Contralateral Interhemispheric Transfalcine Transprecuneus Approach: Advancing Operative Angles to Deep-Seated Lesions

The reach to expose the peritrigonal/atrial territories poses special challenges. The highly functional overlying cortices and white matter tracts, such as the optic radiations lateral to the ventricle, postcentral gyrus laterally and more superficially, and the thalamus anteroinferiorly, constrain the surgical corridors to the atrium. Standard interhemispheric or transcortical approaches involve significant retraction and resection of the normal parenchyma. In this offering, the authors describe the contralateral posterior interhemispheric transfalcine transprecuneus approach (PITTA), which provides flexible working angles while protecting the functional brain tissues. In summary, the PITTA is founded on the concept of using a contralateral operative trajectory to augment a more tangential working angle to the more difficult-to-reach lateral target through a midline route. The PITTA emphasizes the importance of operative working angles (versus necessary operative space) through less disruptive exposures as a more viable parameter for achieving desirable results.