Prevention of postoperative visual field defect after the occipital transtentorial approach: anatomical study

Restricted access

 

OBJECTIVE

A postoperative visual field defect resulting from damage to the occipital lobe during surgery is a unique complication of the occipital transtentorial approach. Though the association between patient position and this complication is well investigated, preventing the complication remains a challenge. To define the area of the occipital lobe in which retraction is least harmful, the surface anatomy of the brain, course of the optic radiations, and microsurgical anatomy of the occipital transtentorial approach were examined.

METHODS

Twelve formalin-fixed cadaveric adult heads were examined with the aid of a surgical microscope and 0° and 45° endoscopes. The optic radiations were examined by fiber dissection and MR tractography techniques.

RESULTS

The arterial and venous relationships of the lateral, medial, and inferior surfaces of the occipital lobe were defined anatomically. The full course of the optic radiations was displayed via both fiber dissection and MR tractography. Although the stems of the optic radiations as exposed by both techniques are similar, the terminations of the fibers are slightly different. The occipital transtentorial approach provides access for the removal of lesions involving the splenium, pineal gland, collicular plate, cerebellomesencephalic fissure, and anterosuperior part of the cerebellum. An angled endoscope can aid in exposing the superior medullary velum and superior cerebellar peduncles.

CONCLUSIONS

Anatomical findings suggest that retracting the inferior surface of the occipital lobe may avoid direct damage and perfusion deficiency around the calcarine cortex and optic radiations near their termination. An accurate understanding of the course of the optic radiations and vascular relationships around the occipital lobe and careful retraction of the inferior surface of the occipital lobe may reduce the incidence of postoperative visual field defect.

ABBREVIATIONS MCA = middle cerebral artery; PCA = posterior cerebral artery.

Article Information

Correspondence Satoshi Matsuo, Department of Neurosurgery, Kyushu Central Hospital, 3-23-1, Shiobaru, Minami-ku, Fukuoka 815-8588, Japan. email: smatsuo1979@gmail.com.

INCLUDE WHEN CITING Published online October 20, 2017; DOI: 10.3171/2017.4.JNS162805.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Surface anatomy and vascular relationships of the posterior part of the left cerebral hemisphere. A: Lateral surface of the brain. No clearly defined sulci separate the occipital lobe from the temporal and parietal lobes on the lateral surface. An imaginary line between the end of the parietooccipital sulcus and the preoccipital notch has occasionally been used as a boundary. The lateral occipital sulcus divides the superior and inferior occipital gyri. B: Lateral surface of an injected brain. The temporooccipital and posterior temporal arteries arising from the MCA supply the lateral surface of the occipital lobe. Cortical branches from the parietooccipital, calcarine, and posterior temporal arteries arising from the PCA (not shown) send branches to supply the lateral surface of the occipital lobe. The posterior parietal vein drains the anterior part of the lateral surface of the occipital lobe. The posterior temporal vein occasionally drains the anterior part of the lateral surface of the occipital lobe. The occipital vein drains the lateral surface of the occipital lobe and is usually directed forward rather than medial or backward so that no large veins enter the superior sagittal and transverse sinuses around the torcular herophili. C: Medial surface of the brain. The parietooccipital sulcus separates the occipital lobe from the parietal lobe. The calcarine sulcus divides this surface into the cuneus above and the lingula below. The cuneus is demarcated anteriorly by the parietooccipital sulcus, posteriorly and superiorly by the calcarine sulcus, and inferiorly by the lower border of the medial surface. Anteriorly, the lingula blends into the posterior part of the parahippocampal gyrus. D: Medial surface of an injected brain. The straight sinus has been removed. The parietooccipital artery supplies the posterior parasagittal region, cuneus, and precuneus. The calcarine artery supplies the inferior cuneus, lingual gyrus, and occipital pole. The calcarine artery sends branches to the lingual gyrus and inferior cuneus. The anterior calcarine vein, also known as the internal occipital vein, drains the anterior part of the cuneus and lingula and empties into the vein of Galen. The posterior calcarine vein drains the posterior part of the calcarine fissure and commonly empties into the veins on the lateral surface. E: Inferior surface of the brain. There are no clearly defined sulci that separate the occipital lobe from the temporal lobe on the inferior surface. The inferior surface contains the lingula and the occipitotemporal and inferior temporal gyri. The collateral sulcus separates the lingula from the occipitotemporal gyrus. The occipitotemporal sulcus separates the occipitotemporal and inferior temporal gyri. F: Inferior surface of an injected brain. The posterior temporal artery, arising from the PCA, supplies the inferior temporal and occipital surfaces. The inferior surface of the occipital lobe is drained by the occipitobasal vein, which usually courses anterolaterally to join the posterior temporobasal vein. A. = artery; Ant. = anterior; Calc. = calcarine; Coll. = collateral; Fiss. = fissure; Gyr. = gyrus; Inf. = inferior; Int. = internal; Lat. = lateral; Mid. = middle; Occ. = occipital; Occ. Basal = occipitobasal; Occ. Temp. = occipitotemporal; Par. = parietal; Par. Occ. = parietooccipital; Parahippo. = parahippocampal; Post. = posterior; Preocc. = preoccipital; Sag. = sagittal; Splen. = splenium; Sulc. = sulcus; Sup. = superior; Temp. = temporal; Temp. Basal = temporobasal; Temp. Occ. = temporooccipital; Transv. = transverse; V. = vein. Figure is available in color online only.

  • View in gallery

    Right occipital transtentorial approach. A: A right occipitoparietal craniotomy has been performed, and the dura mater covering the occipital lobe has been removed. The posterior parietal and posterior temporal veins drain the lateral surface of the anterior part of the occipital lobe. The occipital vein drains the lateral surface of the posterior part of the occipital lobe. There are no large bridging veins between the occipital lobe and superior sagittal and transverse sinuses adjacent to the torcula. B: The occipital lobe has been retracted to expose the falx and tentorium. The internal occipital vein drains the anterior part of the cuneus and lingula and empties into the vein of Galen. The posterior calcarine vein drains the posterior part of the calcarine fissure and empties into the veins on the lateral surface including the posterior parietal, posterior temporal, and occipital veins. The dashed line indicates the site of the tentorial incision. The parietooccipital, calcarine, and posterior temporal arteries send branches to supply the lateral surface of the occipital lobe. C: The tentorium has been incised lateral to the straight sinus and resected. This exposed the vein of Galen, internal occipital vein, basal vein, vein of the cerebellomesencephalic fissure, superior vermian vein, peduncle, superior and inferior colliculi, trochlear nerve, and pineal gland. The anterior part of the tentorial surface of the cerebellum is also exposed. D: A 45° endoscopic view of the cerebellomesencephalic fissure exposing the superior medullary velum between the superior cerebellar peduncles. A. = artery; Ant. = anterior; Calc. = calcarine; Cer. = cerebral; Cer. Mes. = cerebellomesencephalic; Chor. = choroidal; CN = cranial nerve; Coll. = colliculus; Fiss. = fissure; Gl. = gland; Inf. = inferior; Int. = internal; Med. = medial, medullary; Occ. = occipital; P.C.A. = posterior cerebral artery; Par. = parietal; Par. Occ. = parietooccipital; Ped. = peduncle; Post. = posterior; S.C.A. = superior cerebellar artery; Sag. = sagittal; Splen. = splenium; Sulc. = sulcus; Sup. = superior; Temp. = temporal; Tent. = tentorium; Transv. = transverse; V. = vein; Vel. = velum; Verm. = vermian. Figure is available in color online only.

  • View in gallery

    Fiber dissection and MR tractography of the left optic radiations. Lateral view of the optic radiations (A). The insular cortex, extreme capsule, claustrum, ventral and dorsal parts of the external capsule, putamen, inferior frontooccipital fasciculus, anterior commissure, and part of the sagittal stratum have been removed to expose the optic radiations, which arise in the lateral geniculate body and course posterior and inferior to the lentiform nuclei to reach the calcarine cortex. Lateral view of MR tractography (B) of the optic radiations showing the optic tract (yellow) and the anterior (green), central (orange), and posterior (blue) parts of the optic radiations. After the anterior part of the optic radiations projects anteriorly, the fibers turn backward to form Meyer’s loop. Medial view of the optic radiations (C). The right cerebral hemisphere, left brainstem, corpus callosum, and medial cortex of the left hemisphere have been removed. The ependyma of the left lateral ventricle has been removed to expose the tapetum fibers. The optic radiations are separated from the lateral ventricle and atrium by the tapetal fibers. The pulvinar is the prominent posterior part of the thalamus, and the lateral geniculate body is located anterolateral to it. Medial view of the MR tractography (D) shown in panel B. Superior view of the optic radiations (E). The cerebral cortex and white matter above the optic radiations and tapetum have been removed. Part of the tapetal fibers covering the body of the lateral ventricle has been removed to expose the ependyma. Superior view of the MR tractography (F) shown in panel B. Note that the optic radiations end near the medial surface of the occipital pole, potentially the site of greatest retraction in the occipital transtentorial approach. Inferior view of the optic radiations (G). The cerebral cortex of the temporal base and the ependyma covering the temporal horn and atrium have been removed to expose the optic radiations coursing in the roof and lateral wall of the temporal horn. The optic fibers pass above the stria terminalis and the tail of the caudate nucleus and course lateral to the atrium and occipital horn to reach the calcarine cortex. Inferior view of the MR tractography (H) shown in panel B. Amygd. = amygdala; Ant. = anterior; Calc. = calcarine; Caud. = caudate; Cent. = central; Chor. Plex. = choroid plexus; Cor. = corona; Forc. = forceps; Gen. = geniculate; Gl. = gland; Glob. Pall. = globus pallidus; ILF = inferior longitudinal fasciculus; Inf. = inferior; Lat. = lateral; Lim. = limiting; Par. Occ. = parietooccipital; Post. = posterior; Rad. = radiata, radiations; Retrolent. = retrolenticular; Sag. = sagittal; Splen. = splenium; Str. = stria; Strat. = stratum; Sublent. = sublenticular; Sulc. = sulcus; Term. = terminalis; Tr. = tract. Figure is available in color online only.

  • View in gallery

    Coronal views of the MR tractography shown in Fig. 3B at the level of the tip of the temporal horn (A), lateral geniculate body (B), atrium (C), occipital horn (D), junction of the parietooccipital and calcarine sulci (E), and midline between the junction and occipital pole (F). The anterior part of the optic radiations courses in an anterolateral direction after its origin, reaches as far anteriorly as the tip of the temporal horn, then turns backward. This part covers the roof and lateral wall of the temporal horn and inferior surface of the atrium and terminates at the lower lip of the calcarine sulcus. The central part of the optic radiations initially projects laterally from its origin and then turns backward. This part covers the roof of the temporal horn and lateral wall of the atrium and occipital horn to reach the occipital pole. The posterior part of the optic radiations courses directly backward after its origin and along the lateral wall of the atrium and occipital horn to reach the upper lip of the calcarine sulcus. Ant. = anterior; Calc. = calcarine; Cent. = central; Lat. = lateral; Occ. = occipital; Par. Occ. = parietooccipital; Post. = posterior; Rad. = radiata, radiations; Sulc. = sulcus; Temp. = temporal; Vent. = ventricular. Figure is available in color online only.

References

  • 1

    Andersson JLRSkare SAshburner J: How to correct susceptibility distortions in spin-echo echo-planar images: application to diffusion tensor imaging. Neuroimage 20:8708882003

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Andersson JLRXu JYacoub EAuerbach EMoeller SUgurbil K: A comprehensive Gaussian process framework for correcting distortions and movements in diffusion images. Proc Int Soc Mag Reson Med 20:24262012 (Abstract)

    • Search Google Scholar
    • Export Citation
  • 3

    Andrews RJBringas JR: A review of brain retraction and recommendations for minimizing intraoperative brain injury. Neurosurgery 33:105210641993

  • 4

    Ausman JIMalik GMDujovny MMann R: Three-quarter prone approach to the pineal-tentorial region. Surg Neurol 29:2983061988

  • 5

    Azab WANasim KSalaheddin W: An overview of the current surgical options for pineal region tumors. Surg Neurol Int 5:392014

  • 6

    Baydin SYagmurlu KTanriover NGüngör ARhoton AL Jr: Microsurgical and fiber tract anatomy of the nucleus accumbens. Neurosurgery 12:ONS269ONS2882016

    • Search Google Scholar
    • Export Citation
  • 7

    Chi JHLawton MT: Posterior interhemispheric approach: surgical technique, application to vascular lesions, and benefits of gravity retraction. Neurosurgery 59 (1 Suppl 1):ONS41ONS492006

    • Search Google Scholar
    • Export Citation
  • 8

    Feinberg DAMoeller SSmith SMAuerbach ERamanna SGunther M: Multiplexed echo planar imaging for sub-second whole brain FMRI and fast diffusion imaging. PLoS One 5:e157102010 (Erratum in PLoS One 6:10.1371/annotation/d9496d01-8c5d-4d24-8287-94449ada5064)

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Fernández-Miranda JCRhoton AL JrAlvarez-Linera JKakizawa YChoi Cde Oliveira EP: Three-dimensional microsurgical and tractographic anatomy of the white matter of the human brain. Neurosurgery 62 (6 Suppl 3):98910282008

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Fischl B: FreeSurfer. Neuroimage 62:7747812012

  • 11

    Flores LP: Occipital lobe morphological anatomy: anatomical and surgical aspects. Arq Neuropsiquiatr 60 (3-A):5665712002

  • 12

    Glasser MFSotiropoulos SNWilson JACoalson TSFischl BAndersson JL: The minimal preprocessing pipelines for the Human Connectome Project. Neuroimage 80:1051242013

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Güngör ABaydin SMiddlebrooks EHTanriover NIsler CRhoton AL Jr: The white matter tracts of the cerebrum in ventricular surgery and hydrocephalus. J Neurosurg 126:9459712017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Hart MGSantarius TKirollos RW: How I do it—pineal surgery: supracerebellar infratentorial versus occipital transtentorial. Acta Neurochir (Wien) 155:4634672013

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 15

    Hongo KKobayashi SYokoh ASugita K: Monitoring retraction pressure on the brain. An experimental and clinical study. J Neurosurg 66:2702751987

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 16

    Jenkinson MBannister PBrady MSmith S: Improved optimization for the robust and accurate linear registration and motion correction of brain images. Neuroimage 17:8258412002

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17

    Jenkinson MBeckmann CFBehrens TEWoolrich MWSmith SM: FSL. Neuroimage 62:7827902012

  • 18

    Kawashima MRhoton AL JrMatsushima T: Comparison of posterior approaches to the posterior incisural space: microsurgical anatomy and proposal of a new method, the occipital bi-transtentorial/falcine approach. Neurosurgery 62 (6 Suppl 3):113611492008

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Konovalov ANPitskhelauri DI: Principles of treatment of the pineal region tumors. Surg Neurol 59:2502682003

  • 20

    Kucukyuruk BYagmurlu KTanriover NUzan MRhoton AL Jr: Microsurgical anatomy of the white matter tracts in hemispherotomy. Neurosurgery 10 (Suppl 2):3053242014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21

    Little KMFriedman AHFukushima T: Surgical approaches to pineal region tumors. J Neurooncol 54:2872992001

  • 22

    Matsushima TSuzuki SOFukui MRhoton AL Jrde Oliveira EOno M: Microsurgical anatomy of the tentorial sinuses. J Neurosurg 71:9239281989

  • 23

    McLaughlin NMartin NA: The occipital interhemispheric transtentorial approach for superior vermian, superomedian cerebellar, and tectal arteriovenous malformations: advantages, limitations, and alternatives. World Neurosurg 82:4094162014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24

    Moeller SYacoub EOlman CAAuerbach EStrupp JHarel N: Multiband multislice GE-EPI at 7 tesla, with 16-fold acceleration using partial parallel imaging with application to high spatial and temporal whole-brain fMRI. Magn Reson Med 63:114411532010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25

    Moshel YAParker ECKelly PJ: Occipital transtentorial approach to the precentral cerebellar fissure and posterior incisural space. Neurosurgery 65:5545642009

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26

    Nazzaro JMShults WTNeuwelt EA: Neuro-ophthalmological function of patients with pineal region tumors approached transtentorially in the semisitting position. J Neurosurg 76:7467511992

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27

    Papageorgiou EHardiess GSchaeffel FWiethoelter HKarnath HOMallot H: Assessment of vision-related quality of life in patients with homonymous visual field defects. Graefes Arch Clin Exp Ophthalmol 245:174917582007

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28

    Párraga RGRibas GCWelling LCAlves RVde Oliveira E: Microsurgical anatomy of the optic radiation and related fibers in 3-dimensional images. Neurosurgery 71 (1 Suppl Operative):1601722012

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29

    Poppen JL: The right occipital approach to a pinealoma. J Neurosurg 25:7067101966

  • 30

    Qiu BWang YOu SGuo ZWang Y: The unilateral occipital transtentorial approach for pineal region meningiomas: a report of 15 cases. Int J Neurosci 124:7417472014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 31

    Rhoton AL Jr: The cerebral veins. Neurosurgery 51 (4 Suppl):S159S2052002

  • 32

    Rhoton AL Jr: The cerebrum. Neurosurgery 51 (4 Suppl):S1S512002

  • 33

    Rhoton AL Jr: The lateral and third ventricles. Neurosurgery 51 (4 Suppl):S207S2712002

  • 34

    Rhoton AL Jr: The supratentorial arteries. Neurosurgery 51 (4 Suppl):S53S1202002

  • 35

    Rubino PARhoton AL JrTong Xde Oliveira E: Three-dimensional relationships of the optic radiation. Neurosurgery 57 (4 Suppl):2192272005

  • 36

    Schiefer UHart W: Functional anatomy of the human visual pathway in Schiefer UWilhelm HHart W (eds): Clinical Neuro-Ophthalmology. Berlin: Springer2007 pp 1928

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 37

    Setsompop KGagoski BAPolimeni JRWitzel TWedeen VJWald LL: Blipped-controlled aliasing in parallel imaging for simultaneous multislice echo planar imaging with reduced g-factor penalty. Magn Reson Med 67:121012242012

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 38

    Shirane RKumabe TYoshida YSu CCJokura HUmezawa K: Surgical treatment of posterior fossa tumors via the occipital transtentorial approach: evaluation of operative safety and results in 14 patients with anterosuperior cerebellar tumors. J Neurosurg 94:9279352001

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 39

    Shulman K: Small artery and vein pressure in the subarachnoid space of the dog. J Surg Res 5:56611965

  • 40

    Slotnick SDMoo LR: Retinotopic mapping reveals extrastriate cortical basis of homonymous quadrantanopia. Neuroreport 14:120912132003

  • 41

    Stone JLCybulski GRCrowell RMMoody RA: The lateral position–dependant occipital approach–to pineal and medial occipitoparietal lesions. Technical note. Acta Neurochir (Wien) 102:1331361990

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 42

    Tanaka RWashiyama K: Occipital transtentorial approach to pineal region tumors. Oper Tech Neurosurg 6:2152212003

  • 43

    Türe UYaşargil MGFriedman AHAl-Mefty O: Fiber dissection technique: lateral aspect of the brain. Neurosurgery 47:4174272000

  • 44

    Wichmann WMüller-Forell W: Anatomy of the visual system. Eur J Radiol 49:8302004

  • 45

    Xu JMoeller SStrupp JAuerbach EFeinberg DAUgurbil K: Highly accelerated whole brain imaging using aligned-blipped-controlled-aliasing multiband EPI. Proc Int Soc Mag Reson Med 20:23062012 (Abstract)

    • Search Google Scholar
    • Export Citation
  • 46

    Yagmurlu KVlasak ALRhoton AL Jr: Three-dimensional topographic fiber tract anatomy of the cerebrum. Neurosurgery 11 (Suppl 2):2743052015

  • 47

    Yamamoto I: Pineal region tumor: surgical anatomy and approach. J Neurooncol 54:2632752001

  • 48

    Yeh FCWedeen VJTseng WY: Generalized q-sampling imaging. IEEE Trans Med Imaging 29:162616352010

  • 49

    Yokoh ASugita KKobayashi S: Intermittent versus continuous brain retraction. An experimental study. J Neurosurg 58:9189231983

  • 50

    Yoshimoto KAraki YAmano TMatsumoto KNakamizo ASasaki T: Clinical features and pathophysiological mechanism of the hemianoptic complication after the occipital transtentorial approach. Clin Neurol Neurosurg 115:125012562013

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation

TrendMD

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 274 274 30
Full Text Views 319 319 8
PDF Downloads 263 263 5
EPUB Downloads 0 0 0

PubMed

Google Scholar