Comparative anatomical analysis of the transcallosal-transchoroidal and transcallosal-transforniceal-transchoroidal approaches to the third ventricle

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OBJECTIVE

Access to the third ventricle is a veritable challenge to neurosurgeons. In this context, anatomical and morphometric studies are useful for establishing the limitations and advantages of a particular surgical approach. The transchoroidal approach is versatile and provides adequate exposure of the middle and posterior regions of the third ventricle. However, the fornix column limits the exposure of the anterior region of the third ventricle. There is evidence that the unilateral section of the fornix column has little effect on cognitive function. This study compared the anatomical exposure afforded by the transforniceal-transchoroidal approach with that of the transchoroidal approach. In addition, a morphometric evaluation of structures that are relevant to and common in the 2 approaches was performed.

METHODS

The anatomical exposure provided by the transcallosal-transchoroidal and transcallosal-transforniceal-transchoroidal approaches was compared in 8 fresh cadavers, using a neuronavigation system. The working area, microsurgical exposure area, and angular exposure on the longitudinal and transversal planes of 2 anatomical targets (tuber cinereum and cerebral aqueduct) were compared. Additionally, the thickness of the right frontal lobe parenchyma, thickness of the corpus callosum trunk, and longitudinal diameter of the interventricular foramen were measured. The values obtained were submitted to statistical analysis using the Wilcoxon test.

RESULTS

In the quantitative evaluation, compared with the transchoroidal approach, the transforniceal-transchoroidal approach provided a greater mean working area (transforniceal-transchoroidal 150 ± 11 mm2; transchoroidal 121 ± 8 mm2; p < 0.05), larger mean microsurgical exposure area (transforniceal-transchoroidal 101 ± 9 mm2; transchoroidal 80 ± 5 mm2; p < 0.05), larger mean angular exposure area on the longitudinal plane for the tuber cinereum (transforniceal-transchoroidal 71° ± 7°; transchoroidal 64° ± 6°; p < 0.05), and larger mean angular exposure area on the longitudinal plane for the cerebral aqueduct (transforniceal-transchoroidal 62° ± 6°; transchoroidal 55° ± 5°; p < 0.05). No differences were observed in angular exposure along the transverse axis for either anatomical target (tuber cinereum and cerebral aqueduct; p > 0.05). The mean thickness of the right frontal lobe parenchyma was 35 ± 3 mm, the mean thickness of the corpus callosum trunk was 10 ± 1 mm, and the mean longitudinal diameter of the interventricular foramen was 4.6 ± 0.4 mm. In the qualitative assessment, it was noted that the transforniceal-transchoroidal approach led to greater exposure of the third ventricle anterior region structures. There was no difference between approaches in the exposure of the structures of the middle and posterior region.

CONCLUSIONS

The transforniceal-transchoroidal approach provides greater surgical exposure of the third ventricle anterior region than that offered by the transchoroidal approach. In the population studied, morphometric analysis established mean values for anatomical structures common to both approaches.

Article Information

INCLUDE WHEN CITING Published online November 4, 2016; DOI: 10.3171/2016.8.JNS16403.

Correspondence João Luiz Vitorino Araujo, Cesário Mota Júnior Street, 112 Vila Buarque, São Paulo 01221-020, Brazil. email: vitorinomed@yahoo.com.br.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Anatomical dissection of the specimen—superior microsurgical view of the right lateral ventricle in the transcallosal approach. 1 = cerebral falx; 2 = retractor spatula withdrawing the right frontal lobe; 3 = corpus callosum trunk; 4 = interventricular foramen; 5 = thalamus; 6 = thalamostriate vein; 7 = choroid plexus; 8 = fornix column. Figure is available in color online only.

  • View in gallery

    Anatomical dissection of the specimen—superior macroscopic view after the transchoroidal approach showing the surgical corridor obtained after retractor placement. 1 = cerebral falx; 2 = right frontal lobe; 3 = anterior region of the third ventricle floor. Figure is available in color online only.

  • View in gallery

    Schematic representation of the working area in the transchoroidal approach in brain fixed in formaldehyde. The 6 points corresponding to anatomical points of interest and delimiting a hexagonal area are as follows: ipsilateral fornix column (A), anterior tubercle of the thalamus (B), most posterior thalamic limit of the choroidal fissure (C), most distal point of the choroidal fissure, limited by the glomus of the choroid plexus (D), most posterior limit of the fornix body (E), and region of the fornix column adjacent to the venous angle (F). 1 = anterior septal vein; 2 = interthalamic adherence; 3 = thalamostriate vein, 4 = internal cerebral vein; 5 = posterior commissure. Adapted from Sekhar LN, Fessler RG: Atlas of Neurosurgical Techniques: Brain. New York: Thieme, 2006. Copyright Thieme. Published with permission. Figure is available in color online only.

  • View in gallery

    Schematic representation of the microsurgical exposure area of the third ventricle floor. The 6 points corresponding to anatomical points of interest and delimiting a hexagonal area were as follows: the most anterior point exposed (1), point immediately most lateral and anterior to the floor of the right third ventricle (2), point immediately most lateral and posterior to the floor of the right third ventricle (3), cerebral aqueduct (4), point immediately most lateral and posterior to the floor of the left third ventricle (5), and point immediately most lateral and anterior to the floor of the left third ventricle (6). Adapted from Campero A, Ajler P, Emmerich J: Abordajes neuroquirúrgicos al cérebro y la base de crâneo, ed 1. Buenos Aires: Journal, 2013. Copyright Alvaro Campero. Published with permission. Figure is available in color online only.

  • View in gallery

    Anatomical dissection of the specimen—microsurgical view of the anterior third ventricle region with posterior angulation of the microscope. 1 = infundibular recess of the pituitary gland; 2 = exposure of the interpeduncular cistern after opening the tuber cinereum; 3 = mammillary bodies; 4 = right fornix column after section; 5 = anterior commissure. Figure is available in color online only.

  • View in gallery

    Chart comparing the exposure area of the third ventricle floor between the 2 approaches. The bars correspond to ± 2 SD.

  • View in gallery

    Chart comparing the working area between the 2 approaches. The bars correspond to ± 2 SD.

  • View in gallery

    Sagittal section of the brain fixed with formaldehyde—graphic representation, not to scale, of the microsurgical exposure of the 2 approaches. The black line marks the area and structures of the third ventricle exposed by the transchoroidal approach; the white line shows the gain in exposure obtained by sectioning the fornix column in the transforniceal-transchoroidal approach; and the dashed yellow line represents the anterior, posterior, and intermediate viewing angles of the microscope. 1 = callosotomy; 2 = microsurgical exposure area of the transchoroidal approach; 3 = triangular area corresponding to a gain of microsurgical exposure with sectioning of the ipsilateral column of the fornix; 4 = infundibular recess of the pituitary gland; 5 = cerebral aqueduct. Source: Modified with permission from an image provided by Drs. Hung Tzu Wen and Albert L. Rhoton. Figure is available in color online only.

References

  • 1

    Aggleton JPMcMackin DCarpenter KHornak JKapur NHalpin S: Differential cognitive effects of colloid cysts in the third ventricle that spare or compromise the fornix. Brain 123:8008152000

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

    Bellotti CPappadà GSani ROliveri GStangalino C: The transcallosal approach for lesions affecting the lateral and third ventricles. Surgical considerations and results in a series of 42 cases. Acta Neurochir (Wien) 111:1031071991

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 3

    Bengochea FGDe La Torre OEsquivel OVieta RFernandez C: The section of the fornix in the surgical treatment of certain epilepsies; a preliminary report. Trans Am Neurol Assoc 13:79th Meeting1761781954

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Cairns HMosberg WH Jr: Colloid cyst of the third ventricle. Surg Gynecol Obstet 92:5455701951

  • 5

    Campero AAjler PEmmerich J: Abordajes neuroquirúrgicos al cérebro y la base de crâneo ed 1Buenos AiresJournal2013

  • 6

    Chang EFGabriel RAPotts MBBerger MSLawton MT: Supratentorial cavernous malformations in eloquent and deep locations: surgical approaches and outcomes. Clinical article. J Neurosurg 114:8148272011

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Dandy WE: Benign Tumors in the Third Ventricle of the Brain: Diagnosis and Treatment Springfield, ILC.C. Thomas1933

  • 8

    Desai KINadkarni TDMuzumdar DPGoel AH: Surgical management of colloid cyst of the third ventricle—a study of 105 cases. Surg Neurol 57:2953042002

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

    Ehni GEhni BConsiderations in transforaminal entry. Apuzzo MLJ: Surgery of the Third Ventricle ed 2BaltimoreWilliams & Wilkins1998. 326353

    • Search Google Scholar
    • Export Citation
  • 10

    Figueiredo EGDeshmukh PNakaji PCrusius MUCrawford NSpetzler RF: The minipterional craniotomy: technical description and anatomic assessment. Neurosurgery 61:5 Suppl 22562652007

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Figueiredo EGDeshmukh PZabramski JMPreul MCCrawford NRSpetzler RF: The pterional-transsylvian approach: an analytical study. Neurosurgery 62:6 Suppl 3136113672008

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Figueiredo EGZabramski JMDeshmukh PCrawford NRSpetzler RFPreul MC: Comparative analysis of anterior petrosectomy and transcavernous approaches to retrosellar and upper clival basilar artery aneurysms. Neurosurgery 58:1 SupplONS13ONS212006

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 13

    Fujii KLenkey CRhoton AL Jr: Microsurgical anatomy of the choroidal arteries: lateral and third ventricles. J Neurosurg 52:1651881980

  • 14

    Gaffan DGaffan EA: Amnesia in man following transection of the fornix. A review. Brain 114:261126181991

  • 15

    Garcia-Bengochea FFriedman WA: Persistent memory loss following section of the anterior fornix in humans. A historical review. Surg Neurol 27:3613641987

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    Garretson HDCommentary A - memory in man: a neurosurgeons perspective. Apuzzo MLJ: Surgery of the Third Ventricle ed 2BaltimoreWilliams & Wilkins1998. 209212

    • Search Google Scholar
    • Export Citation
  • 17

    Hernesniemi JLeivo S: Management outcome in third ventricular colloid cysts in a defined population: a series of 40 patients treated mainly by transcallosal microsurgery. Surg Neurol 45:2141996

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 18

    Kandel EKupfermann IIversen SLearning and memory. Kandel ESchwartz JJessell T: Principles of Neural Science ed 4New YorkMcGraw-Hill2000

    • Search Google Scholar
    • Export Citation
  • 19

    Karakaş PKoç ZKoç FGülhal Bozkır M: Morphometric MRI evaluation of corpus callosum and ventricles in normal adults. Neurol Res 33:104410492011

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    Konovalov ANGorelyshev SK: Surgical treatment of anterior third ventricle tumours. Acta Neurochir (Wien) 118:33391992

  • 21

    Konovalov NTechnique and strategies of direct surgical management of craniopharyngioma. Apuzzo MLJ: Surgery of the Third Ventricle BaltimoreWilliams & Wilkins1998. 542553

    • Search Google Scholar
    • Export Citation
  • 22

    Koos WTPerneczky AHoraczek A: Problems of surgical technique for the treatment of supratentorial midline tumors in children. Acta Neurochir Suppl 35:31411985

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 23

    Lang J: Anatomy of the midline. Acta Neurochir Suppl 35:6221985

  • 24

    Lang J: Topographic anatomy of preformed intracranial spaces. Acta Neurochir Suppl 54:1101992

  • 25

    Little JRMacCarty CS: Colloid cysts of the third ventricle. J Neurosurg 40:2302351974

  • 26

    Mazarakis NKSummers FMurray ADWaiter GDFouyas IP: Partial recovery from amnesia following bilateral surgical fornix transection is correlated with cortical plasticity. Br J Neurosurg 25:6586612011

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

    McMackin DCockburn JAnslow PGaffan D: Correlation of fornix damage with memory impairment in six cases of colloid cyst removal. Acta Neurochir (Wien) 135:12181995

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

    Morita AKelly PJ: Resection of intraventricular tumors via a computer-assisted volumetric stereotactic approach. Neurosurgery 32:9209271993

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 29

    Nagasawa SMiyake HOhta T: [Transcallosal and transcortical approaches for tumors at the anterior part of the lateral ventricle: relations between visualized and ventricular size.]. No Shinkei Geka 25:3213271997. (Jpn)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 30

    Patel PCohen-Gadol AABoop FKlimo P Jr: Technical strategies for the transcallosal transforaminal approach to third ventricle tumors: expanding the operative corridor. J Neurosurg Pediatr 14:3653712014

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

    Peltier JVerclytte SDelmaire CDeramond HPruvo JPLe Gars D: Microsurgical anatomy of the ventral callosal radiations: new destination, correlations with diffusion tensor imaging fiber-tracking, and clinical relevance. J Neurosurg 112:5125192010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 32

    Rhoton AL Jr: The cerebrum. Anatomy. Neurosurgery 61:1 Suppl371192007

  • 33

    Sekhar LNFessler RG: Atlas of Neurosurgical Techniques: Brain New YorkThieme2006

  • 34

    Shucart WAnterior transcallosal and transcortical approaches. Apuzzo MLJ: Surgery of the Third Ventricle ed 2BaltimoreWilliams & Wilkins1998. 303325

    • Search Google Scholar
    • Export Citation
  • 35

    Tomasello FCardali SAngileri FFConti A: Transcallosal approach to third ventricle tumors: how I do it. Acta Neurochir (Wien) 155:103110342013

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 36

    Tsivilis DVann SDDenby CRoberts NMayes ARMontaldi D: A disproportionate role for the fornix and mammillary bodies in recall versus recognition memory. Nat Neurosci 11:8348422008

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 37

    Tubbs RSOakes PMaran ISSalib CLoukas M: The foramen of Monro: a review of its anatomy, history, pathology, and surgery. Childs Nerv Syst 30:164516492014

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

    Ulm AJRusso AAlbanese ETanriover NMartins CMericle RM: Limitations of the transcallosal transchoroidal approach to the third ventricle. J Neurosurg 111:6006092009

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

    Wen H: Demonstração anatômica da abordagem transcorioidea à porção anterior do terceiro ventrículo [thesis] São PauloFaculdade de Medicina, Universidade de São Paulo2002

    • Search Google Scholar
    • Export Citation
  • 40

    Wen HTRhoton AL Jrde Oliveira E: Transchoroidal approach to the third ventricle: an anatomic study of the choroidal fissure and its clinical application. Neurosurgery 42:120512191998

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 41

    Winkler PAWeis SBüttner ARaabe AAmiridze NReulen HJ: The transcallosal interforniceal approach to the third ventricle: anatomic and microsurgical aspects. Neurosurgery 40:9739821997

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

    Woiciechowsky CVogel SLehmann RStaudt J: Transcallosal removal of lesions affecting the third ventricle: an anatomic and clinical study. Neurosurgery 36:1171231995

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 43

    Woolsey RMNelson JS: Asymptomatic destruction of the fornix in man. Arch Neurol 32:5665681975

  • 44

    Yaşargil MG: Microneurosurgery StuttgartThieme1996

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