Trans-Fissural or Trans-Sulcal Approach Versus Combined Stereotactic-Microsurgical Approach

Summary

The combined stereotactic-microsurgical approach has been used mainly to allow the removal of small subcortical lesions, determining their location and the route to be followed. In our experience, this approach has been most useful in 5 cases of small paraventricular AVMs and another 6 small deep-seated tumoural lesions.

Since the availability of MRI, we have systematically applied Yasargil’s proposal to perform dissection of the cisterns or sulci to reach a lesion with minimal or no injury to normal neuroanatomy. Assisted by Computer Aided Design software, we can superimpose the MR images with those provided by conventional or digital angiography (mainly the venous phase). MRI allows us to select a route or pathway through a sulcus, and angiography helps us in locating it on the brain surface.

We have applied this technique systematically during the past year, and can report 20 cases (1 AVM, 12 tumoural lesions, 1 abscess and 6 haematomas). This trans-fissural or trans-sulcal approach has allowed us resection with minimal surgical damage, after a prompt and precise location.

We think that both methods are not mutually exclusive, although the trans-sulcal approach is more adequate because of less discomfort for the patient, the smaller cerebral parenchyma injury and greater anatomofunctional information for the surgeon.