Aggressive, Multidisciplinary Staged Microsurgical Resection of a Giant Cervicomedullary Junction Chordoma

Chordomas of the cranial base are locally destructive tumors since they are surrounded by significant complex neurovascular structures. Thus, their surgical removal is challenging, recurrence rates are high, and their therapeutic strategies remain controversial.In this video, we present a 47-year-old man with a recent onset of swallowing difficulties, hoarseness, and weight loss for several weeks. In the neurological examination, he had complete paralysis of the 9th, 10th, 11th, and 12th cranial nerves. Magnetic resonance imaging (MRI) showed a heterogeneously enhancing expansile invasive mass lesion centered within the clivus and involving the C1, the occipitocervical junction, the retropharynx, and the hypoglossal canal. The decision was made to proceed with multiple staged surgeries. In the first surgical stage, we performed a mastoidectomy with the infralabyrinthine approach to perform a test clip ligation of the sigmoid sinus and to resect the tumor component that extended into the infralabyrinthine space. In the second stage, we performed a far-lateral transcondylar approach for tumor resection and occipitocervical fusion. In the third stage, we used a transoral approach with endoscopic assistance to complete the excision of the remaining tumor in the retropharyngeal space and anterior aspect of C1 and C2 bodies that were not accessible in the first two stages.The surgeries and postoperative course were uneventful. Postoperative MRI showed a gross total resection of the tumor. Histopathology indicated a chordoma. The patient subsequently received proton radiotherapy and has continued to do well without recurrence at 14 months' follow-up.The link to the video can be found at: https://youtu.be/uP9OSlKg_rE.

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Internal Auditory Canal Reconstruction After Vestibular Schwannomas Removal Through Retrosigmoid-Transmeatal Approach

JBNC - JORNAL BRASILEIRO DE NEUROCIRURGIA ◽

10.22290/jbnc.v26i3.1349 ◽

2018 ◽

Vol 26 (3) ◽

pp. 237-241

Author(s):

Ricardo Ramina ◽

Gustavo Simiano Jung ◽

Erasmo Barros Da Silva Jr ◽

Guilherme José Agnoletto ◽

Luis Fernando Moura Da Silva Jr ◽

...

Keyword(s):

Cranial Nerves ◽

Internal Auditory Canal ◽

Jugular Foramen ◽

Vestibular Schwannomas ◽

Fat Tissue ◽

Resonance Imaging ◽

Tumor Removal ◽

Postoperative Mri ◽

Csf Leakage ◽

Magnetic Resonance Imaging Mri

Objectives: To present a technique of internal auditory canal (IAC) reconstruction using a pediculated dural flap, after removal of vestibular schwannomas through the retrosigmoid craniotomy. Methods: From a series of 213 patients with vestibular schwannomas operated between January 2008 and March 2016 through the retrosigmoid-transmeatal approach, 183 underwent reconstruction of the internal auditory canal with a pediculated dural flap. The IAC was drilled towards the fundus preserving the labyrinthine structures. The dura mater over the IAC was dissected from the bone, remaining pediculated at the entrance of the jugular foramen. This dural flap was used to cover the cranial nerves inside the IAC after tumor removal. Opened mastoid cells and the IAC were closed with muscle or fat grafts and fibrin glue. Results: Reconstruction of the IAC using the described technique was possible in in 183 cases. Fifteen patients (6.8%) developed postoperative cerebrospinal fluid (CSF) leakage and seven patients required reoperation (3.2%) to close the fistulae. Postoperative magnetic resonance imaging (MRI) examinations showed the presence of CSF within the IAC around the preserved cranial nerves. Conclusions: This technique of IAC reconstruction after surgical resection of vestibular schwannomas may avoid scar and adhesion of muscle or fat tissue with preserved cranial nerves, allowing CSF enter inside the IAC. It may help to identify tumor remnants and/or recurrences in postoperative MRI examinations. Comparative studies are needed to evaluate if this technique improves postoperative hearing and facial nerve outcomes.

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Resection of a Lumbar Intradural Extramedullary Schwannoma: 3-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opy238 ◽

2018 ◽

Vol 16 (5) ◽

pp. 640-640 ◽

Cited By ~ 1

Author(s):

Simone E Dekker ◽

Chad A Glenn ◽

Thomas A Ostergard ◽

Mickey L Smith ◽

Brian D Rothstein ◽

...

Keyword(s):

Back Pain ◽

Treatment Options ◽

Tumor Resection ◽

Sensory Nerve ◽

En Bloc ◽

3 Dimensional ◽

Postoperative Mri ◽

Intradural Extramedullary ◽

Magnetic Resonance Imaging Mri ◽

Dural Opening

Abstract This 3-dimensional operative video illustrates resection of a lumbar schwannoma in a 57-yr-old female who presented with right lower extremity numbness, paresthesias, as well as a long history of lower back pain with rest. On magnetic resonance imaging (MRI), there was evidence of an intradural extramedullary enhancing lesion at L5, nearly completely encompassing the spinal canal. This video demonstrates the natural history, treatment options, surgical procedure, risks, and complications of treatment of these types of tumors. The patient underwent a posterior lumbar laminectomy with a midline dural opening for tumor resection. The tumor was encountered intradurally and electromyography recording confirmed that the tumor arose from a lumbar sensory nerve root. The sensory root was then divided and the tumor was then removed. The mass was removed en bloc and histopathologic analysis was consistent with a schwannoma. Postoperative MRI demonstrated gross total resection of the patient's neoplasm with excellent decompression of the spinal cord. The patient had an uneventful postoperative course with full recovery and complete resolution of her back pain and leg paresthesias.

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Olfactory Groove Meningiomas: Clinical Outcome and Recurrence Rates after Tumor Removal Through the Frontolateral and Bifrontal Approach

Neurosurgery ◽

10.1227/01.neu.0000255453.20602.80 ◽

2007 ◽

Vol 60 (5) ◽

pp. 844-852 ◽

Cited By ~ 92

Author(s):

Makoto Nakamura ◽

Melena Struck ◽

Florian Roser ◽

Peter Vorkapic ◽

Madjid Samii

Keyword(s):

Clinical Outcome ◽

Recurrence Rate ◽

Tumor Resection ◽

Surgical Removal ◽

Tumor Removal ◽

Recurrence Rates ◽

Olfactory Groove ◽

Total Tumor Removal ◽

Frontolateral Approach

Abstract OBJECTIVE Olfactory groove meningiomas account for 8 to 13% of all intracranial meningiomas. Surgical removal is often performed through the bifrontal, unilateral subfrontal (frontolateral), or pterional approach. We report on the clinical outcome and recurrence rate after surgical treatment of olfactory groove meningiomas in our neurosurgical department. METHODS A retrospective study was conducted by analyzing the charts of the patients, including surgical records, discharge letters, histological records, follow-up records, and imaging studies. RESULTS A total of 1800 meningiomas were operated on between 1978 and 2002 in our department. There were 82 patients with olfactory groove meningiomas, including 63 women and 19 men with a mean age of 57.8 years (age range, 33–91 yr). Most patients presented with mental disturbance. Tumors were operated through the bifrontal (n = 46), frontolateral (n = 34), and pterional (n = 2) approaches. Total tumor removal (Simpson Grade 1 or 2) was achieved in most cases (91.2% frontolateral, 93.5% bifrontal). Perioperative mortality was 4.9% (four out of 82 patients, all operated through the bifrontal approach). The overall recurrence rate was 4.9%, with four patients requiring surgery. The mean follow-up period was 63.4 months (range, 4–270 mo). CONCLUSION Olfactory groove meningiomas were removed mainly through two different surgical approaches. Even in large tumors, high rates of total tumor resection could also be achieved with low recurrence rates using the simple and minimally invasive frontolateral approach. In recent years, we have preferred to use the frontolateral approach, which provides quick access to the tumor with less brain exposure while still enabling total tumor removal with a low morbidity rate and no mortality.

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Posterior Cervical Laminoplasty for Resection Intradural Extramedullary Spinal Meningioma: 2-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opy204 ◽

2018 ◽

Vol 16 (3) ◽

pp. 392-392 ◽

Cited By ~ 2

Author(s):

Simone E Dekker ◽

Thomas A Ostergard ◽

Chad A Glenn ◽

Efrem Cox ◽

Nicholas C Bambakidis

Keyword(s):

High Speed ◽

Treatment Options ◽

Tumor Resection ◽

Cervical Laminoplasty ◽

En Bloc ◽

Who Grade ◽

Left Hand ◽

Postoperative Mri ◽

Intradural Extramedullary ◽

Magnetic Resonance Imaging Mri

Abstract This operative video demonstrates a posterior cervical laminoplasty for the resection of a cervical intradural extramedullary meningioma. In addition, the natural history, treatment options, and potential complications are discussed. The patient is a 68-yr-old male who presented with left-hand grip weakness and paresthesias. Magnetic resonance imaging (MRI) demonstrated an enhancing mass that displacing the spinal cord anteriorly and causing severe flattening of the cord at C4 and C5. The patient underwent a posterior cervical laminoplasty for tumor resection. Removal of the dorsal elements with a high-speed drill was performed at C3, C4, and C5. A midline durotomy was performed and a large extra-axial intradural tumor was encountered. The tumor was resected en bloc and specimens were sent for permanent pathological analysis. The dura was closed in a watertight fashion using 6-0 Prolene sutures. The laminoplasty was performed by using titanium miniplates and screws to reconstruct the dorsal bony elements, and the wound was closed in layers using sutures. There were no complications. Final pathology was consistent with a WHO grade I meningioma. Postoperative MRI demonstrated gross total resection. The patient's perioperative course was uncomplicated and his preoperative weakness completely resolved by time of discharge.

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Complete Resection of a Large Mediastinal Calcifying Fibrous Tumor

European Journal of Pediatric Surgery Reports ◽

10.1055/s-0040-1713135 ◽

2020 ◽

Vol 08 (01) ◽

pp. e48-e51

Author(s):

Géraldine L. P. Bono ◽

Markus Lehner ◽

Freimut H. Schilling ◽

Nikolai Stahr ◽

Miriam Nowack ◽

...

Keyword(s):

Tumor Resection ◽

Residual Tumor ◽

Anterior Mediastinum ◽

Complete Resection ◽

Venous Stasis ◽

Surgical Removal ◽

Large Tumor ◽

Calcifying Fibrous Tumor ◽

Magnetic Resonance Imaging Mri ◽

Fibrous Tumor

AbstractCalcifying fibrous tumor (CFT) is a benign tumor entity which can present in a variety of different sites. Till date, eight cases with a mediastinal manifestation have been published in literature. Surgical removal is the treatment of choice for this often incidentally detected tumor. Surgery of thoracic CFT may be challenging due to its localization within the mediastinum. A 10-year old boy with a right-sided thoracic pectus carinatum-like deformity was referred for further evaluation, incidentally, revealing a mediastinal mass in computed tomography (CT). Laboratory results were all within normal range. Magnetic resonance imaging (MRI) showed a large tumor in the upper anterior mediastinum suggesting expansive but not infiltrative character. The tumor was displacing surrounding structures like the heart and the diaphragm. Lower venous stasis with dilation of the inferior cava vein could be demonstrated. The tumor was considered to be of benign dignity and surgical removal was indicated. Complete tumor resection could be achieved through a sternotomy approach, along with thymectomy. A partial resection of both the pericardium and diaphragm was required due to adhesion with soft tissue at those sites. The specimen's size was 320 mm × 145 mm × 100 mm, histologically confirmed as CFT. The patient showed no residual tumor at 3- and 9-month follow-up. This case is a report on a large mediastinal CFT which underwent successful complete surgical removal. Following tumor resection, prognosis is considered to be good; however, key issue is complete resection to avoid local tumor recurrence.

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Acoustic neuroma (vestibular schwannoma): surgical results on 240 patients operated on dorsal decubitus position

Arquivos de Neuro-Psiquiatria ◽

10.1590/s0004-282x2007000400011 ◽

2007 ◽

Vol 65 (3a) ◽

pp. 605-609 ◽

Cited By ~ 13

Author(s):

Arquimedes Cavalcante Cardoso ◽

Yvens B. Fernandes ◽

Ricardo Ramina ◽

Guilherme Borges

Keyword(s):

Vestibular Schwannoma ◽

Tumor Resection ◽

Cranial Nerves ◽

Internal Auditory Canal ◽

Air Embolism ◽

Cerebrospinal Fluid Leak ◽

Surgical Removal ◽

Venous Air Embolism ◽

Craniotomy For Tumor Resection ◽

Fluid Leak

OBJECTIVE: To evaluate the result of the surgical treatment of vestibular schwannoma (VS) operated in dorsal decubitus (mastoid position). METHOD: 240 patients with a VS underwent a retrosigmoid craniotomy for tumor resection in dorsal decubitus (mastoid position). The function of 7th and 8th cranial nerves was monitored during surgery and the opened internal auditory canal (IAC) was reconstructed using a vascularized dura flap, muscle and fibrin glue. RESULTS: Complete tumor removal was achieved in 99% of the cases, with a mortality of 1.6%. The facial nerve function was preserved in 85% of cases and hearing in 40% of the patients (with preoperative hearing) with tumors of up 1.5 cm in diameter. The incidence of cerebrospinal fluid leak was 5.8% and meningitis 2.9%. Venous air embolism was registered in 3% of cases; it was not associated to mortality. CONCLUSION: Surgical removal of VS in dorsal position has several advantages; the morbidity and mortality are very low.

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Two-Stage Double Petrosal Approach for the Total Resection of Petroclival-Cavernous Meningioma: 2-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opab049 ◽

2021 ◽

Author(s):

Emad Aboud ◽

Walid Ibn Essayed ◽

Ossama Al-Mefty

Keyword(s):

Cavernous Sinus ◽

Tumor Resection ◽

Cranial Nerves ◽

Transverse Sinus ◽

Jugular Bulb ◽

Neurological Deficits ◽

Surgical Removal ◽

Petroclival Meningiomas ◽

Significant Extension ◽

Anterior Petrosectomy

Abstract The utilization of skull base approaches has markedly facilitated the safe surgical removal of challenging petroclival meningiomas.1 The anterior petrosal approach has been utilized for tumors limited to the upper clivus, above the meatus, whereas the posterior petrosal approach has been the workhorse for the resection of larger tumors in the posterior fossa extending down the clivus.2 Giant cases with extension in the middle fossa, cavernous sinus, and ventral to the brain stem would benefit from a wider exposure than each of these approaches provide. This could be achieved by total petrosectomy. However, in patients with serviceable hearing anterior and posterior petrosals can be combined while preserving the hearing apparatus.2,3 This procedure is lengthy; hence, we tend to stage it in 2 subsequent days. The first stage is focused on the soft tissue and bone work including the mastoidectomy, sigmoid transverse sinus, and jugular bulb skeletonization, as well as anterior petrosectomy. The second stage is dedicated to tumor exposure through tentorial sectioning and microsurgical resection. We report the case of a 40-yr-old woman diagnosed with large left-sided petroclival meningioma with significant extension into the cavernous sinus and Meckel's cave. The patient had neurological deficits including cranial nerves, cerebellar dysfunction, and hydrocephalus, although her hearing was intact. Total tumor resection was achieved through the double petrosal approach in 2002. Extensive anatomic knowledge and thorough preoperative clinical and radiological evaluation, particularly the venous system, are key in the successful planning of this procedure. The patient consented for surgery and publication of their image. Figures at 2:40 and 3:47, ©Ossama Al-Mefty, used with permission.

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The Significance of Cyst Remnants After Endoscopic Colloid Cyst Resection

Neurosurgery ◽

10.1227/01.neu.0000430300.10338.71 ◽

2013 ◽

Vol 73 (2) ◽

pp. 233-239 ◽

Cited By ~ 24

Author(s):

Caitlin E. Hoffman ◽

Nicole J. Savage ◽

Mark M. Souweidane

Keyword(s):

Recurrence Rate ◽

Endoscopic Resection ◽

Colloid Cyst ◽

Complete Resection ◽

Recurrence Rates ◽

Intraoperative Assessment ◽

Postoperative Mri ◽

Colloid Cysts ◽

Magnetic Resonance Imaging Mri

Abstract BACKGROUND: Controversy surrounds the fate of cyst remnants after endoscopic colloid cyst resection. OBJECTIVE: Our study evaluated recurrence rates in patients with total endoscopic resection of colloid cysts vs those with coagulated cyst remnants. METHODS: Sixty-five consecutive patients and 67 procedures for endoscopic resection of colloid cysts from 1995 to 2011 were reviewed. Degree of resection was based on intraoperative assessment and postoperative magnetic resonance imaging (MRI). Recurrence rates were compared between patients with complete resection those with coagulated cyst remnants. RESULTS: Data analysis was performed of 56 patients and 58 procedures, with no follow-up in 9 patients. All patients had MRI-defined complete resection. On intraoperative assessment, 9 procedures had coagulated remnants and 45 procedures had complete resection (4 data unknown). The overall recurrence rate was 6.89% (4/58), 33.3% (3/9) with cyst remnants, and 2.2% (1/45) with total resection (P = .0124). Maximum follow-up was 144 months (mean, 40.4 months). Mean follow-up was 66.0 months for cyst remnant cases, and 33.5 months for totally resected cases. There was no mortality or permanent morbidity. Transient morbidity included memory deficit (n = 2), aseptic meningitis (n = 1), and local wound infection (n = 1). CONCLUSION: Endoscopic colloid cyst resection results in a low overall recurrence rate. Immediate postoperative MRI was insufficient for assessing degree of resection and was a poor predictor of recurrence. Ablation of cyst remnants rather than total removal is associated with a significantly higher rate of recurrence. The primary goal of endoscopic surgery should, therefore, be removal of all cyst contents and wall remnants.

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Large hibernoma of the neck: A case report

Vojnosanitetski pregled ◽

10.2298/vsp170210077m ◽

2019 ◽

Vol 76 (3) ◽

pp. 341-344

Author(s):

Anton Mikic ◽

Miljan Folic ◽

Ivan Boricic ◽

Nenad Arsovic

Keyword(s):

Case Report ◽

Tumor Resection ◽

Cranial Nerves ◽

The Body ◽

Preoperative Embolization ◽

Surgical Removal ◽

Histopathological Analysis ◽

Illustrative Case ◽

Brown Adipose ◽

Supraclavicular Fossa

Introduction. A hibernoma is a rare benign tumor derived from vestigial remnants of brown adipose tissue. In neonates this tissue makes up about 5% of the body mass and its amount greatly decreases after birth, persisting only in scattered subcutaneous areas. In rare cases, brown fat continues to grow leading to a hibernoma that may be located in the head and neck. We present an illustrative case of a large hibernoma of the neck with infraclavicular extension and discuss about diagnostic and treatment difficulties. Case report. A 29-year-old male presented with large, slowly progressive, painless neck mass that was noticed 6 months earlier. Computed tomography (CT) and magnetic resonance (MR) showed a well-vascularized, soft tissue tumor of the lateral region of the neck and supraclavicular fossa with extension below clavicle. Treatment included arterial embolization followed by challenging surgical removal of the tumor. Dissection was performed at III, IV and V levels of the neck, making complete resection possible without the tumor fragmentation or major blood vessels and cranial nerves injuries. The final diagnosis of the hibernoma was made by histopathological analysis. The patient had no signs of recurrence during three-year follow-up. Conclusion. Although the CT scan and MR may raise the suspicion, hibernoma is definitely diagnosed by a pathologist. It is very important to exclude the malignant processes, foremost liposarcoma. The tumor fragmentation during surgery should be avoided because the high vascularity of the tumor tissue carries a substantial risk for hemorrhage. Our experience with preoperative embolization and complete tumor resection in this case showed positive impact on the final outcome.

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Extreme Lateral Transodontoid Approach for Resection of Clival Chordoma: 2-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opz411 ◽

2020 ◽

Vol 19 (3) ◽

pp. E298-E298

Author(s):

Evan J Joyce ◽

Michael A Cohen ◽

Winson Ho ◽

Douglas L Brockmeyer ◽

William T Couldwell

Keyword(s):

Tumor Resection ◽

Oral Intake ◽

Proton Beam Therapy ◽

Craniovertebral Junction ◽

Occipital Condyle ◽

Retropharyngeal Space ◽

Cerebrospinal Fluid Diversion ◽

Postoperative Mri ◽

Dural Closure ◽

Complete Tumor

Abstract This 15-yr-old girl presented with nasal obstruction and dysphagia of duration 3 mo and 8 to 10 pounds of weight loss. On examination, she had a hoarse voice and left tongue deviation without weakness or myelopathy. Computed tomography (CT) demonstrated an erosive lesion arising from the clivus and left occipital condyle. Magnetic resonance imaging (MRI) demonstrated a T1-isointense, T2-hyperintense, enhancing mass centered at the occipital condyle and extending into the craniovertebral junction (CVJ), causing severe brainstem compression and extending inferiorly to C2 and anteriorly into the retropharyngeal space. The patient underwent transoral biopsy to confirm the diagnosis of chordoma and complete tumor resection via a left extreme lateral transodontoid (ELTO) approach. This approach was chosen because it provides bilateral exposure to the ventral CVJ and retropharyngeal space and allows for complete tumor removal using a single approach, although it requires an experienced surgeon. The ELTO incision should provide adequate exposure for occipitocervical fusion (OCF) after the destabilization of the CVJ. Transposition of the vertebral artery and odontoidectomy are key maneuvers that provide exposure to the ventral CVJ bilaterally. Dural closure is performed primarily and augmented with fat, fibrin glue, and temporary cerebrospinal fluid diversion. Postoperative MRI showed a gross-total resection and decompression of the brainstem at the CVJ. The patient remained in a cervical collar until OCF. Postoperatively, she had left vocal cord paralysis and moderate weakness with left arm abduction at the deltoid. At 2-mo follow-up, she had improved lower cranial neuropathies, tolerated oral intake, and was scheduled to begin proton beam therapy. The patient provided consent for publication.

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