Surgery in and around the Brain Stem and the Third ventricle Anatomy· Pathology· Neurophysiology Diagnosis· Treatment Edited by M. Samii With 370 Figures Springer-Verlag Berlin Heidelberg New York London Paris Tokyo Dr. med. M. Samii Professor and Chairman Neurosurgical Clinic City of Hanover Nordstadt Hospital HaltenhoffstraBe 4 I 3000 Hannover I, FRG ISBN -l3: 978-3-642-71242-5 e-ISBN -l3: 978-3-642-71240-1 DOl: 10.1007/978-3-642-71240-1 Library of Congress Cataloging in Publication Data. Surgery in and around the brain stem and the third ventricle. Includes bibliographies and index. I. Brain stem-Surgery. 2. Cerebral ventricles-Sur· gery. 3. Brain stem-Tumors-Surgery. 4. Cerebral ventricles-Tumors-Surgery. I. Samii, Madjid. [DNLM: I. Brain Neoplasms-surgery. 2. Brain Stem-surgery. 3. Cerebral Ventricles-surgery. WL 310 S961] RD594.S9 1986 617'.481 86-15583 ISBN-13:978-3-642-71242-5 (U.S.) This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, specifically those of translation, reprinting, re-use of illustrations, broadcasting, reproducing by photocopying machine or similar means, and storage in data banks. Under § 54 of the German Copyright Law, where copies are made for other than private use, a fee is payable to "Verwertungsgesellschaft Wort", Munich. © Springer· Verlag Berlin Heidelberg 1986 Softcover reprint of the hardcover 1st edition 1986 The use of registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. Product liability: The publisher can give no guarantee for information about drug dosage and applica tion thereof contained in this book. In every individual case the respective user must check its ac curacy by consulting other pharmaceutical literature. 2122/3130-543210 Foreword It is, of course, a real challenge to summon together an International Sym posium in and around the Brain Stem and Third Ventricle. Up to this mo ment the various experiences and papers on this subject were distributed throughout the world literature, making it very difficult for someone in terested in the matter to have access to the actual state of knowledge. Therefore I believe such a meeting was long overdue and is a considerable attempt to open closed doors for present and future ambitious neurosurgi cal activities. After succeeding in previous symposiums of similar interest in Hanno ver, it was obvious that Prof. Madjid Samii and his coworkers took the in itiative of organizing such a meeting, bringing together - in the pure sense of the word - Neurosurgeons with Anatomists, Neurologists, Neuro physiologists, Neuroradiologists, ENT-, Maxillofacial-, Stereotactic-, and Radiosurgeons as well as other colleagues. One contribution after the other followed, from the basic sciences up to the operative management con sidering very new and actual concepts. Through the application of new microsurgical techniques and the incorporation of new understanding for the many problems afflicting the midline of the eNS, and based on a growing closer cooperation between the various disciplines, a wide field has opened up which concerns us all. There were a number of facets covered by the Symposium: the recog nition of the importance of microanatomy, arterial supply and venous drainage, contributions to understanding normal and abnormal functions, new techniques, useful in preserving anatomical and functional integrity, and an outline of new routes and new standards of quality for surgical management. To pick up some facts of common interest it has been shown by anat omists that the brain stem is surrounded by arterial vessels like a circle, fed by larger vessels from the base, from Willis' circle. The veins do not follow the arteries and vice versa, not running hand in hand. The arteries provide landmarks outside the brain and the veins provide clear anatomical land marks within the ventricles. These are important aspects for approaching the brain stem and ventricles for the neurosurgeon. The studies on Evoked Potentials of the brain stem are indeed prelimi nary, but very interesting and encouraging for follow up of function. It is the desire of all to find out which signal would indicate reversible defects and which one permanent defects. VI Foreword Concerning the neuroradiological achievements no method can fully replace the other. Each method has its own indication, and the neurosur geon has to decide in every case what he needs to know. In general one can say that the Magnetic Resonance Imaging (MRI) information is superior in soft tissue lesions (intramedullary gliomas, hydromyelia etc.) to CAT-scan neuroimages. However, in osseous lesions of the skull base the high resolu tion cranial CT shows its superiority in comparison to the MRI informa tion. But also the native X-ray examination retains its lasting value today. With regard to the angiographic examinations it is to stress that the study of the venous system is as important as the examination of the ar terial system in lesions of the brain stem and the third ventricle, par ticularly in connection with A VMs as well as space-occupying lesions. We learned that the neuroradiologist is a useful partner for the neurosurgeon and other colleagues. Especially with the selective and supraselective em bolization technique he can help us treat AV Ms as well as highly vas cularized tumors at the skull base (meningiomas, chemodectomas, etc.). The surgical management of AV Ms of the brain stem presents specific difficulties. The size of the AV M is just one factor, location is another. There are great difficulties in approaching deep-seated angiomas, but if one maintains oneself in the sulci and anatomically bounded structures us· ing stereoscopic magnification, then one does not need more space and minimizes additional damage. This concept should be followed in the fu ture. Furthermore, we heard that indications for Prof. lannetta's vascular decompression operations have enlarged and proved their effectiveness. They will have their place in the future. On the other hand, a new discus sion about the bypass-revascularisation procedures for vertebro-basilar ischemia in respect to the Toronto Bypass Study has originated. Bypass operations seem, under certain circumstances, not to be as effective as one assumed them to be. In any case this chapter has not yet been closed to controversy. New concepts on strategies for approaching clival and petroclival tu mors as well as for the total removal oflarge chemodectomas of the jugular foramen were contributed by the Mainz group of neurosurgeons and oto rhinolaryngologists. By subtotal removal of the pyramid with isolation and displacement of the facial nerve, they facilitated and widened the ap proach to these deep-seated tumors diminishing brain retraction with a subsequent decrease of the operative risk. From a surgical standpoint one can presumably underline once more, what the signer is expressing since years: the shortest and safest route to the lesion is usually the best one. In general and above all this, the Symposium showed that processes in certain deep-seated regions, such as the pineal area, skull base and other deep regions, can be tackled by various surgical approaches as well as by other therapeutical modalities. This is demonstrated by contributions made by stereotaxy, radiosurgery, interstitial radiotherapy and chemo therapy which all have their particular indications. This marvellous Symposium was an extraordinary event for all par ticipants. It offered an intensive coverage by a distinguished faculty who Foreword VII has contributed to our understanding of new information in a very in teresting but not easy to handle field of surgery in and around the brain stem and the third ventricle. Such a survey has not been available till now. However, with modesty and humility, it must be said that only the tip of the iceberg has been discovered and a long road is yet before us. This Sym posium will have served its purpose if we follow the marked way. Once more, we must thank the initiator, Prof. Madjid Samii, for his idea and for the excellent organization ofthis meeting. Also our gratitude to the authors for their contributions and Springer Verlag for their cooperation and efforts enabling this volume to reach you all modern day pioneers! Mainz KURT SCHURMANN Preface After the pioneer work by such neurosurgeons as Foerster, Krause, Hors ley, Cushing, Dandy, Olivecrona, T6nnis, KrayenbUhl, and others, the sur gery on cerebrum and cerebellum experimented a transformation, estab lishing neurosurgical techniques as standard surgical procedures as well as obtaining favorable results. Whilst this was so, before the era of microsurgical operations, the sur gery in and around the brain stem and third ventricle remained plagued with a high percentage of mortality and morbidity and therefore the indi cation for surgical treatment of pathological entities of this area, was cau tiously made and remained very limited. With the introduction of the surgical microscope in the late 1960's the key was found for the beginning of a new era for surgical activities, at first around but now even in deep-seated brain structures. My personal experience in this field started in 1967, supported by my honored teacher, Prof. K. Schurmann, in the Neurosurgical Department of the University of Mainz. With the growing knowledge of the microanato my of structures surrounding the brain stem, some of us could extend the limited indications step by step and deeper each time during the past eighteen years. This progressive unmasking was stimulated by the major breakthroughs in diagnostic measures: CT scans, super selective angiog raphy, and MR!. The new possibilities for neurophysiological recordings provide us with valuable information of the changes in brain stem parame ters which appear often before manifestations capture the clinical eye. Continuous monitoring of brain stem evoked potentials has achieved a defmite place in modem neurosurgery in this area. On these different fronts and thanks to engaged neuroscientists, ad vances were made in the separate fields. It was a dream come true to have had the possibility of bringing together for discussion the leading special ists throughout the world at the International Symposium on Surgery in and around the Brain Stem and the Third Ventricle at Hannover, in February, 1985, to deal with the subject at hand and to share or exchange knowledge for the present and future. All this was compiled as manuscript, and after hard efforts together with joy is presented to the public and interested circle of scientists, eager for the information gathered in what was a marathon and historical week of Symposium. x Preface Full of gratitude to the man who has encouraged my work, allowing me to carry on in this field, seeing the course of things to come, I dedicated the first day of the Symposium to Prof. K. Schurmann to honor his 65th birthday. To the colleagues and friends, who through their knowledge made it all possible, my everlasting acknowledgements for the great service rendered to our patients and to coming generations of colleagues, for we can now say that the surgery in and around the brain stem and the third ventricle, with good results, is a new chapter in our exciting field. Last but not least, I would like to thank Mr. W. Bergstedt of Springer Verlag and his team for their efforts in organizing the publication of this book, as well as Dr. F. Weber for his work on the subject index. Special thanks must be given to Mrs. R. Nitsche and Dr. H. Khalil for their revision of the papers as far as translation and context. They were ir replaceable and a great help to me in every stage of the preparation of the manuscript for this book. Hannover MADJID SAMII Contents Problems of Surgery in and around the Brain Stem and the Third Ventricle. A General Perspective. M. Samii (With 10 Figures) Anatomy Microanatomy of and around the ~rain Stem and the Third Ventricle. J. Lang (With 31 Figures) ....................... 9 The Three-Dimensional Anatomy of the Fourth Ventricle and Adjacent Structures. F. Afshar (With 7 Figures) ............. 46 Trigeminal DREZ for Craniofacial Pain. B. S. Nashold, H. Lopes,. J. Chodakiewitz, and P. Bronec (With 1 Figure) ............. 54 Interpeduncular Fossa Microvascular Anatomy. J. I. Ausman, A. Pedroza, M. Dujovny, F. G. Diaz, J. C. Artero, S. K. Berman, and H. G. Mirchandani (With 2 Figures) ...... 60 Microsurgical Anatomy of the Pineal and Midbrain Region. G. Pendl (With 14 Figures) .............................. 65 Pathology, Metabolic Disturbances Neuropathology of the Processes in the Third Ventricle and the Brain Stem. K. J. Ziilch (With 1 Figure) ................ 79 Clinical and Pathological Findings in Brain Stem Gliomas. J. Artigas, J. Cervos-Navarro, M. Brock, and C. Aruffo (With 6 Figures) ....................................... 86 Blood Flow and Metabolism in Brain Stem - Pathophysiological Implications. A. Baethmann (With 1 Figure) ............... 95 Neurology, Neurophysiology Topographic Analysis of Neurologic Symptoms in Brain Stem Diseases. A. Hartmann and J. Wappenschmidt (With 15 Figures) ...................................... 105 Symptoms of Tumors of the Brain Stem and the Third Ventricle. M. Schirmer ........................................... 129 Functional Anatomy of Sensory Motor Afferences of the Thalamus. A. Struppler and P. Birk (With 6 Figures) ......... 133 XII Contents Intracranial Pressure, Neurological Condition and Operative Management in Relation to the Outcome of Patients with Supratentorial Midline Tumors. K-E. Richard, R. Knipprath, P. Sanker, P. Van den Bergh, and R. A. Frowein (With 6 Figures) ....................................... 139 Neurophysiological Results (Brain Stem Reflexes and Evoked Potentials) in Primary and Secondary Brain Stem Disorders. N. Klug (With 6 Figures) ................................ 147 Intraoperative Monitoring of Evoked Potentials for Surgery in and around the Third Ventricle and the Brain Stem. J. Schramm, C. Cedzich, R. Fahlbusch, T. Mokrusch, and H. Hochstetter (With 6 Figures) ....................................... 153 Stimulation Mapping of the Periventricular-Periaqueductal Gray (PVG-PAG) in Man - an Autopsy Study. R. R. Tasker, M. Yoshida, A. A. F. Sima, and J. Deck (With 6 Figures) 161 Monitoring of Brain Stem Function by Brain Stem Auditory Evoked Potentials (BAEP). C. B. Lumen.ta, M. Kramer, and W. J. Bock (With 6 Figures) .......................... 168 The Perioperative Monitoring of Brain Stem Auditory Evoked Potentials (BAEP). P. Gurtner, E. Kohmura, R. Ramina, R. Lorenz, and M. Sarnii (With 4 Figures) .................. 175 Neuroradiology Artificial Intelligence in Radiology. A. Wackenheim (With 17 Figures) ...................................... 183 Brain Stem and Tentorial Notch. M. Nadjmi (With 7 Figures) 195 Local Cerebral Blood Flow Measurements in the Deep Seated Brain Structures. K-D. Lerch, N. Nemati, E. Kohmura, K Holl, and M. Samii (With 6 Figures) .................... 200 Remote Metabolic Disturbances in Lesions of Brain Stem and Diencephalon. A PET-Study. W.-D. Heiss, G. Pawlik, K Herholz, B. Szelies, C. Beil, R. Wagner, and K Wienhard (With 1 Figure) ........................................ 207 Vascular Malformations Involving the Mesencephalic Region. (Review of26 Personal Cases) P. Lasjaunias, C. Manelfe, L. Lopez Ibor, K. Ter Brugge, and M. Chiu (With 2 Figures) 213 New Embolization Method for Inoperable AVMs and Vascular Rich Tumors - Chemical Embolization Using Conjugated Estrogen. J. Suzuki, Y. Nagamine, and A. Takahashi (With 6 Figures) ....................................... 223 Surgical Management of Specific Lesions: Vascular Lesions, Trauma Cavernous Angioma in the Brain Stem. Report of Successfully Operated Cases. T. Yoshimoto and J. Suzuki (With 6 Figures) 233