Acute Subdural Hematoma Surgical Technique

Acute Subdural Hematoma Surgical Technique

Commonly used surgical techniques for the evacuation of ASDH include cranioplastic craniotomy, large decompressive craniectomytrephination/craniostomy, or combination of these procedures. In reality, surgical techniques are not specified in most papers, and the effectiveness of surgical procedures is not addressed. For example, some institutes use decompressive craniectomies in all ASDH 1).

In case of high energy trauma and GCS ≤8 different neurosurgeons decided to perform most frequently decompressive craniectomy rather than craniotomy. Furthermore, even if not related to survival rate, decompressive craniectomy showed a better neurological outcome especially in patients with GCS ≤8 at admission. In conclusion, even if prospective studies are required, these results depict the current attitude about the choice between craniotomy and decompressive craniectomy 2).


While twist drill craniostomy and placement of subdural evacuating vport system (SEPS) are quick, bedside procedures completed under local anesthesia and appropriate for patients with chronic SDH or patients that cannot tolerate anesthesia, these techniques are not optimal for patients with acute SDH or chronic SDH with septations. Burr hole SDH evacuation under conscious sedation or general anesthesia is an analogous technique; however, it requires basic surgical equipment and operating room staff, with a focus on a closed system with burr hole followed by rapid drain placement to avoid introduction of air into the subdural space, or multiple burr holes with extensive irrigation to reduce pneumocephalus and continue SDH evacuation via drain for several days. Acute SDH associated with significant mass effect and cerebral edema requires aggressive decompression via craniotomy with clot evacuation and frequently a craniectomy. Chronic SDHs that fail conservative management and progress clinically or radiographically are addressed with craniotomy with or without membranectomy. Surgical SDH management is variable depending on its characteristics and etiology, patient’s functional status, comorbidities, goals of care, institutional preferences, and availability of specialized surgical equipment and adjunct therapies. Rapid access to surgical suites and trained staff to address surgical hemorrhages in a timely manner, with appropriate post-operative care by a specialized team including neurosurgeons and neurointensivists, is of paramount importance for successful patient outcomes. Here, we review various aspects of surgical SDH management 3).

Craniotomy

Usually consists of a large craniotomy (centered over the thickest portion of the clot) to decompress the brain; to stop any active subdural bleeding; and if indicated, to evacuate intraparenchymal hematoma in the immediate vicinity of the Acute Subdural Hematoma.

Neurosurgeons frequently encounter bleeding from cortical arteries, which is usually controlled with bipolar coagulation. However, bipolar coagulation is associated with a risk of sacrificing the cortical artery, which may affect the prognosis of neurological symptoms when these cortical arteries supply critical areas.

Uneda et al., described microsurgical repair of damaged cortical arteries using a 10-0 nylon micro-suture in patients with arterial-origin ASDH 4).

Decompressive craniectomy

It is supported that decompressive craniectomy significantly improve outcome in patients with refractory intracranial hypertension due to extensive contusion, compared to routine craniotomy. However, as it has been known that bony decompression result in apparent exacerbation of edema, the superiority of decompressive craniectomy to craniotomy is still controversial.


Craniotomy is the preferred surgical technique for management of ASDH in the United States, being performed 10 times more frequently than craniectomy. Craniectomy was associated with significantly higher in-hospital mortality after propensity score matched analysis 5).

Trephination

Trephination is a quick and easy technique to reduce ICP by evacuating hematoma. However, hematoma evacuation may often result in partially, ICP reduction may be often temporary, and hemostasis may not be obtained occasionally. Thus, emergency trephination should be followed by craniotomy or craniectomy. In recent years, trephination has been also applied as a minimum invasive procedure for elderly or patients with certain risks for craniotomy or craniectomy. As another aspect of trephination, hematoma irrigation with trephination therapy (HITT) has been also applied6).

Endoscopic surgery

After performing the small craniotomy, a 4-mm rigid endoscope was inserted and the hematoma was evacuated. Endoscopic surgery was performed under general or local anesthesia. The bleeding origin was a cortical artery in 2 cases, a bridging vein in 2 cases, and unknown in 1 case. The hematoma was completely removed without re-bleeding and the procedure was lifesaving in all cases. Three patients were discharged with independent gait following rehabilitation whereas 2 patients died due to causes unrelated to ASDH. Despite some surgical limitations, neuroendoscopic hematoma evacuation of ASDH is a safe and effective method that minimizes operative complications in some cases. Small craniotomy was sufficient for inserting and maneuvering ordinal neurosurgical instruments 7).

While endoscopic minimally invasive approaches to chronic subdural collections have been successfully demonstrated, this technique was reported for the first time with an 87-year-old patient presenting with a large acute right-sided subdural hematoma successfully evacuated via an endoscopic minimally invasive technique 8).

Endoscopic hematoma evacuation of acute and subacute SDH is a safe and effective method of clot removal that minimizes operative complications. This technique may be a less invasive method for treating elderly patients with acute and subacute SDHs. 9).

Videos

References

1)

Kotwica Z, Brzeziński J. Acute subdural haematoma in adults: an analysis of outcome in comatose patients. Acta Neurochir (Wien). 1993;121(3-4):95-9. PubMed PMID: 8512021.
2)

Ruggeri AG, Cappelletti M, Tempestilli M, Fazzolari B, Delfini R. Surgical management of acute subdural hematoma: a comparison between decompressive craniectomy and craniotomy on patients treated from 2010 to the present in a single center. J Neurosurg Sci. 2018 Sep 25. doi: 10.23736/S0390-5616.18.04502-2. [Epub ahead of print] PubMed PMID: 30259718.
3)

Fomchenko EI, Gilmore EJ, Matouk CC, Gerrard JL, Sheth KN. Management of Subdural Hematomas: Part II. Surgical Management of Subdural Hematomas. Curr Treat Options Neurol. 2018 Jul 18;20(8):34. doi: 10.1007/s11940-018-0518-1. Review. PubMed PMID: 30019165.
4)

Uneda A, Hirashita K, Yabuno S, Kanda T, Suzuki K, Matsumoto A, Yunoki M, Yoshino K. Repair of damaged cortical artery by direct micro-suture in surgical treatment of acute subdural hematoma: technical note. Acta Neurochir (Wien). 2018 Oct;160(10):1931-1937. doi: 10.1007/s00701-018-3634-5. Epub 2018 Jul 31. PubMed PMID: 30066190.
5)

Rush B, Rousseau J, Sekhon MS, Griesdale DE. Craniotomy Versus Craniectomy for Acute Traumatic Subdural Hematoma in the United States: A National Retrospective Cohort Analysis. World Neurosurg. 2016 Apr;88:25-31. doi: 10.1016/j.wneu.2015.12.034. Epub 2015 Dec 31. PubMed PMID: 26748175; PubMed Central PMCID: PMC4833577.
6)

Aruga T, Mii K, Sakamoto T, Yamashita M, Sasaki M, Tsutsumi H, Toyooka H, Takakura K. [Significance of hematoma irrigation with trephination therapy (HITT) in the management of acute subdural hematoma]. No To Shinkei. 1984 Jul;36(7):709-16. Japanese. PubMed PMID: 6487438.
7)

Ichimura S, Takahara K, Nakaya M, Yoshida K, Mochizuki Y, Fukuchi M, Fujii K. Neuroendoscopic hematoma removal with a small craniotomy for acute subdural hematoma. J Clin Neurosci. 2019 Mar;61:311-314. doi: 10.1016/j.jocn.2018.11.043. Epub 2018 Nov 22. PubMed PMID: 30472341.
8)

Codd PJ, Venteicher AS, Agarwalla PK, Kahle KT, Jho DH. Endoscopic burr hole evacuation of an acute subdural hematoma. J Clin Neurosci. 2013 Dec;20(12):1751-3. doi: 10.1016/j.jocn.2013.02.019. Epub 2013 Aug 17. PubMed PMID: 23962631
9)

Yokosuka K, Uno M, Matsumura K, Takai H, Hagino H, Matsushita N, Toi H, Matsubara S. Endoscopic hematoma evacuation for acute and subacute subdural hematoma in elderly patients. J Neurosurg. 2015 Apr 24:1-5. [Epub ahead of print] PubMed PMID: 25909568.

Cranioplasty materials

Cranioplasty materials

Available evidence on the safety of cranioplasty materials is limited due to a large diversity in study conduct, patients included and outcomes reported. Autologous bone grafts appear to carry a higher failure risk than allografts. Future publications concerning cranioplasties will benefit by a standardized reporting of surgical procedures, outcomes and graft materials used 1).

A literature review in 2016 emphasizes the benefits and weaknesses of each considered material commonly used for cranioplasty, especially in terms of infectious complications, fractures, and morphological outcomes.As regards the latter, this appears to be very similar among the different materials when custom three-dimensional modeling is used for implant development, suggesting that this criterion is strongly influenced by implant design. However, the overall infection rate can vary from 0% to 30%, apparently dependent on the type of material used, likely in virtue of the wide variation in their chemico-physical composition. Among the different materials used for cranioplasty implants, synthetics such as polyetheretherketonepolymethylmethacrylate, and titanium show a higher primary tear resistance, whereas hydroxyapatite and autologous bone display good biomimetic properties, although the latter has been ascribed a variable reabsorption rate of between 3% and 50%. In short, all cranioplasty procedures and materials have their advantages and disadvantages, and none of the currently available materials meet the criteria required for an ideal implant. Hence, the choice of cranioplasty materials is still essentially reliant on the surgeon’s preference 2).


In 19th century, the use of bone from different donor sites, such as ribs or tibia, gained wide population.

Many different types of materials were used throughout the history of cranioplasty. With the evolving biomedical technology, new materials are available to be used by the surgeons. Although many different materials and techniques had been described, there is still no consensus about the best material, and ongoing researches on both biologic and nonbiologic substitutions continue aiming to develop the ideal reconstruction materials.

Cranioplasty can be performed either with gold-standard, autologous bone flaps and osteotomies or alloplastic materials in skeletally mature patients. Recently, custom computer-generated implants (CCGIs) have gained popularity with surgeons because of potential advantages, which include preoperatively planned contour, obviated donor-site morbidity, and operative time savings. A remaining concern is the cost of CCGI production.

see Autologous bone flap cranioplasty

Synthetic implants

Several materials are available. Each has its advantages and disadvantages. Search is on for an ideal material.

Polymethylmethacrylate cranioplasty and polyetheretherketone (PEEK) are the most commonly applied today.

Celluloid cranioplasty

PEEK cranioplasty

Fiberglass cranioplasty

Polypropylene polyester knitwear

Tantalum cranioplasty

Titanium cranioplasty

Acrylic bone cement


An experimental model was developed in an indoor gun range. CAD cranioplasties with a material thickness of 2-6 mm, made of titanium or PEEK-OPTIMA(®) were fixed in a watermelon and shot at with a .222 Remington rifle at a distance of 30 m distance, a .30-06 Springfield rifle at a distance of 30 m, a Luger 9 mm pistol at a distance of 8 m, or a .375 Magnum revolver at a distance of 8 m. The CAD cranioplasties were subsequently inspected for ballistic effects by a neurosurgeon.

Titanium CAD cranioplasty implants resisted shots from the 9 mm Luger pistol and were penetrated by both the .222 Remington and the .30-06 Springfield rifle. Shooting with the .357 Magnum revolver resulted in the titanium implant bursting. PEEK-OPTIMA(®) implants did not resist bullets shot from any weapon. The implants burst on shooting with the 9 mm Luger pistol, the .222 Remington, the .30-06 Springfield rifle, and the .357 Magnum revolver.

Titanium CAD cranioplasty implants may offer protection from ballistic injuries caused by small caliber weapons fired at short distances. This could provide a life-saving advantage in civilian as well as military combat situations 3).


Methylmethacrylate and porous polyethylene (PP) were resistant to fracture and disruption. MMA provided the greatest neuroprotection, followed by PP. Autologous bone provided the least protection with cranioplasty disruption and severe brain injury occurring in every patient. Brain injury patterns correlated with the degree of cranioplasty disruption regardless of the cranioplasty material. Regardless of the energy of impact, lack of dislodgement generally resulted in no obvious brain injury 4).

Sonolucent cranioplasty

References

1)

van de Vijfeijken SECM, Münker TJAG, Spijker R, Karssemakers LHE, Vandertop WP, Becking AG, Ubbink DT; CranioSafe Group. Autologous bone is inferior to alloplastic cranioplasties Safety of autograft and allograft materials for cranioplasties, a systematic review. World Neurosurg. 2018 Jun 4. pii: S1878-8750(18)31147-1. doi: 10.1016/j.wneu.2018.05.193. [Epub ahead of print] Review. PubMed PMID: 29879511.
2)

Zanotti B, Zingaretti N, Verlicchi A, Robiony M, Alfieri A, Parodi PC. Cranioplasty: Review of Materials. J Craniofac Surg. 2016 Aug 19. [Epub ahead of print] PubMed PMID: 27548829.
3)

Lemcke J, Löser R, Telm A, Meier U. Ballistics for neurosurgeons: Effects of firearms of customized cranioplasty implants. Surg Neurol Int. 2013 Apr 3;4:46. doi: 10.4103/2152-7806.110027. Print 2013. PubMed PMID: 23607068; PubMed Central PMCID: PMC3622352.
4)

Wallace RD, Salt C, Konofaos P. Comparison of Autogenous and Alloplastic Cranioplasty Materials Following Impact Testing. J Craniofac Surg. 2015 Jul;26(5):1551-7. doi: 10.1097/SCS.0000000000001882. PubMed PMID: 26114508.

Extreme lateral supracerebellar infratentorial approach

Extreme lateral supracerebellar infratentorial approach

Since the first report of application of the extreme lateral supracerebellar infratentorial (ELSI) approach in resecting the posterolateral pontomesencephalic junction (PMJ) region lesions in 2000, few articles concerning the ELSI approach have been published. A review of Chen et al., provided an intimate introduction of the ELSI approach, and evaluated it in facets of patient position, skin incision, craniectomy, draining veins, retraction against the cerebellum, exposure limits, patient healing, as well as advantages and limitations compared with other approaches. The ELSI approach is proposed to be a very young and promising approach to access the lesions of posterolateral PMJ region and the posterolateral tentorial gap. Besides, it has several advantages such as having a shorter surgical pathway, causing less surgical complications, labor-saving, etc. 1).

The extreme lateral supracerebellar infratentorial approach differs from the midline and paramedian supracerebellar infratentorial variants in the area of exposure, patient positioning, and location of the craniotomy. The technique is effective for approaching the posterolateral mesencephalon2).

The extreme-lateral corridor widens the exposure of the paramedian approach to include the anterolateral brainstem surface, offering a complete view of the cisternal space surrounding the middle incisural space 3). It provided visualization of the ambient and tentorial segments of the trochlear nerve 4).

It was initially proposed to treat lesions of the posterolateral surface of the pons principally cavernomas. The versatility of the approach allowed its use for other pathologies like gliomas, aneurysms, epidermoids, and meningiomas 5).

All the extreme-lateral supracerebellar infratentorial (SCIT) approaches warrant a safe route to the quadrigeminal plate. Among the different variants, the median approach had the smallest median surgical area exposure but presented superior results to access the intercollicular safe entry zone 6).

Lesions located at the lateral midbrain surface are better approached through the lateral mesencephalic sulcus (LMS). The goal of a study was to compare the surgical exposure to the LMS provided by the subtemporal approach and the paramedian and extreme-lateral variants of the supracerebellar infratentorial approach.

These 3 approaches were used in 10 cadaveric heads.

Cavalcanti et al., performed measurements of predetermined points by using a neuronavigation system. Areas of microsurgical exposure and angles of the approaches were determined. Statistical analysis was performed to identify significant differences in the respective exposures.

The surgical exposure was similar for the different approaches-369.8 ± 70.1 mm2 for the ST; 341.2 ± 71.2 mm2 for the SCIT paramedian variant; and 312.0 ± 79.3 mm2 for the SCIT extreme-lateral variant (p = 0.13). However, the vertical angular exposure was 16.3° ± 3.6° for the ST, 19.4° ± 3.4° for the SCIT paramedian variant, and 25.1° ± 3.3° for the SCIT extreme-lateral variant craniotomy (p < 0.001). The horizontal angular exposure was 45.2° ± 6.3° for the ST, 35.6° ± 2.9° for the SCIT paramedian variant, and 45.5° ± 6.6° for the SCIT extreme-lateral variant opening, presenting no difference between the ST and extreme-lateral variant (p = 0.92), but both were superior to the paramedian variant (p < 0.001). Data are expressed as the mean ± SD.

The extreme-lateral SCIT approach had the smaller area of surgical exposure; however, these differences were not statistically significant. The extreme-lateral SCIT approach presented a wider vertical and horizontal angle to the LMS compared to the other craniotomies. Also, it provides a 90° trajectory to the sulcus that facilitates the intraoperative microsurgical technique 7).


Five cavernous malformations, two juvenile pilocytic astrocytomas, and one peripheral superior cerebellar artery aneurysm located in this region were approached in eight patients. In this extreme lateral approach, the sigmoid sinus is unroofed more superiorly and the bone flap includes not only a posterior fossa craniotomy but also a portion that extends just above the transverse sinus. The dural opening is based along the transverse and sigmoid sinuses. After the cerebrospinal fluid has been drained, the lateral aspect of the brainstem is approached via the cerebellar surface. A proximal tentorial incision offers additional rostral exposure where needed.

Seven patients in this series underwent successful resection of their lesion. The remaining patient’s aneurysm was clipped successfully with no major complications.

The extreme lateral supracerebellar infratentorial approach differs from the midline and paramedian supracerebellar infratentorial variants in the area of exposure, patient positioning, and location of the craniotomy. The technique is effective for approaching the posterolateral mesencephalon8).


The extreme lateral infratentorial supracerebellar approach to treat pathologies located in the ambient cistern and posterior incisural space is a technically feasible route in selected cases. In this cadaveric study, we demonstrate the benefits of endoscope-assisted microsurgical maneuvers using the extreme lateral supracerebellar infratentorial approach.

An endoscope-assisted infratentorial supracerebellar approach was performed in six formalin-fixed cadaveric heads using standard microneurosurgical methods. Dissections were performed in a stepwise fashion, comparing the exposure afforded by the microsurgical route alone to the endoscope-assisted route, using 0- and 30-degree angled lenses. Relationships among the target and the surroundings neurovascular structures were described.

Endoscope-assisted maneuvers for the extreme lateral supracerebellar approach provide an improved operative view and have the potential to reduce parenchymal trauma and neurovascular injuries. The endoscopic techniques bring the surgeon to the anatomy, enhancing illumination and surgical visualization.

Direct visualization of the posterior and posterolateral incisural space avoids retraction of the occipital lobe and damage to the deep venous complex. The extreme lateral infratentorial supracerebellar corridor is effective for approaching the posterolateral mesencephalic junction and the posterior incisural space in selected cases. Endoscope-assisted microsurgery can improve visualization and minimize parenchymal retraction, which should enhance surgical control 9).


For endoscopic-controlled approaches, the extreme lateral approach provides the largest surgical freedom when accessing the ipsilateral superior colliculus (P < 0.0001), the lateral approach provides the largest surgical freedom to the pineal gland (P < 0.0001), and the paramedian craniotomy provides the largest surgical freedom when accessing the splenium (P < 0.0001). The extreme lateral approach to the pineal gland provided the largest horizontal angle of attack (P < 0.0001), and the extreme lateral approach to the ipsilateral superior colliculus provided the largest vertical angle of attack (P < 0.001). The microscope provides marginally increased surgical freedom and a better angle of attack to specific anatomical targets in the paramedian and extreme lateral approach compared with those provided by the endoscope, but these differences are negligible during intraoperative application.

Presurgical planning and a detailed understanding of the important neurovascular structures in the pineal region are paramount to safe and successful surgical execution. Our current cadaveric study indicates that the medial-to-lateral location of craniotomy can maximize access to pineal region targets. Furthermore, the endoscope is a viable alternative to the microscope for identifying pathology of the posterior incisura. These differences in surgical freedom and angle of attack to the pineal region may be useful to consider when planning minimal-access approaches 10).

Videos

A video illustrates the case of a 52-year-old man with a history of multiple bleeds from a lateral midbrain cerebral cavernous malformation, who presented with sudden-onset headache, gait instability, and left-sided motor and sensory disturbances. This lesion was eccentric to the right side and was located in the dorsolateral brainstem. Therefore, the lesion was approached via a right-sided extreme lateral supracerebellar infratentorial (exSCIT) craniotomy with monitoring of the cranial nerves. This video demonstrates the utility of the exSCIT for resection of dorsolateral brainstem lesions and how this approach gives the surgeon ready access to the supracerebellar space, and cerebellopontine angle cistern. The lateral mesencephalic safe entry zone can be accessed from this approach; it is identified by the intersection of branches of the superior cerebellar artery and the fourth cranial nerve with the vein of the lateral mesencephalic sulcus. The technique of piecemeal resection of the lesion from the brainstem is presented. Careful patient selection and respect for normal anatomy are of paramount importance in obtaining excellent outcomes in operations within or adjacent to the brainstem. The link to the video can be found at: https://youtu.be/aIw-O2Ryleg 11).

Case series

Five cavernous malformations, two juvenile pilocytic astrocytomas, and one peripheral superior cerebellar artery aneurysm located in this region were approached in eight patients. In this extreme lateral approach, the sigmoid sinus is unroofed more superiorly and the bone flap includes not only a posterior fossa craniotomy but also a portion that extends just above the transverse sinus. The dural opening is based along the transverse and sigmoid sinuses. After the cerebrospinal fluid has been drained, the lateral aspect of the brainstem is approached via the cerebellar surface. A proximal tentorial incision offers additional rostral exposure where needed.

Seven patients in this series underwent successful resection of their lesion. The remaining patient’s aneurysm was clipped successfully with no major complications 12).

References

1)

Chen X, Feng YG, Tang WZ, Li HT, Li ZJ. A young and booming approach: the extreme lateral supracerebellar infratentorial approach. Neurosci Bull. 2010 Dec;26(6):479-85. doi: 10.1007/s12264-010-1036-7. Review. PubMed PMID: 21113199; PubMed Central PMCID: PMC5560335.
2) , 8)

Vishteh AG, David CA, Marciano FF, Coscarella E, Spetzler RF. Extreme lateral supracerebellar infratentorial approach to the posterolateral mesencephalon: technique and clinical experience. Neurosurgery. 2000 Feb;46(2):384-8; discussion 388-9. PubMed PMID: 10690727.
3)

Ammirati M, Bernardo A, Musumeci A, Bricolo A. Comparison of different infratentorial-supracerebellar approaches to the posterior and middle incisural space: a cadaveric study. J Neurosurg. 2002 Oct;97(4):922-8. PubMed PMID: 12405382.
4)

Ammirati M, Musumeci A, Bernardo A, Bricolo A. The microsurgical anatomy of the cisternal segment of the trochlear nerve, as seen through different neurosurgical operative windows. Acta Neurochir (Wien). 2002 Dec;144(12):1323-7. PubMed PMID: 12478346.
5)

Giammattei L, Borsotti F, Daniel RT. Extreme lateral supracerebellar infratentorial approach: how I do it. Acta Neurochir (Wien). 2019 Apr 1. doi: 10.1007/s00701-019-03886-5. [Epub ahead of print] PubMed PMID: 30937609.
6)

Cavalcanti DD, Morais BA, Figueiredo EG, Spetzler RF, Preul MC. Supracerebellar Infratentorial Variant Approaches to the Intercollicular Safe Entry Zone. World Neurosurg. 2019 Feb;122:e1285-e1290. doi: 10.1016/j.wneu.2018.11.033. Epub 2018 Nov 14. PubMed PMID: 30447444.
7)

Cavalcanti DD, Morais BA, Figueiredo EG, Spetzler RF, Preul MC. Surgical approaches for the lateral mesencephalic sulcus. J Neurosurg. 2019 Apr 12:1-6. doi: 10.3171/2019.1.JNS182036. [Epub ahead of print] PubMed PMID: 30978690.
9)

Rehder R, Luiz da Costa MP, Al-Mefty O, Cohen AR. Endoscope-Assisted Microsurgical Approach to the Posterior and Posterolateral Incisural Space. World Neurosurg. 2016 Jul;91:210-7. doi: 10.1016/j.wneu.2016.04.017. Epub 2016 Apr 16. PubMed PMID: 27090972.
10)

Zaidi HA, Elhadi AM, Lei T, Preul MC, Little AS, Nakaji P. Minimally Invasive Endoscopic Supracerebellar-Infratentorial Surgery of the Pineal Region: Anatomical Comparison of Four Variant Approaches. World Neurosurg. 2015 Aug;84(2):257-66. doi: 10.1016/j.wneu.2015.03.009. Epub 2015 Mar 28. PubMed PMID: 25827042.
11)

Kalani MYS, Couldwell WT. Extreme Lateral Supracerebellar Infratentorial Approach to the Lateral Midbrain. J Neurol Surg B Skull Base. 2018 Dec;79(Suppl 5):S415-S417. doi: 10.1055/s-0038-1669981. Epub 2018 Sep 25. PubMed PMID: 30456047; PubMed Central PMCID: PMC6240419.
12)

Vishteh AG, David CA, Marciano FF, Coscarella E, Spetzler RF. Extreme lateral supracerebellar infratentorial approach to the posterolateral mesencephalon: technique and clinical experience. Neurosurgery. 2000 Feb;46(2):384-8; discussion 388-9. PubMed PMID: 10690727.
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