Microsurgery of the Brain: Anatomical and Technical Principles

730 Pages·1980·58.28 MB·English

by  Prof. Dr. med. Wolfgang Seeger (auth.)

Wolfgang Seeger
B r a i n
Anatomical
and Technicc.1 Principles
1
Springer-Verlag Wien GmbH
Prof. Dr. med. WOLFGANG SEEGER
Medical Director of the Department of General Neurosurgery
and Chairman of Neurosurgery of the Neurosurgical Clinic,
University of Freiburg i. Br., Federal Republic of Germany
With 351 Figures
This work is subject to copyright
AH rights are reserved, whether the whole or part of the material is concerned, specifically those of translation,
reprinting, re-use of illustrations, broadcasting, reproduction by photocopying machine or similar means, and storage
in data banks
© 1980 by Springer-Verlag Wien
OriginaHy published by Springer-Verlag Wien New York 1980
Softcover reprint of the hardcover 1s t edition 1980
Design: Hans Joachim Boning, Wien
Library of Congress Cataloging in Publication Data. Seeger, Wolfgang, 1929 -. Microsurgery of the brain. 1. Brain-Surgery. 2. Micro
surgery. 1. Title. [DNLM: 1. Brain-Surgery. 2. Brain-Anatomy and histology. 3. Microsurgery. WL 368 S 451 m] RD 594. S 43.
617'.481059.80-24812
ISBN 978-3-7091-3096-4 ISBN 978-3-7091-3094-0 (eBook)
DOI 10.1007/978-3-7091-3094-0
____________________________________________________
PREFACEI~ ~IV
Preface
This book is a sequel to my "Atlas of Topographi sor A. L. Rhoton, Professor K. Sugita and particu
cal Anatomy of the Brain and Surrounding Struc larly Professor M. G. Ya§argil (with operation dem
tures". Like the first volume it is addressed mainly onstrations in Ziirich), as well as recent descrip
to neurosurgeons, neurologists and neuro tions of operations, provided important stimuli. The
pathologists. Although the two books deal with dif conversations held with my colleagues were also
ferent aspects of the subject, that is, the first with important for the production of this Atlas. I am par
anatomical relationships and the present work with ticularly grateful to Dr. J. Gilsbach, Dr. H.-R. Eg
neurosurgical techniques, this book will also be of gert and Dr. E. Grobner for valuable suggestions.
interest not only to the neurosurgeons but to work Special thanks are also due to Doz. Dr. Ch. Oster
ers in allied fields as well. The book has been tag for his help with the evaluation of the computer
designed to give the neuroradiologist and tomograms. Professor F. Mundinger provided com
neuropathologist a closer insight into the mor puter tomograms from his Department (Stereotaxy
phological problems facing the neurosurgeon work and Nuclear Medicine). Thanks to my collaboration
ing under high magnification, and to assist them in with Dr. H.-H. Riemschneider, Specialist for
making an accurate diagnosis and in determining Radiology, Karlsruhe, from whom I obtained several
the postoperative and postmortem findings. In order computer tomograms. Particular thanks are due to
to meet the requirements of the various specialist Professor W. Sandritter, Director of the Pathological
groups for whom this book is intended, departures Institute, University of Freiburg; Professor
have been made' from the style of traditional surgi P. Kleihues, Director of the Department of Neuro
cal textbooks, both in the technique of presentation pathology, University of Freiburg; and Professor
and in the method of classification of relevant ma J. Staubesand, Director of the Anatomical Institute I,
terial. These changes will be more fully explained in University of Freiburg, for making available the
the introduction. brain preparations. The translation of the text was
The present work is based on 10 years' experience undertaken by my colleague, Dr. E. Grobner, and
in microsurgery. Particularly in the latter half of Mrs. S. J. Brinkmann, Dusseldorf. I am grateful to
that period my colleagues and I carried out all ma Mrs. E. Hilsenbeck-Hottek for typing the
jor operations on the brain with the help of mi manuscript.
crosurgical techniques. Personal discussions with Pro
fessor C. G. Drake, Professor A. Raimondi, Profes- Freiburg, September 1980 Wolfgang Seeger
CONTENTS L.I ________________________- ---ll VII
Contents
Vol. 1: pp. 1 to 460 - Vol. 2: pp. 461 to 727
Introduction IX
Part I
Microsurgery of the Brain - General Aspects
Chapter 1
Basic Principles
Instrumentarium (Figs. 1 to 6) 2
Basic Principles of Operative Procedure
a) For Tumors (Figs. 7 to 20) 14
b) For Vascular Malformations and Richly Vascularized Processes (Figs. 21 to 22) 42
Appendix (Diagnostic Procedures) (Figs. 23 to 26) 46
Part II
Special Microsurgical Operative Procedures in the Brain
Chapter 2
Supratentorial Extracerebral Operations
Anatomical Details at Frontotemporal Operations (Figs. 27 to 36) 56
Pterional Approach: Anatomical Details and Operative Technique (Figs. 37 to 84) 76
Basal Approaches to Cisterna ambiens up to Lateral Quadrigeminal Region (Figs. 85 to 111) 172
Operations in Longitudinal Fissure (Figs. 112 to 141) 226
Chapter 3
Supratentorial Operations in Ventricular System
Operations in Third Ventricle (Figs. 142 to 169) 286
Operations in Lateral Ventricle (Figs. 170 to 180) 342
Chapter 4
Supratentorial Intracerebral Operations
Frontal to Parietal Operations (Figs. 181 to 192) 364
Occipital to Parietal Operations (Figs. 193 to 202) 388
Temporal Operations (Figs. 203 to 224) 408
References (Chapters 1 to 4) 453
VIII L..I _________________________- --'1 CONTENTS
Chapter 5
Infratentorial Extracerebral Operations
Anatomical Details of Cerebellum and Lower Brain Stem (Figs. 225 to 233) 462
Operations in Cerebellopontine Angle and Lobulus quadrangularis Region
a) Details of Operative Approach Along Sinus transversus and sigmoideus (Figs. 234 to 254) 48().
b) Cerebellopontine Angle (Example Acoustic Nerve Neurinoma) (Figs. 255 to 274) 522
Operations in Quadrigeminal Region with Suboccipital Approach (see also Chapter 2) (Figs. 275 to
289) 562
Chapter 6
Operations in the Fourth Ventricle
Medial Operations in Fourth Ventricle (Figs. 290 to 318) 592
Lateral Operations in Fourth Ventricle (Figs. 319 to 333) 650
Chapter 7
Intracerebellar Operations
Medial Intracerebellar Operations (Figs. 334 to 340) 680
Lateral Intracerebellar Operations (Figs. 341 to 351) 694
References (Chapters 5 to 7) 717
Subject Index 725
Introduction
1) Microsurgery is a technique that can be used classification, in contrast to the method used in
with very few exceptions for almost all neurosurgi older works in which the processes involved were
cal operations. The reluctance of some neurosur classified according to changing criteria. There are
geons to abandon conventional methods and adopt two arguments supporting the use of brain localiza
microsurgical techniques may be due to the techni tion alone, to the exclusion of additional criteria
cal and topical difficulties involved. In this book such as tumor type and biological categorization.
these problems will be analyzed in two stages.
- In the case of tumorous disorders it is inapprop
In the first stage the instruments used and the gen
riate to use tumor type and biological category as
eral principles of the operative technique will be de
additional criteria for purposes of classification:
scribed.
On the one hand, tumors of the same type and
In the second stage several specialized operations
biological category (e. g. meningioma) may differ as
will be systematically recorded. Here it was found
regards consistency, type of border, vascularization
necessary to depart from the methods used in tradi
and their tendency to develop in only one or in sev
tional textbooks in relation to a) presentation and
eral cisterns. On the other hand, the converse is
b) classification.
also true: different types of tumour (e. g. menin
a) The differences in presentation refer to four
gioma and craniopharyngioma) may resemble one
main points:
another in consistency, type of border, vasculariza
- Operative techniques are presented in more de
tion and the tendency to develop in only one or in
tail than is usual in traditional textbooks; this ap
several cisterns. It is evident from these two consid
plies both to illustrations of the operation site and
erations that very different operative techniques
to schematic presentations.
may be necessary for one and the same kind of
- The presentations of the operation site are pre
tumor, whereas it may be possible to treat different
ceded by anatomical overviews, details of which are
types of tumor with the same operative technique.
progressively enlarged until the dimensions of the
It is therefore obviously inappropriate in a textbook
operation site are reached.
on operative surgery to use the type or biological
- In order to elucidate the complicated anatomical
category of tumorous processes as preeminent
structures it was found necessary in many cases to
criterion.
present the anatomical overview or the individual
- In the case of nontumorous disorders (e. g.
enlarged details from various viewing angles, even
aneurysm and angioma) the use of the traditional
though the final view of the operation site is seen
classification criteria for tumors (type and biological
from only one of these angles.
category) is not possible. These processes, however,
- It is impossible to reproduce the full complexity
can be systematically classified if, as in this book,
of these structures by means of textual explanations
localization is used as the preeminent criterion. The
or in graphic presentations executed by non
choice of a principle of classification which can be
neurosurgeons. It was therefore decided to confine
used both for tumors and for nontumorous proces
the textual explanations to detailed legends, and to
ses is also expedient, since the operative approach
use the author's own ink drawings made postopera
tively with the help of anatomical preparations *. used for both types of disorder may in principle be
the same.
b) The difference in classification consists in the use 2) The empirical material on which this work is
throughout of brain localization as the criterion for based originates from the Neurochirurgische Uni
versiHitsklinik Freiburg/Br. Special consideration
• Since we have had no operative experience yet with certain rarely
has been given to those problematic cases in which
performed operations, e. g. for aneurysm of A. basilaris, we could not
the operator is compelled to press forward toward
include graphic presentations of these.
______________________________________________ INTRODUCTION
X~I ~I
the limits of operative possibilities. Unless otherwise erations (e. g. acoustic nerve neurinoma), in which
stated the operations were carried out by the au morphology and operative technique vary very little.
thor. Operations described without reference to a The total clinical population and the early mortality
particular clinical case represent typical routine op- rate are shown in Table 1.
Table 1. Statistical Data of Intensive Care Unit Since the Introduction of
Microsurgery in Freiburg (1 June 1975 to 1 January 1979)
Diagnosis Number Mortality
Extracerebral processes:
Aneurysms (since 1976177 all eliminated by
clipping) 61 0
A VM (all radically operated at a first or second
operation) 32 0
Prepontine tumors (not all radically operated) 77 3
Meningiomas 116 6
Intraventricular tumors (majority radically
operated) 12 4
Operations on hypophysis:
Hardy 89 1
Pterional 28 1
Tumors of cerebellopontine angle (almost
exclusively acoustic nerve neurinomas, since 1976
all radically operated, including numerous
recidivations) 61 6
CSF rhinorrhoea 51 0
Intracerebral processes:
Supratentorial intracerebral tumors 230 9
Brain abscesses 13 1
other intracerebral processes 91 7
Other microsurgical operations:
Transoral extirpation of dens epistrophei 9 o
Spinal processes 135 1
1005 39
Other processes operated without microscope or
not operated cases, e. g. atrioventricular shunt,
diagnostic cases, meningitis, encephalitis, vascular
diseases, referals from Department of Stereotaxy
with Neuronuclear Medicine 211 16
Total patients, Intensive Care Unit 1216 55
= total
mortality
of Clinic
INTRODUCTION ---11 XI
L..!_ ----::--____________________
Operations without intensive care, e. g. microsurgical intervertebral disc
operations, peripheral nerve operations, most atrioventricular shunt
operation"s, etc., are not categorized: 2271
Total number of all operations: 3487
Mortality: see statistical data of Intensive Care Unit.