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. 2010 Jul;5(2):97-101.
doi: 10.4103/1817-1745.76093.

Major surgical approaches to the posterior third ventricular region: A pictorial review

Sanjay Behari  1 , Pallav Garg, Sushila Jaiswal, Anup Nair, Ram Naval, Awadhesh K Jaiswal
Affiliations

Major surgical approaches to the posterior third ventricular region: A pictorial review

Sanjay Behari et al. J Pediatr Neurosci. 2010 Jul.
No abstract available

PubMed Disclaimer

Conflict of interest statement

Conflict of Interest: None declared

Figures

Figure 1
Figure 1
Patient 1: (A-C): This 8-year old boy presented with raised pressure, bilateral VIth nerve and upward gaze palsy of 8-months duration. His contrast enhanced CT scan showed a uniformly enhancing, infiltrative, posterior third ventricular lesion reaching the anterior third ventricle nearly until the foramen of Monro and causing hydrocephalus. The right ventriculoperitoneal shunt initially placed at another center got blocked and required revision.
Figure 2
Figure 2
Patient 1: A and B: Contrast enhanced axial T1-weighted MRI following the ventriculoperitoneal shunt revision showed the uniformly enhancing infiltrative lesion occupying the posterior third ventricular region and the quadrigeminal cistern. C: T2-weighted axial image showing the lesion to be heterogeneously iso- to hyperintense. D: Sagittal contrast enhanced T1 image showing the lesion occupying the third ventricle along the internal cerebral vein almost reaching upto the foramen of Monro. E: The coronal-enhanced T1 image showing the vertical extent of the lesion from the foramen of Monro to the midbrain. F: The diffusion-weighted image showing restriction of diffusion within the lesion.
Figure 3
Figure 3
Patient 1: Infratentorial, supracerebellar approach was adopted in sitting position. A: A midline linear incision through the skin and ligamentum nuchae exposed the occipital bone from the external occipital protuberance to the foramen magnum. The craniectomy revealed the exposed rim of the transverse and occipital sinus, and the dura covering bilateral cerebellar hemispheres and foramen magnum. B: The dura is opened with a “Y” shaped incision coagulating the occipital sinus and the annular sinus (the latter at the foramen magnum) and refl ected superiorly along the transverse sinus. C: The anastomotic veins between the superior surface of cerebellar hemispheres and the tentorium are coagulated allowing the cerebellum to fall with gravity away from the tentorium and creating the space for the surgical approach. D: The arachnoid covering the tumor in the posterior third ventricular region and the precentral cerebellar vein in the midline are seen due to gravity-assisted fall of the cerebellum.
Figure 3
Figure 3
Patient 1: E: The precentral cerebellar vein is coagulated and divided. F: The arachnoid covering the tumor is removed exposing the tumor surface. G: The tumor is gently coagulated and removed in a piecemeal manner. H: The opening of the third ventricle following tumor removal drains CSF.
Figure 4A
Figure 4A
Patient 1: Photomicrograph showing round to polygonal tumor cells disposed in groups, displaying conspicuous nucleoli at places and variable amount of pale to amphophilic cytoplasm. The groups of tumor cells are separated by fibrous septa infiltrated by small mature lymphocytes (H and E, ×400)
Figure 4B
Figure 4B
Patient 1: Photomicrograph showing tumor cell positive for CD 117 (Immunohistochemical stain; ×400)
Figure 4C
Figure 4C
Patient 1: Photomicrograph showing tumor cell positive for placenta-like alkaline phosphatase (PLAP) (Immunohistochemical stain; 400×) The histopathology and immunohistochemistry confirmed the presence of a GERMINOMA.
Figure 5
Figure 5
A: Patient 1: Axial T2; B: axial contrast T1; and, C: Sagittal contrast T1-weighted images after surgery and radiotherapy showing a small nonenhancing component of the residual lesion with no hydrocephalus.
Figure 6
Figure 6
Patient 2: A, B: This 16-year-old girl presented with symptoms of raised intracranial pressure, Perinaud’s syndrome and gait ataxia. Her axial contrast T1-weighted images showed the nonenhancing irregular lesion in the posterior third ventricular region and the ambient and quadrigeminal cisterns. There is mild hydrocephalus with dilated anterior third ventricle and bilateral lateral ventricles. C: Sagittal, and D: Coronal contrast T1 images showing the vertical extent of the lesion along the brain stem and its extension into the supratentorial compartment after occupying the tentorial incisural space. The superior vermis of the cerebellum appears flattened by the lesion. E, F: Diffusion-weighted axial images showing the restriction of diffusion in the lesion.
Figure 7
Figure 7
Patient 2: A: Right occipital craniotomy, posterior interhemispheric, transtentorial approach adopted in prone position with the table tilted about 20-30° toward the side of approach to permit a gravity-dependent spontaneous retraction of the right parieto-occipital lobe facilitating the approach through the posterior interhemispheric corridor that is usually devoid of bridging veins. B: The dural exposure after the craniotomy that extends until the rim of the torcula and transverse sinus inferiorly and the posterior part of the superior sagittal sinus medially. The dura is cut in a square shape and refl ected medially based upon the superior sagittal sinus. C: Gentle lateral retraction of the right parieto-occipital lobe exposes the falx cerebri and its junction with the tentorium that encloses the straight sinus within its leaves at the junctional area. D: The tentorium is traced until its incisura parallel to the straight sinus. The epidermoid tumor is visible within its arachnoid covering at the incisura. E: The tentorial surface is coagulated and divided parallel and slightly away from the straight sinus and the arachnoidal covering of the epidermoid removed exposing the tumor. F: The tumor is removed in a piecemeal manner with the help of microdissectors, gentle irrigation and suction.
Figure 7
Figure 7
Patient 2: G: Following tumor removal, the superior surface of cerebellum and brain stem are exposed. The divided tentorium is being retracted with stay sutures providing an adequate corridor. There is a thin capsule of the epidermoid still lining the brain stem, and H: the superior surface of the cerebellum. I: The vein of Galen and basal vein of Rosenthal, and J: the posterior thalamus, collicular plate and the quadrigeminal cistern are visible following tumor removal. K: The cerebellum, brain stem, and, L: the lax brain after the procedure. A bridging vein at the anterior end of the corridor is protected with surgicel.
Figure 8
Figure 8
Patient 2: Photomicrograph showing a cyst lined by thinned out stratified squamous epithelium filled with keratin material suggestive of epidermoid (H and E, ×400)
Figure 9
Figure 9
Patient 2: A: axial T1; B: axial T2; C, D: sagittal T1; E: sagittal T2; and F: diffusion-weighted axial MR images showing the postoperative tumor cavity after total excision of the lesion.
See this image and copyright information in PMC

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