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Trans-fissural or trans-sulcal approach versus combined stereotactic-microsurgical approach
R Garcia Sola1, P Pulido, E Kusak
1Department of Neurosurgery, Hospital de la Princesa, Autonomous University, Madrid, Spain.
Abstract:
The combined stereotactic-microsurgical approach has been used mainly to allow the removal of small subcortical lesions, determining their location and the route to be followed. In our experience, this approach has been most useful in 5 cases of small paraventricular AVMs and another 6 small deep-seated tumoural lesions. Since the availability of MRI, we have systematically applied Yasargil's proposal to perform dissection of the cisterns or sulci to reach a lesion with minimal or no injury to normal neuroanatomy. Assisted by Computer Aided Design software, we can superimpose the MR images with those provided by conventional or digital angiography (mainly the venous phase). MRI allows us to select a route or pathway through a sulcus, and angiography helps us in locating it on the brain surface. We have applied this technique systematically during the past year, and can report 20 cases (1 AVM, 12 tumoural lesions, 1 abscess and 6 haematomas). This trans-fissural or trans-sulcal approach has allowed us resection with minimal surgical damage, after a prompt and precise location. We think that both methods are not mutually exclusive, although the trans-sulcal approach is more adequate because of less discomfort for the patient, the smaller cerebral parenchyma injury and greater anatomofunctional information for the surgeon.
Insights
The trans-sulcal approach, guided by MRI and angiography, enables precise removal of deep-seated brain lesions with minimal patient discomfort and reduced neuroanatomical injury. This method offers superior outcomes compared to traditional combined stereotactic-microsurgical techniques.
Area of Science:
- Neurosurgery
- Neuroradiology
- Medical Imaging
Background:
- The combined stereotactic-microsurgical approach is traditionally used for small subcortical lesions.
- Previous experience highlighted its utility in treating arteriovenous malformations (AVMs) and deep-seated tumors.
Purpose of the Study:
- To evaluate the efficacy and safety of a trans-sulcal approach for accessing and resecting deep-seated intracranial lesions.
- To compare the trans-sulcal approach with the combined stereotactic-microsurgical technique.
Main Methods:
- Systematic application of Yasargil's trans-sulcal dissection technique, guided by Magnetic Resonance Imaging (MRI) and angiography.
- Utilizing Computer Aided Design (CAD) software to superimpose MRI and angiographic data for precise surgical planning.
- Performing lesion resection via a trans-fissural or trans-sulcal pathway.
Main Results:
- Successfully treated 20 cases including AVMs, tumors, abscesses, and hematomas using the trans-sulcal approach.
- Achieved minimal surgical damage and prompt, precise lesion localization in all cases.
- Observed reduced patient discomfort, smaller cerebral parenchyma injury, and enhanced anatomofunctional information.
Conclusions:
- The trans-sulcal approach, augmented by MRI and angiography, is a highly effective method for resecting deep-seated brain lesions.
- This technique offers significant advantages over traditional combined stereotactic-microsurgical methods, including improved patient outcomes and reduced surgical trauma.