Retrosigmoid Approach for Resecting a Giant Lateral Pontine Ependymoma: Two-Dimensional Operative Video

AbstractEpendymoma is one of the most common pediatric tumors in central nervous system, for which gross total resection has been the most favorable prognostic factor.1 2 However, surgery of ependymomas located in brain stem is significantly challenging. This video demonstrates the microsurgical removal of an ependymoma originating from ependymal cells of the lateral recess of fourth ventricle via retrosigmoid approach in an 11-year-old female. The patient presented with a 6-month history of continues headache and vomiting. On examination, she had a walking instability and an emaciated body. Neuroimaging revealed a right lateral pontine lesion extending to the cerebellopontine angle region. The patient underwent a suboccipital craniotomy, followed by excellent exposure for the tumor. Petrosal vein encased by the tumor mass and close adhesion of the tumor and the initial segments of facial and acoustic nerves adjoined brain stem could be seen operatively. While preserving trigeminal nerve, facial and acoustic nerves, posterior cranial nerves, anterior inferior cerebellar artery, labyrinth artery, posterior inferior cerebellar artery, and petrosal vein, gross total resection was achieved under the careful operation along arachnoid spaces together with intratumoral decompression. The patient tolerated the procedure well without any neurological deficits. Histological examination confirmed the tumor as an ependymoma (WHO II). The cytology measurement of the cerebrospinal fluid did not find any tumor cells. Postoperative computed tomography and magnetic resonance imaging scan depicted complete resection of the tumor, and adjuvant radiotherapy was recommended. She remained symptom-free without any evidence of recurrence during the follow-up period of 1 year. Informed consent was obtained from the patient.The link to the video can be found at: https://youtu.be/sZ9GhUeltwc.

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Endoscopic endonasal approach for clipping of a PICA aneurysm

Neurosurgical Focus: Video ◽

10.3171/2020.4.focusvid.19901 ◽

2020 ◽

Vol 2 (2) ◽

pp. V14

Author(s):

Ezequiel Goldschmidt ◽

Philippe Lavigne ◽

Carl Snyderman ◽

Paul A. Gardner

Keyword(s):

Posterior Inferior Cerebellar Artery ◽

Cranial Nerves ◽

Neurological Deficits ◽

Csf Leak ◽

Open Approach ◽

Endonasal Approach ◽

Endoscopic Endonasal ◽

Posthemorrhagic Hydrocephalus ◽

Cerebellar Artery ◽

Lower Cranial Nerves

This video depicts the case of a 59-year-old woman that presented to the emergency department with the worst headache of her life. CT showed subarachnoid hemorrhage and digital subtraction angiogram demonstrated a right-side posterior inferior cerebellar artery (PICA) aneurysm. Given the medial and ventral position of the aneurysm, deep to the lower cranial nerves, which obviated distal control from an open approach, and the absence of an endovascular option able to reliably preserve the PICA, an endonasal approach was offered. A far medial approach was performed, and the aneurysm was successfully clipped. The patient developed a postoperative CSF leak with persistent posthemorrhagic hydrocephalus treated with reexploration and an eventual ventriculoperitoneal shunt. The patient was discharged without neurological deficits.The video can be found here: https://youtu.be/_9hsM2CaMow.

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Endoscopic Assisted Retrosigmoid Approach for Cerebellopontine Angle Epidermoid Tumor

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0038-1669978 ◽

2018 ◽

Vol 79 (S 05) ◽

pp. S413-S414

Author(s):

Katherine Kunigelis ◽

Alexander Yang ◽

A. Youssef

Keyword(s):

Cerebellopontine Angle ◽

Antiviral Agents ◽

Cranial Nerves ◽

Pineal Region ◽

Retrosigmoid Approach ◽

Gross Total Resection ◽

Total Resection ◽

Auditory Evoked Responses ◽

The Right ◽

Surgical Corridor

This case is a 20-year-old male, who presented with 1 month of right facial weakness (HB4) and complaints of ipsilateral eye dryness. He was initially treated for Bell's palsy with steroids and antiviral agents, but subsequently developed diplopia with right lateral gaze and underwent an MRI (magnetic resonance imaging). MRI demonstrated a 4.5 cm irregular lesion in the right cerebellopontine angle consistent with an epidermoid cyst. Because the tumor had grown with the development of the central nervous system, it has extended into different compartments, including the tentorial incisura and pineal region. A predefined surgical corridor created by the tumor facilitated access to the majority of the tumor through a retrosigmoid approach. Angled endoscopes (30-degree up and down) provided further visualization of tumor away from the line of sight of the microscope, thus allowing for gross total resection of the lesion. This video also demonstrates a sharp dissection technique necessary for safe removal of adherent tumor from critical neurovascular structures, including the basilar artery and several cranial nerves. The ipsilateral auditory evoked responses (ABRs) showed slight improvement from baseline toward the end of the case. A gross total resection was achieved, as shown by the MRI. The patient remained at his baseline cranial nerve (CN) V, VII, and VIII deficits during the immediate postoperative period.The link to the video can be found at: https://youtu.be/vCq5juJh8hk.

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Microsurgical Gross Total Resection of a WHO Grade II Cerebellopontine Angle Ependymoma in an Adult

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0038-1669969 ◽

2018 ◽

Vol 79 (S 05) ◽

pp. S426-S427

Author(s):

Sima Sayyahmelli ◽

Melih Ucer ◽

Mustafa Baskaya

Keyword(s):

Cerebellopontine Angle ◽

Residual Disease ◽

Posterior Inferior Cerebellar Artery ◽

Cranial Nerves ◽

Choroid Plexus Papilloma ◽

Gross Total Resection ◽

Direct Stimulation ◽

Total Resection ◽

Who Grade ◽

Grade Ii

Infratentorial ependymomas that arise in the fourth ventricle and extend into the cerebellopontine angle (CPA) through the foramina of Luschka are well described. However, a primary CPA location of an ependymoma is distinctly uncommon. In this video, we present a 46-year-old man with episodes of dizziness, left-sided tinnitus, imbalance, double vision, and nausea. An magnetic resonance imaging (MRI) scan of the head showed a large mass lesion centered in the CPA with heterogenous enhancement. Differential diagnosis included ependymoma, meningioma, schwannoma of the vestibular nerve, or lower cranial nerves, and choroid plexus papilloma. He underwent microsurgical gross total resection of the tumor via a retrosigmoid approach. Direct stimulation of the cranial nerves was performed throughout the case and there was no attachment of the tumor to any cranial nerve to suggest that this might be a schwannoma. The tumor encased important vasculature, including the posterior-inferior cerebellar artery. The histopathology was a grade II ependymoma. The patient tolerated the surgery well and his postoperative course was uneventful. He remained neurologically intact. He received radiation therapy and there was no recurrent or residual disease on follow-up studies. This video demonstrates important steps of the surgical approach and microsurgical resection techniques for this type of challenging tumor.The link to the video can be found at: https://youtu.be/KK-y6EYh888.

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Successful rescue treatment of right posterior inferior cerebellar artery (PICA) vascular stasis with tirofiban following endovascular coil implantation

BMJ Case Reports ◽

10.1136/bcr-2020-238120 ◽

2021 ◽

Vol 14 (1) ◽

pp. e238120

Author(s):

Christopher Houle ◽

Varun Reddy

Keyword(s):

Hospital Stay ◽

Continuous Infusion ◽

Posterior Inferior Cerebellar Artery ◽

Neurological Deficits ◽

Antiplatelet Treatment ◽

Fixed Rate ◽

Rescue Treatment ◽

Cerebellar Artery

This report describes a patient who developed intraprocedural vascular stasis immediately following elective endovascular coil emboliation. Urgent antiplatelet treatment with the GpIIb/IIIa agent tirofiban was used. It was infused intra-arterially during the procedure, followed by a fixed rate intravenous continuous infusion, and successfully restored normal circulation. There were no reports of further bleeding or haemodynamic compromise during the hospital stay. The patient’s condition returned to baseline and he was discharged the following day with no neurological deficits.

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Gross Total Resection of Large Cerebellopontine Angle Meningioma with a Supratentorial Extension via Retrosigmoid Approach with Suprameatal Drilling and Tentorial Sectioning

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0038-1669973 ◽

2018 ◽

Vol 79 (S 05) ◽

pp. S399-S401

Author(s):

Sima Sayyahmelli ◽

Adi Ahmetspahic ◽

Mustafa Baskaya

Keyword(s):

Surgical Resection ◽

Cerebellopontine Angle ◽

Surgical Techniques ◽

Retrosigmoid Approach ◽

World Health ◽

Gross Total Resection ◽

Total Resection ◽

Facial Numbness ◽

Magnetic Resonance Imaging Mri ◽

Health Organization

Meningiomas are the second most common neoplasm in the cerebellopontine angle (CPA), and are challenging lesions to treat surgically. With significant refinements in surgical techniques, operative morbidity, and mortality have been substantially reduced. Total or near-total surgical resection can be accomplished in the majority of cases via appropriately selected approaches, and with acceptable morbidity. In this video, we present a 51-year-old woman, who had a 2-year history of vertigo with symptoms that progressed over time. She presented with blurry vision, sensorineural hearing loss, tinnitus, left-sided facial numbness, and double vision. Magnetic resonance imaging (MRI) showed a left-sided homogeneously enhancing mass at CPA with a supratentorial extension. MRI appearance was consistent with a CPA meningioma with supratentorial extension. The patient underwent surgical resection via a retrosigmoid approach. Suprameatal drilling and tentorial sectioning were necessary to achieve gross total resection. The surgery and postoperative course were uneventful. The histopathology was a WHO (world health organization) grade I meningioma. MRI showed gross total resection of the tumor. After a 1.5-year follow-up, the patient is continuing to do well with no residual or recurrent disease. In this video, microsurgical techniques and important steps for the resection of this challenging meningioma of the cerebellopontine angle are demonstrated.The link to the video can be found at: https://youtu.be/CDto52GxrG4.

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Microsurgical Gross-Total Resection of an Intracanalicular-Cisternal (Koos-4) Vestibular Schwannoma via a Retrosigmoid Approach with intraoperative Endoscopic assistance.

World Neurosurgery ◽

10.1016/j.wneu.2021.11.110 ◽

2021 ◽

Author(s):

Juan M. Revuelta Barbero ◽

Edoardo Porto ◽

Eduardo J. Medina ◽

David P. Bray ◽

Tomas Garzon-Muvdi ◽

...

Keyword(s):

Vestibular Schwannoma ◽

Retrosigmoid Approach ◽

Gross Total Resection ◽

Total Resection ◽

Endoscopic Assistance

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Revascularization of the Posterior Inferior Cerebellar Artery Using the Occipital Artery: A Cadaveric Study Comparing the p3 and p1 Recipient Sites

Operative Neurosurgery ◽

10.1093/ons/opaa023 ◽

2020 ◽

Vol 19 (2) ◽

pp. E122-E129 ◽

Cited By ~ 1

Author(s):

Peyton L Nisson ◽

Xinmin Ding ◽

Ali Tayebi Meybodi ◽

Ryan Palsma ◽

Arnau Benet ◽

...

Keyword(s):

Posterior Inferior Cerebellar Artery ◽

Cranial Nerves ◽

Median Number ◽

Cerebellar Tonsil ◽

Occipital Artery ◽

Recipient Site ◽

Cerebellar Artery ◽

Feasible Alternative ◽

End To End ◽

Lower Cranial Nerves

Abstract BACKGROUND Revascularization of the posterior inferior cerebellar artery (PICA) is typically performed with the occipital artery (OA) as an extracranial donor. The p3 segment is the most accessible recipient site for OA-PICA bypass at its caudal loop inferior to the cerebellar tonsil, but this site may be absent or hidden due to a high-riding location. OBJECTIVE To test our hypothesis that freeing p1 PICA from its origin, transposing the recipient into a shallower position, and performing OA-p1 PICA bypass with an end-to-end anastomosis would facilitate this bypass. METHODS The OA was harvested, and a far lateral craniotomy was performed in 16 cadaveric specimens. PICA caliber and number of perforators were measured at p1 and p3 segments. OA-p3 PICA end-to-side and OA-p1 PICA end-to-end bypasses were compared. RESULTS OA-p1 PICA bypass with end-to-end anastomosis was performed in 16 specimens; whereas, OA-p3 PICA bypass with end-to-side anastomosis was performed in 11. Mean distance from OA at the occipital groove to the anastomosis site was shorter for p1 than p3 segments (30.2 vs 48.5 mm; P < .001). Median number of perforators on p1 was 1, and on p3, it was 4 (P < .001). CONCLUSION Although most OA-PICA bypasses can be performed using the p3 segment as the recipient site for an end-to-side anastomosis, a more feasible alternative to conventional OA-p3 PICA bypass in cases of high-riding caudal loops or aberrant anatomy is to free the p1 PICA, transpose it away from the lower cranial nerves, and perform an end-to-end OA-p1 PICA bypass instead.

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Gross total resection of intracisternal accessory nerve schwannomas using a familiar midline suboccipital subtonsilar approach

Journal of Surgical Case Reports ◽

10.1093/jscr/rjz220 ◽

2019 ◽

Vol 2019 (7) ◽

Author(s):

Elias Antoniades ◽

Alkinoos Athanasiou ◽

Panagiotis Sarlis ◽

Ioannis Magras ◽

Ioannis Patsalas

Keyword(s):

Relevant Literature ◽

Accessory Nerve ◽

Gross Total Resection ◽

Neurological Deficits ◽

Cerebrospinal Fluid Leakage ◽

Spinal Root ◽

Total Resection ◽

Suboccipital Craniotomy ◽

Rare Lesion ◽

Chronic Headaches

Abstract Background Intracisternal Accessory Nerve Schwannomas (ANS) constitute a rare clinical entity with only a few cases reported so far. Their symptoms are usually due to brainstem compression and not manifested until they render of great size. Secondary neuropathy and muscle atrophy are other late signs. The hitherto reported literature advocates a suboccipital craniotomy as a suitable approach. In most of the cases the spinal root was the location tumor arose from. Gross total resection was possible to be carried out in most cases with only sporadic tolerable postoperative deficits reported. Case description We hereby present three cases of patients with intracisternal ANS treated in the same fashion. Two patients were male and one female. Two patients complained of mainly chronic headaches and neck pain, whereas in the third patient the lesion was found incidentally. Only one patient suffered post-operatively cerebrospinal fluid leakage and wound healing complication, which was treated with revision surgery and administration of antibiotics. None of the patients had postoperative neurological deficits. Furthermore, we conducted a review of the relevant literature where we noted that there is no consensus yet with regards to the appropriate surgical approach. Conclusions Based on relevant anatomical studies, we advocate that suboccipital subtonsilar approach provides a wide corridor to the area of lesion allowing complete and safe resection of intracisternal ANS. We thus support that, in most cases, the neurosurgeon should consider using this familiar approach for treating this rare lesion.

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Microvascular decompression for hemifacial spasm

Journal of Neurosurgery ◽

10.3171/jns.1991.75.3.0388 ◽

1991 ◽

Vol 75 (3) ◽

pp. 388-392 ◽

Cited By ~ 45

Author(s):

Shinji Nagahiro ◽

Akira Takada ◽

Yasuhiko Matsukado ◽

Yukitaka Ushio

Keyword(s):

Hemifacial Spasm ◽

Microvascular Decompression ◽

Posterior Inferior Cerebellar Artery ◽

Cranial Nerves ◽

Anterior Inferior Cerebellar Artery ◽

Vascular Compression ◽

Content Type ◽

Seventh Cranial Nerve ◽

Cerebellar Artery

✓ To determine the causative factors of unsuccessful microvascular decompression for hemifacial spasm, the follow-up results in 53 patients were assessed retrospectively. The mean follow-up period was 36 months. There were 32 patients who had compression of the seventh cranial nerve ventrocaudally by an anterior inferior cerebellar artery (AICA) or a posterior inferior cerebellar artery. Of these 32 patients, 30 (94%) had excellent postoperative results. Of 14 patients with more severe compression by the vertebral artery, nine (64%) had excellent results, three (21%) had good results, and two (14%) had poor results; in this group, three patients with excellent results experienced transient spasm recurrence. There were seven patients in whom the meatal branch of the AICA coursed between the seventh and eighth cranial nerves and compressed the dorsal aspect of the seventh nerve; this was usually associated with another artery compressing the ventral aspect of the nerve (“sandwich-type” compression). Of these seven patients, five (71%) had poor results including operative failure in one and recurrence of spasm in four. The authors conclude that the clinical outcome was closely related to the patterns of vascular compression.

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