clinical article

J Neurosurg 123:1045–1054, 2015

Posterior interhemispheric transfalcine transprecuneus

approach for microsurgical resection of periatrial lesions:
indications, technique, and outcomes
Bradley N. Bohnstedt, MD, Charles G. Kulwin, MD, Mitesh V. Shah, MD, and
Aaron A. Cohen-Gadol, MD, MSc
Goodman Campbell Brain and Spine, Indiana University Department of Neurological Surgery, Indianapolis, Indiana

Object Surgical exposure of the peritrigonal or periatrial region has been challenging due to the depth of the region
and overlying important functional cortices and white matter tracts. The authors demonstrate the operative feasibility of a
contralateral posterior interhemispheric transfalcine transprecuneus approach (PITTA) to this region and present a series
of patients treated via this operative route.
Methods Fourteen consecutive patients underwent the PITTA and were included in this study. Pre- and postoperative
clinical and radiological data points were retrospectively collected. Complications and extent of resection were reviewed.
Results The mean age of patients at the time of surgery was 39 years (range 11–64 years). Six of the 14 patients
were female. The mean duration of follow-up was 4.6 months (range 0.5–19.6 months). Pathology included 6 arteriove-
nous malformations, 4 gliomas, 2 meningiomas, 1 metastatic lesion, and 1 gray matter heterotopia. Based on the results
shown on postoperative MRI, 1 lesion (7%) was intentionally subtotally resected, but ≥ 95% resection was achieved in
all others (93%) and gross-total resection was accomplished in 7 (54%) of 13. One patient (7%) experienced a temporary
approach-related complication. At last follow-up, 1 patient (7%) had died due to complications of his underlying malig-
nancy unrelated to his cranial surgery, 2 (14%) demonstrated a Glasgow Outcome Scale (GOS) score of 4, and 11 (79%)
manifested a GOS score of 5.
Conclusions Based on this patient series, the contralateral PITTA potentially offers numerous advantages, including
a wider, safer operative corridor, minimal need for ipsilateral brain manipulation, and better intraoperative navigation and
working angles.
http://thejns.org/doi/abs/10.3171/2015.3.JNS14847
Key Words arteriovenous malformation; tumor; surgical approach; atrium; trigone; interhemispheric approach;
microsurgical resection; surgical technique

P
eritrigonal lesions pose special neurosurgical chal- mus anteroinferiorly.13 These structures significantly limit
lenges for their exposure and resection because of the surgical corridor to the peritrigonal area. With the use
their proximity to critical structures, including the of standard interhemispheric or transcortical approaches,
overlying cortices and white matter fiber tracts. The an- there is a need for significant retraction/disruption and re-
terior and posterior choroidal, pericallosal, and splenial section of normal parenchyma and white matter tracts to
arteries provide blood flow to the surrounding normal pa- reach such lesions; these approaches carry a risk of mor-
renchyma as well as to lesions in this area. There is also bidity to the patient.
significant deep venous drainage via the indispensable in- A wide variety of approaches have been described to
ternal cerebral veins, vein of Rosenthal, and the straight facilitate relatively safe lesion exposure while dealing
sinus. Highly functional cerebral cortex and white matter with the surrounding normal anatomy. In 1854, Shaw26
tracts in this area include the optic radiations lateral to the described the first approach to this area for a meningio-
ventricle,20 postcentral gyrus supralaterally, and the thala- ma. Subsequent approaches required an anterior-inferior

Abbreviations AVM = arteriovenous malformation; GOS = Glasgow Outcome Scale; PITTA = posterior interhemispheric transfalcine transprecuneus approach.
accompanying editorial See pp 1042–1044. DOI: 10.3171/2014.10.JNS142002.
submitted April 14, 2014. accepted March 19, 2015.
include when citing Published online May 1, 2015; DOI: 10.3171/2015.3.JNS14847.
Disclosure Dr. Shah has served as a consultant to Stryker.

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B. N. Bohnstedt et al.

temporal resection, a posterior-inferior temporal resec- Preoperative and Postoperative Clinical and Radiological
tion, a parahippocampal resection, a paramedian posterior Evaluation
parietal resection, a parasagittal resection, and cingulate All patients underwent preoperative and postopera-
resection.9 Wang and colleagues,30 through their cadav- tive imaging. If visual dysfunction was among patients’
eric study, described a contralateral posterior interhemi- presenting symptoms or detected on a detailed confron-
spheric transfalcine transprecuneus approach (PITTA) to tational visual field examination, they also underwent an
the atrium that offers numerous hypothetical advantages, ophthalmological evaluation. All patients, except 1 who
including a wider operative corridor, minimal ipsilateral underwent subtotal resection of his periventricular hetero-
brain manipulation, and better intraoperative navigation topia (Case 13, Table 1), were evaluated by postoperative
due to decreased perilesional parenchymal retraction. He- MRI or cerebral arteriograms within 24 hours after sur-
ros10 rightfully questioned the application of this operative gery to assess the extent of resection of their tumors or
approach because of its associated risks, but considered it arteriovenous malformations (AVMs), respectively. Any
potentially feasible. postoperative new neurological deficit or asymptomatic
Although Goel8 initially described the contralateral imaging findings related to the contralateral, unaffected,
transfalcine route for tumor resection, he used this meth- or “approach” hemisphere were recorded as an “approach-
od for a medial frontal lesion accompanied by significant related” complication. Any other complication was re-
ipsilateral edema, interfering with the tumor’s ipsilateral corded as “resection-related.”
exposure. A transfalcine approach to avoid ipsilateral re-
traction on a vascular lesion has also been described for Operative Technique
anterior interhemispheric pathology.6 The patient is placed in a three-quarter prone position
More recently, Zaidi et al.33 described contralateral with the ipsilateral hemisphere harboring the lesion in the
transcallosal and transcingulate approaches through the nondependent (up) position and the normal, unaffected
lateral ventricle for resection of deep-seated (thalamic and or “approach” hemisphere in the dependent (down) posi-
basal ganglion) cavernous malformations. To our knowl- tion to facilitate the use of gravity retraction to mobilize
edge, there are only 2 case reports34 but no patient series the normal contralateral hemisphere away from the falx,
in the literature describing the operative details of the con- thereby avoiding the need for fixed rigid retractors on the
tralateral posterior interhemispheric transprecuneus route normal hemisphere (Fig. 1A–C). The patient’s head is ro-
for periatrial or trigonal lesions. We present 14 consecu- tated so that the axis of the superior sagittal sinus makes
tive cases managed microsurgically via the contralateral a 45° angle with the floor. Neuronavigation guidance is
PITTA. We will outline the associated challenges and ad- used in every case to assist with mapping the craniotomy
vantages of this operative route. The clinical details of 2 flap, avoiding the parasagittal bridging veins, using a pre-
representative patients will also be presented. cise trajectory of approach, and making an accurate cor-
ticotomy site at the precuneus. A lumbar drain is placed
Methods to drain CSF and minimize retraction on the unaffected
contralateral hemisphere. We did not use neurophysiologi-
We performed a retrospective review of the medical re- cal monitoring.
cords of all pertinent surgeries performed by the senior We use a small linear incision perpendicular to the su-
author (A.A.C.G.) at Methodist Hospital, Indianapolis, In- perior sagittal sinus over the superior parietal lobule (Fig.
diana, from November 2010 through February 2014. Four- 1C). The craniotomy (often 4 × 3 cm) is completed on the
teen patients underwent resection of their periatrial lesions contralateral parietooccipital region while the important
through the contralateral PITTA. Furthermore, all patients bridging veins in the region are monitored and therefore
underwent the same exact operative exposure for access avoided as guided by neuronavigation (Fig. 1D). A posteri-
to their lesions. Pre- and postoperative clinical and ra- orly located craniotomy over the occipital lobe is avoided
diological data were collected with particular attention to to protect the cortices responsible for vision. Similarly, a
approach-related and resection-related complications and more posterior frontal or anterior parietal craniotomy is
extent of resection. Each patient’s Glasgow Outcome Scale avoided to prevent exposure and injury to the sensorimo-
(GOS) score at the last follow-up evaluation was also re- tor cortex. After placement of 2 bur holes over the superior
corded. The Indiana University Institutional Review Board sagittal sinus, a parasagittal craniotomy is elevated with
approved this retrospective review of the patient data. exposure of the corresponding length and entire width of
During this 4-year interval, the senior author used this the dural sinus. The dura is opened in a horseshoe-shaped
approach for all periatrial lesions, except for 1 large meta- fashion based on the shape of the sinus (Fig. 1E and F).
static tumor that had extended more anteriorly and had Two retraction or tack-up sutures are placed through the
displaced the posterior thalamus. This lesion was deemed superior portion of the falx just below the sinus, allowing
unsuitable for this approach due to its significant anterior for gentle retraction of the falx and rotation of the dural
progression into the diencephalon. We employed the pos- venous sinus, therefore extending the operative corridor
terior contralateral interhemispheric route for lesions con- medially (Fig. 1G and H). Parasagittal bridging veins may
fined to the medial wall of the atrium as well as within need to be untethered microsurgically to expand the inter-
the trigone of the ventricle. Significant anterior or lateral hemispheric operative view anteriorly or posteriorly.
extension of the lesion into the posterior diencephalon or Approximately 50–60 ml of CSF is gradually removed
lateral walls of the atrium, respectively, were considered (in 10–15-ml aliquots) through the lumbar drain after
contraindications for use of the approach. dural opening to maximize cerebral relaxation before in-

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 TABLE 1. Data for 14 consecutive patients treated using a PITTA
Case Age (yrs), Side of Size of Extent of Approach-Related Resection-Related GOS Score Length of
No. Sex Pathology Pathology Pathology (cm3) Presenting Symptoms Resection (%) Complications Complications at Follow-Up Follow-Up (mos)
1 55, M Glioblastoma Lt 4.4 × 3.9 × 4.6 Headache, vision >98 None None 5 19.6
changes
2 30, F AVM Rt 2.8 × 2.7 × 2.3 Headache, vision 100 None None 5 0.6
changes
3 28, M Meningioma Bilat 7.7 × 6.7 × 5.1 Memory loss >98 Temporary lt foot Seizure (once) 5 3.2
weakness
4 62, M Metastasis (LSCC) Lt 3.6 × 3.0 × 2.6 AMS 98 None None 1* 0.5
5 58, F Atypical meningioma Lt 3.9 × 3.6 × 3.0 Headache, aphasia 100 None None 4 3.5
6 31, F AVM Lt 2.8 × 1.7 × 1.0 Headache 100 None Rt hemianopsia 5 5.1
7 28, M AVM Lt 3.5 × 2.0 × 2.2 Headache, emesis 100 None Rt hemianopsia, 5 4.5
Seizure
8 43, F AVM Lt 1.5 × 1.2 × 1.0 Seizures 100 None None 5 1.0
9 35, M OA w/ mapping Rt 5.3 × 4.2 × 3.8 Headache, emesis, AMS 95 None None 5 13.9
10 58, F AO Rt 5.0 × 5.0 × 4.0 Headache, emesis >98 None Lt hemianopsia 5 0.7
11 64, F Glioblastoma Lt 4.5 × 3.0 × 2.5 Vision changes, alexia, 95 None None 4 2.2
aphasia
12 28, M AVM Rt 2.2 × 2.5 × 3.3 Headache, LOC 100 None None 5 4.1
13 20, M Grey matter hetero- Rt 3.3 × 2.8 × 2.3 Headache Subtotal resec- None None 5 2.7
topia tion
14 11, M AVM Lt 2.1 × 1.9 × 2.6 Headache 100 None None 5 2.4
AMS = altered mental status; AO = anaplastic oligodendroglioma; HA = headache; LOC = loss of consciousness; LSCC = lung squamous-cell carcinoma; OA = oligoastrocytoma.
* Patient subsequently died due to systemic complications of metastatic lung disease unrelated to his intracranial disease or craniotomy.

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Fig. 1. Illustrations and intraoperative photographs of the procedure. A–C: Patient position and various incision options for
approaching a left periatrial lesion while placing the contralateral “approach” hemisphere in the more dependent position to use
gravity retraction. D: Bur holes are placed on the superior sagittal sinus and a parasagittal craniotomy is completed while expos-
ing the corresponding segment of the dural sinus. E: A dural opening is made while avoiding the important bridging veins in the
region (inset). F: The bridging vein is untethered to increase the working zone for the interhemispheric corridor. G and H: Two
sutures are placed on the superior aspect of the falx to facilitate gentle dural sinus retraction. I: The “T-shaped” incision within the
falx cerebri to expose the contralateral medial hemisphere. J: Placement of additional sutures on the falcine dural flaps (inset) to
increase the transfalcine working angle and corridor to the contralateral atrium. K: Corresponding intraoperative image for expos-
ing the left precuneus. L: Following a corticotomy within the precuneus, we exposed the choroid plexus (*) within the contralateral
atrium. Copyright The Neurosurgical Atlas (A–J), Aaron A. Cohen-Gadol, MD, MSc. Used with permission. Figure is available in
color online only.

cisions within the falx are completed. Cottonoid patties posteriorly located lesions. If the vertical incision within
protect the contralateral unaffected hemisphere while a the falx approaches the straight sinus as guided by neu-
T-shaped incision in the falx is performed as guided by ronavigation, this vertical incision is completed in an
neuronavigation to provide access to the precuneus over oblique fashion from the posterior to anterior direction to
the lesion (Fig. 1I). The horizontal part of the “T-shaped” protect the straight sinus along the inferior aspect of the
incision is made near the inferior aspect of the superior vertical falcine incision. Using this methodology, as the
sagittal sinus, whereas the vertical portion of the incision falcine flaps are reflected, the more posterior regions of
is extended until the inferior sagittal sinus is coagulated the precuneus are generously exposed.
and cut. This maneuver creates 2 dural flaps that can be After resection of the lesion, the falcine retraction su-
retracted with retention sutures over 2 cottonoids to ad- tures are removed. The falcine dural flaps are not sutured
equately expose the contralateral medial parietooccipital to each other to reconstruct the falx. It is important to em-
lobe (Fig. 1J and K). Resection of the lesion can then prog- phasize the importance of neuronavigation for planning
ress through a cortical incision within the precuneus to of the craniotomy flap location, protecting the parasagit-
reach the periatrial region, remove the pathology at hand, tal bridging veins, and confirming operative trajectory.
and expose the choroid plexus in the atrium (Fig. 1L). Two patients underwent MR venography in addition to
Certain details must be kept in mind to avoid com- their preoperative MRI. In these cases, based on the lat-
plications during preparation of the contralateral inter- ter study, we suspected numerous veins near the trajectory
hemispheric corridor. It is important to avoid injury to the of our approach; the former study guided us to move our
straight sinus during completion of the “T-shaped” inci- craniotomy slightly more posteriorly. Although we did not
sion within the falx, especially for the exposure of more routinely use a preoperative catheter or MR venography

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 Posterior interhemispheric transfalcine transprecuneus approach

to localize the bridging veins, we recommend the use of forded an ample working zone to handle highly vascular
these modalities to prevent any risk to the parasagittal and neoplastic lesions. Importantly, we employed dynamic
veins. We did not use tractography fused with neuronavi- retraction by using bipolar forceps to provide additional
gation to avoid subcortical functional white matter tracts. axes of freedom, especially along the edges of the corti-
Temporary postoperative external ventricular drainage cotomy and lateral aspects of the atrium for navigation of
was not used in any of our patients because all the blood dissecting instruments and resection of these deep-seated
products and debris were cleared from the ventricular sys- lesions. In all cases, the atrium and the corresponding cho-
tem before closure. In 2 patients with slightly more poste- roid plexus were readily exposed.
rior extension of their lesions, fluorescence angiography
was used to localize the exact location of the straight sinus
before the vertical portion of the incision within the falx Illustrative Cases
was performed. Case 2
A 30-year-old woman presented with a severe sudden
Results headache and left-sided homonymous hemianopsia (Table
1). Diagnostic tests revealed a hemorrhagic right trigonal
Relevant patient information is summarized in Table
1. The mean age of patients at the time of surgery was AVM (Fig. 2A–D). Following endovascular embolization
39 years (range 11–64 years). Six (43%) of 14 patients of the AVM, the patient underwent a left-sided parasag-
were female. Pathology included 6 AVMs, 4 gliomas (2 ittal craniotomy and interhemispheric transfalcine ap-
glioblastomas, 1 anaplastic oligodendroglioma, and 1 oli- proach to expose the lesion through a corticotomy in the
goastrocytoma), 2 meningiomas (1 atypical), 1 metastatic precuneus cortex. Placement of a lumbar drain and CSF
lesion (squamous-cell lung cancer), and 1 gray matter drainage allowed for generous relaxation of the unaffected
heterotopia. The average lesion size was 25 cm3 (range left hemisphere with minimal retraction for its mobiliza-
1–132 cm3). The most common presenting symptom was tion to access the contralateral periatrial region and resect
headache (10 of 14, 71%), followed by emesis and vision the AVM. The interhemispheric transfalcine approach fa-
changes (3 of 14, 21% for each). Other presenting symp- cilitated an adequate exposure of the AVM and proximal
toms included altered mental status (2 of 14, 14%), aphasia control over the choroidal and posterior cerebral artery
(2 of 14, 14%), memory loss, worsening seizures, loss of feeders early on with minimal normal brain transgression.
consciousness, and alexia (1 of 14, 7% for each). One le- We identified the main draining vein from the AVM
sion (heterotopia) was intentionally subtotally resected; of along the medial parietooccipital region and splenium and
the remaining 13 patients (93%), 95% or greater resection protected it during resection. In addition, this route afford-
was achieved, whereas gross-total resection was accom- ed a variety of working angles to manipulate the vascular
plished in 7 (54%) of 13 based on postoperative MRI. One lesion without a need for fixed retractors. The interhemi-
patient underwent awake cortical mapping of the posterior spheric corridor, unlike the transcortical route, provided
medial frontal and anterior parietal cortices for resection ample landmarks to orient us to the relevant nearby struc-
of his low-grade glioma located along the medial wall of tures during microsurgery. Postoperative angiography and
the atrium and extending along the medial frontoparietal head CT confirmed removal of the AVM (Fig. 2E and F)
region just inferior to the sensorimotor cortex. as well as no injury to the contralateral hemisphere (Fig.
There was 1 approach-related temporary complication 2G). At 0.6 months of follow-up, Goldmann perimetry
that lasted 2 weeks: a distal left lower-extremity weakness visual field evaluation demonstrated resolution of the pa-
related to the side of the approach (1 of 14, 7%) in a patient tient’s preoperative deficits.
who harbored a giant meningioma. Four patients (29%)
had postoperative complications attributable to microsur- Case 1
gical resection of their lesion. Two (14%) had postopera-
tive seizures controlled with a single medication; 3 (21%) A 55-year-old man presented with a 6-week history of
had new postoperative visual field deficits; and 1 patient headaches and partial right-sided hemianopsia (Table 1).
(7%) suffered from both a postoperative seizure and vi- Preoperative imaging demonstrated a left occipital/pe-
sual field defect. These visual field deficits may have been ritrigonal mass suspected to be a high-grade glioma with
caused by aggressive coagulation of the choroid plexus extensive vasogenic edema (Fig. 3A–C). A right-sided
within the atrium and adjacent ependymal en passage ves- PITTA was planned to avoid the optic radiations during
sels due to bleeding from associated highly vascular le- removal of the tumor. Exposure of the superiorly located
sions. At last follow-up (mean 4.6 months, range 0.5–19.6 enhancing cyst wall would have required significant tem-
months), 1 patient (7%) had died because of complications poral lobe retraction through the lateral approach, poten-
of his underlying malignancy unrelated to his cranial sur- tially placing the cortical speech areas at risk.
gery, 2 patients (14%) demonstrated a GOS score of 4, and Intraoperatively, this route allowed exposure of the tu-
11 (79%) manifested a GOS score of 5. None of our pa- mor and associated cyst as it came closest to the cortical
tients required postoperative CSF diversion. surface of the precuneus with minimal normal brain re-
None of the patients in this series required fixed re- section (Fig. 3D–H). One month after surgery, the patient’s
tractors for exposure and resection of their tumor masses. visual field deficit had improved. Gross-total resection of
The “cross-court” working angle and dynamic retraction this histologically confirmed high-grade glioma was evi-
provided by the suction apparatus and bipolar forceps af- dent on MRI (Fig. 3I–K) immediately after surgery.

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Fig. 2. Case 2. Axial CT scan of the head (A) reveals a right periatrial hemorrhagic lesion with intraventricular extension of hemor-
rhage. Lateral (B) and anteroposterior (C) late arterial phases of vertebral angiography demonstrate a right periatrial or trigonal
AVM. An axial T1-weighted MR image with contrast (D) reveals the exact location of the periatrial AVM. We excised the AVM using
the PITTA. Lateral (E) and anteroposterior (F) early arterial phases of vertebral angiography reveal gross-total removal of the
AVM. An axial postoperative CT scan (G) excluded any unexpected injury to either posterior hemisphere.

Discussion er, the risks include injury to the optic radiations and lan-
The trigone or atrium of the lateral ventricle is a trian- guage deficits in the dominant hemisphere.21 Other risks of
gular area defined by the junction of body, temporal, and the transtemporal approach include aphasia, agraphia and
occipital horns of the ventricle. It is a well-recognized, alexia, and visual spatial apraxia. Current morbidity rates
albeit rare (< 1%) site of AVMs and tumors such as cho- with the use of neuronavigation for transtemporal routes
roid plexus papillomas and meningiomas.4,5 A variety of range from 0% to 20%.12
tumors, such as gliomas and metastases, also originate in Other operators11 have preferred an ipsilateral parieto-
the peritrigonal area and extend into the atrium. Lesions occipital interhemispheric approach. This approach was
in this area typically present with hemorrhage, seizures, developed by Kempe and Blaylock.14 Visual field deficits
visual disturbances, and mental status change.1,2 ranging from 20% to 60% have been reported with this
Surgeons have studied various operative corridors to approach,22 and Menon et al.21 found other complications,
the periatrial region that allow complete microsurgical including new motor deficits (3 of 15), seizures (2 of 15),
resection while minimizing risk to the surrounding struc- and dysphasia (1 of 15).21 Others have recommended use
tures. Kawashima et al.13 described 3 general routes: ante- of the posterior transcallosal approach.11,15,28 McDermott20
rior transsylvian, posterior transcortical/transcallosal, and developed a modification of this route using a contralateral
lateral trans- or subtemporal. In our opinion, the anterior transcallosal trajectory.20 He described transection of the
transsylvian approach provides a very narrow corridor to inferior one to two-thirds of the falx and inferior sagittal
handle highly vascular lesions and places motor fibers and sinus followed by no more than a 2-cm callosotomy. This
optic radiations at risk. The ipsilateral posterior transcorti- approach allows the surgeon to access lesions while mini-
cal/transcallosal approach requires significant brain retrac- mizing transgression of the cortex and lateral white matter
tion to reach laterally located atrium. The transtemporal tracts. It also circumvents some of the shortcomings and
approaches place optic radiations lining the lateral wall of risks of other described operative corridors. However, the
the trigone at risk.19 An alternative route is the subtemporal challenges of traversing the corpus callosum for access to
corridor through the inferior temporal or occipitotemporal the trigone include the limitations of a narrow operative
gyrus. This route is associated with less risk of speech and corridor and the risk of disconnection syndrome.
visual field disturbances; however, excessive temporal lobe The ipsilateral posterior interhemispheric route is the
retraction and traction on the vein of Labbe are especially standard and most commonly used approach for resec-
problematic for the dominant hemisphere.13,25,31 tion of medial periatrial lesions. Placement of an exter-
Other surgeons have advocated the posterior middle nal ventricular drain within the occipital horn will deflate
temporal gyrus approach.3,11,14,15,28 This approach permits the ventricle, minimize hemispheric retraction, and allow
an early access to anterior choroidal arteries and good ex- exposure of the precuneus. Based on our experience, the
posure to tumors extending into the temporal horn; howev- PITTA provides a more “cross-court” trajectory to the lat-
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 Posterior interhemispheric transfalcine transprecuneus approach

Fig. 3. Case 1. Axial (A), coronal (B), and sagittal (C) T1-weighted MR images with contrast reveal a large heterogeneously
enhancing mass in the medial parietooccipital region with associated edema. The contralateral hemisphere is placed in the
dependent position (D). Retention sutures are used on the falx to increase the interhemispheric working zone (E). The “T-shaped”
incision in the falx has been completed and the retraction sutures on the falcine dural flaps assist with extension of the transfalcine
operative angles. Corticotomy within the precuneus exposes the tumor with minimal disruption of normal cortex (F). Contralateral
tentorium (asterisk) is evident at the end of tumor resection (G). A demagnified view of the operative corridor is shown in which 1 of
the falcine sutures has been removed (H). Postoperative axial (I) and coronal (J) T1-weighted MR images with contrast demon-
strate gross-total resection of the mass. The axial T2-weighted MR image shows no evidence of retraction injury to the “approach”
or right hemisphere (K). Figure is available in color online only.

eral aspect of the lesion while minimizing the degree of route, i.e., the operator starts the surgical approach and
hemispheric retraction. We have attempted to describe this interhemispheric dissection contralateral to the lesion
principle in Fig. 4. Please see Video 1 for further descrip- and works across the midline, as has been described via a
tion of our technique. contralateral transcallosal approach.17 Wang et al.30 used
Video 1. Clip showing technical aspects of the PITTA. Copyright a cadaveric model to modify the classic interhemispheric
Aaron A. Cohen-Gadol. Published with permission. Click here to transprecuneus approach by performing a contralateral
view with Media Player. Click here to view with Quicktime. craniotomy and reaching the ipsilateral precuneus through
One modification of the posterior transcortical/transcal- a transfalcine method. In their specimens, a larger work-
losal approach is the ipsilateral posterior interhemispheric ing angle was available (mean 44.5°) as compared with
transprecuneus approach for meningiomas located within those of the classic ipsilateral approach (mean 25.8°). This
the trigone of the dominant hemisphere.23,32 The precuneus method decreases the risk of visual and speech deficits
is involved in self-awareness, episodic memory, and pre- associated with the temporal transcortical approach and
motor visualization/imagery.18 Injury to the precuneus is the risks of somatosensory and visual deficits associated
associated with temporary deficits.7,16,29 Although this ap- with the transcortical parietooccipital approach. They be-
proach allows the surgeon to avoid optic radiations and lieved this new method improves the working angle and
violation of the functional temporal cortex, it affords only avoids excessive ipsilateral hemispheric retraction—both
a narrow working corridor and requires ipsilateral brain critical for minimizing adverse effects and handling vas-
retraction.29 The advantages and limitations of the opera- cular lesions in the region. We have applied the principles
tive corridors to the trigone are summarized in Table 2. of their technique to our patients to facilitate expanding
One solution to this narrow operative corridor is ex- the operative corridor while minimizing brain transgres-
pansion of the working angles through the “cross-court” sion.
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B. N. Bohnstedt et al.

and gentle mobilization to extend the interhemispheric

corridor for contralateral or “cross-court” visualization.
In addition, sutures on the falcine flaps further broadened
exposure at the depth of the field toward the atrium.
The lesions amenable to the above-described approach
are rare as they are mostly small and peri/intraventricular,
often involving the medial wall of the ventricle and thus
asymptomatic. In the case of peritrigonal AVMs and vas-
cular tumors, critical arterial feeders originate from the
posterior cerebral artery, the anterior choroidal artery, the
posterior choroidal artery, the pericallosal and splenial ar-
teries, and the drainage system that leads to the galenic
system.2 Transtemporal or other transcortical traditional
approaches may carry a high operative risk, partly because
the surgeon has limited control over the feeding vessels
early in the operation.27 Alternatively, PITTA provides a
more direct route and early control over the arterial feed-
ers and venous drainage systems. In addition, the PITTA
allows a more generous exposure of the lateral aspect of
the AVM so the operator can stay on the outside border
of the lesion and manage problematic deep white matter
feeders. This generous exposure is especially important
in the case of AVMs. Furthermore, meningiomas in the
atrium of the lateral ventricle can be devascularized early
Fig. 4. Based on our experience, the PITTA (green) provides a more in their dissection due to a direct exposure of their feeders
“cross-court” trajectory to the lateral aspect of the lesion than the ipsilat- from the choroid plexus (Fig. 5). Based on our experience,
eral approach (red) while minimizing the degree of hemispheric retrac- large lesions may be accessed safely and efficaciously with
tion. Copyright The Neurosurgical Atlas, Aaron A. Cohen-Gadol, MD, this approach.
MSc. Used with permission. Figure is available in color online only. Unfortunately, 3 of our patients suffered from visual
worsening due to postoperative ischemic lesions. These
were the only cases during which the atrial choroid plexus
With all of our cases in this series, patients were placed (associated with 2 patients with AVMs and 1 with tumor)
in the three-quarter prone position. The “approach” or was aggressively coagulated due to significant bleed-
unaffected hemisphere was placed in the dependent posi- ing from the choroid plexus that was intimately associ-
tion, allowing gravity retraction to aid with exposure. The ated with these vascular lesions. Most likely, we injured
parasagittal bridging veins were relatively easy to untether the subependymal arteries by coagulating the choroid
to provide enough interhemispheric exposure. We used plexus. Saito and colleagues have also previously reported
navigation to avoid placing the craniotomy centered over this complication.24 Based on our experience, we advise
the important parasagittal veins. Retraction sutures along against significant manipulation and coagulation of the
the superior falx facilitated superior sagittal sinus rotation atrial choroid plexus if possible.

TABLE 2. A summary of advantages and disadvantages of the described approaches to atrial lesions
Approach Advantages Disadvantages
Anterior distal transsylvian Simpler patient positioning; early control over middle cere- Risk of motor, visual, or hearing deficit; postop
bral artery feeders seizures
Transcortical parietooccipital Avoids motor and speech areas Risk of parietal lobe syndrome, vision deficit;
postop seizures; long working distance; late
access to vascular pedicle
Subtemporal/transtemporal Shorter working distance; early access to vascular pedicle; Risk of speech and vision deficits; subtemporal
exposure of temporal horn approach carries risk of retraction and vein of
Labbe injury; postop seizures
Posterior interhemispheric Avoids optic radiations, temporal and parietal cortices; mini- Risk of disconnection syndromes; long working
transcallosal mizes postop seizures; early access to vascular pedicle distance
Posterior interhemispheric Avoids optic radiations, temporal and parietal cortices; early Narrow working angle; significant ipsilateral hemi-
ipsilateral transprecuneus access to vascular pedicle spheric retraction; long working distance
PITTA Wider operative corridor; minimal retraction; avoids optic Risk of injury to contralateral hemisphere; long
radiations, temporal and parietal cortices; early access to working distance
vascular pedicle

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 Posterior interhemispheric transfalcine transprecuneus approach

of our study as ophthalmological evaluation was not avail-

able in all patients.

Conclusions
Based on our experience, the posterior interhemispheric
transfalcine approach to precuneus and trigonal lesions is
a reasonable alternative to previously described approach-
es. This modification of the interhemispheric approach re-
duces the need for significant ipsilateral cortical resection/
retraction while improving the operator’s working angles.
This series demonstrates that through appropriate patient
selection, this alternative route can be applied safely and
effectively to a wide variety of pathologies within and me-
dial to the trigone of the lateral ventricle.

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injury. J Neurosurg 119:158–163, 2013 authors. Approved the final version of the manuscript on behalf
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