Extreme Lateral Supracerebellar Infratentorial Approach: Surgical Anatomy and Review of the Literature.

OBJECTIVE: The extreme lateral supracerebellar infratentorial (ELSI) approach has the potential to access several distinct anatomical regions that are otherwise difficult to reach. We have illustrated the surgical anatomy through cadaveric dissections and provided an extensive review of the literature to highlight the versatility of this approach, its limits, and comparisons with alternative approaches. METHODS: The surgical anatomy of the ELSI has been described using 1 adult-injected cadaveric head. Formalized noninjected brain specimens were also dissected to describe the brain parenchymal anatomy of the region. An extensive review of the literature was performed according to each targeted anatomical region. Illustrative cases are also presented. RESULTS: The ELSI approach allows for wide exposure of the middle and posterolateral incisural spaces with direct access to centrally located intra-axial structures such as the splenium, pulvinar, brainstem, and mesial temporal lobe. In addition, for skull base extra-axial tumors such as petroclival meningiomas, the ELSI approach represents a rapid and adequate method of access without the use of extensive skull base approaches. CONCLUSIONS: The ELSI approach represents one of the most versatile approaches with respect to its ability to address several anatomical regions centered at the posterior and middle incisural spaces. For intra-axial pathologies, the approach allows for access to the central core of the brain with several advantages compared with alternate approaches that frequently involve significant brain retraction and cortical incisions. In specific cases of skull base lesions, the ELSI approach is an elegant alternative to traditionally used skull base approaches, thereby avoiding approach-related morbidity.

[Topography of the hypophysis and its neighboring structures]. / Topographie der Hypophyse und der benachbarten Strukturen.

The first part of the article informs about four points: the skeletal structures of the middle cranial fossa, the basic divisions of the gland and their connections with the hypothalamus, its blood supply, and its development. The topographic part deals with the incorporation of the pituitary gland in the sella turcica, its relationship to the meninges, the subarachnoid cavity and other neighbouring structures, especially the sphenoidal sinus, the posterior ethmoidal cells as well as the chiasma opticum. With respect to the latter, the position of the fibres in the optic nerve, chiasma and optic tract and the consequences of lesions in characteristic areas are described. Finally, the variant structures of the cavernous sinus and the topography of its contents are discussed. Detailed data can be found about the course of the oculomotor nerves and the possible locations of their lesions.