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The Contralateral Transcingulate Approach: Operative Technique and Results With Vascular Lesions

Davies, Jason MD, PhD*; Tawk, Rabih G. MD; Lawton, Michael T. MD*

doi: 10.1227/NEU.0b013e318246a7f8
Operative Nuances

BACKGROUND: The contralateral transcingulate approach is a variation of the contralateral transcallosal approach for lesions located in the cingulate gyrus and deep white matter of the medial frontal lobe.

OBJECTIVE: To more thoroughly describe the contralateral transcingulate approach by reporting our operative technique and results.

METHODS: This approach positions the head with the midline horizontally, lesion on the upside, allowing gravity retraction of the dependent frontal lobe. Bifrontal craniotomy and splitting of the interhemispheric fissure create a crossing trajectory from the contralateral fissure to the ipsilateral cingulate gyrus that maximizes lateral exposure.

RESULTS: Eleven patients with vascular lesions were treated with the contralateral transcingulate approach (9 patients with cavernous malformations and 2 patients with arteriovenous malformations). Eight lesions were located on the left side, 5 in the cingulate gyrus, and 6 in the deep frontal lobe. The falx was cut in 5 patients to extend the crossing trajectory. All lesions were removed completely, with neurological morbidity in 1 patient caused by venous infarction.

CONCLUSION: Although similar to the contralateral transcallosal approach, the contralateral transcingulate approach accesses lesions outside the ventricle and has a steeper crossing trajectory. This approach requires no disruption of brain tissue with lesions on the cingulate surface and only a small incision in cingulate gyrus with lesions in the deep frontal lobe. The ipsilateral pericallosal and callosomarginal arteries provide dependable landmarks for transcingulate dissection. The contralateral transcingulate approach offers an alternative medial approach to lesions near language and motor areas and avoids lateral transcortical approaches, awake speech mapping, and risk to eloquent cortex in the dominant hemisphere.

ABBREVIATIONS: AVM, arteriovenous malformation

CM, cavernous malformation

SSS, superior sagittal sinus

*Department of Neurological Surgery, University of California, San Francisco, San Francisco, California

Mayo Clinic, Jacksonville, Florida

Correspondence: Michael T. Lawton, MD, Department of Neurological Surgery, University of California, San Francisco, 505 Parnassus Avenue, M780, Box 0112, San Francisco, CA 94143-0112. E-mail: lawtonm@neurosurg.ucsf.edu

Received July 22, 2011

Accepted November 30, 2011

Copyright © by the Congress of Neurological Surgeons