Mascitelli Justin R, Gandhi Sirin, Cavallo Claudio, Nanaszko Michael J, Wright Ernest J, Lawton Michael T
Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona.
Oper Neurosurg (Hagerstown). 2019 Apr 1;16(4):E113. doi: 10.1093/ons/opy242.
Brainstem cavernous malformations (CMs) account for 15% to 18% of all intracranial CMs1 and 13% of all cerebrovascular pathology in the posterior fossa.1,2 This video demonstrates the resection of a pontomesencephalic CM through a pretemporal approach through the oculomotor-tentorial triangle (OTT).3 A 49-yr-old woman presented with an acute onset of left hemiparesis, diplopia, vertigo, partial oculomotor, and facial palsy. Neuroimaging revealed a 25-mm diameter right pontomesencephalic CM with evidence of prior hemorrhage. Institutional Review Board approval and patient consent were obtained for surgery. A right orbitozygomatic craniotomy was performed, and the lesion was exposed through a pretemporal-transsylvian approach. After a wide Sylvian fissure split, the oculomotor nerve (CN III) was dissected away from the temporal lobe, and the temporal lobe was mobilized posteriorly to access the OTT. The posterior cerebral and superior cerebellar arteries were visualized in this triangle, and the cerebral peduncle and the CM were accessed deep to these arteries. After hematoma evacuation, the CM was resected in a piece-meal fashion using an intracapsular technique. Postoperative imaging confirmed the gross total resection of the lesion. The patient had persistent right CN III palsy and a slight worsening of left hemiparesis, which had resolved completely at the 6-mo follow-up. The OTT provides access to the upper ventrolateral pontomesencephalic area.3 This triangular surgical workspace is entered through a pretemporal-transsylvian corridor and widened with posterior temporal lobe retraction. The OTT is an important working space for accessing midbrain and upper pontine CMs posterolateral to CN III.
脑干海绵状血管畸形（CMs）占所有颅内CMs的15%至18%，占后颅窝所有脑血管病变的13%。本视频展示了通过经动眼神经 - 小脑幕三角（OTT）的颞前入路切除脑桥中脑CM。一名49岁女性，急性起病，出现左侧偏瘫、复视、眩晕、部分动眼神经麻痹和面瘫。神经影像学检查显示一个直径25毫米的右侧脑桥中脑CM，有既往出血迹象。手术获得了机构审查委员会的批准并取得了患者同意。进行了右侧眶颧开颅术，通过颞前 - 经侧裂入路暴露病变。广泛分开外侧裂后，将动眼神经（CN III）从颞叶分离，将颞叶向后移位以进入OTT。在这个三角区域可见大脑后动脉和小脑上动脉，在这些动脉深部可到达大脑脚和CM。血肿清除后，采用囊内技术分块切除CM。术后影像学检查证实病变全切。患者术后持续存在右侧CN III麻痹，左侧偏瘫略有加重，在6个月随访时已完全恢复。OTT可通向脑桥中脑上部腹外侧区域。这个三角形手术操作空间通过颞前 - 经侧裂通道进入，并通过颞叶后部牵拉扩大。OTT是进入动眼神经后外侧中脑和脑桥上部CM的重要操作空间。
