Transsulcal parafascicular brain path-assisted approach to subcortical lesions: 2-dimensional operative video

Approaches to subcortical lesions have traditionally been limited by the morbidity of white matter dissection and fixed blade retraction required to reach these targets. Visualization of deep surgical fields with a traditional operating microscope is also poor. Coordinated use of intra-operative image guidance, a tubular retractor (BrainPath^®, Nico Corp, Indianapolis, Indiana), a high-definition exoscope (Vitom^®, Karl Storz Endoscopy America, Inc, El Segundo, California), and a low-profile resection device (Myriad^®, Nico Corp) facilitates atraumatic access to and resection of subcortical lesions including primary brain tumors, brain metastases, and intracerebral hemorrhages.[1] Use of pre-planned transsulcal and parafascicular trajectories based on magnetic resonance imaging (MRI) and diffusion tensor imaging (DTI) can further mitigate damage to white matter tracts with this technique.

We herein present details of the transsulcal parafascicular BrainPath^®-assisted approach to subcortical lesions and demonstrate the utility of this technique using two patient examples: a spontaneous deep left posterior temporal lobe hematoma in a 41-year-old male and a left hippocampal glioblastoma in a 54-year-old female. Key steps include selection of appropriate patients with non-skull base subcortical lesions, preoperative trajectory and tube depth planning based on MRI (including diffusion-weighted imaging and DTI), patient positioning and operating room setup to facilitate pre-planned trajectories and surgeon ergonomics, and use of low-profile instruments with a two-handed surgical technique.

Given recent data demonstrating the utility of this approach for hematoma evacuation and a likely increased future usage of this technique,[2] surgeon familiarity with the above steps will be of increasing importance.