Suboccipital trans-horizontal fissure approach for cerebellar hemorrhage with rupture into the upper fourth and third ventricles: the first clinical experience. Illustrative cases.

Ryota Tamura,Takashi Horiguchi,Yuki Kuranari,Makoto Katayama

doi:10.3171/case21647

Abstract

BACKGROUNDThe authors’ previous cadaveric study reported a new surgical approach that can expose the deep cerebellar hemisphere, cerebellopontine angle, and upper fourth ventricle through dissection of the horizontal fissure of the suboccipital cerebellar hemisphere. Here, the authors present their experience with the first clinical use of the suboccipital trans-horizontal fissure (SOTHF) approach requiring access to the third and upper fourth ventricle lesions, a challenging compartment to access by traditional approaches.OBSERVATIONSIn cases 1 and 2, computed tomography demonstrated large hematomas in the left cerebellar hemisphere with extension into the third ventricle and/or the upper fourth ventricle, resulting in obstructive hydrocephalus. Large hematomas in both the cerebellar hemisphere and the upper fourth ventricle were successfully removed via an SOTHF approach alone without external ventricular drainage. Furthermore, the hematoma in the third ventricle was removed through the aqueduct in case 2. Access to the upper fourth ventricle and the third ventricle were intraoperatively verified using a neuronavigation system. The patients immediately regained consciousness, and the result of cerebellar function testing was almost normal after the operation.LESSONSAn SOTHF approach can achieve the removal of cerebellar and intraventricular hematomas simultaneously, is a faster and potentially safer method than others, and subsequently allows rapid clinical improvement.

Highlights

The authors’ previous cadaveric study reported a new surgical approach that can expose the deep cerebellar hemisphere, cerebellopontine angle, and upper fourth ventricle through dissection of the horizontal fissure of the suboccipital cerebellar hemisphere
We previously reported a novel surgical approach that can expose the deep cerebellar hemisphere, cerebellopontine angle, and upper fourth ventricle through dissection of the horizontal fissure (HF) of the suboccipital cerebellar hemisphere.[1]
Combination of the intermediate suboccipital trans-horizontal fissure (SOTHF) and medial SOTHF approaches can accomplish the simultaneous removal of hematomas in the cerebellar hemisphere and upper fourth and third ventricles in case 2

Summary

BACKGROUND

The authors’ previous cadaveric study reported a new surgical approach that can expose the deep cerebellar hemisphere, cerebellopontine angle, and upper fourth ventricle through dissection of the horizontal fissure of the suboccipital cerebellar hemisphere. OBSERVATIONS In cases 1 and 2, computed tomography demonstrated large hematomas in the left cerebellar hemisphere with extension into the third ventricle and/or the upper fourth ventricle, resulting in obstructive hydrocephalus Large hematomas in both the cerebellar hemisphere and the upper fourth ventricle were successfully removed via an SOTHF approach alone without external ventricular drainage. We previously reported a novel surgical approach that can expose the deep cerebellar hemisphere, cerebellopontine angle, and upper fourth ventricle through dissection of the horizontal fissure (HF) of the suboccipital cerebellar hemisphere.[1] In the previous study, the suboccipital trans-HF (SOTHF) approach was compared with other conventional approaches through a cadaveric study.[1]. We present our experience with the first clinical use of a medial SOTHF approach to the third and upper fourth ventricle lesions

Illustrative Cases

Medial SOTHF Approach Dissecting the Arachnoid Membrane and Cortex

Discussion