Table Of ContentSurgery 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.)
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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
