Clinic of Neurosurgery, University Clinical Center of Vojvodina, Novi Sad, Serbia; University of Novi Sad, Faculty of Medicine, Novi Sad, Serbia.
Clinic of Neurosurgery, University Clinical Center of Vojvodina, Novi Sad, Serbia; University of Novi Sad, Faculty of Medicine, Novi Sad, Serbia.
J Clin Neurosci. 2024 Oct;128:110782. doi: 10.1016/j.jocn.2024.110782. Epub 2024 Aug 23.
Cavernous malformations surrounding the fourth ventricle are challenging lesions to access and treat surgically owing to the complexity and eloquence of adjacent neural tissue [1] Long-standing practice included tissue transgression through the overlying cerebellar cortical surface of the hemisphere or vermis [1-3]. Using natural corridors such as tonsillobiventral fissure, cerebellomedullary fissure, and tonsillouvular fissure (TUF) offers elegant access to the fourth ventricle, avoiding traversing of neural tissue [4-7]. A 32-year-old male presented with headache, nausea, vomiting, double vision, and vertigo. Neuroimaging demonstrated a 17-mm diameter cavernous malformation protruding into the left lateral recess of the fourth ventricle. The patient consented for the procedure and underwent a middline suboccipital craniotomy in a prone position. TUF approach was performed by dissecting the arachnoid to the depth of the fissure, and after identifying the tonsillomedullary segment of the posterior inferior cerebellar artery, minimal white matter transgression was used to reach cavernous malformation. Complete removal of the lesion was achieved and confirmed on postoperative imaging. The postoperative course was uneventful. TUF approach with manipulation by ipsilateral and contralateral retraction of tonsills allows the widening of the surgical corridor and better exposure of lesions of the lateral recess of the fourth ventricle [1]. TUF approach is a valuable alternative to transvermian and transcerebellar approaches that minimize the division of neural tissue [6]. To the best of our knowledge this is the first case describing the TUF approach to exophytic cavernoma presenting in the lateral recess of the fourth ventricle. Under our institutional ethical review board regulations, approval was not necessary.
第四脑室周围的海绵状畸形由于毗邻神经组织的复杂性和重要性，手术治疗极具挑战性[1]。长期以来，手术方法包括通过半球或蚓部的小脑皮质表面进行组织侵犯[1-3]。利用自然通道，如扁桃体-背侧裂、小脑延髓裂和扁桃体-蚓状突裂（TUF），可以优雅地进入第四脑室，避免穿越神经组织[4-7]。一名 32 岁男性因头痛、恶心、呕吐、复视和眩晕就诊。神经影像学显示一个 17 毫米直径的海绵状畸形向左侧第四脑室外侧隐窝突出。患者同意进行手术，并在俯卧位接受了中线枕下开颅术。通过将蛛网膜解剖至裂的深度来进行 TUF 入路，在识别出小脑后下动脉的扁桃体-髓质段后，仅进行最小程度的白质侵犯以到达海绵状畸形。完全切除病变，并在术后影像学上得到证实。术后过程无并发症。通过同侧和对侧扁桃体的牵拉，TUF 入路可以扩大手术通道，更好地暴露第四脑室外侧隐窝的病变[1]。TUF 入路是一种替代经蚓部和经小脑的方法，可最大限度地减少神经组织的分割[6]。据我们所知，这是首例描述 TUF 入路治疗外侧隐窝第四脑室外生海绵状血管瘤的病例。根据我们机构的伦理审查委员会规定，不需要批准。
