The transcallosal—transforaminal approach to the third ventricle with regard to the venous variations in this region

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✓ Surgical approaches to lesions located in the anterior and middle portions of the third ventricle are challenging, even for experienced neurosurgeons. Various exposures involving the foramen of Monro, the choroidal fissure, the fornices, and the lamina terminalis have been advocated in numerous publications. The authors conducted a microsurgical anatomical study in 20 cadaveric brain specimens (40 hemispheres) to identify an exposure of the third ventricle that would avoid compromising vital structures.

An investigation of the variations in the subependymal veins of the lateral ventricle in the region of the foramen of Monro was performed, as these structures are intimately associated with the surgical exposure of the third ventricle. In 16 (80%) of the brain specimens studied, 19 (47.5%) of the hemispheres displayed a posterior location of the anterior septal vein—internal cerebral vein (ASV—ICV) junction, 3 to 13 mm (average 6 mm) beyond the foramen of Monro within the velum interpositum, not adjacent to the posterior margin of the foramen of Monro (the classic description). Based on this finding, the authors advocate opening the choroidal fissure as far as the ASV—ICV junction to enlarge the foramen of Monro posteriorly. This technique achieves adequate access to the anterior and middle portions of the third ventricle without causing injury to vital neural or vascular structures.

The high incidence of posteriorly located ASV—ICV junctions is a significant factor influencing the successful course of surgery. Precise planning of the surgical approach is possible, because the location of the junction is revealed on preoperative neuroradiological studies, in particular on magnetic resonance venography. It can therefore be determined in advance which foramen of Monro qualifies for posterior enlargement to gain the widest possible access to the third ventricle. This technique was applied in three patients with a third ventricular tumor, and knowledge of the venous variations in this region was an important resource in guiding the operative exposure.

Article Information

Address reprint requests to: UUğur Türe, M.D., Department of Neurosurgery, University of Arkansas for Medical Sciences, 4301 West Markham, Slot 507, Little Rock, Arkansas 72205.

© AANS, except where prohibited by US copyright law.

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Figures

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    Drawings showing variations in location of the ASV—ICV junction relative to the foramen of Monro (fm). Type IA: The ASV (asv) joins the ICV (icv) at the venous angle, which lies adjacent to the posterior margin of the foramen of Monro as is classically described (52.5% of hemispheres studied). Type IB: In the presence of a venous angle, the ASV joins the main stem of the ICV beyond the foramen of Monro (15% of hemispheres). Type IIA: The ASV joins the false venous angle, which lies beyond the foramen of Monro (25% of hemispheres). Type IIB: In the presence of a false venous angle, the ASV joins the main stem of the ICV far beyond the foramen of Monro (7.5% of hemispheres). tv = thalamostriate vein.

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    Photographs of cadaveric brains showing various structures. Left: Superior view of the lateral ventricles and foramina of Monro following removal of the superior portion of the cerebral hemispheres. Right: The fornix and the choroid plexus have been partially removed bilaterally to demonstrate the velum interpositum in the roof of the third ventricle. The asterisks indicate the ASVs. In this specimen, the left ASV—ICV junction (black arrow) is located at the venous angle adjacent to the posterior margin of the foramen of Monro (Type IA). The right ASV—ICV junction (white arrow) is located 6 mm beyond the foramen of Monro in the presence of the venous angle (Type IB). Enlarging the right foramen of Monro as far as the ASV—ICV junction would assure adequate access to the third ventricle. bf = body of fornices; cc = corpus callosum; cf = column of fornix; cn = caudate nucleus; cp = choroid plexus; crf = crus of fornix; fm = foramen of Monro; ia = interthalamic adhesion; icv = internal cerebral vein; scv = superior choroidal vein; sp = septum pellucidum; st = stria terminalis; t = thalamus; tv = thalamostriate vein.

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    Photographs of cadaveric brain structures. Upper: Photograph showing the medial surface of the right cerebral hemisphere following midsagittal section of the brain specimen. The septum pellucidum has been removed. Lower: Photograph taken after partial removal of the fornix demonstrating the choroidal fissure and velum interpositum where the ICVs and branches of the medial posterior choroidal arteries are located. In this specimen, the ASV—ICV junction (arrow) is located 7 mm beyond the posterior margin of the foramen of Monro in the velum interpositum, in the presence of a false venous angle (asterisk) (Type IIB). In this case the foramen of Monro could be enlarged posteriorly as far as the ASV—ICV junction without sacrificing any neural or vascular structures. The dissector indicates the access gained to the third ventricle through the posteriorly enlarged foramen of Monro. ac = anterior commissure; asv = anterior septal vein; bf = body of fornix; cc = corpus callosum; cf = column of fornix; cn = caudate nucleus; cp = choroid plexus; d = dissector; fc = falx cerebri; fm = foramen of Monro; h = hypothalamus; hs = hypothalamic sulcus; ia = interthalamic adhesion; icv = internal cerebral vein; m = midbrain; mb = mamillary body; mpc = medial posterior choroidal artery; pa = pericallosal artery; pc = posterior commissure; r = rostrum of corpus callosum; sa = subcallosal artery; scv = superior choroidal vein; st = stria terminalis; t = thalamus; tv = thalamostriate vein.

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    Photographs of a cadaveric brain specimen showing transforaminal exposure of the third ventricle. Left: Superior view of the right lateral ventricle following removal of the right cerebral hemisphere. Right: The right choroidal fissure has been opened along the tenia fornicis, thus enlarging the foramen of Monro posteriorly and exposing the anterior and middle portions of the third ventricle. The body of the fornix is retracted medially to demonstrate the ASV—ICV junction (arrow). In this specimen, the junction was located 4 mm beyond the posterior margin of the foramen of Monro, in the velum interpositum, and beyond the venous angle (asterisk) (Type IB). acv = anterior caudate vein; asv = anterior septal vein; bf = body of fornix; cc = corpus callosum; cf = column of fornix; cn = caudate nucleus; cp = choroid plexus; d = dissector; fc = falx cerebri; fm = foramen of Monro; icv = internal cerebral vein; pa = pericallosal artery; sp = septum pellucidum; st = stria terminalis; t = thalamus; tc = tenia choroidea; tf = tenia fornicis; tv = thalamostriate vein.

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    Imaging studies of a craniopharyngioma in a 17-year-old boy. Contrast-enhanced T1-weighted sagittal (upper left) and coronal (upper right) MR images showing a heterogeneous lesion in the suprasellar area and third ventricle. Note the left lateral ventricle enlarged due to obliteration of the left foramen of Monro by tumor. Sagittal (center left) and axial (center right) views of the MR venography showing asymmetrical localization of the right and left ASV—ICV junctions (arrows). On the left side the ASV (asv) joins the ICV (icv) beyond the foramen of Monro in the presence of a false venous angle (Type IIA). This indicates that an approach via the left foramen of Monro would provide wider exposure. Postoperative T1-weighted sagittal (lower left) and coronal (lower right) MR images showing radical removal of the tumor. Note the small incision in the corpus callosum. tsv = thalamostriate vein.

  • View in gallery

    Neuroradiological studies showing the location of different types of ASV—ICV junctions (arrows). Upper Left: Sagittal T1-weighted MR image showing the ASV joining the ICV far beyond the foramen of Monro in the velum interpositum in the presence of a venous angle (Type IB). Upper Right: Axial T1-weighted MR image showing asymmetric localization of the right and left ASV—ICV junctions. Lower Left: Magnetic resonance venography showing the ASV joining the ICV beyond the foramen of Monro in the presence of a false venous angle (Type IIB). Lower Right: Venous phase of a cerebral angiogram showing the ASV joining the false venous angle beyond the foramen of Monro (Type IIA).

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