USING OF TRANSSULCAL MICROSURGICAL APPROACH IN SURGICAL TREATMENT OF INTRACEREBRAL LESIONS - LITERATURE REVIEW <s> VALKANOV ST., et al. <s> Surgical resection of mesiotemporal lesions, particularly those in the dominant hemisphere, is often challenging. Standard approaches require excessive brain retraction, removal of normal cortex, or manipulation of the middle cerebral artery branches. This report describes a transsulcal temporal approach to mesiotemporal lesions and its application in three patients. Gross-total resection of the lesion was accomplished in all cases. An anatomical cadaveric study was also performed to delineate the microsurgical anatomy of this approach. Precise knowledge of temporal intraventricular landmarks allows navigation to the lesion without the need for a navigational system. This approach is helpful for neurologically intact patients with mesiotemporal lesions. <s> BIB001 </s> USING OF TRANSSULCAL MICROSURGICAL APPROACH IN SURGICAL TREATMENT OF INTRACEREBRAL LESIONS - LITERATURE REVIEW <s> VALKANOV ST., et al. <s> We describe a transsulcal microsurgical approach for removal of small subcortical brain lesions, guided by frameless stereotaxy. This technique of simultaneous stereotactic localization of the subcortical lesion and its adjacent sulcus, before surgical approach, results in optimal surgical planning, leading to minimal brain tissue loss and excellent surgical outcome. <s> BIB002 </s> USING OF TRANSSULCAL MICROSURGICAL APPROACH IN SURGICAL TREATMENT OF INTRACEREBRAL LESIONS - LITERATURE REVIEW <s> VALKANOV ST., et al. <s> OBJECTIVE ::: Surgical options to remove lesions located deep in the sulcus at the paracentral area are limited. To minimize therapeutic morbidities, such as cortical injuries before the removal, a transsulcal approach was applied by taking the results of neuroimaging and functional mapping into consideration. ::: ::: ::: METHODS ::: Four patients with paracentral inner lesions including anaplastic astrocytoma, cortical dysplasia, and cavernous angioma were operated on. All lesions were located deep in the paracentral sulci. According to the outcome of MRI and functional mapping of the cortex over the lesion, the central or the postcentral sulcus was opened toward the lesion. Immediately after complete dissection of the sulcus to remove the lesion, neurological findings were evaluated in the awake state. ::: ::: ::: RESULTS ::: All lesions were situated beneath the hand or foot area. The transsulcal approach was successfully conducted without any neurological deficits in all cases. ::: ::: ::: CONCLUSION ::: Microsurgical techniques based on anatomic and functional information allow surgeons to reach the lesions deep in the paracentral area safely. <s> BIB003 </s> USING OF TRANSSULCAL MICROSURGICAL APPROACH IN SURGICAL TREATMENT OF INTRACEREBRAL LESIONS - LITERATURE REVIEW <s> VALKANOV ST., et al. <s> AIM ::: More than two thirds of cerebral cavernomas are located supratentorially. The transsulcal approach without excision of the perilesional gliotic parenchyma and simple lesionectomy are keys to surgery on eloquent areas. ::: ::: ::: MATERIAL AND METHODS ::: We present 11 supratentorial cerebral cavernomas operated between 2003 and 2007 with signs of seizures in six and focal neurological deficit in four cases. The age ranged from 19 years to 69 years with a mean of 40 years and the male/female ratio was 6:5. The mean follow-up was 26 months. ::: ::: ::: RESULTS ::: All lesions were lobar and the size ranged between 18 and 48 mm. Four were located in eloquent areas and two were deeply seated. Total lesionectomy was performed in all without major complications. A gliotic hemosiderin ring was noted in 7 and resected in 5 of them. Postoperative outcome was improved in all patients with complete seizure control in four. Seizure control was partial in 2 of the cases without any recurrence or residual mass. ::: ::: ::: CONCLUSION ::: Asymptomatic cerebral cavernomas should be followed with regular MR scans. Symptomatic ones in noneloquent or accessible areas should be resected. Deeply situated cavernomas in eloquent areas should also be resected with the guidance of fMRI and stereotactic marking if available. <s> BIB004
Depending on the location of the lesion it is necessary to consider whether it is required to reach the bottom of the sulcus, or it is more direct to enter through one of the sulcal walls. The author describes the whole trans-sulcal approach in details, noting that it is safe and minimally invasive method. In 2005. A. Jabre stated that it was useful to work through the cortical sulci, as conventional approaches require potential cortical dissection that leads to traumatic injuries of the surrounding parenchyma. He uses a frameless stereotaxy for localization of the lesion (subcortical cavernous angioma) and also for locating the nearest sulcus through which the lesion can be safely reached and removed. After reaching the bottom of the sulcus, a limited leukotomy was performed to expose and totally resect the cavernous angioma. In conclusion, the author notes that this minimally invasive technique, targeting both the adjacent sulcus and the lesion, is relatively simple and provides added accuracy and safety to the surgical procedure BIB002 . The same year, Nagata S. and Sasaki T. presents the lateral trans-sulcal approach to the treatment of asymptomatic trigonal meningiomas. The approach is studied on two cadaver brains and three patients with asymptomatic trigonal meningiomas. They opened the posterior part of Sylvian fissure or superior temporal sulcus to its bottom. The trigone of the lateral ventricle was exposed in the shortest distance by a small horizontal cortical incision trigone of the lateral ventricle. The meningiomas were detached from the choroid plexus and then removed. Although there is a potential risk of damage to the association fibers, radiatio opticus, the transverse gyrus of Heschl and parietal lobe, in-depth knowledge of the topographical anatomy and careful dissection technique can avoid operational injuries. The authors said that the wide opening of the Sylvian fissure and debulking of the tumor are other important factors to reduce the retraction of the parietal and temporal lobes (11). L. Wang et al retrospectively studied 41 patients with lesions of the septum pellucidum, comparing and analyzing statistically the therapeutic effect, extends of tumor, and resection of normal brain tissue after the application of frontal transcortical, transsulcal and interhemispheric transcallosal approaches. They concluded that trans-sulcal and transcallosal approaches are fit with the concept of minimally invasive surgery (12). In 2006. Ribas E. et al reported that brain sulci constitute the main microanatomic delimiting landmarks and surgical corridors of modern microneurosurgery. Due to the frequent difficulties in intraoperative localization and visual identification of brain sulci with assurance, the authors doing a study which main purpose was to establish cortical -sulcal key points that are essential in microneurosurgical aspect and to provide a sulcal anatomic framework for precise localization of the craniotomies over the process and to facilitate intraoperative identification of the main sulci (13). In 2008, Kaya A.H. et al used a stereotactic localization with a frame for reaching small subcortical lesions, noting that this method facilitates trans-sulcal approach to these lesions  . In 2010, Daglioglu E. et al noted that more than two-thirds of the cerebral cavernomas are located supratentorially and trans-sulcal approach without excision of the peritumoral parenchyma and simple tumorectomy are the keys to surgery on eloquent areas BIB004 . This overview of the literature indicates that surgical resection of intracerebral lesions, and particularly those in the dominant hemisphere, is often a challenge. Standard approaches require significant brain retraction or resection of normal neural tissue. However, the type of surgical approach affects on the postoperative recovery and complications. The introduction of the microsurgery and computer-led stereotactic laser resection, neuronavigation, brain mapping -all these methods which allows a complete resection and sparing of the surrounding normal neural tissue, even in the basal ganglia and thalamus, improves the results and the pursuit of atraumatic neurosurgical operations  . Transsulcal microsurgical approach is a minimally invasive technique that is relatively simple and provides additional accuracy and safety of the surgical procedure BIB002 . It should be recommended especially when working in the dominant brain hemisphere, to avoid disturbances in higher cognitive functions. Its use requires in-depth knowledge of microanatomy of the operative field, and knowledge of the existing anatomical markers, for selecting an appropriate sulcus to access the lesion BIB001 BIB003   .