Surgical Approaches for Brainstem Tumors in Pediatric Patients

The brainstem is a complex anatomical structure, and tumors in this region account for approximately 12% of all pediatric brain tumors. In this chapter, we detail both the intrinsic and extrinsic anatomy of the brainstem, propose a new redivision into eight anatomical compartments, and describe ten traditional safe entry zones-adding two novel approaches: the supratrigeminal zone for anterior-superior pontine lesions and the interpeduncular cerebellar route for lesions located between the middle and superior cerebellar peduncles. Anatomic knowledge of intrinsic and extrinsic brainstem structures, in association with refined microsurgical technique, intraoperative neurophysiological monitoring, and preoperative planning based on magnetic resonance imaging (MRI) and tractography, has enabled broader resection of brainstem lesions with low mortality and acceptable morbidity rates. However, it is the surgeon's responsibility to select the most appropriate surgical trajectory to maximize resection while minimizing functional impairment.