Advertisement

Acta Neurochirurgica

, Volume 155, Issue 6, pp 1011–1016 | Cite as

Transcerebellomedullary fissure approach to lesions of the fourth ventricle: less is more?

  • Sheng Han
  • Zixun Wang
  • Yunjie Wang
  • Anhua WuEmail author
Clinical Article - Brain Tumors

Abstract

Background

The transcerebellomedullary fissure (trans-CMF) approach is safe and effective. Nevertheless, previous research documented a few differences in the use of this approach with regard to the opening portion of the fissure and roof of the ventricle. Here, we present a series of patients with fourth ventricular lesions and our experience using the trans-CMF approach.

Methods

Fifty patients who underwent the trans-CMF approach were analyzed. The tela choroidea was simply incised in 32 patients: 27 unilaterally and 5 bilaterally. Both the tela and inferior medullary velum were cut in 18 patients: 16 unilaterally and 2 bilaterally. Unless the tumor extended below the C1 level, C1 was preserved intact. Brainstem mapping (BSM) and corticobulbar tract (CBT) motor-evoked potential (MEP) monitoring were used.

Results

Gross total removal was achieved in 41 (82 %) cases, and sub-total removal was achieved in 9 (18 %) cases. Two deaths occurred 1–2 months postoperatively because of pulmonary complications. Four patients developed temporary mutism, all of whom underwent the bilateral trans-CMF approach (this rate is significantly higher than that of the unilateral approach, P < 0.05). No permanent neurological deficit occurred.

Conclusion

The trans-CMF approach provides excellent access to fourth ventricular lesions without splitting the vermis. The opening portion of the fissure and roof of the ventricle should be determined by the location, extension and size of the lesion. In most cases, the unilateral trans-CMF approach with only a tela choroidea incision is adequate; this procedure is mini-invasive and possibly prevents postoperative mutism.

Keywords

Cerebellomedullary fissure Telovelar approach Fourth ventricle Surgical approach Brain tumor 

Notes

Conflicts of interest

None.

References

  1. 1.
    Dailey AT, McKhann GM 2nd, Berger MS (1995) The pathophysiology of oral pharyngeal apraxia and mutism following posterior fossa tumor resection in children. J Neurosurg 83:467–475PubMedCrossRefGoogle Scholar
  2. 2.
    Deshmukh VR, Figueiredo EG, Deshmukh P, Crawford NR, Preul MC, Spetzler RF (2006) Quantification and comparison of telovelar and transvermian approaches to the fourth ventricle. Neurosurgery 58:ONS-202-6; discussion ONS-206-7Google Scholar
  3. 3.
    El-Bahy K (2005) Telovelar approach to the fourth ventricle: operative findings and results in 16 cases. Acta Neurochir (Wien) 147:137–142, discussion 142CrossRefGoogle Scholar
  4. 4.
    Gok A, Alptekin M, Erkutlu I (2004) Surgical approach to the fourth ventricle cavity through the cerebellomedullary fissure. Neurosurg Rev 27:50–54PubMedCrossRefGoogle Scholar
  5. 5.
    Hermann EJ, Rittierodt M, Krauss JK (2008) Combined transventricular and supracerebellar infratentorial approach preserving the vermis in giant pediatric posterior fossa midline tumors. Neurosurgery 63:ONS30-35, discussion ONS35-37CrossRefGoogle Scholar
  6. 6.
    Jittapiromsak P, Sabuncuoglu H, Deshmukh P, Spetzler RF, Preul MC (2010) Accessing the recesses of the fourth ventricle: comparison of tonsillar retraction and resection in the telovelar approach. Neurosurgery 66:30–39, discussion 39–40PubMedCrossRefGoogle Scholar
  7. 7.
    Kellogg JX, Piatt JH Jr (1997) Resection of fourth ventricle tumors without splitting the vermis: the cerebellomedullary fissure approach. Pediatr Neurosurg 27:28–33PubMedCrossRefGoogle Scholar
  8. 8.
    Matsushima T, Rhoton AL Jr, Lenkey C (1982) Microsurgery of the fourth ventricle: Part 1. Microsurgical anatomy. Neurosurgery 11:631–667PubMedCrossRefGoogle Scholar
  9. 9.
    Matsushima T, Fukui M, Inoue T, Natori Y, Baba T, Fujii K (1992) Microsurgical and magnetic resonance imaging anatomy of the cerebello-medullary fissure and its application during fourth ventricle surgery. Neurosurgery 30:325–330PubMedCrossRefGoogle Scholar
  10. 10.
    Matsushima T, Inoue T, Inamura T, Natori Y, Ikezaki K, Fukui M (2001) Transcerebellomedullary fissure approach with special reference to methods of dissecting the fissure. J Neurosurg 94:257–264PubMedCrossRefGoogle Scholar
  11. 11.
    Matsushima T, Abe H, Kawashima M, Inoue T (2012) Exposure of the wide interior of the fourth ventricle without splitting the vermis: importance of cutting procedures for the tela choroidea. Neurosurg Rev 35:563–571, discussion 571–572PubMedCrossRefGoogle Scholar
  12. 12.
    Mei C, Morgan AT (2011) Incidence of mutism, dysarthria and dysphagia associated with childhood posterior fossa tumour. Childs Nerv Syst 27:1129–1136PubMedCrossRefGoogle Scholar
  13. 13.
    Mussi AC, Rhoton AL Jr (2000) Telovelar approach to the fourth ventricle: microsurgical anatomy. J Neurosurg 92:812–823PubMedCrossRefGoogle Scholar
  14. 14.
    Parkinson D (2001) The posterior cranial fossa: microsurgical anatomy and surgical approaches. Neurosurgery 48:1196PubMedCrossRefGoogle Scholar
  15. 15.
    Pollack IF, Polinko P, Albright AL, Towbin R, Fitz C (1995) Mutism and pseudobulbar symptoms after resection of posterior fossa tumors in children: incidence and pathophysiology. Neurosurgery 37:885–893PubMedCrossRefGoogle Scholar
  16. 16.
    Rajesh BJ, Rao BR, Menon G, Abraham M, Easwer HV, Nair S (2007) Telovelar approach: technical issues for large fourth ventricle tumors. Childs Nerv Syst 23:555–558PubMedCrossRefGoogle Scholar
  17. 17.
    Rhoton AL Jr (2000) Cerebellum and fourth ventricle. Neurosurgery 47:S7–S27PubMedCrossRefGoogle Scholar
  18. 18.
    Shimoji K, Miyajima M, Karagiozov K, Yatomi K, Matsushima T, Arai H (2009) Surgical considerations in fourth ventricular ependymoma with the transcerebellomedullary fissure approach in focus. Childs Nerv Syst 25:1221–1228PubMedCrossRefGoogle Scholar
  19. 19.
    Talacchi A, Sala F, Alessandrini F, Turazzi S, Bricolo A (1998) Assessment and surgical management of posterior fossa epidermoid tumors: report of 28 cases. Neurosurgery 42:242–251, discussion 251–252PubMedCrossRefGoogle Scholar
  20. 20.
    Van Calenbergh F, Van de Laar A, Plets C, Goffin J, Casaer P (1995) Transient cerebellar mutism after posterior fossa surgery in children. Neurosurgery 37:894–898PubMedCrossRefGoogle Scholar
  21. 21.
    Zaheer SN, Wood M (2010) Experiences with the telovelar approach to fourth ventricular tumors in children. Pediatr Neurosurg 46:340–343PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Wien 2013

Authors and Affiliations

  1. 1.Department of NeurosurgeryThe First Hospital of China Medical UniversityShenyangChina

Personalised recommendations