Variations in venous anatomy associated with the suboccipital transhorizontal fissure approach: Imaging and cadaveric studies with clinical application

This study aimed to examine the venous anatomy of the horizontal fissure (HF) of the cerebellum by using contrast-enhanced magnetic resonance imaging (MRI) and computed tomography venography (CTV). We also studied the venous anatomy and cerebellar structures surrounding the HF relevant to the suboccipital trans-HF (SOTHF) approach in cadaver studies.

We conducted an imaging analysis of 200 cerebellar hemispheres from 100 patients who underwent surgical treatment for intracranial supratentorial lesions between March 2021 and March 2023 at our institution. All patients underwent preoperative contrast-enhanced MRI and CTV. A cadaver study was conducted to assess the feasibility of the medial, intermediate, and lateral surgical corridors of the SOTHF approach while preserving the veins. We also present a clinical case.

Veins traversing the HF longitudinally, which act as a potential barrier when splitting the HF, were observed in 82% of the hemispheres, with an average of 1.28 per hemisphere. Distinctive veins running horizontally along the HF, observed in 24% of hemispheres, also act as potential barriers during wide HF opening. Cadaver studies demonstrated essential anatomical structures around the HF and that the medial, intermediate, and lateral corridors of the SOTHF approach could be achieved while preserving surrounding venous structures.

The SOTHF approach is feasible for accessing deep cerebellar lesions, the medial aspect of cerebellopontine angle, and the upper fourth ventricle. Preoperative analysis and prediction of the venous architecture around the HF can enhance the safety and efficiency of the surgery.