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Three-dimensional microsurgical anatomy of cerebellar peduncles

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Abstract

The microsurgical anatomy of cerebellar peduncles and their relationships with neighbouring fasciculi were investigated by using a fibre dissection technique. As the dissection progressed, photographs of each progressive layer were obtained and stereoscopic images were created using the 3D anaglyphic method. These findings provided the anatomical basis for a conceptual division of cerebellar peduncles into segments. The middle cerebellar peduncle (MCP) was divided into two segments: cisternal and intracerebellar segments. The inferior cerebellar peduncle (ICP) was divided into three segments: cisternal, ventricular and intracerebellar segments. The superior cerebellar peduncle (SCP) was divided into three segments: intracerebellar, intermediate and intrategmental segments. The fibre dissection technique disclosed a constant course of peduncular fibres inside the white core of the cerebellum. The pontocerebellar fibres of the MCP pass over and laterally to the bundles of the ICP and SCP. The centripetal fibres of the ICP wrap around the radiation of the SCP and the dentate nucleus, directed towards the cortex of the vermis. The centrifugal bundle of the SCP ascends towards the mesencephalon where it sinks passing below the fibres the lateral lemniscus. The knowledge gained by studying the intrinsic anatomy of the cerebellum is useful to accomplish appropriate surgical planning and, ultimately, to understand the repercussions of surgical procedures on the white matter tracts in this region.

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Acknowledgments

We thank Nicola Benedetto Ph.D., M.D., for the illustrations of cerebellar peduncles.

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Authors and Affiliations

  1. Department of Neurosurgery, Azienda Ospedaliero Universitaria Pisana (AOUP), Via Paradisa 2, 56100, Pisa, Italy

    Paolo Perrini, Giacomo Tiezzi & Riccardo Vannozzi

  2. Department of Human Pathology, University of Pisa, Pisa, Italy

    Maura Castagna

Authors
  1. Paolo Perrini
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  2. Giacomo Tiezzi
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  3. Maura Castagna
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  4. Riccardo Vannozzi
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Corresponding author

Correspondence to Paolo Perrini.

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Comments

Antonio Bernardo, New York, USA

The authors have performed a detailed, richly illustrated anatomical study of the cerebellar peduncles. The elegant 3D photography helps to understand the intricate anatomy of the region. Mastering the complex anatomy of the cerebellar peduncles and their relationship with adjacent structures and overlying cerebellar lobules is required in order to attempt the exposure of the fourth ventricle. Several studies have already investigated the structure and functions of the cerebellum and its connections, providing beautiful 2D photography. A significant problem with this method is the inherent conceptual limitation of conveying or teaching 3D relationships via 2D images. The ability to visualize and understand anatomical spatial relationships is crucial in surgical planning, and the use of stereoscopic projection is invaluable for this purpose. The elegant 3D representation provided by the authors helps to improve surgeons’ conceptual grasp of the complex anatomy of the region.

Guilherme Carvalhal Ribas, São Paulo, Brazil

Despite having been based only in five specimens and being more descriptive than analytical (in the sense that it does not evaluate/describe anatomical variations and/or measure structures) as most of the surgical anatomy articles, and in spite of the density of the topic itself (complex cerebellar and brainstem nuclei and tracts), the article definitely describes very well the surgical anatomy pertinent to these structures, and the 3D illustrations, as usually, enhance very much its comprehension.

The didactic division of the cerebellar peduncles into topographic segments here proposed is very appropriate for posterior fossa microneurosurgery, and the text is very well subdivided. Regarding their naming, maybe the intermediate segment of the superior cerebellar peduncle (SCP) could be designated as SCP intraventricular segment, as adopted for the equivalent segment of the inferior cerebellar peduncle, which, in our understanding, is a more “surgical” term that would enhance its comprehension.

Also regarding denominations, now related to the current utilization of different types of stereoscopic images, maybe the expression “three-dimensional (3D) relationships” could be changed to “spatial relationships” or to “tridimensional relationships”, leaving the expression “three-dimensional (3D)” only to designate generically stereoscopic images. Congratulations for your excellent article.

João Paulo C. de Almeida and Evandro de Oliveira, São Paulo, Brazil

We would like to congratulate Perrini et al. for the excellent description of the anatomical nuances of the cerebellar peduncles. The authors present in a detailed fashion the microsurgical anatomy of the cerebellar peduncles and their white fibres using the Klinger’s method of white dissection with the support of the operating microscope. The high-quality 3D images presented adequately demonstrate such complex anatomy, facilitating the comprehension of the manuscript.

As an original contribution, the authors describe the complex anatomy of the intracerebellar segments of the peduncles considering the pathway of the fibres (superior, middle or inferior peduncle) and propose a detailed classification of the segments of the peduncles. According to such classification, the superior cerebellar peduncle is divided in three segments: intracerebellar, intermediate and intrategmental; the middle cerebellar peduncle in two segments: cisternal and intracerebellar; and the inferior cerebellar peduncle in three segments: cisternal, ventricular and intracerebellar. Such classification, as the authors comment, may help in the decision of the surgical approach for cavernomas and arteriovenous malformations affecting the peduncles. It is important to remember, however, that the surgical route for brainstem cavernomas must remain the area wherein the lesion abuts the pial or ependymal surface.

The authors have added a significative contribution to the literature regarding the microsurgical anatomy of the brainstem and cerebellar peduncles. For the neurosurgeons interested in vascular malformations and brainstem surgery, it represents an interesting guide for the surgical planning of such complex procedures.

Toshio Matsushima, Saga, Japan

My congratulations to Dr. Paolo Perrini and the authors for this paper which shows well-done anatomical study of the cerebellar peduncles by using a fibre dissection technique. Each peduncle is explained being divided into a few segments.

When I studied the anatomy of the fourth ventricle and developed transcerebellomedurally fissure approach, we did not think of incising the brainstem at all (1, 2, 3, 4). After development of MRI, however, many cases of cavernoma have been found as a cause of pontine hemorrhage, and now neurosurgeons try to attack an intrinsic lesion in the brainstem. This study will be useful in incising the brainstem.

If I were to venture an opinion, I would say that the authors should have shown by an illustration which portion of the brainstem should have been incised and which direction of an incision should be selected in order to minimize the postoperative neurological deficits, though I understand that this study had limitation. Recently cavernoma in the pons is removed not only through the floor of the fourth ventricle but also through the lateral wall of the pons including the middle cerebellar peduncle (5). It is because the injury of the middle cerebellar peduncle develops lower morbidity than that of the floor of the fourth ventricle. In conclusion again my congratulations to Dr. Perrini for this well-done paper.

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Helmut Bertalanffy, Hannover, Germany

The authors are to be commended for this detailed anatomical description of the cerebellar peduncles using the white matter dissection technique. A detailed anatomical knowledge is always an important prerequisite for safe surgery in this area, and this nicely illustrated article contributes to our understanding of the complex anatomy of the cerebellum and the three cerebellar peduncles. However, concentrating with anatomical studies solely upon the neural tissue after having removed the arachnoid membrane and vascular structures does not completely reflect the clinical situation at surgery. My experience with primarily intrinsic brainstem lesions comprises over 250 surgical cases treated for cavernous malformations and gliomas. Only a part of these lesions were readily visible on the surface of the brainstem and thus directly accessible. In a great number of cases, the surface of the brainstem showed at exposure either an apparently normal aspect or perhaps a bulging or discoloration in case of an intraaxial hemorrhage. In all these cases, I had to penetrate the pial surface at some point and enter into the brainstem to reach the underlying pathological lesion. I am convinced that choosing the optimal location for this entry point was of crucial importance for the surgical result. In my experience, the selection of the entry point into the brainstem was not only dictated by the location of the intrinsic fibre system and nuclei but also by the (quite variable) vascular anatomy on the surface of the brainstem. Particularly the area of the cerebellomesencephalic fissure contains an abundant vascular network. I was very careful in preserving perforating arteries supplying the brainstem and superficial draining veins as much as possible, which also influenced my choice of the optimal entry point into the brainstem.

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Perrini, P., Tiezzi, G., Castagna, M. et al. Three-dimensional microsurgical anatomy of cerebellar peduncles. Neurosurg Rev 36, 215–225 (2013). https://doi.org/10.1007/s10143-012-0417-y

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