Microsurgery of the Brain: Anatomical and Technical Principles PDF
Preview Microsurgery of the Brain: Anatomical and Technical Principles
Wolfgang Seeger B r a i n Anatomical and Technicc.1 Principles 1 Springer-Verlag Wien GmbH Prof. Dr. med. WOLFGANG SEEGER Medical Director of the Department of General Neurosurgery and Chairman of Neurosurgery of the Neurosurgical Clinic, University of Freiburg i. Br., Federal Republic of Germany With 351 Figures This work is subject to copyright AH rights are reserved, whether the whole or part of the material is concerned, specifically those of translation, reprinting, re-use of illustrations, broadcasting, reproduction by photocopying machine or similar means, and storage in data banks © 1980 by Springer-Verlag Wien OriginaHy published by Springer-Verlag Wien New York 1980 Softcover reprint of the hardcover 1s t edition 1980 Design: Hans Joachim Boning, Wien Library of Congress Cataloging in Publication Data. Seeger, Wolfgang, 1929 -. Microsurgery of the brain. 1. Brain-Surgery. 2. Micro surgery. 1. Title. [DNLM: 1. Brain-Surgery. 2. Brain-Anatomy and histology. 3. Microsurgery. WL 368 S 451 m] RD 594. S 43. 617'.481059.80-24812 ISBN 978-3-7091-3096-4 ISBN 978-3-7091-3094-0 (eBook) DOI 10.1007/978-3-7091-3094-0 ____________________________________________________ PREFACEI~ ~IV Preface This book is a sequel to my "Atlas of Topographi sor A. L. Rhoton, Professor K. Sugita and particu cal Anatomy of the Brain and Surrounding Struc larly Professor M. G. Ya§argil (with operation dem tures". Like the first volume it is addressed mainly onstrations in Ziirich), as well as recent descrip to neurosurgeons, neurologists and neuro tions of operations, provided important stimuli. The pathologists. Although the two books deal with dif conversations held with my colleagues were also ferent aspects of the subject, that is, the first with important for the production of this Atlas. I am par anatomical relationships and the present work with ticularly grateful to Dr. J. Gilsbach, Dr. H.-R. Eg neurosurgical techniques, this book will also be of gert and Dr. E. Grobner for valuable suggestions. interest not only to the neurosurgeons but to work Special thanks are also due to Doz. Dr. Ch. Oster ers in allied fields as well. The book has been tag for his help with the evaluation of the computer designed to give the neuroradiologist and tomograms. Professor F. Mundinger provided com neuropathologist a closer insight into the mor puter tomograms from his Department (Stereotaxy phological problems facing the neurosurgeon work and Nuclear Medicine). Thanks to my collaboration ing under high magnification, and to assist them in with Dr. H.-H. Riemschneider, Specialist for making an accurate diagnosis and in determining Radiology, Karlsruhe, from whom I obtained several the postoperative and postmortem findings. In order computer tomograms. Particular thanks are due to to meet the requirements of the various specialist Professor W. Sandritter, Director of the Pathological groups for whom this book is intended, departures Institute, University of Freiburg; Professor have been made' from the style of traditional surgi P. Kleihues, Director of the Department of Neuro cal textbooks, both in the technique of presentation pathology, University of Freiburg; and Professor and in the method of classification of relevant ma J. Staubesand, Director of the Anatomical Institute I, terial. These changes will be more fully explained in University of Freiburg, for making available the the introduction. brain preparations. The translation of the text was The present work is based on 10 years' experience undertaken by my colleague, Dr. E. Grobner, and in microsurgery. Particularly in the latter half of Mrs. S. J. Brinkmann, Dusseldorf. I am grateful to that period my colleagues and I carried out all ma Mrs. E. Hilsenbeck-Hottek for typing the jor operations on the brain with the help of mi manuscript. crosurgical techniques. Personal discussions with Pro fessor C. G. Drake, Professor A. Raimondi, Profes- Freiburg, September 1980 Wolfgang Seeger CONTENTS L.I ________________________- ---ll VII Contents Vol. 1: pp. 1 to 460 - Vol. 2: pp. 461 to 727 Introduction IX Part I Microsurgery of the Brain - General Aspects Chapter 1 Basic Principles Instrumentarium (Figs. 1 to 6) 2 Basic Principles of Operative Procedure a) For Tumors (Figs. 7 to 20) 14 b) For Vascular Malformations and Richly Vascularized Processes (Figs. 21 to 22) 42 Appendix (Diagnostic Procedures) (Figs. 23 to 26) 46 Part II Special Microsurgical Operative Procedures in the Brain Chapter 2 Supratentorial Extracerebral Operations Anatomical Details at Frontotemporal Operations (Figs. 27 to 36) 56 Pterional Approach: Anatomical Details and Operative Technique (Figs. 37 to 84) 76 Basal Approaches to Cisterna ambiens up to Lateral Quadrigeminal Region (Figs. 85 to 111) 172 Operations in Longitudinal Fissure (Figs. 112 to 141) 226 Chapter 3 Supratentorial Operations in Ventricular System Operations in Third Ventricle (Figs. 142 to 169) 286 Operations in Lateral Ventricle (Figs. 170 to 180) 342 Chapter 4 Supratentorial Intracerebral Operations Frontal to Parietal Operations (Figs. 181 to 192) 364 Occipital to Parietal Operations (Figs. 193 to 202) 388 Temporal Operations (Figs. 203 to 224) 408 References (Chapters 1 to 4) 453 VIII L..I _________________________- --'1 CONTENTS Chapter 5 Infratentorial Extracerebral Operations Anatomical Details of Cerebellum and Lower Brain Stem (Figs. 225 to 233) 462 Operations in Cerebellopontine Angle and Lobulus quadrangularis Region a) Details of Operative Approach Along Sinus transversus and sigmoideus (Figs. 234 to 254) 48(). b) Cerebellopontine Angle (Example Acoustic Nerve Neurinoma) (Figs. 255 to 274) 522 Operations in Quadrigeminal Region with Suboccipital Approach (see also Chapter 2) (Figs. 275 to 289) 562 Chapter 6 Operations in the Fourth Ventricle Medial Operations in Fourth Ventricle (Figs. 290 to 318) 592 Lateral Operations in Fourth Ventricle (Figs. 319 to 333) 650 Chapter 7 Intracerebellar Operations Medial Intracerebellar Operations (Figs. 334 to 340) 680 Lateral Intracerebellar Operations (Figs. 341 to 351) 694 References (Chapters 5 to 7) 717 Subject Index 725 Introduction 1) Microsurgery is a technique that can be used classification, in contrast to the method used in with very few exceptions for almost all neurosurgi older works in which the processes involved were cal operations. The reluctance of some neurosur classified according to changing criteria. There are geons to abandon conventional methods and adopt two arguments supporting the use of brain localiza microsurgical techniques may be due to the techni tion alone, to the exclusion of additional criteria cal and topical difficulties involved. In this book such as tumor type and biological categorization. these problems will be analyzed in two stages. - In the case of tumorous disorders it is inapprop In the first stage the instruments used and the gen riate to use tumor type and biological category as eral principles of the operative technique will be de additional criteria for purposes of classification: scribed. On the one hand, tumors of the same type and In the second stage several specialized operations biological category (e. g. meningioma) may differ as will be systematically recorded. Here it was found regards consistency, type of border, vascularization necessary to depart from the methods used in tradi and their tendency to develop in only one or in sev tional textbooks in relation to a) presentation and eral cisterns. On the other hand, the converse is b) classification. also true: different types of tumour (e. g. menin a) The differences in presentation refer to four gioma and craniopharyngioma) may resemble one main points: another in consistency, type of border, vasculariza - Operative techniques are presented in more de tion and the tendency to develop in only one or in tail than is usual in traditional textbooks; this ap several cisterns. It is evident from these two consid plies both to illustrations of the operation site and erations that very different operative techniques to schematic presentations. may be necessary for one and the same kind of - The presentations of the operation site are pre tumor, whereas it may be possible to treat different ceded by anatomical overviews, details of which are types of tumor with the same operative technique. progressively enlarged until the dimensions of the It is therefore obviously inappropriate in a textbook operation site are reached. on operative surgery to use the type or biological - In order to elucidate the complicated anatomical category of tumorous processes as preeminent structures it was found necessary in many cases to criterion. present the anatomical overview or the individual - In the case of nontumorous disorders (e. g. enlarged details from various viewing angles, even aneurysm and angioma) the use of the traditional though the final view of the operation site is seen classification criteria for tumors (type and biological from only one of these angles. category) is not possible. These processes, however, - It is impossible to reproduce the full complexity can be systematically classified if, as in this book, of these structures by means of textual explanations localization is used as the preeminent criterion. The or in graphic presentations executed by non choice of a principle of classification which can be neurosurgeons. It was therefore decided to confine used both for tumors and for nontumorous proces the textual explanations to detailed legends, and to ses is also expedient, since the operative approach use the author's own ink drawings made postopera tively with the help of anatomical preparations *. used for both types of disorder may in principle be the same. b) The difference in classification consists in the use 2) The empirical material on which this work is throughout of brain localization as the criterion for based originates from the Neurochirurgische Uni versiHitsklinik Freiburg/Br. Special consideration • Since we have had no operative experience yet with certain rarely has been given to those problematic cases in which performed operations, e. g. for aneurysm of A. basilaris, we could not the operator is compelled to press forward toward include graphic presentations of these. ______________________________________________ INTRODUCTION X~I ~I the limits of operative possibilities. Unless otherwise erations (e. g. acoustic nerve neurinoma), in which stated the operations were carried out by the au morphology and operative technique vary very little. thor. Operations described without reference to a The total clinical population and the early mortality particular clinical case represent typical routine op- rate are shown in Table 1. Table 1. Statistical Data of Intensive Care Unit Since the Introduction of Microsurgery in Freiburg (1 June 1975 to 1 January 1979) Diagnosis Number Mortality Extracerebral processes: Aneurysms (since 1976177 all eliminated by clipping) 61 0 A VM (all radically operated at a first or second operation) 32 0 Prepontine tumors (not all radically operated) 77 3 Meningiomas 116 6 Intraventricular tumors (majority radically operated) 12 4 Operations on hypophysis: Hardy 89 1 Pterional 28 1 Tumors of cerebellopontine angle (almost exclusively acoustic nerve neurinomas, since 1976 all radically operated, including numerous recidivations) 61 6 CSF rhinorrhoea 51 0 Intracerebral processes: Supratentorial intracerebral tumors 230 9 Brain abscesses 13 1 other intracerebral processes 91 7 Other microsurgical operations: Transoral extirpation of dens epistrophei 9 o Spinal processes 135 1 1005 39 Other processes operated without microscope or not operated cases, e. g. atrioventricular shunt, diagnostic cases, meningitis, encephalitis, vascular diseases, referals from Department of Stereotaxy with Neuronuclear Medicine 211 16 Total patients, Intensive Care Unit 1216 55 = total mortality of Clinic INTRODUCTION ---11 XI L..!_ ----::--____________________ Operations without intensive care, e. g. microsurgical intervertebral disc operations, peripheral nerve operations, most atrioventricular shunt operation"s, etc., are not categorized: 2271 Total number of all operations: 3487 Mortality: see statistical data of Intensive Care Unit.
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