Neurosurgery notes/Procedures/Cranial procedures/Approaches/Skull base approaches/Posterior fossa approaches/Extreme lateral supracerebellar infratentorial (ELSCIT) approach

Extreme lateral supracerebellar infratentorial (ELSCIT) approach

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Posterior fossa approaches

Indications

  • Approach for disease processes in the
    • Posterolateral mesencephalon and upper pons
    • Ambient and crural cisterns
    • Posterior and middle incisural spaces
    • Tentorial edge and lateral midbrain region
    • Splenium and pulvinar of the thalamus (in extended versions

Positioning

Semi-sitting position
Semi-sitting position
 
Lateral positions
Lateral positions

Incision

  • Retroauricular incision is extended slightly cranially, allowing exposure of the transverse sinus; with slight retraction, this incision thus increases exposure of the cerebellomesencephalic fissure

Approach

  • The dissection is carried out along the tentorial surface of the cerebellum to the limits of the posterior incisural space.
  • Small bridging veins can be coagulated and divided close to the cerebellar surface to avoid avulsion from the tentorium.
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  • The ELSCIT offers an oblique view of the quadrigeminal plate.
  • A neurotomy over the inferior brachium triangular zone (IBTZ, dashed line) is depicted in this dissection.
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  • A straightforward corridor to the lateral mesencephalic sulcus (LMS, dashed line) is possible with such an approach, retracting the superior cerebellar artery (SCA) and the trochlear nerve (cranial nerve [CN] IV).
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  • Area of exposure provided by the ELSCIT approach, providing a wide view of the posterolateral midbrain as well as the safe zones cited above (dashed line represents the LMS safe entry zone).
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  • Surgical view of the cerebellomesencephalic fissure, after the quadrigeminal and ambient cisterns were opened.
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  • The SCA and the trochlear nerve (CN IV) are dissected free and kept away from the resection field.
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  • Final view of the microsurgical site through the LMS, depicting complete resection of the lesion.
 
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Pros

  • Avoids temporal lobe retraction risks seen in subtemporal approaches (protecting the vein of Labbé)
  • Provides direct posterolateral access with minimal brain manipulation
  • Can be combined with tentorial incision for additional exposure of the crural cistern and upper clival region
  • Offers a versatile corridor for both intra-axial and extra-axial pathologies, including vascular, neoplastic, and cavernous lesions