A Modern Minimally Invasive Transcallosal Approach to the Third Ventricle. A personal experience of 30 patientsR. Savu, D. Mohan, A. Mohan, H.A. Moisa, A.V. Ciurea
Original article, no. 1, 2014
AbstractIntroduction: Expansive processes around the third ventriclehave always been a major neurosurgical challenge. Despite allthe technological and scientific progress recorded over the lastfew years, third ventricle tumors are still a very difficultpathology to approach due to their formidable complexity.Treating such a tumor demands a good knowledge of localanatomy, pathophysiology, pathology and a good capacity tointegrate all the data gathered from the patient prior to andduring surgery. Last but not least, the correct means toapproach such a tumor involves using modern neuronavigationtechnology which might be too expensive to access ÃƒÂ®ncertain clinics (1,2).Objective: This article presents the personal experience ofthe authors, gathered while using a novel surgical approach,configured to maximize the success rate of interventions fortumors within the third ventricle, without using neuronavigationtechnology.Materials and methods: The authors have developed a study ofneuroanatomy using 30 adult human brains, without anypathological lesions, harvested during routine autopsies andanalysed using a a standard protocol (Protocol of the Ludwig-Maximilians University Clinic of Neurosurgery, Laboratory ofMicroanatomy Ã¢Â€" Munich, Germany). The authors assessed aseries of anatomic elements which were later used aslandmarks to build the neurosurgical operative field. Aftercompleting the anatomic study the authors moved on torecord morphometric data for 30 volunteers. The authors usedsagittal T1 weighted images. The volunteers were males andfemales, all adults, with the mean age of 45.3 years. (The ageinterval: 21-83 years, sex distribution: 17 males and 13females). The images were digitally enhanced and the specifictargets were outlined using Corel Draw, thus allowing for asystematic identification of contours and landmarks. Eachcontour was recorded and saved as a sequence of dots. Thenext stage of the study, after having studied all the datarecorded, consisted of establishing the appropriate transcallosalsurgical corridor (transforaminal or interforniceal) for each of the 30 patients (not to be mistaken with the 30 volunteers)who were admitted for third ventricle tumors and who wereincluded in this study. After having performed surgery for theresection of the above mentioned third ventricle tumors, theauthors observed pre- and postoperative clinical data whichwere corroborated with the neuropsychological examinationwhich was also performed prior to and after surgery.Conclusions: The results obtained through observation andanatomical measurements have proven to be highly valuable indetermining a standard access corridor through the corpuscallosum. The data gathered and the patientÃ¢Â€Â™s MRI examimages helped obtain an optimal surgical corridor of the thirdventricle. In what regards the surgical act in 23 cases (77%) theauthors managed to achieve a complete resection of the tumor.In 6 cases (20%) the authors managed a subtotal resection ofthe tumors. In a single case the authors performed only abiopsy. A number of 24 patients (80%) achieved an excellentoutcome (Glasgow Outcome Scale - GOS V). Minor deficitswere recorded in 5 patients (17%) (disabled but independent)(GOS IV) No cases were recorded with serious impairment(GOS III) or vegetative state (GOS II). One patient withanaplastic glioma died 4 months after surgery after an initialfavorable evolution. The tumor had spread to thehypothalamus. A single postoperative complication was linkedto the surgical approach in a 73-year-old female patient whosuffered a venous infarction due to a venous thrombosis in atributary vein of the superior sagittal sinus in the access area.The patient, after a slow recovery managed to improve hercondition reaching GOS IV. There were no other complicationsconnected to the surgical act.