We searched MEDLINE and Google Scholar for studies containing terms related to the surgical management of brainstem lesions to determine the most frequently discussed safe entry zones. It is critical to note that large lesions may distort safe entry zones and that neurophysiological monitoring is a critical adjunct in these cases. Through detailed dissection images of these approaches, we visually demonstrate what can be seen on the brainstem surface through each of these corridors and delineate the safe entry zones provided by each approach. We examined 13 safe entry zones on the brainstem, which have been described in the literature, and used detailed cadaveric dissections to evaluate the main surgical approaches currently employed to manage intrinsic brainstem lesions. The aim of our study was to enhance the planning and use of microsurgical resection techniques for intrinsic brainstem lesions. Such zones represent entry points and trajectories where eloquent structures and perforators are sparse and where a neurotomy would cause the least possible damage. Awareness of the main safe entry zones on the brainstem is key to reducing morbidity for any lesion that does not emerge to the pial or ependymal surface. ![]() Nevertheless, the brainstem, roughly the size of the human thumb, contains a rich concentration of nuclei and fibers in a small sectional area, resulting in a high likelihood of morbidity after manipulation. Knowledge of different skull base exposures, gained through laboratory dissections, allows neurosurgeons to approach lesions in the brainstem. 33 The development and improvement of complex skull base surgical approaches and incremental advances in neuroimaging, parallel to image-guided surgery, allowed a few authors to safely and effectively resect lesions in the brainstem. 15 Concurrent with Epstein and McCleary’s report, Raimondi would rationally state that to have the child merely survive (i.e., with severe neurological deficits) is no justification for surgery. By 1986, Epstein and McCleary reported that surgery was feasible with reasonable morbidity and mortality. 25 were among the first to advocate surgical intervention. ![]() 3 declared this subject to be a pessimistic chapter in neurosurgery 30 years later, Matson and Ingraham 26 would still claim such lesions were inoperable. The surgical extirpation of focal gliomas, cavernous malformations, or hemangioblastomas within the brainstem has caused heated discussions in scientific meetings and the literature. H istorically, the surgical management of intrinsic brainstem lesions has been controversial.
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