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Occipital transtentorial approach to the precentral cerebellar fissure and posterior incisural space

Yaron A Moshel, Erik C Parker, Patrick J Kelly
Neurosurgery 2009, 65 (3): 554-64; discussion 564
19687701

OBJECTIVE: To describe the surgical techniques and postoperative clinical outcomes with the occipital transtentorial (OT) approach in patients harboring lesions arising from the precentral cerebellar fissure, posterior incisural space, and adjoining structures.

METHODS: Twenty-two patients underwent microsurgical resection of intra-axial lesions arising within the precentral cerebellar fissure and posterior incisural space between 1997 and 2006. Patient demographics, presenting symptoms, pathology, and neurological outcomes were retrospectively reviewed. Pre- and postoperative magnetic resonance imaging scans were evaluated to determine the anatomic extensions of the lesion and the degree of surgical resection. Patients with lesions primarily confined to the pineal and posterior third ventricle approached by a supracerebellar infratentorial trajectory were excluded from this study.

RESULTS: Of the 22 patients reported in this series, 17 (77%) had contrast-enhancing lesions, and 5 (23%) had nonenhancing lesions arising from the precentral cerebellar fissure and posterior incisural space. The lesions were oriented dorsomedial to the midbrain and diencephalon in 6 patients (27%), dorsolateral in 14 patients (64%), and lateral in 2 patients (9%). A lateral OT approach directed under the occipitotemporal junction was used in 16 patients (73%), and an interhemispheric OT approach was used in 6 patients (27%). Transient visual field loss occurred in 3 patients (14%); it resolved by the third follow-up month. Gross total resection or near-total resection of the imaging-defined lesion volume was achieved in 19 patients (86%).

CONCLUSION: The OT approaches provide excellent exposure for lesions of the precentral cerebellar fissure, posterior incisural space, and adjacent structures. The lateral OT approach directed under the occipitotemporal junction provides an inline view for lesions situated posterolateral to the brainstem. It also provides an inferiorly directed view under the venous system into the precentral cerebellar fissure and fourth ventricular roof. Visual field deficits are minimized by directing the trajectory under the occipitotemporal junction instead of retracting along the interhemispheric corridor. The interhemispheric OT approach was primarily used for lesions extending superiorly, in the midline or near midline, above the tentorium and venous system into the splenium of corpus callosum, lateral ventricle, and posterior thalamus, where extensive lateral retraction was not required.

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