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CC BY-NC-ND 4.0 · Asian J Neurosurg 2024; 19(03): 490-500
DOI: 10.1055/s-0044-1787885
Original Article

Intrasylvian Retraction Technique to Facilitate the Sylvian Fissure Dissection: A Clinical Study of 125 Cases

Kitiporn Sriamornrattanakul
1   Division of Neurosurgery, Department of Surgery, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
,
Chanon Ariyaprakai
1   Division of Neurosurgery, Department of Surgery, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
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Abstract

Although many authors have recommended the retractorless technique to avoid retractor-induced brain injury, others usually use brain retractors with a meticulous technique to facilitate the surgery, especially for sylvian fissure dissection. The intrasylvian retraction technique was described for sylvian fissure opening, but no clinical evidence was found. We evaluate the efficacy and safety of this technique for the distal transsylvian approach. We reviewed the video records of clinical cases where the distal transsylvian approach was performed using the intrasylvian retraction technique for aneurysm treatment and middle cerebral artery (MCA) bypass between September 2018 and August 2022. Operative techniques are described. The efficacy and safety of the technique were assessed by full exposure of the sylvian fissure and new postoperative perisylvian hematoma, respectively. One hundred twenty-five cases were included and had an average age of 53.5 (range 16–85) years. Women comprised 73.6%. Aneurysm surgery, pure MCA revascularization, and aneurysm surgery with MCA revascularization were 106 (84.8%), 12 (9.6%), and 7 cases (5.6%), respectively. The most common aneurysm location was the internal carotid artery-posterior communicating artery junction in 37 cases (34.9%), followed by the anterior communicating artery in 27 (25.5%). Full exposure of the Sylvian fissure was achieved in all cases. No perisylvian hematoma was detected by immediate postoperative computed tomography in any patient. Using an appropriate technique for brain retractor application, sylvian fissure dissection was safely performed. The intrasylvian retraction technique effectively facilitated sylvian fissure dissection and provided wide exposure for the distal transsylvian approach.

Keywords

brain retractor - distal transsylvian approach - intrasylvian retraction - sylvian fissure dissection - sylvian fissure split

Author's Contributions

K.S. and C.A. conceived and designed the study, acquired the data, and performed the analysis and interpretation. K.S. drafted and critically revised the article, reviewed the submitted version, and supervised the study.


Ethical Approval

The study was approved by the Institutional Review Board of the Faculty of Medicine Vajira Hospital, COA no. was 076/2566.




Publication History

Article published online:
24 June 2024

© 2024. Asian Congress of Neurological Surgeons. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

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  • References

  • 1 Yasargil MG. Interfascial pterional (frontotemporosphenoidal) craniotomy. In: Yasargil MG. ed. Microneurosurgery. Vol: 1. Stuttgart: George Thieme Verlag; 1984: 215-220
    Google Scholar
  • 2 Andrews RJ, Bringas JR. A review of brain retraction and recommendations for minimizing intraoperative brain injury. Neurosurgery 1993; 33 (06) 1052-1063 , discussion 1063–1064
    PubMedGoogle Scholar
  • 3 Assina R, Rubino S, Sarris CE, Gandhi CD, Prestigiacomo CJ. The history of brain retractors throughout the development of neurological surgery. Neurosurg Focus 2014; 36 (04) E8
    CrossrefPubMedGoogle Scholar
  • 4 Dujovny M, Ibe O, Perlin A, Ryder T. Brain retractor systems. Neurol Res 2010; 32 (07) 675-683
    CrossrefPubMedGoogle Scholar
  • 5 Greenberg IM. Self-retaining retractor and handrest system for neurosurgery. Neurosurgery 1981; 8 (02) 205-208
    CrossrefPubMedGoogle Scholar
  • 6 Rosenørn J. The risk of ischaemic brain damage during the use of self-retaining brain retractors. Acta Neurol Scand Suppl 1989; 120: 1-30
    CrossrefPubMedGoogle Scholar
  • 7 Muhammad S, Tanikawa R, Lawton M, Regli L, Niemelä M, Korja M. Microsurgical dissection of sylvian fissure-short technical videos of third generation cerebrovascular neurosurgeons. Acta Neurochir (Wien) 2019; 161 (09) 1743-1746
    CrossrefPubMedGoogle Scholar
  • 8 Samson DS, Hodosh RM, Clark WK. Microsurgical evaluation of the pterional approach to aneurysms of the distal basilar circulation. Neurosurgery 1978; 3 (02) 135-141
    CrossrefPubMedGoogle Scholar
  • 9 Schaller C, Klemm E, Haun D, Schramm J, Meyer B. The transsylvian approach is “minimally invasive” but not “atraumatic”. Neurosurgery 2002; 51 (04) 971-976 , discussion 976–977
    PubMedGoogle Scholar
  • 10 Yasargil MG, Vise WM, Bader DC. Technical adjuncts in neurosurgery. Surg Neurol 1977; 8 (05) 331-336
    PubMedGoogle Scholar
  • 11 Dashti R, Hernesniemi J, Niemelä M. et al. Microneurosurgical management of middle cerebral artery bifurcation aneurysms. Surg Neurol 2007; 67 (05) 441-456
    CrossrefPubMedGoogle Scholar
  • 12 Ogilvy CS, Crowell RM, Heros RC. Surgical management of middle cerebral artery aneurysms: experience with transsylvian and superior temporal gyrus approaches. Surg Neurol 1995; 43 (01) 15-22 , discussion 22–24
    CrossrefPubMedGoogle Scholar
  • 13 Kalani MYS. Prospective evaluation of the need for fixed brain retractors during complex cranial surgery. World Neurosurg 2020; 139: e61-e69
    CrossrefPubMedGoogle Scholar
  • 14 Spetzler RF, Sanai N. The quiet revolution: retractorless surgery for complex vascular and skull base lesions. J Neurosurg 2012; 116 (02) 291-300
    CrossrefPubMedGoogle Scholar
  • 15 Sun H, Safavi-Abbasi S, Spetzler RF. Retractorless surgery for intracranial aneurysms. J Neurosurg Sci 2016; 60 (01) 54-69
    PubMedGoogle Scholar
  • 16 Yu LH, Yao PS, Zheng SF, Kang DZ. Retractorless surgery for anterior circulation aneurysms via a pterional keyhole approach. World Neurosurg 2015; 84 (06) 1779-1784
    CrossrefPubMedGoogle Scholar
  • 17 Hafez A, Buçard JB, Tanikawa R. Integrated multimaneuver dissection technique of the sylvian fissure: operative nuances. Oper Neurosurg (Hagerstown) 2017; 13 (06) 702-710
    CrossrefPubMedGoogle Scholar
  • 18 Katsuno M, Tanikawa R, Izumi N, Hashimoto M. A modified anterior temporal approach for low-position aneurysms of the upper basilar complex. Surg Neurol Int 2015; 6: 10
    CrossrefPubMedGoogle Scholar
  • 19 Zagzoog N, Reddy KK. Modern brain retractors and surgical brain injury: a review. World Neurosurg 2020; 142: 93-103
    CrossrefPubMedGoogle Scholar
  • 20 Katsuno M, Tanikawa R, Miyazaki T. et al. Tips and process in the dissection of the interhemispheric fissure or sylvian fissure to provide a bloodless field for cerebral aneurysm surgery. Sug Cereb Stroke (Jpn) 2013; 41: 406-410
    CrossrefGoogle Scholar
  • 21 Hongo K, Kobayashi S, Yokoh A, Sugita K. Monitoring retraction pressure on the brain. An experimental and clinical study. J Neurosurg 1987; 66 (02) 270-275
    CrossrefPubMedGoogle Scholar
  • 22 Konya B, Dankbaar JW, van der Zwan A. Brain retraction injury after elective aneurysm clipping: a retrospective single-center cohort study. Acta Neurochir (Wien) 2022; 164 (03) 805-809
    CrossrefPubMedGoogle Scholar
  • 23 Rosenørn J. Self-retaining brain retractor pressure during intracranial procedures. Acta Neurochir (Wien) 1987; 85 (1-2): 17-22
    CrossrefPubMedGoogle Scholar
  • 24 Zhong J, Dujovny M, Perlin AR, Perez-Arjona E, Park HK, Diaz FG. Brain retraction injury. Neurol Res 2003; 25 (08) 831-838
    CrossrefPubMedGoogle Scholar
  • 25 Katsuno M, Tanikawa R, Miyazaki T. et al. The results of interhemispheric approach for unruptured anterior communicating artery aneurysms. Surg Cereb Stroke 2012; 40: 106-111
    CrossrefGoogle Scholar
  • 26 Noda K, Tanikawa R, Kamiyama H. et al. Interhemispheric approach for Acom aneurysm. Jpn J Neurosurg (Tokyo) 2012; 21: 834-841
    CrossrefGoogle Scholar
  • 27 Tanikawa R. Technical points of interhemispheric approach for anterior communicating aneurysms. Nosotchu No Geka 2002; 30: 208-212
    Google Scholar
  • 28 Hokari M, Tanikawa R, Hayashi Y. et al. The technical points for the distal transsylvian approach and the management of sylvian vein: opening the arachnoid membrane from the temporal side of the superficial sylvain veins. Sug Cereb Stroke (Jpn) 2003; 31: 349-354
    CrossrefGoogle Scholar
  • 29 Sriamornrattanakul K, Wongsuriyanan S. Anterior temporal approach for clipping posterior-projecting supraclinoid carotid artery aneurysms: a more lateral corridor to better visualize the aneurysm neck and related branches. World Neurosurg 2021; 149: e549-e562
    CrossrefPubMedGoogle Scholar
  • 30 Kaido T, Nakase H, Nagata K, Otsuka H, Sakaki T. Intermittent isometric exposure prevents brain retraction injury under venous circulatory impairment. Neurol Res 2001; 23 (07) 739-744
    CrossrefPubMedGoogle Scholar
  • 31 Yokoh A, Sugita K, Kobayashi S. Intermittent versus continuous brain retraction. An experimental study. J Neurosurg 1983; 58 (06) 918-923
    CrossrefPubMedGoogle Scholar