Surgical approaches for brainstem tumors in pediatric patients

To analyze the pathways to brainstem tumors in childhood, as well as safe entry zones. 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 So Paulo Federal University from 1991 to 2011. 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 %. 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.