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Frontobasal Interhemispheric Trans-Lamina Terminalis Approach for Suprasellar Lesions

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Frontobasal Interhemispheric Trans-Lamina Terminalis Approach for Suprasellar Lesions OPERATIVE NUANCES FRONTOBASAL INTERHEMISPHERIC TRANS-LAMINA TERMINALIS APPROACH FOR SUPRASELLAR LESIONS Amir R. Dehdashti, M.D. THE FRONTOBASAL INTERHEMISPHERIC APPROACH for suprasellar tumors cur- Department of Neurosurgery, rently incorporates technological advancements and refinements in patient selection, Geneva University Hospitals, operative technique, and postoperative care. This technique is a valid choice for the Geneva, Switzerland removal of suprasellar lesions with extension into the third ventricle without major Nicolas de Tribolet, M.D. sequelae related to the surgical approach. The method described here reflects the Department of Neurosurgery, combination of the frontal interhemispheric and trans-lamina terminalis approaches. Geneva University Hospitals, KEY WORDS: Craniopharyngioma, Interhemispheric, Lamina terminalis, Suprasellar tumors, Third ventricle Geneva, Switzerland Neurosurgery 56[ONS Suppl 2]:ONS-418–ONS-424, 2005 DOI: 10.1227/01.NEU.0000157027.80293.C7 Reprint requests: Amir R. Dehdashti, M.D., Department of Neurosurgery, Centre Hospitalier Universitaire rontal craniotomy, isolating an osseous Suzuki et al. (15) have previously described an Vaudois, 46 Rue de Bugnon, flap only from the anterior wall of the interhemispheric approach for the treatment Lausanne 1011, Switzerland. Email: [email protected] Ffrontal sinus, was initially used only to of such lesions. The advantage of this ap- approach the frontal sinus (5). It was used by proach lies in its limited brain retraction. In Received, April 15, 2004. Dandy (1) as a craniotomy to expose and cure addition, the arteries and veins coursing along Accepted, October 25, 2004. cerebrospinal fluid fistulae through the poste- the exposed dorsal and medial surfaces of the rior wall of the frontal sinus. It was then de- frontal lobe and over the corpus callosum can veloped and adapted to the different patho- always be saved. Nevertheless, this surgical logical conditions of the base. The approach is reported to be complex, and post- microsurgical technique aimed at preserving operative psychological problems and olfac- olfaction during a subfrontal approach of the tory tract damage are other inherent disad- anterior cranial fossa was described for the vantages. This article describes a modified first time by Suzuki (14) in the treatment of version of the traditional frontal interhemi- aneurysms of the anterior communicating ar- spheric approach and basal interhemispheric tery (AComA). approach combined with the trans-lamina ter- The approach to the anterior cranial fossa minalis approach, which is a frontobasal inter- for intracranial lesions can be performed by a hemispheric approach for lesions protruding frontal transsinusal approach (if the frontal from the sellar-suprasellar region to the third sinuses are sufficiently large), a suprasinus ventricle or septum pellucidum. This ap- transfrontal approach, or a frontobasal or pte- proach provides a good view of the structures rional approach. Suprasellar lesions are poten- of the infundibulohypophyseal axis and tends tial challenges for surgical treatment. Intrasel- not to require strong retraction of the frontal lar or intracisternal tumors located in the lobes, thus preserving olfactory tracts (3, 6, 7, subdiaphragmatic portion can be treated via a 11, 13). Among the lesions that grow primarily transsphenoidal approach. Tumors extending within the third ventricle are optic gliomas, to or located in the third ventricle can be pituitary adenomas, craniopharyngiomas, me- treated via the transcallosal approach. For ningiomas, cavernous angiomas, and rarely, sellar and suprasellar tumors with extension arteriovenous malformations (AVMs). In into the third ventricle, a subfrontal or pteri- cases of suprasellar lesions that displace the onal approach can be used (2, 8). third ventricle inferoposteriorly, however, this Tumors protruding from the sellar- approach provides a wide operative field and suprasellar region to the third or lateral ven- consequently good operative results without tricle or septum pellucidum present a partic- significant damage to brain tissue itself. Once ular difficulty, with a risk of producing again, if the frontal sinuses are sufficiently damage to the optic pathways and the hypo- large, a transsinusal craniotomy can provide thalamus. Fahlbusch et al. (2), Oi et al. (8), and the same access. ONS-418 | VOLUME 56 | OPERATIVE NEUROSURGERY 2 | APRIL 2005 www.neurosurgery-online.com FRONTOBASAL INTERHEMISPHERIC TRANS-LAMINA TERMINALIS APPROACH CONCEPTUAL NUANCES Craniotomy A bifrontal craniotomy is The frontobasal interhemispheric trans-lamina terminalis performed under the incised approach is suitable for lesions located in the anterior part of area of the pericranium. the third ventricle, especially for those that develop anteriorly First, a burr hole is placed on from the line joining the anterior ridge of the foramen of each side at the junction of Monro and the cerebral aqueduct. For lesions of the pineal the orbital ridge, the zygo- region, complete excision is not possible by opening only the matic process of the frontal FIGURE 1. Illustration showing the lamina terminalis. Moreover, this approach is facilitated when bone, and the linea tempora- site of the craniotomy. As noted in the optic nerves are short. lis (the pterional keyhole). text, a craniotomy can also be per- The third burr hole is placed formed in smaller format and even lim- CLINICAL PRESENTATIONS on the midline 4 cm away ited to the extension of the frontal sinus. from the nasofrontal suture. The common clinical manifestations of suprasellar lesions Using the craniotome, a cra- are increased intracranial pressure, endocrine system dysfunc- niotomy is performed as low as possible on the orbital roofs. tion, visual field defects, and hemorrhage in cases of AVM. The base of the craniotomy is drilled with a high-speed drill or an oscillating saw (Fig. 1). After release of all dural attach- PREOPERATIVE WORKUP ments, the bifrontal bone flap is cut in one piece. The frontal sinus has been opened, the mucous membrane is removed, Endocrine evaluation and neuropsychological examination and the internal bone lamina of the sinus is rongeured away to are routinely performed before admission. Replacement of decrease the dead space. The residual bone is removed with a hormones can be done before operation if needed. Computed high-speed drill. The frontonasal canal is plugged with tem- tomography and magnetic resonance imaging (MRI) are both poral muscle. essential for identifying the tumor margin and the surgical plan. Dural Incision With the aid of the microscope, the dura is opened trans- OPERATIVE TECHNIQUE (FOR versely along the anterior orbital bone edge as far forward as SUPRASELLAR TUMORS) possible to minimize damage to the frontal bridging veins. (see video at web site) Then the dura is elevated in a U-shape posteriorly, and the anterior sagittal sinus is sectioned and ligated in its most Positioning anterior portion. The falx cerebri is also cut. The patient is supine after induction of general anesthesia and intubation. The patient’s head is fixed in a four-point Intradural Dissection headrest centrally. The vertex is rotated approximately 15 The constant existence of an arachnoidal cistern surround- degrees toward the floor, placing the head in slight extension. ing all the olfactory structures on the inferior face of the frontal Lumbar drainage of cerebrospinal fluid and mannitol (0.5 lobes gives a microsurgical plane of cleavage. The arachnoid is g/kg) allows the brain to relax and minimizes the need for sharply divided, and dissection of the olfactory tracts, alter- retraction. nating between the left and the right, is performed. If a uni- lateral olfactory tract is completely dissected before the start of Incision the dissection of the other side, there is the danger of avulsion The scalp is incised through the galea, beginning 1 cm of the contralateral olfactory tract. It is important to sharply anterior to the tragus and staying within the hairline, follow- dissect the olfactory tracts in parallel, proceeding by alternat- ing a bicoronal incision. The galea is elevated from the peri- ing between the left and the right sides. In the dissection of cranium by use of sharp dissection. At the superior temporal these tracts, pressure should not be applied inferiorly but line on each side, the connective tissue layer over the temporal rather in a superior direction. Inadvertent traction during the fascia contiguous medially with the pericranium is elevated operation can lead to the complete avulsion of the olfactory with the galeal layer. Elevation of the scalp flap is continued tract or bulb and loss of olfaction. The olfactory bulb can be forward, preserving the bilateral supraorbital nerves adherent reinforced with fibrin glue, fixing it to the cribriform plate. The to the galea. The galeal layer is separated from the pericra- olfactory tract should not be allowed to become dry during the nium until it reaches the supraorbital rim. The pericranium is operation. The olfactory bulb, together with the olfactory tract, incised separately and is elevated along the vertical line up to is separated from the orbital surface of the frontal lobe bilat- the supraorbital nerve bilaterally. The periosteum is elevated erally as far as the olfactory trigonal region. At the completion along the midline to the nasofrontal suture, and finally, a large of dissection of the olfactory tracts, a small portion of both pericranial
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