• Salomon Cohen-Cohen, Aaron A Cohen-Gadol, Juan L Gomez-Amador, Joao T Alves-Belo, Kushal J Shah, and Juan C Fernandez-Miranda.
• Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
• Oper Neurosurg (Hagerstown). 2019 Mar 1; 16 (3): 351-359.

BackgroundDue to the critical neurovascular structures that surround the pulvinar, deciding the best surgical approach can be challenging, with multiple options available.ObjectiveTo analyze and compare the ipsilateral vs the contralateral version of the 2 main approaches to the cisternal pulvinar surface: paramedian supracerebellar infratentorial (PSCI) and interhemispheric occipital transtentorial (IOT).MethodsThe PSCI and IOT approaches were performed on 7 formalin-fixed adult cadaveric heads to evaluate qualitatively and quantitatively the microsurgical exposure of relevant anatomic structures. We quantitatively measured the corridor distance to our target with each approach.ResultsThe ipsilateral PSCI approach provided an easier access and a better exposure of the anteromedial portion of the cisternal pulvinar surface. The contralateral approach provided a wider and more accessible exposure of the posterolateral portion of the cisternal pulvinar surface. When protrusion of the posterior parahippocampal gyrus above the free edge of the tentorium was present, the contralateral PSCI approach provided an unobstructed view to both areas. The IOT approach provided a better view of the anteromedial portion of the cisternal pulvinar surface, especially with a contralateral approach.ConclusionMultiple approaches to the pulvinar have been described, modified, and improved. Based on this anatomic study we believe that although the corridor distance with a contralateral approach is longer, the surgical view and access can be better. We recommend the use of a PSCI contralateral approach especially when a significant protrusion of the posterior parahippocampal gyrus is present.Copyright © 2018 by the Congress of Neurological Surgeons.

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