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Anterior callosal section is useful for the removal of large tumors invading the dorsal part of the anterior third ventricle: operative technique and results

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Abstract

Large tumors invading the dorsal part of the anterior third ventricle are difficult to manage. The anterior transcallosal approach is usually used to manage these tumors. In our clinic, anterior callosal section was combined with the anterior interhemispheric (AIH) translamina terminalis approach for these tumors with excellent results. The AIH approach is useful for removing tumors in and around the anterior part of the third ventricle. However, AIH alone is insufficient for large tumors invading the dorsal part of the anterior third ventricle. In such situations, simple anterior callosal section enables the neurosurgeon to extirpate the caudal part of the tumors deeply hidden from operative field, sparing the foramen of Monro, fornix, etc. We treated four large tumors (malignant teratoma, recurrent chordoid glioma, recurrent papillary tumor of pineal region occupying the third ventricle, and paraventricular meningioma) without major complications. The malignant teratoma case exhibited no recurrence with >10 years follow-up. The chordoid glioma and papillary tumor of pineal region were totally removed. The meningioma was subtotally removed except only a small tumor around the bilateral anterior cerebral artery. This simple technique is a new way to manage difficult large lesions in and around the third ventricle.

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Authors and Affiliations

  1. Department of Neurosurgery, Moriyama Memorial Hospital, 7-12-7 Nishikasai, Edogawa-ku, Tokyo, 134-8608, Japan

    Hideki Shiramizu, Tomokatsu Hori, Seigo Matsuo, Kaku Niimura, Haruko Yoshimoto, Atsushi Ishida, Keizoh Asakuno, Miki Yuzawa & Takashi Moriyama

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  1. Hideki Shiramizu
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  2. Tomokatsu Hori
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  3. Seigo Matsuo
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  4. Kaku Niimura
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  5. Haruko Yoshimoto
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  6. Atsushi Ishida
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  7. Keizoh Asakuno
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  8. Miki Yuzawa
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  9. Takashi Moriyama
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Correspondence to Hideki Shiramizu.

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Comments

William T. Couldwell, Salt Lake City, USA

The authors report on four patients with large tumors invading the dorsal part of the anterior third ventricle, for which an anterior callosal section, combined with the anterior interhemispheric translamina terminalis approach was used with excellent results. This reviewer found this to be an interesting report. While the authors have tried to avoid entering the frontal sinus, one might question whether the anterior callosal section would be necessary in some of these cases if a more basal approach was chosen and the lamina terminalis approach was used. A basal approach would allow greater superior visualization in the third ventricle. Olfaction does not need to be sacrificed if the surgeon stays parasagittal on one side, which avoids dissection and risk of injury to the contralateral olfactory tract.

Many surgeons would choose a more posterior traditional transcallosal approach coming from the region of the coronal suture in case 3. This would avoid having to work around the anterior commissure and to perform an anterior interforniceal approach. The traditional approach could be used with a translateral ventricular–transchoroidal approach to the third ventricle without having to dissect between the fornices.

I appreciate the authors demonstrating their nuances of this approach; it will add to the surgical armamentarium of approaches to this important area.

Chang Jin Kim, Seoul, Korea

Surgical approaches into the third ventricle are to be appreciated greatly with the functional as well as anatomical complexities of this region. Exact location and dimension of the pathology are primary determinants in selecting the optimal approach. In this technical note, the authors combined the anterior interhemispheric approach with anterior callosal section for addressing tumors located deep dorsal in the third ventricle and demonstrated its feasibility and safety. If one would select a different way in some individual cases (e.g., more basal interhemispheric approach without combining callosal section for tumors with anterior and dorsal location, or traditional transcallosal or transchoroidal approach for those with caudal location), the technique presented here is pretty notable and appreciated.

Basant Misra, Mumbai, India

The authors present their experience with four cases of diencephalic/peridiencephalic lesions operated by them through a combined anterior interhemispheric and anterior transcallosal approach. A combined basal approach along with transcallosal approach either in one sitting or sequence is well described.1 The authors’ main contention is AIH approach along with anterior callosotomy through the genu has not been described before. This is a nice modification. The callosal section is planned depending on the location of the lesion.

In some of the cases described by the authors, the case could have been operated by a single approach. For e.g., case 3 could have been done through a transcallosal approach from a more posterior trajectory. Coming from a posterior trajectory, one could also remove the inferior and anterior extension of the lesion. Case 2 could have been done through a frontal parasagittal interhemorrhagic approach without opening the frontal sinus. Of course, the proposal by the authors may be a useful approach in select circumstances. However, we have serious reservation in employing interforniceal approach. Having been very enthusiastic about interforniceal entry to the third ventricle2 in our early experience, we do not utilize the interforniceal approach today, unless and until the tumor has separated and presenting between the fornices. It may not be a good idea to do an interforniceal approach as one has to handle both fornices with a real risk of memory impairment. The third ventricle is better approached through a transchoroidal/suprachoroidal or transforaminal approach to reduce the risk of memory disturbances. 3, 4

References

1. Yasargil MG, Teddy PJ, Roth P (1987) Combined approaches. In: Michael LJ Apuzzo (eds) Surgery of the third ventricle. Williams & Wilkins, Baltimore, pp. 462–475

2. Misra BK, Rout D, Padmanabha J, Radhakrishna VV (1993) Transcallosal approach in third ventricular lesion: a review of 62 cases. Ann Acad of Medicine Singapore 22:3(supp); 435–440

3. Misra BK (2000) Surgery of the third ventricle: technical consideration. Neurosurgery 47: 519–520

4. Misra BK (2000) Surgery of the third ventricle: technical consideration. Progress in Clinical Neurosciences 15:127–33

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Shiramizu, H., Hori, T., Matsuo, S. et al. Anterior callosal section is useful for the removal of large tumors invading the dorsal part of the anterior third ventricle: operative technique and results. Neurosurg Rev 36, 467–475 (2013). https://doi.org/10.1007/s10143-013-0455-0

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