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J Neurol Surg B Skull Base 2024; 85(02): 172-188
DOI: 10.1055/a-2018-4745
Original Article

Anatomical Step-by-Step Dissection of Midline Suboccipital Approaches to the Fourth Ventricle for Trainees: Surgical Anatomy of the Telovelar, Transvermian, and Superior Transvelar Routes, Surgical Principles, and Illustrative Cases

Danielle D. Dang‡   *
1   Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
2   Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, United States
,
Julian S. Rechberger‡   *
1   Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
2   Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, United States
,
Luciano C.P.C. Leonel
1   Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
2   Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, United States
,
Hana Hallak
1   Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
2   Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, United States
,
Stephen Graepel
1   Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
,
Michael J. Link
1   Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
2   Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, United States
3   Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, United States
,
David J. Daniels   **
1   Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
,
Maria Peris-Celda   **
1   Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
2   Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, United States
3   Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, United States
› Author Affiliations Funding The Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program within which this work was completed received the funding from Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, Joseph and Barbara Ashkins Endowed Professorship in Surgery and Radiology, Mayo Clinic, Rochester, Minnesota and Charles B. and Ann L. Johnson Endowed Professorship in Neurosurgery, Mayo Clinic, Rochester, Minnesota.
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Abstract

Introduction Safe, effective access to the fourth ventricle for oncologic resection remains challenging given the depth of location, restricted posterior fossa boundaries, and surrounding eloquent neuroanatomy. Despite description in the literature, a practical step-by step dissection guide of the suboccipital approaches to the fourth ventricle targeted to all training levels is lacking.

Methods Two formalin-fixed, latex-injected specimens were dissected under microscopic magnification and endoscopic visualization. Dissections of the telovelar, transvermian, and supracerebellar infratentorial-superior transvelar approaches were performed by one neurosurgery resident (D.D.D.), under guidance of senior authors. The dissections were supplemented with representative clinical cases to highlight pertinent surgical principles.

Results The telovelar and transvermian corridors afford excellent access to the caudal two-thirds of the fourth ventricle with the former approach offering expanded access to the lateral recess, foramen of Luschka, adjacent skull base, and cerebellopontine angle. The supracerebellar infratentorial-superior transvelar approach reaches the rostral third of the fourth ventricle, the cerebral aqueduct, and dorsal mesencephalon. Key steps described include positioning and skin incision, myofascial dissection, burr hole and craniotomy, durotomy, the aforementioned transventricular routes, and identification of relevant skull base landmarks.

Conclusion The midline suboccipital craniotomy represents a foundational cranial approach, particularly for lesions involving the fourth ventricle. Operatively oriented resources that combine stepwise neuroanatomic dissections with representative cases provide a crucial foundation for neurosurgical training. We present a comprehensive guide for trainees in the surgical anatomy laboratory to optimize familiarity with fourth ventricle approaches, mastery of relevant microsurgical anatomy, and simultaneous preparation for learning in the operating room.

Keywords

fourth ventricle - brain tumor - posterior fossa - skull base - superior transvelar approach - suboccipital craniotomy - supracerebellar infratentorial - telovelar - transvermian

* These authors contributed equally to the article and are first co-authors.


** These authors are senior co-authors.




Publication History

Received: 28 November 2022

Accepted: 17 January 2023

Accepted Manuscript online:
24 January 2023

Article published online:
24 February 2023

© 2023. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

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