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Mario Ammirati, Antonio Bernardo, Angelo Musumeci and Albino Bricolo

T he median infratentorial—supracerebellar approach first described by Horsley 6 and Krause 10 and subsequently popularized by Stein 25 exposes the posterior incisural space, 17, 21, 22 that is, the space located behind the brainstem at the level of the tentorial incisura. Other infratentorial—supracerebellar approaches, such as the paramedian and the extreme-lateral ones, have since been developed to target the lateral portion of the posterior incisural space as well as the middle incisural space, that is, the incisural space located lateral to the

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Andrea Cardia, Manuela Caroli, Mauro Pluderi, Cesare Arienta, Sergio M. Gaini, Giuseppe Lanzino and Manfred Tschabitscher

behind corners that are difficult to visualize optimally using traditional microscopic techniques. We performed an anatomical study of the endoscope-assisted infratentorial–supracerebellar approach to define the view of the posterior third ventricle afforded by this route. Unlike Konovalov and Pitskhelauri’s 8 original description of this approach, in which the entry zone into the third ventricle was made above the habenular commissure through the suprapineal recess, we describe an alternative pathway: a parapineal entrance that is immediately lateral to the pineal

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

-midline approaches due to the height of the culmen of the vermis. The off-midline infratentorial supracerebellar approaches, namely the paramedian, lateral, and far-lateral routes, have been developed to minimize the need for cerebellar retraction and facilitate exposure of different parts of the posterior incisural space. 8 , 12 , 14 , 17 , 19 , 20 , 28 , 30 , 31 The paramedian and lateral routes have been selected for pineal lesions, and the far-lateral route has been selected for lesions in posterolateral mesencephalon rather than the pineal gland. 14 , 30 Komune et al. 11

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Bennett M. Stein

discrete nature and lack of invasiveness, are potentially resectable. The approaches of Dandy, 10 Van Wagenen, 41 Horrax, 20 and Poppen, 32 in current use, all have the inherent disadvantage that the tumor must be approached through the crucial deep venous system that overlies and surrounds the tumor; 18, 31 hence the high mortality and morbidity. Krause 29 first described the infratentorial supracerebellar approach to the pineal region in 1926. Since his report there have been sporadic instances in which this approach was used without comment as to the merits or

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Vikram V. Nayar, Ronald J. Benveniste and Frederick F. Lang

T he infratentorial supracerebellar approach is commonly used for the resection of pineal region tumors, superior vermian lesions, and tentorial meningiomas. This midline approach requires visualization and instrument manipulation under the straight sinus, which has a steeper angle than the more lateral aspects of the tentorium. The patient's neck must be flexed sufficiently to allow the surgeon to work along a trajectory parallel to the straight sinus. Inadequate flexion can result in an uncomfortable working angle that may severely limit access to the more

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Neurosurgical Forum: Letters to the Editor To The Editor Manas Panigrahi , M.D. Nizam's Institute of Medical Sciences Panjagutta, Hyderabad, India 916 917 Abstract The supracerebellar transtentorial (SCTT) approach, a modification of the infratentorial supracerebellar approach, facilitates simple and minimally invasive access to posterior temporomedial structures without requiring retraction of the temporal or occipital lobe. The SCTT approach was used in 16 patients over a 3-year period. Eleven patients

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Neurosurgical Forum: Letters to the Editor To the Editor Ibrahim M. Ziyal , M.D. Tunçalp Özgen, M.D. Hacettepe University Ankara, Turkey 541 541 Abstract The supracerebellar transtentorial (SCTT) approach, a modification of the infratentorial supracerebellar approach, facilitates simple and minimally invasive access to posterior temporomedial structures without requiring retraction of the temporal or occipital lobe. The SCTT approach was used in 16 patients over a 3-year period. Eleven patients harbored

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Yasuhiro Yonekawa, Hans-Georg Imhof, Ethan Taub, Marijan Curcic, Yasuhiko Kaku, Peter Roth, Heinz Gregor Wieser and Peter Groscurth

giant aneurysm of the proximal P 2 segment treated by ligation, and one BA—SCA giant aneurysm treated by OA—PCA bypass), one case of Moyamoya disease treated by indirect revascularization of the PCA territory, and one case of medically intractable epilepsy. Operative Technique The SCTT approach is performed in the following manner ( Fig. 1 ). The patient is placed in the sitting position. Fixation of the head is the same as that used during the standard posterior fossa craniotomy, including the infratentorial supracerebellar approach. A paramedian incision

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Alexander Nikolaevich Konovalov, Aldo Spallone and David Ilich Pitzkhelauri

resonance (MR) imaging represented the chief diagnostic tools. Angiography was not performed in any of the present cases. Surgery was performed using either an infratentorial—supracerebellar approach (Cases 1 and 3) or an occipital—transtentorial approach (Cases 2, 4, 5, and 6). Because there was diagnostic suspicion of a brainstem tumor, direct surgery was preceded by stereotactic biopsy in one case (Case 5; Fig. 1 ). Fig. 1. Case 5. Sagittal T 1 -weighted MR image demonstrating a round, hypointense lesion located in the posterior portion of the third ventricle, which

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Shervin R. Dashti, Shenandoah Robinson, Mark Rodgers and Alan R. Cohen

as an enhancing 2-cm-diameter pineal region mass that was isointense to gray matter on T 1 -weighted and hypointense on T 2 -weighted sequences ( Fig. 1 ). This mass was shown to enlarge slightly on follow-up MR images. There was no evidence of surrounding parenchymal edema or hydrocephalus. Fig. 1. Preoperative sagittal (upper) and coronal (lower) T 1 -weighted MR images revealing an enhancing pineal tumor. Operation The tumor was removed via an infratentorial supracerebellar approach by using both the operative microscope and a rigid