Posterior Interhemispheric Transtentorial Approach: Planning and positioning
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This video segment gives a thorough analysis of the pre-operative MRI. It explains the decision of the approach to perform with evaluation of the available alternatives.
- Clinical case
- Preoperative MRI
- Pineal tumor
- callosal approach
- Interhemispheric transtentorial approach
About this video
- Giuseppe Cinalli
- Matteo Sacco
- First online
- 16 March 2019
- Online ISBN
- Springer, Cham
- Copyright information
- © The Author(s) 2019
The MRI shows a very significant mass arising from the pineal region, with a significant supratentorial extension into the third ventricle, and both lateral ventricle with the upward displacement of internal cerebral vein. Sagittal images clearly showed the previews in the surgery of callosotomy performed in another country, and the very significant trans-tentorial extension.
Sagittal T2 DRIVE sequences shows the inhomogeneous pattern of the tumor, with the internal cerebral vein apparently enclosed into the tumor tissue, the significant extension anteriorly to the third ventricle, and the significant cystic component in the posterior fossa with downward displacement of the cerebellum.
The VP shunt implanted in another country is visible in the frontal region. Coronal section shows very nicely the tumor with a significant bi-thalamic displacement, and the very significant tumor mass into the lateral ventricle. This is the area of previous callosotomy. The hypothesis of a surgical approach to the previous callosotomy was considered because the two largest diameter of the tumor develop in caudal-cranial way.
And certainly, this kind of approach is shown in this project and reconstruction. The trajectory is extremely good. The profile view of the trajectory shows that the target of the distal target in the region of the upper vermis is extremely far away. And for this reason, this first approach was discarded, also because of the two areas that could not be seen through this approach.
So another approach was considered, also because the very steep angle of the tentorium and of the very wide space between the lowest part of the corpus callosum and the upper vermis, allowing a very large surgical corridor.
If considering the inter hemispheric transtentorial approach, certainly there is a black area not visible. But this reconstruction trajectory shows that with a straight line, there is a sufficient possibility to reach the anterior pole.