OPERATIVE NUANCES

TRANSCALLOSAL TRANSCHOROIDAL APPROACH TO

TUMORS OF THE THIRD VENTRICLE
Hahnah J. Kasowski, M.D.
Department of Neurosurgery,
Yale University
School of Medicine,
New Haven, Connecticut
Brian V. Nahed, M.D.
Department of Neurosurgery,
Yale University
School of Medicine,
New Haven, Connecticut
ALTHOUGH THE LITERATURE is rich with descriptions of the approach to the third
ventricle, surgeons remain cautiously reserved. In this report, we demonstrate that the
transcallosal approach can be easily performed provided that preoperative planning is
adequate. Familiarity with the course of major cortical and deep draining veins grants
the surgeon a wide exposure of the posterior third ventricle. We discuss the indica-
tions, surgical technique, and pitfalls to this approach while providing an accompa-
nying video mirroring our discussion.
KEY WORDS: Third ventricle tumor, Transcallosal, Transchoroidal
Neurosurgery 57[ONS Suppl 3]:ONS-361–ONS-366, 2005 DOI: 10.1227/01.NEU.0000176652.59747.40

Joseph M. Piepmeier, M.D.

Department of Neurosurgery,

Yale University
School of Medicine,
New Haven, Connecticut
Reprint requests:
Joseph M. Piepmeier, M.D.,
Department of Neurosurgery,
Yale University
School of Medicine, TMP 4,
333 Cedar Street,
New Haven, CT 06510.
Email: joseph.piepmeierl@yale.edu
Received, January 16, 2004.
Accepted, May 19, 2005.
W ILLUSTRATIVE CASE
e present the surgical treatment of a
tumor in the posterior third ventri-
cle using a transcallosal approach.
Third ventricular tumors are relatively rare,
and few neurosurgeons approach these tu-
mors regularly, although much has been writ-
ten on this topic (1–9). The transcallosal ap-
proach provides excellent exposure to third
ventricular lesions, but careful preoperative
planning and knowledge of the anatomy is
necessary to prevent complications. In partic-
ular, care should be taken to understand and
predict the course of major cortical and deep
draining veins with preoperative imaging. We
discuss the indications, surgical technique,
and pitfalls to this approach.
PREOPERATIVE PLANNING
A clear understanding of venous anatomy
is critical for the success of this operation.
Adequate access to the corpus callosum and
third ventricle requires that the surgeon estab-
lish an interhemispheric corridor that is 2 to 3
cm in diameter. Because the location of major
cortical draining veins can limit this access
and dictate the side on which the craniotomy
is based, a magnetic resonance venogram, in
addition to standard magnetic resonance im-
aging (MRI) sequences, proves to be quite use-
ful. Although we usually plan to approach the
ventricular system from the nondominant
hemisphere, we may choose to enter on the
opposite side if a wider corridor is available.
The patient was a 21-year-old woman who pre-
sented with a history of progressive headaches over
a period of 1 month. MRI demonstrated hydroceph-
alus and a posterior third ventricular mass (Fig. 1).
The patient initially underwent endoscopic third
ventriculostomy and tumor biopsy, which was di-
agnostic of ependymoma. The third ventriculos-
tomy was successful, and subsequent imaging dem-
onstrated resolution of her hydrocephalus. Given
the natural history of ependymoma, a complete ex-
cision of the tumor was planned.
PATIENT POSITIONING
The patient was positioned supine, with the
left shoulder elevated by a shoulder roll. The
head was then rotated such that the coronal
suture was oriented in the vertical plane and
the right hemisphere was inferior. We prefer
to have the right side down so that gravity
aids in the retraction of the hemisphere. The
head was fixed with a Mayfield frame, and a
linear bicoronal incision was prepared and
draped.
CRANIOTOMY
(see video at web site)
A bone flap that is centered two-thirds in
front of and one-third behind the coronal su-
ture is generally sufficient, but the bone flap
may need to be moved slightly more anteri-
orly or posteriorly, depending on venous
anatomy and location of the tumor (Fig. 2,

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KASOWSKI ET AL.
FIGURE 1. Preoperative MRI
images (A, axial; B, sagittal; C,
coronal).
inset). In this patient, because the tumor was located in the
posterior third ventricle, our bone flap was made slightly
more anterior to provide better direct visualization of the
posterior third ventricle. The bone flap should allow several
centimeters of visualization of the right hemisphere and ex-
tend just past the sagittal sinus on the left. To prevent damage
to the sinus, we prefer to take the bone flap in two pieces: first,
taking a bone flap over the right hemisphere that extends just
to the right of midline; next, dissecting the sagittal sinus from
the bone just medial to the previous bone flap. The bone over
the sagittal sinus is then removed.
It is critical that the dural opening provide exposure up to
the edge of the superior sagittal sinus. We begin opening the
dura laterally and then carefully extend the opening toward
the midline where the dural flap is based. It is not uncommon
to find that dominant frontal cortical veins enter the dura
lateral to the superior sagittal sinus. When this occurs, the
dura can be incised on either side of the vein such that a dural
roof is formed over the vein, sparing the vein. Dural tenting
stitches are then placed such that the dura is carefully re-
tracted across the midline to the sagittal sinus. Care must be
taken not to place too much tension on the dural flap, because
this can partially or completely occlude the sagittal sinus.
INTERHEMISPHERIC DISSECTION
Brain relaxation is critically important to minimize
retraction-induced injury and should occur before interhemi-
spheric dissection. A combination of hyperventilation, osmotic
dieresis, and ventricular drainage can be used. We routinely
ONS-362 | VOLUME 57 | OPERATIVE NEUROSURGERY 4 | OCTOBER 2005
FIGURE 2. Transcallosal approach to the lateral and third ventricles.
Inset, we positioned the head and extended the scalp incision (solid line),
which allowed us to turn the bone flap (broken line) across the superior
sagittal sinus. A, using an incision in the anterior part of the corpus cal-
losum, we exposed the body and frontal horn of the right lateral ventricle.
B, there are several possible incisions used to reach lesions in the third
ventricle: 1, the foramen of Monro may be enlarged by incising the ipsilat-
eral column of the fornix at the anterosuperior margin of the foramen of
Monro; 2, the transforniceal approach is completed using an incision along
the body of the fornix in the midline; and 3, the transchoroidal approach is
completed by opening the choroidal fissure by incising along the tenia for-
nicis. C, the transchoroidal approach requires an incision along the tenia
fornicis rather than the tenia thalami to avoid the many veins and arteries
that pass through the tenia thalami. Notice the internal cerebral veins that
run along the roof of the third ventricle (from, Rhoton AL Jr: The supra-
tentorial cranial space: Microsurgical anatomy and surgical approaches.
Neurosurgery 51[Suppl 1]:S207–S272, 2002 [9]).
give 0.5 g/kg of mannitol at skin incision and maintain the
end-tidal CO2 in the range of 25 to 30 mm Hg. If the brain is
not adequately relaxed at this point, a ventricular drain can be
placed ipsilateral to the craniotomy. However, large tumors
may necessitate placement of a contralateral ventriculostomy.
A self-retaining retractor system is brought onto the field
and used to gently retract the right hemisphere. The operating
microscope is then brought in and used for the remainder of
the operation. Both blunt and sharp dissecting instruments are
used to develop the plane along the falx and then between the
cingulate gyri. The pericallosal arteries must then be identi-
fied. Once the surgeon is sure of their course, the corpus
callosum can be identified by its relative hypovascularity and
pale white color.
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 TRANSCALLOSAL TRANSCHOROIDAL APPROACH
CALLOSOTOMY
The callosal incision is planned between the two anterior
cerebral arteries with the goal of entering the right lateral
ventricle. We suggest incising the callosum just beneath the
right anterior cerebral artery, aiming slightly toward the right
hemisphere. The surgeon should avoid dissecting toward the
left side because of the effect of the right-side-down head
positioning and the resultant shift of the right hemisphere.
Both of these techniques will help to keep the callosum from
opening into the left ventricle or in line with the attachment of
the septum pellucidum. Although this is not necessarily a
problem, it can cause unnecessary confusion.
The length and placement of the callosotomy is determined
by the location and size of the tumor. Our callosal incision in
this case measures approximately 2 cm in length and is made
with bipolar coagulation and suctioning with a 6-French suc-
tion tip. The corpus callosum can be variable in thickness,
depending on the underlying tumor mass and/or preexisting
hydrocephalus, and can be stretched to just a few millimeters.
In this patient, the corpus callosum was relatively thick, mea-
suring approximately 1 cm. The exact placement of the callo-
sotomy may vary, depending on the surgical window af-
forded by the cortical draining veins. The preoperative MRI
scan may be helpful in localizing the preferred distance of the
callosotomy from the genu of the corpus callosum. The
ependymal lining is recognized by its deep gray coloring just
before the ventricle is entered. Once the ventricle is opened, a
self-retaining retractor blade can be advanced just into the
ventricle.
TRANSCHOROIDAL DISSECTION
Once the ventricle is opened, it is important to first establish
normal landmarks. The structure that is most obvious and easiest
to identify is the choroid plexus, which can be followed anteri-
orly to the foramen of Monro. Further identification of the septal
and thalamostriate veins can be used to determine which ventri-
cle has been opened (Fig. 2A). In the right lateral ventricle, the
thalamostriate vein is to the right of the choroid plexus. If callosal
sectioning has led to the contralateral ventricle, the septum pel-
lucidum can be opened to gain access to the contralateral side.
Should this occur, however, the surgeon must take care to pre-
serve the fornices at the base of the septum.
Below the fornix, the roof of the third ventricle is composed of
two layers of the tela choroidea and the velum interpositum, a
vascular space that is located between these layers. The internal
cerebral veins and the medial posterior choroidal arteries run
within the velum interpositum. Our approach was through the
tela choroidea and velum interpositum into the third ventricle.
Dissection through the tela choroidea should be performed
medial to the choroidal fissure in the tenia fornicis rather than in
the tenia thalami, because the veins that drain the internal cap-
sule and medial hemisphere pass through the tenia thalami and
should not be sectioned (Fig. 2, B and C). We prefer to begin the
dissection by gently lifting the choroid plexus, coagulating it, and
NEUROSURGERY
TO THIRD VENTRICLE
then removing it along its insertion at the choroid fissure, allow-
ing for visualization of the choroidal fissure. We begin our dis-
section along the medial edge of the choroidal fissure while
gently elevating the adjacent fornix to avoid inadvertent damage.
Once the tenia fornix is divided, the velum interpositum is en-
tered and the internal cerebral veins and the medial posterior
choroidal arteries are visualized. These vessels should be re-
tracted laterally until the lower layer of tela is visualized, which
may then also be divided (Fig. 3).
The choroid plexus of the third ventricle, the massa inter-
media, and the floor of the third ventricle are now seen. A
small portion of the tumor can also be seen below the massa
intermedia. At this point, we encountered two anatomic struc-
tures that limited our view and approach to the tumor. The
first was a large massa intermedia. This patient was known
from the preoperative imaging to have a large massa interme-
dia, and as expected, the massa intermedia significantly ob-
structed our view of the posterior third ventricle and tumor.
As mentioned, this patient had had a previous endoscopic
third ventriculostomy, which alleviated her hydrocephalus.
We suspect that if the patient had still had significant hydro-
cephalus, the massa intermedia would have been significantly
stretched and easier to work around. However, in this case, we
were forced to divide it so as to better visualize and resect the
tumor, a maneuver that we have not previously had to per-
form. Postoperatively, the patient experienced no appreciable
neurological deficit from this maneuver.
After the massa intermedia was sectioned, our entry into the
third ventricle was also limited by two thalamostriate veins.
We initially attempted to dissect the anterior vein from the
lateral wall of the ventricle. However, when this proved dif-
ficult, we thought that it was preferable to sacrifice the vein
rather than risk its rupture. Rarely do we sacrifice draining
veins; however, when there is duplication of the venous drain-
age, as in this patient, we have not had complications when a
single vein is sacrificed.
LESION EXCISION
Tumor resection is facilitated by maintaining the dissection
plane between the ependyma and the lesion. Because it is not
uncommon for intraventricular tumors to grow slowly and be-
come quite large, we often must first decompress the tumor and
then identify the space between the tumor edge and ependyma.
Determining the type of tumor is important in predicting
the blood supply. Papillomas and meningiomas, for example,
receive their blood supply from the choroidal vessels. With
these tumors, early identification and transection of these
vessels will significantly reduce bleeding. In contrast, tumors
that arise from the ependymal surface and septum pelluci-
dum, such as gliomas and neurocytomas, receive their blood
supply from the small vessels of the ventricular walls. In this
patient, the blood supply was encountered after primary de-
bulking. These vessels tend to be smaller and cause less blood
loss but still require meticulous dissection and good
visualization.
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KASOWSKI ET AL.

FIGURE 3. Transchoroidal approached the posterior

approach to the third ventricle part of the tumor beneath the
directed along the forniceal side posterior commissure, many
of the choroidal fissure. A, supe- small tumor vessels were en-
rior view of the frontal horn and countered. Visualization of
body of the lateral ventricle. The
the most posterior portion of
body of the fornix forms the
upper part of the roof of the
the tumor was limited by the
third ventricle. The left thalam- overlying posterior commis-
ostriate vein passes through the sure. The resection continued
posterior margin of the foramen until we felt that the risk of
of Monro, and the right thalam- further resection outweighed
ostriate vein passes through the the risk of some small resid-
choroidal fissure a few millime- ual tumor. Although we
ters behind the foramen. Ante- strive for a complete tumor
rior septal and anterior caudate excision, extending the resec-
veins cross the wall of the fron-
tion into the underlying mid-
tal horn. Posterior septal and
posterior caudate veins cross the
brain can be devastating and
wall of the body of the lateral should not be attempted if
ventricle. The thalamus sits in the tumor plane is unclear.
the floor of the body. The choroi- After tumor resection, it is
dal fissure, located between the important to ensure complete
thalamus and fornix, is opened hemostasis. To prevent ven-
by dividing the tenia fornix, tricular obstruction and hy-
which attaches the choroid drocephalus, blood that may
plexus to the lateral edge of the have accumulated should be
fornix, leaving the attachment of
gently irrigated out of the
the choroid plexus to the thala-
mus undisturbed. B, enlarged
ventricular system. The ven-
view. The columns of the fornix tricles are then filled with sa-
form the anterior and superior line to displace any air that
walls of the foramen of Monro. may have become trapped. A
The massa intermedia is seen ventricular catheter is left for
through the foramen. Anterior 24 to 48 hours to measure
and posterior septal veins cross ventricular pressure and to
the septum pellucidum and for- demonstrate that the ventric-
nix. C, the tenia fornix, which attaches the choroid plexus to the fornix, ular system is patent. A com-
has been divided and the body of the fornix retracted medially to expose
puted tomographic or MRI
the internal cerebral vein and medial posterior choroidal arteries. The
lower layer of tela, which attaches to the striae medullaris thalami and
scan is obtained on the first
forms the floor of the velum interpositum, is intact. D, the separation of postoperative day to check
the fornix and choroid plexus has been extended posteriorly to the junc- for obstruction and to evalu-
tion of the atrium and body of the ventricle. The lower layer of tela ate the resection. Postopera-
remains intact. E, the lower layer of tela has been opened to expose the tively, the patient was neuro-
massa intermedia, the posterior commissure, and the floor of the third logically intact and did not
ventricle. The ependymal covering of the anterior septal vein has been experience any complications
opened so that a short segment of the vein can be mobilized. The possi- related to the procedure.
bility of damaging the thalamostriate vein is reduced by allowing the
choroid plexus to remain attached to the thalamus and the upper surface
of the vein (from, Rhoton AL Jr: The supratentorial cranial space: LIMITATIONS OF
Microsurgical anatomy and surgical approaches. Neurosurgery THIS APPROACH
51[Suppl 1]:S207–S272, 2002 [9]).
This case demonstrates that
the transcallosal approach is
easily performed, provided
that the surgeon is familiar
The tumor was small, and initial tumor removal was easily with the anatomy and achieves wide exposure of the posterior
accomplished with suctioning. As the tumor was aspirated, third ventricle. However, postoperative imaging revealed small
the cerebral aqueduct was visualized. The previous third ven- residual tumor in the posterior third ventricle (Fig. 4). In this
triculostomy was also appreciated more anteriorly. As we patient, our exposure was limited in the pineal recess of the third

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 TRANSCALLOSAL TRANSCHOROIDAL APPROACH
ventricle, which might have
been avoided if the surgery
had been performed before
resolution of the patient’s
hydrocephalus, because this
approach is greatly facili-
tated by a dilated ventricular
system. Alternatively, the oc-
cipital transtentorial ap-
proach might have provided
better access to the posterior
third ventricle; however, a
discussion of this approach
is beyond the scope of this
article and is useful for le-
FIGURE 4. Postoperative axial MRI
sions in the pineal recess of scan.
the third ventricle. Although
a gross total resection would
have been preferred, we stress that the risks of inadvertently
entering the underlying midbrain far outweigh the benefit of a
gross total resection if the margins are difficult to identify. In the
future, we may also use the endoscope in the open transcallosal
approach. Several authors have recently described the use of the
endoscope in open surgery to provide better visualization of
deep structures not easily seen with the standard operating
microscope.
REFERENCES
1. Apuzzo MLJ (ed): Surgery of the Third Ventricle. Baltimore, Williams &
Wilkins, 1998, ed 2.
2. Apuzzo MLJ, Chikovani OK, Gott PS, Teng EL, Zee CS, Giannotta SL, Weiss MH:
Transcallosal, interfornicial approaches for lesions affecting the third ventricle: Sur-
gical considerations and consequences. Neurosurgery 10:547–554, 1982.
3. Apuzzo MLJ, Litofsky NS: Surgery in and around the anterior third ventricle,
in Apuzzo MLJ (ed): Brain Surgery: Complication Avoidance and Management.
New York, Churchill Livingstone, 1993, pp 541–579.
4. Kasowski HJ, Piepmeier JM: Transcallosal approach for tumors of the lateral
and third ventricles. Neurosurg Focus 10:Article 3, 2001.
5. Lavyne MH, Patterson RH: Subchoroidal trans-velum interpositum ap-
proach, in Apuzzo MLJ (ed): Surgery of the Third Ventricle. Baltimore, Williams
& Wilkins, 1998, ed 2, pp 453–469.
6. Piepmeier JM: Tumors and approaches to the lateral ventricles: Introduction
and overview. J Neurooncol 30:267–274, 1996.
7. Piepmeier JM, Spencer DD, Sass KJ, George TM: Lateral ventricular masses,
in Apuzzo MLJ (ed): Brain Surgery: Complication Avoidance and Management.
New York, Churchill Livingstone, 1993, pp 581–600.
8. Rhoton AL Jr: The supratentorial cranial space: Microsurgical anatomy and
surgical approaches. Neurosurgery 51[Suppl 1]:S207–S272, 2002.
9. Wen HT, Rhoton AL Jr, de Oliveira EP: Transchoroidal approach to the third
ventricle: An anatomic study of the choroidal fissure and its clinical applica-
tion. Neurosurgery 42:1205–1217, 1998.
COMMENTS
K asowski et al. review the transcallosal transchoroidal approach to
tumors of the third ventricle. Although the authors present little
new information, they have created a good resource for residents or
practicing neurosurgeons to review this elegant approach. A concise,
pertinent video is provided, as are anatomic drawings.
NEUROSURGERY
TO THIRD VENTRICLE
We agree that positioning the head so that longitudinal access is
parallel to the floor is preferable to positioning it so that longitu-
dinal access is perpendicular to the floor. As the authors note, an
advantage of this horizontal position is that gravity is used to allow
the ipsilateral hemisphere to fall away, thus naturally providing a
larger interhemispheric corridor. The second advantage to this
position is that the surgeon’s hands can work side by side. This
position is much more comfortable and convenient than the su-
peroinferior hand position required when operating with the head
in the vertical position.
We have found that when a wider corridor is needed to access the
third ventricle via the transcallosal approach, the septal vein can be
sacrificed and cut. The opening through the velum interpositum can
then be extended to incorporate the foramen magnum. The result is a
relatively large corridor into the third ventricle. In our experience,
sacrifice of the septal vein has minimal or no negative ramifications
for the patient.
Jeffrey Klopfenstein
Robert F. Spetzler
Phoenix, Arizona
K asowski et al. present one approach for the removal of tumors
located in the third ventricle. As an example, the authors demon-
strate a case of a 21-year-old woman with a third ventricular ependy-
moma that became symptomatic with obstructive hydrocephalus.
After a third ventriculocisternostomy, the authors performed a tran-
scallosal approach in a second surgery and removed the lesion
incompletely.
This is an excellent case for the presentation and indication of
this approach. The article gains from its detailed description of
surgical steps, including positioning, attention to brain relaxation,
and dealing with bridging veins and the sagittal sinus. Pitfalls and
important planning details, such as respecting the cortical draining
veins in the planning of the side of the craniotomy, are underlined.
In our opinion, surgery in this area benefits greatly from neu-
ronavigation, especially in the planning of the craniotomy with
respect to cortical draining veins. We completely agree with the
authors regarding the planning of the craniotomy, if possible, in the
nondominant hemisphere. Not only cortical draining veins but also
the location and lateral growth of the lesion can change the plan-
ning of the craniotomy in this approach.
The authors show their experience with this approach in their
description of how to avoid opening of a wrong-sided ventricle or a
cavum septi pellucidi or cavum vergae. Regarding the transchoroidal
dissection, they point out the importance of anatomic identification
and respecting the fornix and deep draining veins.
Regarding the preoperative ventriculocisternostomy, we agree
with the authors that the surgical procedure might be easier and
more successful if they had not performed it preoperatively. Even
the division of the adhesio interthalamica (massa intermedia)
might have been avoided. If really necessary, we would recom-
mend the introduction of a temporary ventricular drainage that can
be closed before surgical tumor removal. This will render micro-
surgery in the third ventricle much easier, and obstruction of the
massa intermedia and thalamostriate veins would be diminished.
We have to point out that third ventriculocisternostomy is a more
dangerous procedure than a ventricular drainage, especially be-
cause the procedure might be unnecessary after a successful
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KASOWSKI ET AL.
surgery. This article offers a lot of insight into the application and
indications of this anatomically interesting approach.
Wolf Lüdemann
Madjid Samii
Hannover, Germany
T his is a very nice description of the transchoroidal approach to the
third ventricle, with excellent illustrations. The advantage of this
technique is to spare the veins.
The authors are very cautious in performing six burr holes for the
craniotomy in two flaps. One or two burr holes on the midline over
the sagittal sinus might be enough in young patients.
The transchoroidal approach is particularly suitable for tumors in
the midportion of the third ventricle. The tumor in the present patient
is in the posterior third ventricle, and I would have preferred an
occipital transtentorial approach.
Nicholas de Tribolet
Geneva, Switzerland
T he authors present their treatment of tumors involving the posterior
third ventricle using a transcallosal approach. They emphasize that
the transcallosal approach provides excellent exposure when coupled
with diligent and careful preoperative planning. Knowledge of the sa-
lient venous anatomy, variants of the choroidal fissure anatomy, and
three-dimensional relationships of the fissure to the pineal region and
quadrigeminal plate cistern is requisite to prevent complications. Preop-
erative understanding of midline draining veins is essential in tailoring
the approach to minimize venous sacrifice and compromise. The use of
ONS-366 | VOLUME 57 | OPERATIVE NEUROSURGERY 4 | OCTOBER 2005
gravity to aid in the retraction of the hemisphere is also an important
factor. We use the three-quarter lateral position to maximize this. In
addition, we prefer soft retraction with rolled patties placed at the ante-
rior and posterior limits of the interhemispheric corridor.
Although the authors suggest an interhemispheric corridor that is 2
to 3 cm in diameter, we have had good results with smaller ap-
proaches, given that the anteroposterior dimension of the corridor is
more important than the lateral dimension (which only promotes the
potential for excessive retraction). We also prefer to take the flap as a
single piece and actually use the drill to place burr holes over the
midline. We have not had a problem with sinus injury using this
approach in children, given that the ability to separate the dura from
the overlying bone is easier in younger children. In addition to dural
tenting stitches, as noted, we also place dural sutures in the falx for
additional retraction. The use of ventricular drainage to allow for
relaxation of the brain cannot be overemphasized. A 2-cm callosal
incision will usually allow for any approach in this region. In addition,
as the authors note, the surgeon must take care to preserve the
fornices at the base of the septum. It is also important that dissection
through the tela choroidea is performed medial to the choroidal
fissure in the tenia fornicis rather than in the tenia thalami.
Finally, although complete excision is an appropriate goal, extend-
ing the resection into the underlying midbrain can be devastating and
should not be attempted if the tumor plane is unclear. The only other
consideration is the use of concurrent endoscopy, as initially described
by Perneczky, which is now common in a number of institutions.
Michael L. Levy
San Diego, California
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