'Let the Lesion Do the Talking'
Only a small subset of neurosurgeons are willing to tackle the complexities and risks associated with surgery of the ventral brainstem and thalamus. With so few cases available and limited cumulative experience for any one surgeon, one must often be innovative for the necessity of each patient’s case by applying anatomical knowledge and drawing on personal confidence. These surgical approaches are considered complex and often require experience in skull base surgery. Additionally, the target ‘real estate’ is densely populated with nuclear tissue and fiber tracts that are unforgiving if transgressed.

We created illustrations to support this book chapter emphasizing two principles in the design of surgical approaches to these lesions. First, “Let the lesion do the talking” because it will determine the timing of surgery, goals of surgery, and operative approach. Second, “Build the approach from inside-out” describes a strategy that starts with the target, proceeds to the safe zone of entry and then trajectory, and concludes with the craniotomy.

Client: Harry van Loveren, MD, Department of Neurosurgery and Brain Repair, University of South Florida.
Illustrator: Tonya Hines, CMI © 2016 Glia Media. All rights reserved.
Figure 1. Pontine cavernoma (with anterolateral expanding hematoma cavity) removed through an anterior petrosectomy approach and eloquent trajectory through the peritrigeminal safe zone. © 2016 Glia Media. All rights reserved.
Figure 2. Medullary cavernoma removed through an endoscopic transclival approach to the ventral brainstem with eloquent passage through the olivary safe zone. © 2016 Glia Media. All rights reserved.
Figure 3. Exophytic brainstem glioma biopsied and debulked through a transsylvian frontotemporal approach.© 2016 Glia Media. All rights reserved.
Figure 4. Medial thalamic arteriovenous malformation removed through a interhemispheric transcallosal transventricular approach. © 2016 Glia Media. All rights reserved.
Figure 5. Thalamic pilocytic astrocytoma removed through a transtemporal transventricular approach, yielding the most direct route to the bulk of the tumor while avoiding injury to the internal capsule and fornices. © 2016 Glia Media. All rights reserved.