Limitations of the transcallosal transchoroidal approach to the third ventricle

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  • 1 Georgia Neurosurgical Institute, Mercer University School of Medicine, Macon, Georgia;
  • 3 Department of Neurosurgery, University of Florida, Gainesville, Florida; and
  • 2 Department of Neurosurgery, Vanderbilt University, Nashville, Tennessee
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Object

The aim of this study was to determine the anatomical limitations of the transcallosal transchoroidal approach to the third ventricle.

Methods

Twenty-six formalin-fixed specimens were studied. Sagittal dissections were used to determine the anatomical relationships of the foramen of Monro, the angle of approach to landmarks, and placement of a callosotomy. Lateral ventricular dissections were performed to quantitate the forniceal anatomy.

Results

The foramen of Monro was found 1.07 ± 0.11 cm superior and slightly anterior to the mammillary bodies, 1.48 ± 0.16 cm posterosuperior to the optic recess, and 2.26 ± 0.16 cm anterosuperior to the aqueduct. Relative to the genu, a callosal incision 2.64 ± 0.53 cm long and angled 37 ± 4.3° anterior was needed to access the aqueduct, and an incision 4.92 ± 0.71 cm long and angled 49 ± 7.4° posterior was needed to access the optic recess. The fornix progressively widened within the lateral ventricle, from 1.25 ± 0.63 mm at the foramen of Monro to > 7 mm at 2 cm behind the foramen. Three zones of exposure were identified, requiring unique craniotomies, callosotomies, and angles of approach. The major limiting factors in the approach included the columns of the fornix anteriorly, the width of the fornix posteriorly, and the draining veins of the parietal cortex. The choroidal fissure opening was limited to 1.5 cm posterior to the foramen of Monro; this limited opening created an aperture effect that required an anterior-to-posterior angle, an anterior craniotomy, and an anteriorly placed callosotomy to access the posterior landmarks. In contrast, a posterior-to-anterior angle, posteriorly placed craniotomy, and posteriorly placed callosotomy were required to access anterior landmarks.

Conclusions

The transcallosal transchoroidal approach was ideally suited to access the foramen of Monro and the middle and posterior thirds of the third ventricle. Exposure of the anterior third ventricle was limited by the columns of the fornix and by the presence of parietal cortical draining veins.

Abbreviations used in this paper: ICV = internal cerebral vein; PChA = posterior choroidal artery.

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Contributor Notes

Address correspondence to: Arthur J. Ulm, M.D., Mercer University School of Medicine, Georgia Neurosurgical Institute, 840 Pine Street, Suite 880, Macon, Georgia 31201. email: jayulm@ganeurosurg.org.

Please include this information when citing this paper: published online January 30, 2009; DOI: 10.3171/2008.7.JNS08124.

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