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Abuzer Güngör, Serhat Baydin, Erik H. Middlebrooks, Necmettin Tanriover, Cihan Isler and Albert L. Rhoton Jr.

OBJECTIVE

The relationship of the white matter tracts to the lateral ventricles is important when planning surgical approaches to the ventricles and in understanding the symptoms of hydrocephalus. The authors' aim was to explore the relationship of the white matter tracts of the cerebrum to the lateral ventricles using fiber dissection technique and MR tractography and to discuss these findings in relation to approaches to ventricular lesions.

METHODS

Forty adult human formalin-fixed cadaveric hemispheres (20 brains) and 3 whole heads were examined using fiber dissection technique. The dissections were performed from lateral to medial, medial to lateral, superior to inferior, and inferior to superior. MR tractography showing the lateral ventricles aided in the understanding of the 3D relationships of the white matter tracts with the lateral ventricles.

RESULTS

The relationship between the lateral ventricles and the superior longitudinal I, II, and III, arcuate, vertical occipital, middle longitudinal, inferior longitudinal, inferior frontooccipital, uncinate, sledge runner, and lingular amygdaloidal fasciculi; and the anterior commissure fibers, optic radiations, internal capsule, corona radiata, thalamic radiations, cingulum, corpus callosum, fornix, caudate nucleus, thalamus, stria terminalis, and stria medullaris thalami were defined anatomically and radiologically. These fibers and structures have a consistent relationship to the lateral ventricles.

CONCLUSIONS

Knowledge of the relationship of the white matter tracts of the cerebrum to the lateral ventricles should aid in planning more accurate surgery for lesions within the lateral ventricles.

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Satoshi Matsuo, Serhat Baydin, Abuzer Güngör, Koichi Miki, Noritaka Komune, Ryota Kurogi, Koji Iihara and Albert L. Rhoton Jr.

OBJECTIVE

A common approach to lesions of the pineal region is along the midline below the torcula. However, reports of how shifting the approach off midline affects the surgical exposure and relationships between the tributaries of the vein of Galen are limited. The purpose of this study is to examine the microsurgical and endoscopic anatomy of the pineal region as seen through the supracerebellar infratentorial approaches, including midline, paramedian, lateral, and far-lateral routes.

METHODS

The quadrigeminal cisterns of 8 formalin-fixed adult cadaveric heads were dissected and examined with the aid of a surgical microscope and straight endoscope. Twenty CT angiograms were examined to measure the depth of the pineal gland, slope of the tentorial surface of the cerebellum, and angle of approach to the pineal gland in each approach.

RESULTS

The midline supracerebellar route is the shortest and provides direct exposure of the pineal gland, although the culmen and inferior and superior vermian tributaries of the vein of Galen frequently block this exposure. The off-midline routes provide a surgical exposure that, although slightly deeper, may reduce the need for venous sacrifice at both the level of the veins from the superior cerebellar surface entering the tentorial sinuses and at the level of the tributaries of the vein of Galen in the quadrigeminal cistern, and require less cerebellar retraction. Shifting from midline to off-midline exposure also provides a better view of the cerebellomesencephalic fissure, collicular plate, and trochlear nerve than the midline approaches. Endoscopic assistance may aid exposure of the pineal gland while preserving the bridging veins.

CONCLUSIONS

Understanding the characteristics of different infratentorial routes to the pineal gland will aid in gaining a better view of the pineal gland and cerebellomesencephalic fissure and may reduce the need for venous sacrifice at the level of the tentorial sinuses draining the upper cerebellar surface and the tributaries of the vein of Galen.