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Anatomical step-by-step dissection of common approaches to the third ventricle for trainees: surgical anatomy of the anterior transcortical and interhemispheric transcallosal approaches, surgical principles, and illustrative pediatric cases

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Abstract

Purpose

To create a high-quality, cadaver-based, operatively oriented resource documenting the anterior transcortical and interhemispheric transcallosal approaches as corridors to the third ventricle targeted towards neurosurgical trainees at all levels.

Methods

Two formalin-fixed, latex-injected specimens were dissected under microscopic magnification and endoscopic-assisted visualization. Dissections of the transcortical and transcallosal craniotomies with transforaminal, transchoroidal, and interforniceal transventricular approaches were performed. The dissections were documented in a stepwise fashion using three-dimensional photographic image acquisition techniques and supplemented with representative cases to highlight pertinent surgical principles.

Results

The anterior transcortical and interhemispheric corridors afford excellent access to the anterior two-thirds of the third ventricle with varying risks associated with frontal lobe versus corpus callosum disruption, respectively. The transcortical approach offers a more direct, oblique view of the ipsilateral lateral ventricle, whereas the transcallosal approach readily establishes biventricular access through a paramedian corridor. Once inside the lateral ventricle, intraventricular angled endoscopy further enhances access to the extreme poles of the third ventricle from either open transcranial approach. Subsequent selection of either the transforaminal, transchoroidal, or interforniceal routes can be performed through either craniotomy and is ultimately dependent on individual deep venous anatomy, the epicenter of ventricular pathology, and the concomitant presence of hydrocephalus or embryologic cava. Key steps described include positioning and skin incision; scalp dissection; craniotomy flap elevation; durotomy; transcortical versus interhemispheric dissection with callosotomy; the aforementioned transventricular routes; and their relevant intraventricular landmarks.

Conclusions

Approaches to the ventricular system for maximal safe resection of pediatric brain tumors are challenging to master yet represent foundational cranial surgical techniques. We present a comprehensive operatively oriented guide for neurosurgery residents that combines stepwise open and endoscopic cadaveric dissections with representative case studies to optimize familiarity with third ventricle approaches, mastery of relevant microsurgical anatomy, and preparation for operating room participation.

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Data availability

All data supporting the findings of this study are available within the paper and its Supplementary Information.

Abbreviations

ASV:

Anterior septal vein

CSF:

Cerebrospinal fluid

CSP:

Cavum septum pellucidum

ICV:

Internal cerebral vein

MFG:

Middle frontal gyrus

MRI:

Magnetic resonance imaging

MRV:

Magnetic resonance venography

SSS:

Superior sagittal sinus

STL:

Superior temporal line

TSV:

Thalamostriate vein

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Funding

This study was funded by the Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, the Joseph and Barbara Ashkins Endowed Professorship in Surgery and the Radiology Department, Mayo Clinic, Rochester, Minnesota, and the Charles B. and Ann L. Johnson Endowed Professorship in Neurosurgery, Mayo Clinic, Rochester, Minnesota.

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Authors and Affiliations

  1. Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA

    Danielle D. Dang, Julian S. Rechberger, Luciano C. P. C. Leonel, Rima S. Rindler, Cody L. Nesvick, Stephen Graepel, Michael J. Link, David J. Daniels & Maria Peris Celda

  2. Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, 200 1S St SW, Rochester, MN, 55902, USA

    Danielle D. Dang, Julian S. Rechberger, Luciano C. P. C. Leonel, Rima S. Rindler, Michael J. Link & Maria Peris Celda

  3. Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, MN, USA

    Michael J. Link & Maria Peris Celda

Authors
  1. Danielle D. Dang
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  2. Julian S. Rechberger
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  3. Luciano C. P. C. Leonel
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Contributions

Conceptualization: DDD, JSR, DJD, MPC; methodology: DDD, JSR, LCPCL, DJD, MPC; Formal analysis and investigation: DDD, JSR, LCPCL, RSR, CLN, SG; writing—original draft preparation: DDD, JSR, CLN, DJD, MPC; writing—review and editing: DDD, JSR, RSR, MJL, DJD, MPC; funding acquisition: MJL, DJD, MPC; supervision: MJL, DJD, MPC.

Corresponding author

Correspondence to Maria Peris Celda.

Ethics declarations

Consent to participate

Informed consent for participation and publication in research was obtained by all patients for this study.

Research involving human participants and/or animals

Institutional review board and biospecimens committee approval from the Mayo Clinic was obtained for this study.

Conflict of interest

The authors declare no competing interests.

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Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Danielle D. Dang and Julian S. Rechberger contributed equally to the manuscript and are first co-authors.

David J. Daniels and Maria Peris-Celda are senior co-authors.

Supplementary Information

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Dang, D.D., Rechberger, J.S., Leonel, L.C.P.C. et al. Anatomical step-by-step dissection of common approaches to the third ventricle for trainees: surgical anatomy of the anterior transcortical and interhemispheric transcallosal approaches, surgical principles, and illustrative pediatric cases. Acta Neurochir 165, 2421–2434 (2023). https://doi.org/10.1007/s00701-023-05697-1

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