The oculomotor-tentorial triangle. Part 2: a microsurgical workspace for vascular lesions in the crural and ambient cisterns.
J Neurosurg
; : 1-11, 2018 Jun 01.
Article
en En
| MEDLINE
| ID: mdl-29957110
ABSTRACT
OBJECTIVEPathology in the region of the basilar quadrifurcation, anterolateral midbrain, medial tentorium, and interpeduncular and ambient cisterns may be accessed anteriorly via an orbitozygomatic (OZ) craniotomy. In Part 1 of this series, the authors explored the anatomy of the oculomotor-tentorial triangle (OTT). In Part 2, the versatility of the OTT as a surgical workspace for treating vascular pathology is demonstrated.METHODSSixty patients with 61 vascular pathologies treated within or via the OTT from 1998 to 2017 by the senior author were retrospectively reviewed. Patients were grouped together based on pathology/surgical procedure and included 1) aneurysms (n = 19); 2) posterior cerebral artery (PCA)/superior cerebellar artery (SCA) bypasses (n = 24); 3) brainstem cavernous malformations (CMs; n = 14); and 4) tentorial region dural arteriovenous fistulas (dAVFs; n = 4). The majority of patients were approached via an OZ craniotomy, wide sylvian fissure split, and temporal lobe mobilization to widen the OTT.RESULTSAneurysm locations included the P1-P2 junction (n = 7), P2A segment (n = 9), P2/3 (n = 2), and basilar quadrification (n = 1). Aneurysm treatments included clip reconstruction (n = 12), wrapping (n = 3), proximal occlusion (n = 2), and trapping with (n = 1) or without (n = 1) bypass. Pathologies in the bypass group included vertebrobasilar insufficiency (VBI; n = 3) and aneurysms of the basilar trunk (n = 13), basilar apex (n = 4), P1 PCA (n = 2), and s1 SCA (n = 2). Bypasses included M2 middle cerebral artery (MCA)-radial artery graft (RAG)-P2 PCA (n = 8), M2 MCA-saphenous vein graft (SVG)-P2 PCA (n = 3), superficial temporal artery (STA)-P2 PCA (n = 5) or STA-s1 SCA (n = 3), s1 SCA-P2 PCA (n = 1), V3 vertebral artery (VA)-RAG-s1 SCA (n = 1), V3 VA-SVG-P2 PCA (n = 1), anterior temporal artery-s1 SCA (n = 1), and external carotid artery (ECA)-SVG-s1 SCA (n = 1). CMs were located in the midbrain (n = 10) or pontomesencephalic junction (n = 4). dAVFs drained into the tentorial, superior petrosal, cavernous, and sphenobasal sinuses. High rates of aneurysm occlusion (79%), bypass patency (100%), complete CM resection (86%), and dAVF obliteration (100%) were obtained. The overall rate of permanent oculomotor nerve palsy was 8.3%. The majority of patients in the aneurysm (94%), CM (93%), and dAVF (100%) groups had stable or improved modified Rankin Scale scores.CONCLUSIONSThe OTT is an important anatomical triangle and surgical workspace for vascular lesions in and around the crural and ambient cisterns. The OTT can be used to approach a wide variety of vascular pathologies in the region of the basilar quadrifurcation and anterolateral midbrain.
ACA = anterior cerebral artery; AChA = anterior choroidal artery; ATA = anterior temporal artery; CM = cavernous malformation; CN = cranial nerve; COT = carotid-oculomotor triangle; CS = cavernous sinus; CTA = CT angiography; DSA = digital subtraction angiography; ECA = external carotid artery; ICA = internal carotid artery; ICG = indocyanine green; MCA = middle cerebral artery; ONP = oculomotor nerve palsy; OTT = oculomotor-tentorial triangle; OZ = orbitozygomatic; PCA = posterior cerebral artery; PCP = posterior clinoid process; PCoA = posterior communicating artery; PIA = posterior interhemispheric approach; RAG = radial artery graft; SAH = subarachnoid hemorrhage; SBS = sphenobasal sinus; SCA = superior cerebellar artery; SCIT = supracerebellar infratentorial; SPS = superior petrosal sinus; STA = superficial temporal artery; SVG = saphenous vein graft; TS = tentorial sinus; VA = vertebral artery; VBI = vertebrobasilar insufficiency; ambient cistern; brainstem cavernous malformation; crural cistern; dAVF = dural arteriovenous fistula; mRS = modified Rankin Scale; oculomotor triangle; pontomesenphalic junction; posterior circulation aneurysms; posterior circulation revascularization; surgical technique; tentorial dural arteriovenous fistula; vascular disorders
Texto completo:
1
Colección:
01-internacional
Base de datos:
MEDLINE
Idioma:
En
Revista:
J Neurosurg
Año:
2018
Tipo del documento:
Article