Microsurgical Resection of Dorsal Pontine Cavernous Malformation: The Telovelar Approach Augmented by the Tonsillouvular Fissure Exposure: 2-Dimensional Operative Video

2021 ◽  
Author(s):  
Devi P Patra ◽  
Evelyn L Turcotte ◽  
Bernard R Bendok
Keyword(s):  
Cavernous Malformation ◽  
Neural Tissue ◽  
Complete Resection ◽  
Surgical Approaches ◽  
Suboccipital Craniotomy ◽  
Tela Choroidea ◽  
Microsurgical Resection ◽  
Telovelar Approach ◽  
Posterior Laminectomy ◽  
Good Exposure

Abstract Surgical approaches to lesions of the fourth ventricle (FV) have been modified over the years to reduce the complications associated with splitting the inferior cerebellar vermis (ICV) and disrupting the brainstem and critical surrounding structures.1-4 Two common approaches to lesions of this region include the transvermian approach (TVA) and telovelar approach (TeVA).2 The TVA was initially considered the conventional route of access to lesions of the FV1 but has been associated with significant risks, including possible gait ataxia and dysarthria.3 The TeVA is advantageous, as it involves dissection along natural clefts and division of non-neural tissue and provides good exposure of the superolateral recess with modest exposure of the rostral FV. The TeVA approach can be augmented by opening the tonsilouvular fissures (TUFs). This added dissection allows greater lateral and superior exposure with less need for retraction. In this operative video, we demonstrate a case in which we augmented the TeVA with a TUF dissection to access a dorsal pontine cavernous malformation. We performed a midline suboccipital craniotomy with a C1 posterior laminectomy. TUF dissection was followed by division of the tela choroidea (TC), which allowed for more lateral exposure of the FV and excellent visualization of the cavernous malformation without the need to traverse neural tissue. TeVA augmented by TUF dissection provided adequate access to the dorsal pons for complete resection of the cavernous malformation. The patient consented to the procedure as shown in this operative video and gave informed written consent for use of her images in publication. Anatomic images provided by courtesy of © The Rhoton Collection. http://rhoton.ineurodb.org/. Video © Mayo Foundation for Medical Education and Research, 2021. Used with permission.

scholarly journals Microsurgical resection of symptomatic intramedullary cervical spinal cord cavernous malformation

2019 ◽  
Vol 1 (1) ◽  
pp. V12
Author(s):  
Tomasz A. Dziedzic ◽  
Andrzej Marchel
Keyword(s):  
Spinal Cord ◽  
Postoperative Morbidity ◽  
Cavernous Malformation ◽  
Cervical Spinal Cord ◽  
Significant Risk ◽  
Neural Tissue ◽  
Complete Resection ◽  
Surgical Removal ◽  
Cavernous Malformations ◽  
Microsurgical Resection

Intramedullary cavernous malformations account for approximately 5% of all intraspinal lesions. Symptomatic lesions are treated with microsurgical resection. Due to surrounding eloquent spinal neural tissue, surgical removal of these lesions can be technically challenging. Surgical treatment carries a significant risk for postoperative morbidity. This video demonstrates the main steps for the microsurgical technique of resection of a symptomatic intramedullary cervical spinal cord cavernous malformation at the C2–3 level. Complete resection was achieved with minimal posterior column deficit. The operative technique and surgical nuances, including the patient’s positioning, surgical approach, intraspinal cavernous malformation removal, and closure, are illustrated.The video can be found here: https://youtu.be/UKttTiXlEb8.

scholarly journals Microsurgical resection of a large cavernous malformation of the medulla oblongata

2019 ◽  
Vol 1 (1) ◽  
pp. V25
Author(s):  
Sima Sayyahmelli ◽  
Mustafa K. Başkaya
Keyword(s):  
Surgical Resection ◽  
Medulla Oblongata ◽  
Cavernous Malformation ◽  
Foramen Magnum ◽  
Total Resection ◽  
Postoperative Course ◽  
Suboccipital Craniotomy ◽  
Postoperative Mri ◽  
Microsurgical Resection

In this surgical video, we present a 57-year-old man with neck pain, dizziness, and imbalance. MRI showed a heterogeneously enhancing mass lesion within the posterior medulla at the level of the foramen magnum. Because the patient was symptomatic from this cavernous malformation, the decision was made to proceed with surgical resection. The patient underwent a midline suboccipital craniotomy with C1 laminectomy for surgical resection of the cavernous malformation in the medulla oblongata, with concurrent monitoring of motor and somatosensory evoked potentials.The surgery and postoperative course were uneventful. The postoperative MRI showed gross-total resection of the mass with histopathology indicating a cavernous malformation. The patient continues to do well without recurrence at 7 years of follow-up. In this video, we demonstrate important microsurgical steps for the resection of this challenging and rare vascular malformation.The video can be found here: https://youtu.be/gbGleLowzxo.

Microsurgical resection of brainstem cervicomedullary ganglioglioma: operative video and technique of creating a surgical pseudoplane for near-total resection

2019 ◽  
Vol 1 (2) ◽  
pp. V13
Author(s):  
James K. Liu ◽  
Vincent N. Dodson
Keyword(s):  
Neural Tissue ◽  
Residual Tumor ◽  
Complete Resection ◽  
Neurological Function ◽  
Neurological Injury ◽  
Low Grade ◽  
Total Resection ◽  
Sharp Dissection ◽  
Microsurgical Resection ◽  
Eloquent Location

Cervicomedullary gangliogliomas are rare low-grade neoplasms of the brainstem. They can be challenging lesions to resect due to the eloquent location in the brainstem. In some instances, the absence of a clear surgical plane between the tumor and normal neural tissue can prohibit a complete resection. Therefore, it is important to leave a thin rim of residual tumor at the tumor-brainstem interface in order to avoid irreversible neurological injury. In this operative video, the authors demonstrate the technique to develop a surgical pseudoplane using sharp microdissection for a cervicomedullary brainstem ganglioglioma without a clear interface between the tumor and normal neural tissue. This strategy allowed for radical near-total resection of the tumor, thereby maximizing the extent of removal while preserving neurological function. Postoperatively, the patient had normal neurological function and returned to work without any disability. In summary, due to the lack of a clear surgical dissection plane, a pseudoplane near the surgical interface can be performed using sharp dissection to facilitate radical near-total resection.The video can be found here: https://youtu.be/biD4G1Hh0yk.

Telovelar approach for microsurgical resection of fourth ventricular subependymoma arising from rhomboid fossa: operative video and technical nuances

2019 ◽  
Vol 1 (2) ◽  
pp. V5
Author(s):  
James K. Liu ◽  
Vincent N. Dodson
Keyword(s):  
Fourth Ventricle ◽  
Total Resection ◽  
Tela Choroidea ◽  
Safe Technique ◽  
Microsurgical Resection ◽  
Cerebellomedullary Fissure ◽  
Telovelar Approach ◽  
Ventricular Tumors ◽  
Rhomboid Fossa ◽  
Neurologically Intact

Fourth ventricular tumors have traditionally been removed via transvermian approaches, which can result in potential dysequilibrium and mutism. The telovelar approach is an excellent alternative to widely expose fourth ventricular tumors without transgressing the cerebellar vermis. This is achieved by opening the cerebellomedullary fissure and incising the tela choroidea and inferior medullary velum, which form the lower half of the roof of the fourth ventricle. In this operative video manuscript, the authors demonstrate microsurgical resection of a fourth ventricular subependymoma arising from the rhomboid fossa via the telovelar approach. The key technical nuance in this video is to demonstrate a gentle and safe technique to identify a dissectable plane to peel the tumor off of the rhomboid fossa using a microspreading technique with fine micro-bayonetted forceps. A gross-total resection was achieved, and the patient was neurologically intact.The video can be found here: https://youtu.be/ZEHHbUGb9zk.

Microsurgical resection of intramedullary spinal cord cavernous malformation. Operative video and technical nuances

2014 ◽  
Vol 37 (v2supplement) ◽  
pp. Video1
Author(s):  
James K. Liu
Keyword(s):  
Spinal Cord ◽  
Cavernous Malformation ◽  
Significant Risk ◽  
Complete Resection ◽  
Definitive Treatment ◽  
Intramedullary Spinal Cord ◽  
Cavernous Malformations ◽  
Spinal Stabilization ◽  
Progressive Myelopathy ◽  
Microsurgical Resection

Intramedullary spinal cord cavernous malformations account for approximately 5% of all intraspinal lesions. These lesions can present with either acute neurological compromise secondary to hemorrhage inside the spinal cord, or with chronic progressive myelopathy due to repeated microhemorrhages. Surgical resection of spinal cord cavernous malformations remains the definitive treatment strategy for symptomatic lesions. Because of the intimate relationship with surrounding eloquent neural tissue, these lesions can be technically challenging to remove with a significant risk for morbidity. In this operative video, the author demonstrates an illustrative step-by-step technique for microsurgical resection of a large intramedullary spinal cord cavernous malformation at C4–5 causing progressive myelopathy. Complete resection was achieved without neurologic compromise. The operative technique and surgical nuances, including the surgical approach, intradural cavernoma removal, and spinal stabilization are illustrated.The video can be found here: http://youtu.be/3FUjGSyrKO0.

scholarly journals Median suboccipital craniotomy and telovelar approach for posterior pontine cavernous malformations

2019 ◽  
Vol 1 (1) ◽  
pp. V8
Author(s):  
Daniel D. Cavalcanti ◽  
Paulo Niemeyer Filho
Keyword(s):  
Cavernous Malformation ◽  
Resonance Imaging ◽  
Cavernous Malformations ◽  
Entry Zone ◽  
Suboccipital Craniotomy ◽  
Telovelar Approach ◽  
Lateral Decubitus ◽  
Neurologically Intact ◽  
Safe Entry Zone

The pons is the preferred location for cavernous malformations in the brainstem. When these lesions do not surface, it is critical to select the optimal safe entry zone to reduce morbidity.1–3 In this video, we demonstrate in a stepwise manner the medial suboccipital craniotomy and the telovelar approach performed in a lateral decubitus position. They were used to successfully resect a pontine cavernous malformation in a centroposterior location in a 19-year-old patient with diplopia, right-sided numbness, and imbalance. The paramedian supracollicular safe entry zone was used once the lesion did not reach the ependymal surface.2,3 Late magnetic resonance imaging demonstrated total resection and the patient was neurologically intact after 3 months of follow-up. The approach is also demonstrated in a cadaveric dissection to better illustrate all steps.The video can be found here: https://youtu.be/ChArkxA8kig.

Microsurgical resection of medullary cavernoma via the olivary zone by the retrosigmoid supracondylar approach

2019 ◽  
Vol 1 (2) ◽  
pp. V7
Author(s):  
Ken Matsushima ◽  
Michihiro Kohno ◽  
Helmut Bertalanffy
Keyword(s):  
Cavernous Malformation ◽  
Cleavage Plane ◽  
Foramen Magnum ◽  
Senior Author ◽  
Neurological Deficits ◽  
Lateral Part ◽  
Sitting Position ◽  
Brainstem Cavernoma ◽  
Microsurgical Resection

Microsurgical resection of the medullary cavernoma is rare, comprising less than 15% of more than 250 surgeries of brainstem cavernoma performed by the senior author (H.B.).1 This video demonstrates a case of a cavernous malformation inside the lateral part of the medulla, which was surgically treated via the olivary zone by the retrosigmoid supracondylar approach in a half-sitting position. Osseous drilling of the lateral foramen magnum provided wide exposure of the cerebellomedullary cistern around the olive.2,3 The lesion was completely dissected at the appropriate cleavage plane from the normal parenchyma. The patient developed no new neurological deficits and had no recurrence during 3 years of follow-up after the operation.The video can be found here: https://youtu.be/7i7SccS5HmU.

Microsurgical resection of foramen magnum meningioma through a transcondylar approach: three-dimensional operative video

2019 ◽  
Vol 1 (2) ◽  
pp. V3
Author(s):  
Guilherme H. W. Ceccato ◽  
Rodolfo F. M. da Rocha ◽  
Duarte N. C. Cândido ◽  
Wladimir O. Melo ◽  
Marcio S. Rassi ◽  
...  
Keyword(s):  
Nerve Palsy ◽  
Three Dimensional ◽  
Foramen Magnum ◽  
Complete Resection ◽  
Neurophysiological Monitoring ◽  
Cervical Instability ◽  
Transcondylar Approach ◽  
Postoperative Mri ◽  
Microsurgical Resection

Foramen magnum (FM) meningiomas are challenging lesions. We present the case of a 38-year-old female with neck pain, dysphonia, and slight twelfth nerve palsy. Imaging workup was highly suggestive of an FM meningioma, and microsurgical resection with the aid of intraoperative neurophysiological monitoring was indicated. A transcondylar approach was employed, the vertebral artery was mobilized, and the tumor was completely removed. Postoperative MRI demonstrated complete resection. There were no signs of cervical instability. The patient presented with improvement of her symptoms and no new neurological deficit on follow-up. FM meningiomas can be successfully resected using a transcondylar approach, since it increases the exposure of the ventral FM, allowing the surgeon to work parallel to the skull base and flush with the tumor’s attachment. Informed consent was obtained from the patient for publication of this operative video.The video can be found here: https://youtu.be/itfUOB-6zM0.

scholarly journals How I do it: parietal trans-sulcal para-fascicular approach to lateral thalamic/internal capsule cavernous malformation

2021 ◽  
Author(s):  
Michael Amoo ◽  
Kieron J. Sweeney ◽  
Ronan Kilbride ◽  
Mohsen Javadpour
Keyword(s):  
White Matter ◽  
Cavernous Malformation ◽  
Internal Capsule ◽  
Complete Resection ◽  
Brain Lesions ◽  
Tubular Retractor ◽  
Surgical Technology ◽  
Feasible Alternative ◽  
Traditional Approaches ◽  
Deep Brain

Abstract Background The surgical management of deep brain lesions is challenging, with significant morbidity. Advances in surgical technology have presented the opportunity to tackle these lesions. Methods We performed a complete resection of a thalamic/internal capsule CM using a tubular retractor system via a parietal trans-sulcal para-fascicular (PTPF) approach without collateral injury to the nearby white matter tracts. Conclusion PTPF approach to lateral thalamic/internal capsule lesions can be safely performed without injury to eloquent white matter fibres. The paucity of major vessels along this trajectory and the preservation of lateral ventricle integrity make this approach a feasible alternative to traditional approaches.

scholarly journals Impact of combined use of intraoperative MRI and awake microsurgical resection on patients with gliomas: a systematic review and meta-analysis

2021 ◽  
Author(s):  
Constantin Tuleasca ◽  
Henri-Arthur Leroy ◽  
Iulia Peciu-Florianu ◽  
Ondine Strachowski ◽  
Benoit Derre ◽  
...  
Keyword(s):  
Systematic Review ◽  
Postoperative Complications ◽  
Brain Tumors ◽  
Standard Error ◽  
Complete Resection ◽  
Awake Craniotomy ◽  
Intraoperative Mri ◽  
Primary Brain Tumors ◽  
Combined Use ◽  
Microsurgical Resection

AbstractMicrosurgical resection of primary brain tumors located within or near eloquent areas is challenging. Primary aim is to preserve neurological function, while maximizing the extent of resection (EOR), to optimize long-term neurooncological outcomes and quality of life. Here, we review the combined integration of awake craniotomy and intraoperative MRI (IoMRI) for primary brain tumors, due to their multiple challenges. A systematic review of the literature was performed, in accordance with the Prisma guidelines. Were included 13 series and a total number of 527 patients, who underwent 541 surgeries. We paid particular attention to operative time, rate of intraoperative seizures, rate of initial complete resection at the time of first IoMRI, the final complete gross total resection (GTR, complete radiological resection rates), and the immediate and definitive postoperative neurological complications. The mean duration of surgery was 6.3 h (median 7.05, range 3.8–7.9). The intraoperative seizure rate was 3.7% (range 1.4–6; I^2 = 0%, P heterogeneity = 0.569, standard error = 0.012, p = 0.002). The intraoperative complete resection rate at the time of first IoMRI was 35.2% (range 25.7–44.7; I^2 = 66.73%, P heterogeneity = 0.004, standard error = 0.048, p < 0.001). The rate of patients who underwent supplementary resection after one or several IoMRI was 46% (range 39.8–52.2; I^2 = 8.49%, P heterogeneity = 0.364, standard error = 0.032, p < 0.001). The GTR rate at discharge was 56.3% (range 47.5–65.1; I^2 = 60.19%, P heterogeneity = 0.01, standard error = 0.045, p < 0.001). The rate of immediate postoperative complications was 27.4% (range 15.2–39.6; I^2 = 92.62%, P heterogeneity < 0.001, standard error = 0.062, p < 0.001). The rate of permanent postoperative complications was 4.1% (range 1.3–6.9; I^2 = 38.52%, P heterogeneity = 0.123, standard error = 0.014, p = 0.004). Combined use of awake craniotomy and IoMRI can help in maximizing brain tumor resection in selected patients. The technical obstacles to doing so are not severe and can be managed by experienced neurosurgery and anesthesiology teams. The benefits of bringing these technologies to bear on patients with brain tumors in or near language areas are obvious. The lack of equipoise on this topic by experienced practitioners will make it difficult to do a prospective, randomized, clinical trial. In the opinion of the authors, such a trial would be unnecessary and would deprive some patients of the benefits of the best available methods for their tumor resections.

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