Surgical approaches for brainstem tumors in pediatric patients.
OBJECTIVE
To analyze the pathways to brainstem tumors in childhood, as well as safe entry zones.


METHODS
We conducted a retrospective study of 207 patients less than 18 years old who underwent brainstem tumor resection by the first author (Cavalheiro, S.) at the Neurosurgical Service and Pediatric Oncology Institute of the São Paulo Federal University from 1991 to 2011.


RESULTS
Brainstem tumors corresponded to 9.1 % of all pediatric tumors operated in that same period. Eleven previously described "safe entry zones" were used. We describe a new safe zone located in the superior ventral pons, which we named supratrigeminal approach. The operative mortality seen in the first 2 months after surgery was 1.9 % (four patients), and the morbidity rate was 21.2 %.


CONCLUSIONS
Anatomic knowledge of intrinsic and extrinsic brainstem structures, in association with a refined neurosurgical technique assisted by intraoperative monitoring, and surgical planning based on magnetic resonance imaging (MRI) and tractography have allowed for wide resection of brainstem lesions with low mortality and acceptable morbidity rates.
Department of Neurosurgery, Pediatric Oncology Institute, Federal University of Sao Paulo, Sao Paulo, Brazil. sergiocavalheironeuro@gmail.com.|, Rua Botucatu, 591, conj 41, CEP: 04023-062, Sao Paulo, SP, Brazil. sergiocavalheironeuro@gmail.com.
Sergio
S
Cavalheiro
Department of Neurosurgery, University of Florida, College of Medicine, Gainesville, FL, USA.
Kaan
K
Yagmurlu
Department of Neurosurgery, Federal University of Sao Paulo, Sao Paulo, Brazil.
Marcos Devanir Silva
MD
da Costa
Department of Neurosurgery, Pediatric Oncology Institute, Federal University of Sao Paulo, Sao Paulo, Brazil.
Jardel Mendonça
JM
Nicácio
Department of Neurosurgery, Federal University of Sao Paulo, Sao Paulo, Brazil.
Thiago Pereira
TP
Rodrigues
Department of Neurosurgery, Vascular Division, Federal University of Sao Paulo, Sao Paulo, Brazil.
Feres
F
Chaddad-Neto
Department of Neurosurgery, University of Florida, College of Medicine, Gainesville, FL, USA.
Albert L
AL
Rhoton
D000293:Adolescent; D001933:Brain Stem / Q000473:pathology* / Q000601:surgery; D020295:Brain Stem Neoplasms / Q000473:pathology / Q000601:surgery*; D002648:Child; D002675:Child, Preschool; D005260:Female; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D019635:Neurosurgical Procedures / Q000379:methods*; D012189:Retrospective Studies
Brainstem surgery; Low-grade astrocytoma; Pediatric brainstem gliomas; Safe entry zone; Supratrigeminal approach; White fiber anatomy