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Extreme lateral supracerebellar infratentorial approach: how I do it

  • How I Do it - Tumor - Meningioma
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Abstract

Background

The extreme lateral supracerebellar infratentorial (ELSI) approach was initially proposed to treat lesions of the posterolateral surface of the pons principally cavernomas. The versatility of the approach allowed its use for other pathologies like gliomas, aneurysms, epidermoids, and meningiomas.

Method

We describe here the ELSI approach along with its advantages and limits in comparison with other surgical approaches for the treatment of meningiomas of the petroclival region.

Conclusion

ELSI is a versatile approach that allows access to the anterolateral brainstem surface including extensions to the midbrain diencephalic junction when needed. ELSI compares favorably to other surgical alternatives with respect to the approach-related morbidity, while allowing adequate access to treat the pathology.

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Author information

Authors and Affiliations

  1. Department of Neurosurgery, University Hospital of Lausanne, Lausanne, Switzerland

    L. Giammattei, F. Borsotti & R. T. Daniel

Authors
  1. L. Giammattei
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  2. F. Borsotti
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  3. R. T. Daniel
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Corresponding author

Correspondence to L. Giammattei.

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Conflict of interest

The authors declare that they have no conflict of interest.

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The patient/next of kin/guardian has consented to the submission of this “How I Do It” to the journal.

Additional information

Key points

1. ELSI is a versatile approach that can be used to resect lesions within the posterior and middle tentorial incisura.

2. ELSI is rapid and, when compared with petrosal approaches, could prove to be useful in reducing the approach-related morbidity. The global morbidity of this pathology still remains mostly dependent on the relationship with vital neurovascular structures

3. Compared with the subtemporal approach, ELSI avoids the need for temporal lobe retraction and possible venous complications.

4. Compared with retrosigmoid approach, ELSI reduces the manipulation of VII/VIII cranial nerves.

5. A careful analysis of the anatomy of the transverse and sigmoid sinuses, and pneumatization of the mastoid bone is important for a safe craniotomy.

6. Surgery in a park-bench position reduces the incidence of air embolism that is associated with the semi-sitting position.

7. Opening of the lateral cerebellomedullary cistern allows early relaxation of the cerebellum.

8. Dissection of the external surface of the tumor should only be attempted after adequate internal debulking.

9. A tentorial incision is only performed if the visualization of the superior part of the tumor is limited.

10. Tumor remnants left in place due to critical adherence to neurovascular structures can be later treated with radiosurgery.

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This article is part of the Topical Collection on Tumor - Meningioma

Electronic supplementary material

A short video showing the resection of a petroclival meningioma through an extreme lateral supracerebellar infratentorial approach is added. (MP4 417,221 kb)

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Giammattei, L., Borsotti, F. & Daniel, R.T. Extreme lateral supracerebellar infratentorial approach: how I do it. Acta Neurochir 161, 1013–1016 (2019). https://doi.org/10.1007/s00701-019-03886-5

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  • DOI: https://doi.org/10.1007/s00701-019-03886-5

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