Transmiddle Cerebellar Peduncle Approach to a Large Pontine Tumor: 2-Dimensional Operative Video.

Brainstem tumor surgery presents a unique challenge for neurosurgeons given the difficulty and high stakes in navigating highly eloquent neural territories through limited operative corridors.1,2 Patient selection, indication, surgical approach, and intraoperative decision-making are critical factors for achieving maximal safe resection and a good clinical outcome.This video presents the case of 12-year-old boy with NF1 and worsening right spastic hemiparesis due to progression of a low-grade glioma involving the middle and left lateral pons. The video shows not just the technical pearls of the microscopic transmiddle cerebellar peduncle approach but a discussion of the indication over other therapeutic options as chemotherapy or radiation and even more important a thorough explanation of the elected approach over its alternatives. Intraoperative decision-making is also highlighted because right motor-evoked potentials were lost during initial exposure. Near total resection was achieved, and the patient presented a remarkable improvement of his symptoms since the immediate postoperative period. The transmiddle cerebellar approach constitutes a valid alternative for tumors in the middle and lateral pons, where patient selection and a thorough intraoperative decision making are equally essential to achieve the best possible clinical outcome. The patient and the family consented to the procedure and the publication of his/her image.