopic treatment of colloid cysts of the third ventricle. Technical note and review of the literature. J Neurosurg 1998; 89 (06) 1062-1068
    CrossrefPubMedGoogle Scholar
  • 56 Hellwig D, Bauer BL, Schulte M, Gatscher S, Riegel T, Bertalanffy H. Neuroendoscopic treatment for colloid cysts of the third ventricle: the experience of a decade. Neurosurgery 2008; 62 (06) (Suppl. 03) 1101-1109
    CrossrefPubMedGoogle Scholar
  • 57 Horn EM, Feiz-Erfan I, Bristol RE. et al. Treatment options for third ventricular colloid cysts: comparison of open microsurgical versus endoscopic resection. Neurosurgery 2008; 62 (06) (Suppl. 03) 1076-1083
    CrossrefPubMedGoogle Scholar
  • 58 Kehler U, Brunori A, Gliemroth J. et al. Twenty colloid cysts: comparison of endoscopic and microsurgical management. Minim Invasive Neurosurg 2001; 44 (03) 121-127
    Article in Thieme ConnectPubMedGoogle Scholar
  • 59 Lewis AI, Crone KR, Taha J, van Loveren HR, Yeh HS, Tew Jr JM. Surgical resection of third ventricle colloid cysts. Preliminary results comparing transcallosal microsurgery with endoscopy. J Neurosurg 1994; 81 (02) 174-178
    CrossrefPubMedGoogle Scholar
  • 60 Rodziewicz GS, Smith MV, Hodge Jr CJ. Endoscopic colloid cyst surgery. Neurosurgery 2000; 46 (03) 655-660 , discussion 660–662
    CrossrefPubMedGoogle Scholar
  • 61 Kelly PJ, Goerss SJ, Kall BA. The stereotaxic retractor in computer-assisted stereotaxic microsurgery. Technical note. J Neurosurg 1988; 69 (02) 301-306
    CrossrefPubMedGoogle Scholar
  • 62 Barlas O, Karadereler S. Stereotactically guided microsurgical removal of colloid cysts. Acta Neurochir (Wien) 2004; 146 (11) 1199-1204
    CrossrefPubMedGoogle Scholar
  • 63 Bander ED, Jones SH, Kovanlikaya I, Schwartz TH. Utility of tubular retractors to minimize surgical brain injury in the removal of deep intraparenchymal lesions: a quantitative analysis of FLAIR hyperintensity and apparent diffusion coefficient maps. J Neurosurg 2016; 124 (04) 1053-1060
    CrossrefPubMedGoogle Scholar
  • 64 Recinos PF, Raza SM, Jallo GI, Recinos VR. Use of a minimally invasive tubular retraction system for deep-seated tumors in pediatric patients. J Neurosurg Pediatr 2011; 7 (05) 516-521
    CrossrefPubMedGoogle Scholar
  • 65 Fernandez-Miranda JC, Engh JA, Pathak SK. et al. High-definition fiber tracking guidance for intraparenchymal endoscopic port surgery. J Neurosurg 2010; 113 (05) 990-999
    CrossrefPubMedGoogle Scholar
  • 66 Salamon N, Sicotte N, Drain A. et al. White matter fiber tractography and color mapping of the normal human cerebellum with diffusion tensor imaging. J Neuroradiol 2007; 34 (02) 115-128
    CrossrefPubMedGoogle Scholar
  • 67 Hong CS, Prevedello DM, Elder JB. Comparison of endoscope- versus microscope-assisted resection of deep-seated intracranial lesions using a minimally invasive port retractor system. J Neurosurg 2016; 124 (03) 799-810
    CrossrefPubMedGoogle Scholar