A study of safe entry zones via the floor of the fourth ventricle for brain-stem lesions. Report of three cases

Abstract

Direct surgery for intra-axial lesions of the brain stem is considered a hazardous procedure, and morbidity of varying degrees cannot be avoided even with partial removal or biopsy. The main causes of morbidity relate to direct damage during removal of the lesion, selection of an entry route into the brain stem, and the direction of brain stem retraction. The authors examined the possibility of making a medullary incision and retracting the brain stem, taking into account the symptomatology and surgical anatomy, and found two safe entry zones into the brain stem through a suboccipital approach via the floor of the fourth ventricle. These safe entry zones are areas where important neural structures are less prominent. One is the "suprafacial triangle," which is bordered medially by the medial longitudinal fascicle, caudally by the facial nerve (which runs in the brain-stem parenchyma), and laterally by the cerebellar peduncle. The second is the "infrafacial triangle," which is bordered medially by the medial longitudinal fascicle, caudally by the striae medullares, and laterally by the facial nerve. In order to minimize the retraction-related damage to important brain-stem structures, the brain stem should be retracted either laterally or rostrally in the suprafacial triangle approach and only laterally in the infrafacial triangle approach. Three localized intra-axial brain-stem lesions were treated surgically via the safe entry zones using the suprafacial approach in two and the infrafacial approach in one. The cases are described and the approaches delineated. Both approaches are indicated for focal intra-axial lesions located unilaterally and dorsal to the medial lemniscus in the lower midbrain to the pons. Magnetic resonance imaging is useful in selecting these approaches, and intraoperative ultrasonography is helpful to confirm the exact location of a lesion before a medullary incision is made. These approaches can also be used as routes for aspiration of brain-stem hemorrhage as well as for tumor biopsy.