Transsylvian-transinsular Approach Research Articles

Microsurgical anatomy and approaches to thalamic gliomas. Part 1: A cartography guide for navigating to the thalamus. Integrating 3D model rendering with anatomical dissections.

The selection of appropriate microsurgical approaches to treat thalamic pathologies is currently largely subjective. The objective of this study was to provide a structured cartography map for surgical navigation to treat gliomas involving different surfaces of the thalamus. Fifteen formalin-fixed, silicone-injected cadavers (30 sides) were dissected, and 10 adult brain specimens (20 sides) were used to illustrate thalamic microsurgical anatomy using the Klingler fiber dissection technique. Exposures and trajectories for the six most common microsurgical approaches were depicted using MR data from healthy subjects converted into surface-rendered 3D virtual brain models. Additionally, thalamic surfaces exposed with all six approaches were color mapped on the virtual 3D model and compared side-by-side in 360° views with previously reported microsurgical approaches. These 3D models were then used in conjunction with topographic data to guide cadaveric dissection steps. There are two general surgical routes to thalamic lesions: the subarachnoid transcisternal and transcortical routes. The transcisternal route consists of the following three approaches: 1) anterior interhemispheric transcallosal approach, which exposes the anterior and superior thalamus; 2) posterior interhemispheric transcallosal approach, which exposes the posterosuperior thalamus; and 3) supracerebellar infratentorial approach, which exposes the posteromedial cisternal thalamus and can be extended laterally to approach the posterolateral thalamus by cutting the tentorium. The three transcortical approaches are the 1) superior parietal lobule approach, which exposes the posterosuperior thalamus and is particularly advantageous in the setting of hydrocephalus; 2) transtemporal gyrus approach, which exposes the inferolateral thalamus; and 3) transsylvian transinsular approach, which exposes the lateral thalamus (slightly more superiorly and posteriorly) and is advantageous for pathologies extending laterally into the peduncle, lenticular nucleus, or insula. Microsurgical approaches to thalamic gliomas continue to be challenging. Nonetheless, safe and effective cisternal, ventricular, and cortical corridors can be developed with thoughtful planning, anatomical understanding, and knowledge of the advantages, risks, and limitations of each approach. In some cases, it is wise to combine these approaches with staged procedures, as the authors demonstrate in Part 2. In Part 1 of this two-part series, they discuss thalamic microsurgical anatomy and illustrate the trajectory and exposures of all six approaches to guide decision-making. Part 2 discusses their thalamic glioma microsurgical case series, which utilizes these microsurgical approaches.

Hematoma evacuation based on active strategies versus conservative treatment in the management of moderate basal ganglia hemorrhage: A retrospective study.

The internal capsule of the basal ganglia is vulnerable to direct pressure from the hematoma and to secondary damage from toxic products of hemorrhage. Our study evaluated the risk and benefits of active strategies including ultra-early surgery and hematoma evacuation through a transsylvian-transinsular approach for moderate basal ganglia hemorrhage. We retrospectively collected patients with moderate basal ganglia hemorrhage in two hospitals. The conservative group contained 51 patients who had the best medical treatment, and the surgery group contained 36 patients who were treated with hematoma evacuation through a transsylvian-transinsular approach within 6 h from ictus. Motor function of upper and lower limbs recorded with the motor sub-score of NIHSS (m-NIHSS) at the baseline, 7 days, 30 days, and 90 days, the modified Rankin Scale (mRS), and Barthel Index (BI) scores at 30 and 90 days were compared between the two groups. Good recovery was defined as an m-NIHSS of 0-2 and poor recovery as 3-4. Favorable prognosis was defined as an mRS of 0-3 and unfavorable prognosis as 4-5. The mean time from ictus to surgery was 250.3 ± 57.3 min. The good recovery proportions of upper and lower limbs in the surgery group were significantly higher than that in the conservative group (p < 0.05) at 7 days after hemorrhage. The good recovery proportion of upper limbs was significantly higher in the surgery group than in the conservative group (p < 0.05) at 3 months after hemorrhage. Living ability using BI scores was significantly higher in the surgery group than the conservative group (p < 0.05) at 3 months after hemorrhage. The favorable prognosis proportion had no statistically significant difference between the two groups at 3 months after hemorrhage. Ultra-early hematoma evacuation through a transsylvian-transinsular approach are active strategies for moderate basal ganglia hemorrhage and have potential advantages in improving motor function recovery and daily living. The postoperative rebleeding rate does not increase simultaneously.

Clinical efficacy of minipterional craniotomy with rostral transsylvian-transinsular approach for hypertensive basal ganglion hemorrhage

Background: Clinical applications of transsylvian-transinsular (TS-TI) approaches to hypertensive basal ganglia hemorrhages (HBGHs) have an enormous difference in functional independence rate. The aim of this study is to investigate the clinical efficacy of minipterional craniotomy with rostral TS-TI approach to HBGH and compare functional independence rate with distal TS-TI variant. Methods: From April 2017 to April 2019, eleven patients with symptomatic HBGH accepting minipterional craniotomies with rostral TS-TI approaches were analyzed retrospectively. Results: The mean volume of preoperative hematoma was 57.08 ml with a 99.20% evacuation rate. Postoperative images revealed no rebleeding or newly developed hypodense lesion. Nine out of eleven patients got clear consciousness with functional independence at 3 months postoperatively. Conclusions: In comparison with distal TS-TI approach, minipterional craniotomy with rostral TS-TI approach to HBGH provides satisfactory outcome with higher functional independence rate.

Clinical efficacy of minipterional craniotomy with rostral transsylvian-transinsular approach for hypertensive basal ganglion hemorrhage

Background: Clinical applications of transsylvian-transinsular (TS-TI) approaches to hypertensive basal ganglia hemorrhages (HBGHs) have an enormous difference in functional independence rate. The aim of this study is to investigate the clinical efficacy of minipterional craniotomy with rostral TS-TI approach to HBGH and compare functional independence rate with distal TS-TI variant. Methods: From April 2017 to April 2019, eleven patients with symptomatic HBGH accepting minipterional craniotomies with rostral TS-TI approaches were analyzed retrospectively. Results: The mean volume of preoperative hematoma was 57.08 ml with a 99.20% evacuation rate. Postoperative images revealed no rebleeding or newly developed hypodense lesion. Nine out of eleven patients got clear consciousness with functional independence at 3 months postoperatively. Conclusions: In comparison with distal TS-TI approach, minipterional craniotomy with rostral TS-TI approach to HBGH provides satisfactory outcome with higher functional independence rate.

Microsurgical treatment of hypertensive basal ganglia hematomas through transsylvian-transin-sular approach

Objective To study the surgical experience and clinical efficacy of microsurgical treatment on patients with hypertensive basal ganglia hematomas through transsylvian-transinsular approach. Methods A retrospective analysis was performed on 68 consecutive patients with hypertensive basal ganglia hematomas who underwent surgical treatment at Department of Neurosurgery, Shanxi Dayi Hospital from June 2013 to May 2018. All of them were operated on for hematomas evacuation through transsylvian-transinsular approach.The degree of hematomas evacuation was evaluated by postoperative CT scan results. Glasgow outcome scale (GOS) was used to access the clinical prognosis. Results The volume of remaining hematoma was 0-10 ml (median: 3.5±0.5 ml) on CT scan obtained 24 hours postoperatively. In this group, near complete (>90%) evacuation was achieved in 83.8%(57/68), 70-90% in 8.8% (6/68) and less than 70% in 7.4% (5/68). None of the patients had edema or contusion around the surgical corridor. There were rebleeding in 1 (1.5%) case, severe pulmonary infection in 6, intracranial infection in 3, hydrocephalus in 2 and epilepsy in 1. The mortality rate was 4.4% (3/68). There was 42 cases with good function, 18 cases with disability, and 5 cases in vegetative state at 6 months post surgery among 65 surviving patients. Conclusions Microsurgery through transsylvian-transinsular approach is one of safe and effective treatments for hypertensive basal ganglia hematomas. Keeping proper dissection plane is crucial to preserve the veins during the sylvian dissection. It could offer a sufficiently wide surgical corridor to evacuate the hematomas. Key words: Intracranial hemorrhage, hypertensive; Basal ganglia; Transsylvian-transinsular approach; Treatment outcome

Transsylvian-Transinsular Approach for an Insular Cavernous Malformation Resection: 3-Dimensional Operative Video.

Surgical resection of insular lesions is challenging due to their proximity to critical neurovascular structures such as the middle cerebral arteries (MCA), Sylvian veins, thalamus, internal capsule (IC), and lenticulostriate arteries. A surgical series using the transsylvian-transinsular approach to treat cerebrovascular pathologies reported ∼5% permanent neurological morbidity.1,2 This case demonstrates the utility of this approach for resecting an insular cavernous malformation (CM).A 25-yr-old female presented with an acute-onset right homonymous hemianopsia. Neuroimaging revealed a large left insular CM, adjacent to the posterior limb of IC. After obtaining IRB approval and patient consent, a left pterional craniotomy with a wide distal Sylvian fissure split was completed. Using neuronavigation, an insular entry point was chosen for corticectomy. The CM was opened with subsequent hematoma evacuation and intracapsular resection technique. Inspection of the cavity revealed remnants anteromedially near the IC, which were removed meticulously, mobilizing the CM away from the IC. Postoperative MRI demonstrated gross total resection of the CM. The patient was discharged home on postoperative day 5 with persistent homonymous hemianopia.This case describes the use of a transsylvian-transinsular approach to access deep lesions with the shortest surgical distance and minimal cortical transgression. A wide Sylvian fissure split exposes the M2 MCA and accesses a safe insular zone, keeping the most eloquent structures deep to the lesion in the surgical corridor. This approach can safely expose vascular pathologies in the insular region without the risk of injury to overlying eloquent frontal and temporal lobes, even in the dominant hemisphere.

Surgical treatment of lenticulostriate aneurysms (a case report and literature review)

The study objective is to describe a rare case of putaminal intracerebral hemorrhage (PICH) results from a rupture of the distal lateral lenticulostriate artery (LSA) aneurysm and to summarize currently available information on its diagnosis and treatment.Materials and methods. A 40-year-old female patient was admitted to the N.V. Sklifosovsky Research Institute of Emergency Medicine. Her arterial pressure was 200/110 mm Hg. Brain computed tomography (CT) revealed a 25 сm3 right-sided PICH with a minimal perifocal edema. CT angiography revealed a saccular aneurysm located in the right distal LSA with the dome of 5 mm and the neck of 2 mm. We performed right frontotemporoparietal osteoplastic craniotomy and used the transsylvian transinsular approach to PICH represented by ruptured while we were removing the blood clots. We performed aneurysm trapping and removed the hematoma.Results. This clinical case demonstrates the possibility of successful microsurgical repair of the distal lateral LSA aneurysm rupture. Six months postoperatively, the patient had complete regression of left leg paresis and partial restoration of left hand functions.Conclusion. This case report appears quite interesting since deep intracerebral hematomas of this etiology are extremely rare. An optimal treatment for LSA aneurysms remains a subject of debate due to the small number of patients with this disorder and limited data on it. Patients with fusiform aneurysms require conservative treatment and dynamic follow-up with periodic cerebral angiography. Patients with typical saccular aneurysms or PICH presenting mass effect should undergo surgical treatment.

Treatment of hypertensive basal ganglia cerebral hemorrhage with different surgical approaches

According to the locations of main hematomas, 60 patients with hypertensive basal ganglia hemorrhage were surgically treated through different approaches from June 2014 to September 2017. Thirty six cases with anterior hematoma near the Sylvian point were treated through transsylvian-transinsular approach, 24 cases with the posterior hematoma far from the Sylvian point were treated through translower-rolandic-point (transLRP) transinsular approach (n=11) or transsuperior-temporal-sulcus (transSTS) transinsular approach (n=13), respectively. All patients were followed up for at least 6 months and evaluated by Glasgow Outcome Scale. Fourteen patients showed good recovery, 25 patients showed moderate disability, 18 patients showed severe disability, one patients showed vegetative survival and two patients died. Key words: Intracerebral hemorrhage, hypertensive; Basal ganglia; Surgical approach

Early microsurgery via transsylvian-transinsular approach in hypertensive intracerebral hematomas in the basal ganglia

Objective To investigate the clinical value of early microsurgery of hypertensive intracerebral hematomas in the basal ganglia via transsylvian-transinsular and cortical fistula approach. Methods A retrospective study was performed on 122 cases of patients with hypertensive intracerebral hematomas in the basal ganglia who were admitted from January 2013 to December 2016.According to different surgical approaches, the patients were divided into the cortical fistula approach (CFA) group and the transsylvian-transinsular approach (TTA) group.In the CFA group, the ipsilateral left middle temporal gyrus was used as the hematoma cavity; in the TTA group, the ipsilateral lateral fissure and the upper lobe of the insular cortex reached the hematoma cavity.After the operation, the patients were examined by brain CT to determine the clearance rate of the hematoma, and the NICU admission time and the daily living ability score were compared between the two groups. Results The differences of postoperative hematoma clearance rate, NICU admission time and ADL between the two groups were statistically significant (P<0.05). Conclusion Compared with the cortical fistula approach, the transsylvian-transinsular approach has higher hematoma clearance rate, shorter NICU admission time and better prognosis, which is worth of clinical promotion. Key words: Transsylvian-transinsular approach; Cortical fistula approach; Microsurgery; Hypertension; Intracerebral hematoma; Basal ganglia

Minipterional craniotomy with transsylvian-transinsular approach for hypertensive putaminal hemorrhage: A preliminary report

Background: There is no consensus regarding optimal treatment of spontaneous intracerebral hemorrhage (ICH) till date. The role of surgery in managing spontaneous ICH is debatable because of lacking clear benefit as compared to conservative treatment. The aim of this study is to assess the clinical efficacy of minipterional craniotomy in the treatment of hypertensive putaminal hemorrhage (HPH). Materials and Methods: From January 2015 to December 2015, four patients with large HPHs accepting minipterional craniotomies and transsylvian-transinsular (TS-TI) approaches were analyzed retrospectively in terms of hematoma evacuation rate, recovery of consciousness, and short-term functional prognosis. Results: The average volume of residual hematoma was 3.68 ml with 93.53% evacuation rate. There was no delayed hemorrhage or newly developed hypodense lesion on postoperative images. Three out of four patients got clear consciousness with improved muscle strength of involved limbs on discharge from our institute. The modified Rankin scale grades were 3 at 3 months postoperatively. Conclusions: Minipterional craniotomy with TS-TI approach is a feasible procedure for HPH in selected candidate. The recommendation of this procedure is due to satisfactory hematoma evacuation rate, minimal brain damage, and improved functional outcome.

Large traumatic basal ganglia hematoma: surgical treatment versus conservative management.

Traumatic basal ganglia hematomas (TBGHs) are uncommon events in patients with closed head injuries. The overall prognosis is poor, particularly when large hematoma exists. This study was designed to compare surgical evacuation through transsylvian-transinsular approach with conservative management in large TBGHs. Thirty-two patients, admitted between July 2002 and July 2013, with closed head injury and TBGH more than 25 mL were included in this study. Among these patients, sixteen were conservatively managed whereas another sixteen patients underwent hematoma evacuation via transsylvian-transinsular approach. The modified Rankin scale was used to assess the functional outcomes of patients for at least 6 months after treatment. There were no significant differences between two groups with respect to age (21.0 vs. 18.9 years, P=0.635), sex (P=0.220), and admission GCS Score (7.5 vs. 6.5, P=0.234). The patients treated with surgical approach revealed a better functional outcome compared to the conservative group (68.8% vs. 31.3%, P=0.043). The mean of late TBGH volume in the conservative group was less than surgical group (33.9 mL vs. 40.0 mL, P=0.047). The mortality rates were not significantly different between the surgical and conservative groups (18.8% vs. 37.5%, P=1.000). This study suggests that hematoma evacuation through a transsylvian-transinsular approach improves the functional outcome in patients with TBGH.

Cavernomas and Arteriovenous Malformations in the Mesial Temporal Region: Microsurgical Anatomy and Approaches.

The mesial temporal region (MTR) is located deep in the temporal lobe and it is surrounded by important vascular and nervous structures that should be preserved during surgery. To describe microsurgical anatomy and approaches to the MTR in relation to cavernomas and arteriovenous malformations (AVMs). Five formalin-fixed and red silicone-embedded heads of adult cadavers were used for this study. Between January 2003 and June 2014, 7 patients with cavernomas and 6 patients with AVMs in the MTR underwent surgery. The MTR of the cadavers was divided into 3 areas: anterior, middle, and posterior. Of the 7 patients with MTR cavernomas, 4 were located anteriorly, 2 were located medially, and 1 was located posteriorly. Of the 6 patients with MTR AVMs, 3 were located in the anterior sector, 2 in the middle sector, and 1 in the posterior sector. For the anterior portion of the MTR, a transsylvian-transinsular approach was used; for the middle portion of the MTR, a transtemporal approach was used (anterior temporal lobectomy); and for the posterior portion of the MTR, a supracerebellar-transtentorial approach was used. Dividing the MTR into 3 regions allows us to adapt the approach to lesion location. Thus, the anterior sector can be approached via the sylvian fissure, the middle sector can be approached transtemporally, and the posterior sector can be approached via the supracerebellar approach.

Transsylvian-transinsular approach to large lateral thalamus hemorrhages.

Here, we aimed to evaluate the experience of transsylvian-transinsular microsurgical approach (TTH) to the huge lateral thalamic hemorrhages (THs). A total of 37 patients with huge lateral TH (hematoma volumes between 30 and 90 cm) who underwent surgical treatment through middle or distal TTH at the Bayi Brain Hospital from January 2007 to May 2012 were included in this series. By using TTH, near-complete (99%) evacuation was achieved in 29 patients (78.4%). Glasgow Coma Scale (GOS) scores were significantly improved at discharge compared with admission scores (P < 0.001). The overall survival rate at 3 months was 81.08% (30/37), including 51.35% (19/37) with good function (GOS, 4-5), 13.51% (5/37) with disability (GOS, 3), and 16.22% (6/37) in a vegetative state (GOS, 2). The mortality rate (GOS, 1) was 18.92% (7/37). Our series showed that, according to the extension direction of hematomas, to select middle or distal TTH is effective and safe for TH.

Cavernomas de la Región Temporal Mesial: Anatomía Microquirúrgica y Abordajes

Objetivo:Describir la anatomía microquirúrgica y los abordajes a la región temporal mesial (RTM), en relación a cavernomas de dicho sector.Materiales y Método:Cinco cabezas de cadáveres adultos, fijadas en formol e inyectadas con silicona coloreada, fueron estudiadas. Además, desde enero de 2007 a junio de 2014, 7 pacientes con cavernomas localizados en la RTM fueron operados por el autor.Resultados:Anatomia: La RTM fue dividida en 3 sectores: Anterior, medio y posterior. Pacientes: 7 enfermos con cavernomas de la RTM fueron operados por el autor. De acuerdo a la ubicacion en la RTM, 4 cavernomas se ubicaron en el sector anterior, 2 cavernomas se localizaron en el sector medio y 1 cavernoma se ubico en el sector posterior. Para el sector anterior de la RTM se utilizo un abordaje transsilviano-transinsular; para el sector medio de la RTM se utilizo un abordaje transtemporal (lobectomia temporal anterior); y para el sector posterior de la RTM se utilizo un abordaje supracerebeloso-transtentorial.Conclusión:Dividir la RTM en 3 sectores nos permite adecuar el abordaje en función a la localización de la lesión. Así, el sector anterior es bien abordable a través de la fisura silviana; el sector medio a través de una vía transtemporal; y el sector posterior por un abordaje supracerebeloso.

Pterional transsylvian–transinsular approach in three cavernomas of the left anterior mesiotemporal region

ObjectiveTo describe the pterional transsylvian–transinsular approach for cavernomas of the left anterior mesiotemporal region in three patients. MethodsA retrospective analysis of patients who underwent surgery for cavernous angiomas in the temporal lobe was performed via the left mesiotemporal lobe (MTL). The technique was as follows: using the pterional approach, the Sylvian fissure was widely opened, distally to proximally. The temporal branch of the middle cerebral artery was displaced medially, and once the limiting sulcus of the insula was located, an 8mm long corticotomy was performed, just behind the limen insulae. The dissection was extended through the white matter until the anterior portion of the temporal horn was reached. Finally, lesion resection was performed. ResultsThree patients presented with cavernomas in the anterior sector of the MTL and underwent the transsylvian–transinsular approach. There were no deaths in this series. One patient sustained a permanent postoperative deficit, a right homonymous quadrantanopia. ConclusionThe pterional transsylvian–transinsular approach allows for selective resection of lesions located in the anterior mesiotemporal region (MTR) of the dominant hemisphere, while avoiding damage to the lateral or basal cortex of the temporal lobe or to structures in the dominant hemisphere.

Anatomical study of insula and its relationship with the adjacent structures.

Insular lobe is folded deep in the sylvian fissure, and the transsylvian transinsular approach is one of the most commonly used methods for lesions in the insula, basal ganglia, amygdala, and hippocampus. Hence, it is essential for surgeons to master a specific anatomic knowledge of the insula and its adjacent structures. This study aims to locate the insula, measure relevant parameters, and reduce the occurrence of surgical injury and postoperative complications. One hundred three individuals (53 males and 50 females) were selected randomly, and magnetic resonance imaging-based morphometric analysis was performed. We located the landmark and measured the parameters related to the transsylvian transinsular approach. The parameters and figures in the sagittal, coronal, and axial planes were used to illustrate the anatomical relationship between the insular lobe and its adjacent structures. The length of the superior limiting sulcus (line A) was 52.05 ± 3.30 mm in the left and 51.56 ± 2.90 mm in the right. The length of the inferior limiting sulcus (line B) was 48.18 ± 3.01 mm in the left and 48.40 ± 3.34 mm in the right. The length of the anterior limiting sulcus (line C) was 22.64 ± 1.47 mm in the left and 22.50 ± 1.57 mm in the right. The length of the central insular sulcus (line D) was 31.36 ± 2.68 mm in the left and 31.52 ± 2.53 mm in the right. The distance from insular apex to brain surface through sylvian fissure (line E) was 19.26 ± 2.21 mm in the left and 19.36 ± 2.26 in the right. The distance from inferior limiting sulcus to the roof of temporal horn (line J) was 9.75 ± 1.38 mm in the left and 9.66 ± 1.18 mm in the right. The angle (θ), which was formed by line J and the vertical line via the inferior limiting sulcus (line I), was 30.51 ± 3.60 degrees in the left and 30.56 ± 3.11 degrees in the right. The distance from insular apex to the lateral side of putamen (line L) was 10.10 ± 1.59 mm in the left and 10.62 ± 1.39 mm in the right. The distance from insular apex to the middle of genu capsulae internae (line K) was 25.73 ± 1.02 mm in the left and 26.50 ± 1.15 mm in the right. Independent-samples t test showed no significant difference of the means between the right side and the left side. The statistics in our study can help to understand the complicated anatomical structures of insula and its surrounding area. Moreover, the parameters can increase the feasibility and safety of the surgery via transsylvian transinsular approach.

高血压基底节区中少量出血早期手术治疗

Objective: To evaluate the efficacy of operative approach via lateral fissure in hypertensive basal ganglia hemorrhage with bleeding volume 20～30ml during early period. Methods: A total of 33 patients with hypertensive basal ganglia hemorrhage underwent microsurgical treatment transsylvian-transinsular approach within 24 hours after stroke. All the patients had definite neurological dysfunction and the blooding volume 20～30ml. The remained hematoma volume after 24 hours, the efficacy after 2 weeks, and activity of Daily Living after 6 months were measured to be compared between the two groups. Results: 24 hours after operation, hematoma was evacuated more than 90% in 27 cases, 70% in 3 cases. 2 weeks after surgical operation, 26 cases got remarkably effect and 5 cases turned better. Follow-up assessment according to the Activity of Daily Living (ADL) for 6 months revealed a good recovery of grade I in 8 cases, grade II in 17,grade III in 5, grade IV in 1. Conclusion: Microsurgical treatment transsylvian-transinsular approach has a significant therapeutic effect on hypertensive basal ganglia hemorrhage of 20～30ml hematoma cases with definite neurological dysfunction.

Distal Transsylvian-Traninsular Approach for the Putaminal Hypertensive Hemorrhages

Up to now, no systemic studies about the surgical approaches and microsurgical techniques of distal transsylvian-transinsular approach to putaminal hypertensive intracranial hemorrhages (PHHs) were reported. A retrospective analysis was performed on 68 consecutive patients with PHH who underwent surgical treatment at the Department of the affiliated Bayi Brain Hospital, the Military General Hospital of Beijing PLA, from May 2009 to December 2011. By using transsylvian-transinsular approach, near-complete (>90%) evacuation was achieved in 51 cases (75%). Glasgow Coma Scale scores were significantly improved at discharge compared with admission scores (P < 0.001). The overall survival rate at 6 months was 95.6% (65/68), including 60.3% (41/68) with good function (Glasgow Outcome Scale [GOS] score, 4-5), 19.1% (13/68) with disability (GOS score, 3), and 16.2% (11/68) in a vegetative state (GOS score, 2). The mortality rate (GOS score, 1) was 4.4% (3/68). Transsylvian-transinsular approach is effective and minimally invasive for PHH. The opening of sylvian fissure toward the pars opercularis behind the level of anterior ascending rami could provide a more suitable angle to hematoma and the ability to treat the responsible vessels.

Transsylvian-Transinsular Approach for the Removal of Basal Ganglia Hemorrhage Under a Modified Intracerebral Hemorrhage Score

Spontaneous intracerebral hemorrhages account for 20% of all strokes. The Modified Intracerebral Hemorrhage (MICH) score provides a simple, reliable system for decision making regarding surgical treatment. The transsylvian-transinsular approach had previously been neglected because of the dependence on great surgical experience. We believe this approach not only compares favorably with the minimally invasive surgery concept but also preserves most of the cerebral functional cortex with a maximum hematoma evacuation rate. From May 2007 to September 2008, a single surgeon treated 32 patients with basal ganglia hemorrhage using the transsylvian-transinsular approach. Of these, 20 had MICH scores of 2 to 3; 5 had MICH scores of 4; and 7 had MICH scores of 5. After 24 postoperative hours, we evaluated the hematoma evacuation rate by a computed tomography scan. The functional recovery was evaluated by the Barthel Index at 1, 3, and 6 months postoperatively. All data were analyzed according to MICH score. The hematoma evacuation rates were in the following order: MICH scores 2 to 3 (97%) > MICH score 4 (92%) > MICH score 5 (90%). Surgery-related mortality was MICH2, 3 (0%) < MICH4 (20%) < MICH5 (43%). The Barthel Index of the MICH2, 3 patients (n = 18) improved from 16.9 at 1 postoperative month to 41.94 at 6 postoperative months. The transsylvian-transinsular approach for the removal of an ICH was not difficult, and it was found to be a safe method for treating a spontaneous basal ganglion ICH. In addition, this approach conformed with the spirit of minimally invasive surgery.

Comparison between transsylvian-transinsular and transcortical-transtemporal approach for evacuation of intracerebral hematoma

Hypertensive cerebral hemorrhage in the basal ganglia is a potentially life-threatening cerebrovascular disease with high mortality. Surgical evacuation is an important treatment for intracerebral hemorrhage. However, little is reported about the comparison on the efficacy of various approaches on the prognosis. Clinical data of 80 cases of intracerebral hemorrhage which surgically treated via transsylvian-transinsular approach or transcortical-transtemporal approach were collected. The proportion of post-surgery tracheostomy, incidence of digestive tract hemorrhage, revision surgery, the average length of hospital stay, and the six-month efficacy (defined by an ADL score) rate between these two groups were compared. The six-month efficacy rates were 75% and 50% in patients receiving transsylvian-transinsular and transcortical-transtemporal surgery, respectively (p<0.05). Compared to the transcortical-transtemporal group, the proportion of revision surgery was statistically significantly lower in the transsylvian-transinsular group, (p<0.05). The proportion of post-surgery tracheostomy, the incidence of digestive tract hemorrhage, and the average length of hospital stay were lower in the transsylvian-transinsular group, compared to the transcortical-transtemporal group, but no statistically significant differences were noted in them between the two groups. The transsylvian-transinsular approach for evacuation of intracerebral hematoma demonstrates limited complications, shorter length of hospital stay, and improved long-term efficacy and prognosis. These findings suggest this operative approach has potential for wider application.