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The Transylvian Trans-Insular Approach to Lateral Thalamic Lesions

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The Transylvian Trans-Insular Approach to Lateral Thalamic Lesions Original Article The transylvian trans-insular approach to lateral thalamic lesions Shashwat Mishra, Ramesh C. Mishra Department of Neurosurgery, Neurosurgical Clinics, Kamayani Hospital, Agra, India Abstract Background: Thalamic tumors are rare intracranial tumors. The most common approaches to the thalamus have been directed through the ventricular system, which surrounds it. The transsylvian trans-insular approach to the lateral thalamus has been infrequently described probably because of the vulnerability of the internal capsule, which skirts this part of the thalamus. Aims: To describe the approach emphasizing its anatomical basis and also to evaluate its safety and efficacy. Settings and Design: Retrospective study conducted at a tertiary hospital. Materials and Methods: Patient population included all the patients who underwent surgery for the lesions in lateral thalamus using the transylvian trans-insular approach between 2005 and 2011. A trephine craniotomy was made, centered over posterior sylvian fissure and the surgical corridor was developed through the insular cortex. Results: During the study period Address for correspondence: 10 patients (7 tumors and inflammatory lesions and 3 hypertensive bleeds) were treated using Dr. Shashwat Mishra, this approach. One peri-operative mortality was noted. In patients with lesions other than A-31, Gyandeep Apartments, hypertensive thalamic hemorrhage, there was no postoperative worsening of neurological Mayur Vihar Phase-1, deficit as comparative to preoperative deficits. Total excision/evacuation of the lesion could New Delhi-91, India. be accomplished in all the patients. Conclusions: The transylvian trans-insular approach is E-mail: [email protected]. safe, effective, anatomical procedure, and can be performed at a peripheral center without Received : 07-05-2012 the need for navigation and intra-operative monitoring. Review completed : 28-06-2012 Accepted : 17-07-2012 Key words: Surgical approach, thalamus, trans-insular, transylvian Introduction of surgical corridors have been utilized for approaching thalamic lesions with transventricular approaches being The thalamus (Gk: “meeting place”/“bridal chamber”), the most frequent and popular among neurosurgeons. as the name suggests, is a secluded part of the brain and The extra-axial approaches to the thalamus through the is the largest component of the diencephalon. Thalamic subarachnoid space are advantageous in not violating the lesions are rare and thalamic tumors account for 4% of cortex but often employ a long corridor and sometimes all intracranial tumors.[1] Surgical treatment of thalamic require special positioning of the patient. Though, lesions has generally been associated with significant the posterior transylvian trans-insular approach for morbidity, necessitating a careful evaluation of the risks thalamic lesions has been described long ago, but is and benefits before making a decision to operate. A variety only infrequently mentioned in published literature. We describe our experience with this approach in treating a Access this article online spectrum of thalamic lesions at a small peripheral center, Quick Response Code: emphasizing the efficacy and safety of this approach. Website: www.neurologyindia.com Materials and Methods PMID: *** Surgical anatomy of the thalamus DOI: A brief discussion of relevant surgical anatomy of 10.4103/0028-3886.100725 the thalamus is pertinent to the discussion of our Neurology India | Jul-Aug 2012 | Vol 60 | Issue 4 385 Mishra and Mishra: Trans-insular approach to thalamic lesions technique and results. Thalamus is often represented fissure was opened. Sometimes, a minor bridging vein as a tetrahedron with three free surfaces exposed to was sacrificed to widen the operating space. An effort was ventricular system and one surface in contact with critical made to open the sylvian fissure along its entire visible neural structures. The posterior, dorsal, and medial length to allow atraumatic separation of the operacula. faces of this tetrahedron are open to the atrium, body We adopt an “inside-out” technique for opening the of lateral ventricle, and third ventricle, respectively. sylvian fissure, separating the opercular arachnoid bands Anteriorly, thalamus is bounded by foramen of Monro; in the depth before slitting the superficial arachnoid. dorsally, by the roof of third ventricle and posteriorly it Attention was directed toward the temporal operculum is delimited by the posterior commissure. Inferiorly, the and transverse temporal gyri were identified by their hypothalamic sulcus distinguishes it from sub-thalamic oblique orientation and undulating appearance on an structures. The enlarged lateral and caudal parts of the otherwise flat opercular surface. Normally, the postero- thalamus overlie the brain stem. Thalamic radiations, medial ends of these gyri converge toward the posterior emanating from the lateral surface of the thalamus, half of the superior limiting sulcus of the insula, which is are the reciprocal connections of thalamic nuclei with superficial to the posterior thalamus, the retro-lentiform cerebral cortex. Upon the dorsal surface of the thalamus, internal capsule and the anterior limit of the atrium.[2,3] thalamostriate vein delineates it from caudate nucleus Though the transverse temporal gyri still remain anterolaterally. Ventrolaterally, the thalamus is in contact identifiable when the tumor distorts posterior insula, with posterior limb of internal capsule, a structure of their medial ends are often rendered obscure. Mechanical critical importance in approaches directed towards the retraction of the opercula was conscientiously avoided lateral surface. From the insular segment of sylvian as initial tumor decompression provided the required fissure, the insular cortex, extreme capsule, external working space. For the initial approach, the opercula capsule and the retrolentiform limb of internal capsule were held apart with cottonoids wedged into the fissure. are sequentially traversed to reach the lateral aspect of However, keeping the normal relationship in mind, the the thalamus [Figure 1]. posterior insular cortex (the long insular gyri posterior to the central sulcus) was entered and the lesion was Materials and Methods found beneath a thin cortical layer. The lesion was then removed using routine microsurgical techniques. Care We analyzed case records of patients with thalamic was taken to remain within the substance of the tumor. lesions treated by transylvian trans-insular approach at Lesion excision was followed by hemostasis and routine Kamayani Hospital, Agra, India, between 2005 and 2011. closure. Transylvian trans-insular approach was employed for patients with laterally projecting thalamic lesions Results approaching the posterior sylvian fissure on imaging. Following the surgery, these patients were closely The clinical data of the patients who underwent this followed up and outcome information was collected. The surgical approach are presented in Table 1. Seven clinical presentation, imaging studies and the outcome tumors and three hypertensive thalamic hematomas data for eligible patients were analyzed. were treated using this approach. We had one death in the peri-operative period. One patient remains in Surgical technique chronic vegetative state following evacuation of thalamic Patients were positioned supine and the head was hematoma. In patients with thalamic lesions other rotated to the contralateral side with an aim to bring than hypertensive thalamic hematoma, there was no sagittal suture parallel to the floor. Ipsilateral shoulder postoperative worsening of the preoperative deficits. was propped up with padding to check excessive Total excision of the lesion could be achieved in all the neck rotation. The head was held in this position with cases [Figure 3]. Sugita head holder and a linear incision was marked, centered at a point along the surface projection of the Discussion posterior sylvian fissure about 2–3 cm anterior to the parietal eminence [Figure 2]. The incision was deepened Thalamic lesions, historically, have been considered through fascia and temporalis muscle and bone exposed. to be inoperable due to the complex architectural A trephine craniotomy was made as shown in the figure. organization of vital thalamic nuclei and the proximity After opening the dura, posterior sylvian fissure was to critically important structures such as the internal identified by the presence of prominent superficial capsule, subthalamus, and basal ganglia. However, middle cerebral vein and the M4 branches entering the with the evolution of microsurgical techniques and fissure along both operculae. Arachnoid over the veins improved understanding of microsurgical anatomy, was sharply divided on the frontal side and the sylvian these lesions no longer remain unassailable. Recent 386 Neurology India | Jul-Aug 2012 | Vol 60 | Issue 4 Mishra and Mishra: Trans-insular approach to thalamic lesions studies have demonstrated improved outcomes with Tumors arising in one of the thalamic nuclei remain aggressive surgical resection of thalamic lesions.[4] confined to the segment of the origin and distort as Complete excision of benign tumors can be curative well as displace the surrounding structures as they while the resection of high grade tumors confers a expand. Alternatively, when arising from the thalamus survival advantage.[1,5-7] in proximity to the ventricular surface, an exophytic tumor growth beneath the intact ventricular ependyma
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