Combined Transventricular and Supracerebellar Infratentorial Approach Preserving the Vermis in Giant Pediatric Posterior Fossa Midline Tumors

Abstract Objective: Giant pediatric midline tumors of the posterior fossa involving the fourth ventricle and the tectal region are difficult to approach and present a high risk of postoperative neurological deficits. Children with sequelae such as cerebellar mutism and ataxia experience a compromise in their quality of life. Here, we present our combined transventricular and supracerebellar infratentorial approach to avoid complications of vermian splitting. Methods: The combined transventricular and supracerebellar infratentorial approach described here was used in a total of four pediatric patients. A medial suboccipital craniotomy with opening of the foramen magnum and resection of the C1 lamina was performed with the patient in the semisitting position. The tumor mass filling the fourth ventricle was removed via a transventricular telovelar route through the foramen of Magendie, preserving the vermis. The rostral tumor portions in the peritectal region extruding up to the thalami were exposed and resected via an infratentorial supracere-bellar route to preserve the venous drainage of the cerebellum. Results: There were no new neurological deficits postoperatively. Two patients had low-grade astrocytomas, and two patients had malignant tumors. Complete tumor resection was achieved in two patients, and near-total tumor removal in the two others. CONCLUSION: The combined transventricular and supracerebellar infratentorial approach offers a unique possibility of safely removing giant pediatric midline tumors. Splitting of the cerebellar vermis is not necessary for removal of such tumors.

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“Drowning Brain in a Pool of CSF” — A Rare Complication of Periencephalic Subdural Panhygroma following Removal of a Posterior Fossa Tumor

Indian Journal of Neurosurgery ◽

10.1055/s-0037-1602751 ◽

2017 ◽

Vol 07 (03) ◽

pp. 223-226

Author(s):

Bikash Behera ◽

Ram Deo ◽

Sanjib Mishra ◽

Jyotirmayee Biswal ◽

Deepak Das

Keyword(s):

Posterior Fossa ◽

Case Reports ◽

Rare Complication ◽

Tumor Resection ◽

Foramen Magnum ◽

Posterior Fossa Tumor ◽

Subdural Hygroma ◽

Posterior Fossa Tumors ◽

Suboccipital Craniotomy ◽

Pediatric Age Group

AbstractPosterior fossa tumors are commonly encountered in pediatric age group patients. Most of these tumors present with features of hydrocephalus in the child. Conventionally, these cases are managed by suboccipital craniotomy with decompression of the tumor mass to establish the free flow of cerebrospinal fluid (CSF) across fourth ventricle and aqueduct of Sylvius. Following resection of posterior fossa tumor, appearance of subdural hygroma is a rare phenomenon.Though few cases of subdural hygroma are reported in literature following foramen magnum decompression in Chiari's malformation, their appearance following posterior fossa tumor resection is alien to medical literature and limited to only two case reports. Here the authors present a patient with periencephalic subdural panhygroma (PSP) following posterior fossa tumor resection who was successfully treated with a ventriculoperitoneal shunt (VPS) to accomplish a symptomatic and radiologic remission.

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Management of low-grade gliomas

10.5327/1516-3180.052 ◽

2021 ◽

Author(s):

Milla Giancristofaro Dutra ◽

Bernardo Valle Zanetti ◽

Ana Luiza Badini Tubenchlak ◽

Bárbara Gomes Muffato ◽

Leonardo Moreira Dutra ◽

...

Keyword(s):

Large Scale ◽

Randomized Clinical Trials ◽

Malignant Tumors ◽

Tumor Resection ◽

Progression Free Survival ◽

Functional Results ◽

Therapeutic Modality ◽

Low Grade ◽

Low Grade Gliomas ◽

The Central Nervous System

Background: Gliomas are the most aggressive and prevalent primary malignant tumors of the central nervous system. For better mapping, they are subclassified into degrees in proportion to their malignancy. Although low-grade patients have a better prognosis, they are extremely heterogeneous. Since the high variability in the outcomes of the condition, it is essential to investigate the current therapeutic strategies available. Objective: Analyze the management of low-grade gliomas. Methods: In April 2021, a literature review was conducted on MEDLINE using the descriptors: “Glioma”, “Low Grade”; “Treatment”; as well as their variations obtained in MeSH. Controlled and randomized clinical trials carried out on humans in the last five years were included. Results: 63 articles were found and 10 of them were analyzed in this review. The research has shown that total tumor resection is the therapeutic modality that causes the greatest drop in the mortality rates. Furthermore, the greater the extraction, the greater the progression-free survival. In this way, for greater safety of large-scale surgeries, several intraoperative techniques have been developed. An example is the waking approach, which presents favorable long-term functional results and low failure rates. However, the isolated surgery is often not sufficiently curative. Therefore, it is necessary to complement radiotherapy and chemotherapy with temozolomide, associated with a 5 to 10 year survival rate when combined. Conclusions: Studies have shown that total resection of the tumor is the best way to manage low-grade gliomas, but it is often combined with temozolamide chemotherapy and radiotherapy for a better prognosis.

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NCMP-05. THE INCIDENCE AND IMPACT OF POST-OPERATIVE STROKE IN SURGERY FOR LGG

Neuro-Oncology ◽

10.1093/neuonc/noz175.751 ◽

2019 ◽

Vol 21 (Supplement_6) ◽

pp. vi180-vi180

Author(s):

Asaf Berger ◽

Garry Tzarfati ◽

Mathias Costa ◽

Marga Serafimova ◽

Akiva Korn ◽

...

Keyword(s):

Ischemic Stroke ◽

Performance Status ◽

Tumor Resection ◽

Neurological Deficits ◽

Functional Improvement ◽

Motor Deficit ◽

Low Grade ◽

Post Surgery ◽

One Year

Abstract BACKGROUND Postoperative neurological deficits may outweigh the benefit conferred by maximal resection of gliomas. We evaluated the incidence of ischemic events in patients undergoing surgery for low-grade gliomas (LGG) and the long-term neurological and cognitive sequelae. METHODS Between 2013–2017, 168 patients underwent surgical resection or biopsy for LGG at our center. A full dataset, including pre- and postoperative magnetic resonance imaging (MRI) and long-term clinical evaluation findings, was available for 82 patients (study group). Ischemic complications, overall and progression-free survival, and functional and neurocognitive outcomes were evaluated. RESULTS The immediate postoperative MRI revealed an acute ischemic stroke adjacent to the tumor resection cavity in 19 patients (23%), 13 of whom developed new neurological deficits due to the ischemic event. Infarcts were more common in patients with recurrent tumors, especially those involving the Sylvian fissure (p< 0.05). Surgery for insular gliomas had the strongest association with postoperative infarcts. Survival of patients w/wo a postoperative infarct was the same. The median Karnofsky-Performance Status was lower for the infarct group vs. the non-infarct group at 3 months post-surgery (p=0.016), with a gradual significant improvement for the former over one year (p=0.04). Immediately after surgery, 27% of the patients without infarcts and 58% of those with infarcts experienced a new motor deficit (p=0.037), decreasing to 16% (p=0.028) and 37% (p=0.001), respectively, at one year. Neurocognitive analysis findings before and 3 months after surgery were unchanged, but patients with an infarct had a significant decrease in naming (p=0.04). Confusion during awake craniotomy was a strong predictor of an ischemic stroke. CONCLUSIONS Intraoperative strokes are more prevalent among patients who undergo recurrent surgeries, especially in the insula. Although they do not affect survival, these strokes negatively impact the patients’ activity and performance status, especially during the first 3 postoperative months, with gradual functional improvement over one year.

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Surgical approaches to posterior fossa tumours

Oxford Textbook of Neurological Surgery ◽

10.1093/med/9780198746706.003.0031 ◽

2019 ◽

pp. 375-382

Author(s):

Jacques J. Morcos ◽

Osaama Khan ◽

Ashish H. Shah

Keyword(s):

Posterior Fossa ◽

Fourth Ventricle ◽

Cranial Nerves ◽

Surgical Techniques ◽

Foramen Magnum ◽

Surgical Approaches ◽

Tumour Resection ◽

Surgical Morbidity ◽

Preoperative Workup ◽

Lower Cranial Nerves

Lesions of the fourth ventricle and foramen magnum can be difficult to manage surgically due to their proximity to critical brainstem structures. Understanding the anatomy of the fourth ventricle, lower cranial nerves, and basilar cisterns remains paramount for deciding surgical approaches to this location. Detailed preoperative workup and planning are necessary to minimize surgical morbidity and maximize tumour resection. This chapter provides an overview of the relevant anatomy and surgical techniques for lesions in the posterior fossa, specifically the fourth ventricle the foramen magnum. We will split this chapter into two main sections: microsurgical approaches to the fourth ventricle and skull base approaches to the foramen magnum.

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Endoscopic-Assisted Resection of Anterior Foramen Magnum Meningiomas through a Midline Suboccipital Subtonsillar Approach

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0041-1727126 ◽

2021 ◽

Author(s):

Florian Roser ◽

Luigi Rigante

Keyword(s):

Anterior Part ◽

Tumor Resection ◽

Cranial Nerves ◽

Foramen Magnum ◽

Anterior Portion ◽

Suboccipital Craniotomy ◽

Dural Attachment ◽

Surgical Corridor ◽

Lower Cranial Nerves ◽

Brain Retraction

Abstract Objective This study was aimed to demonstrate the resection of anterior foramen magnum meningiomas through an endoscopic-assisted posterior midline suboccipital subtonsillar approach. Design This study was designed with illustration of the surgical steps and safety of this approach. Setting Evidence of cerebrospinal fluid (CSF) cleft between the tumor and brainstem on MRI was studied (Fig. 1A and B). Preoperative tracheotomy was considered in cases of preoperative dysphagia to prevent any further neurological deterioration due to the bilateral access through the lower cranial nerves corridors. Semisitting position with extensive electrophysiological neuromonitoring and transesophageal echocardiogram was adopted. A standard midline incision with bilateral suboccipital craniotomy and C1-laminotomy was performed (Fig. 2A). After partial resection and elevation of the tonsils, tumor was debulked unilaterally around the lower cranial nerves and the vertebral artery, devascularized from the clival dura and then dissected from the brainstem (Fig. 2B, C). Endoscopic-assisted removal of its anterior portion followed. The same procedure was repeated from the opposite site for the contralateral portion, before approaching the purely anterior part with endoscope assistance (Fig. 2D). Participants Four consecutive patients were included in the study. Main Outcome Measures Grade of tumor resection and outcome (mRS) were primary measurement of this study. Results Clinical outcome and grade of resection are comparable to other series of patient treated with other foramen magnum approaches (Fig. 1C and D). Conclusion Anterior foramen magnum meningiomas can be safely removed through this relatively faster midline suboccipital approach with bilateral exposure of lower cranial nerves (CNs) and vertebral arteries and lower approach-related morbidity (no condyle drilling). The surgical corridor is created by the tumor during debulking reducing need for brain retraction and the removal of the anterior dural attachment coagulated under the microscope is verified and completed endoscopically with pituitary curettes (Simpson's grade II) (Fig. 1C and D).The link to the video can be found at: https://youtu.be/9eACAJVwQBs.

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Management of a Persistent Oblique Occipital Sinus with Staged Ligation in a Case of Medulloblastoma: A Case Report

Pediatric Neurosurgery ◽

10.1159/000517214 ◽

2021 ◽

pp. 1-5

Author(s):

Gaurav Tyagi ◽

Gyani Jail Singh ◽

Manish Beniwal ◽

Dwarakanath Srinivas

Keyword(s):

Case Report ◽

Posterior Fossa ◽

Tumor Resection ◽

Female Child ◽

Transverse Sinus ◽

Venous Hypertension ◽

Venous Outflow ◽

Excessive Bleeding ◽

Occipital Sinus ◽

Suboccipital Craniotomy

Introduction: A patent persistent occipital sinus (OS) can be seen in 10% of adults. The presence of such a dominant draining OS can present as a challenge for posterior fossa surgeries. Occlusion or division of the sinus can cause venous hypertension, causing a cerebellar bulge or increased intra-op bleeding. Case report: A 3-and-a-half-year-old female child presented with a vermian medulloblastoma with hydrocephalus. MR venography (MRV) revealed a large patent OS draining from the torcula to the right sigmoid sinus. She underwent a left Frazier’s point VP shunt followed by a midline suboccipital craniotomy for the lesion. The OS was divided during a “Y”-shaped durotomy. Following the sinus ligation, there was a significant cerebellar bulge and excessive bleeding from the lesion. We released cisternal CSF and punctured the tumor cysts to allow the brain bulge to settle. Hemostasis was secured, and surgery was deferred, an augmented duroplasty was done, and bone flap was removed to allow for intracranial pressure decompression. The patient was electively ventilated for 24 h and weaned off gradually. A repeat MRV at 7 days showed the reorganization of the venous outflow at the torcula. Reexploration with tumor resection was done on post-op day 10. The patient recovered well from the surgery and was referred for adjuvant therapy. Conclusion: Surgeons should carefully analyze venous anatomy before posterior fossa surgeries. The persistent dominant OS, when present, should be taken care of while planning the durotomy. A hypoplastic but persistent transverse sinus allowed us to ligate and divide the OS. By doing a staged division of the sinus, reorganization of the venous outflow from the torcula can be allowed to occur, and the lesion can be resected.

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Infradentate Approach to the Fourth Ventricle

Operative Neurosurgery ◽

10.1093/ons/opy175 ◽

2018 ◽

Vol 16 (2) ◽

pp. 167-178

Author(s):

Ali O Jamshidi ◽

Blake Priddy ◽

Andre Beer-Furlan ◽

Daniel M Prevedello

Keyword(s):

Posterior Fossa ◽

Fourth Ventricle ◽

Dentate Nucleus ◽

Cerebellar Vermis ◽

Neurological Deficits ◽

Tubular Retractor ◽

Surgical Access ◽

Successful Removal ◽

Surgical Modality ◽

Traditional Approaches

Abstract BACKGROUND The use of minimally invasive transcranial ports for the resection of deep-seated lesions has been shown to be safe and effective for supratentorial lesions. The routine use of this surgical modality for posterior fossa masses has not been well established in the literature. In particular, fourth ventricular tumors are not the typical target for neuro-port surgery because of potential injury to the dentate nucleus. OBJECTIVE To describe the use of a tubular retractor system to reach the fourth ventricle while sparing the cerebellar vermis and the dentate nucleus. Three cases illustrations are presented. METHODS Surgical access to the fourth ventricle was developed sparing the cerebellar vermis and the dentate nucleus. The authors reviewed 3 cases to illustrate the feasibility of minimal access transcerebellar port surgery for the resection of these lesions using an infradentate access. RESULTS None of the patients developed new neurological deficits and the pathology was successfully resected in all cases. There were no major complications related to surgery and no mortalities. CONCLUSION The infradentate approach obviates the need for traditional approaches to the fourth ventricle, thus making this challenging target in the posterior fossa more accessible to neurosurgeons. The authors observed successful removal of lesions involving the fourth ventricle while avoiding any associated morbidity or mortality.

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Association between postoperative DTI metrics and neurological deficits after posterior fossa tumor resection in children

Journal of Neurosurgery Pediatrics ◽

10.3171/2019.5.peds1912 ◽

2019 ◽

Vol 24 (4) ◽

pp. 364-370 ◽

Cited By ~ 1

Author(s):

Aditya Vedantam ◽

Katie M. Stormes ◽

Nisha Gadgil ◽

Stephen F. Kralik ◽

Guillermo Aldave ◽

...

Keyword(s):

Posterior Fossa ◽

Median Duration ◽

Structural Damage ◽

Diffusion Tensor ◽

Statistical Significance ◽

Tumor Resection ◽

Neurological Deficits ◽

Posterior Fossa Tumors ◽

Cerebellar Peduncles

OBJECTIVEResection of posterior fossa tumors in children may be associated with persistent neurological deficits. It is unclear if these neurological deficits are associated with persistent structural damage to the cerebellar pathways. The purpose of this research was to define longitudinal changes in diffusion tensor imaging (DTI) metrics in white matter cerebellar tracts and the clinical correlates of these metrics in children undergoing resection of posterior fossa tumors.METHODSLongitudinal brain DTI was performed in a cohort of pediatric patients who underwent resection of posterior fossa tumors. Fractional anisotropy (FA) of the superior cerebellar peduncles (SCPs) and middle cerebellar peduncles (MCPs) was measured on preoperative, postoperative, and follow-up DTI. Early postoperative (< 48 hours) and longer-term follow-up neurological deficits (mutism, ataxia, and extraocular movement dysfunction) were documented. Statistical analysis was performed to determine differences in FA values based on presence or absence of neurological deficits. Statistical significance was set at p < 0.05.RESULTSTwenty children (mean age 6.1 ± 4.1 years [SD], 12 males and 8 females) were included in this study. Follow-up DTI was performed at a median duration of 14.3 months after surgery, and the median duration of follow-up was 19.7 months. FA of the left SCP was significantly reduced on postoperative DTI in comparison with preoperative DTI (0.44 ± 0.07 vs 0.53 ± 0.1, p = 0.003). Presence of ataxia at follow-up was associated with a persistent reduction in the left SCP FA on follow-up DTI (0.43 ± 0.1 vs 0.55 ± 0.1, p = 0.016). Patients with early postoperative mutism who did not recover at follow-up had significantly decreased FA of the left SCP on early postoperative DTI in comparison with those who recovered (0.38 ± 0.05 vs 0.48 ± 0.06, p = 0.04).CONCLUSIONSDTI after resection of posterior fossa tumors in children shows that persistent reduction of SCP FA is associated with ataxia at follow-up.

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SURG-28. PRESENTATION OF A POSTERIOR FOSSA TUMOR AT A HOSPITAL IN WESTERN JAMAICA

Neuro-Oncology ◽

10.1093/neuonc/noaa215.874 ◽

2020 ◽

Vol 22 (Supplement_2) ◽

pp. ii209-ii209

Author(s):

Brandon Dixon ◽

Renn Holness ◽

Tasha-Kay Walker ◽

Franz Pencle

Keyword(s):

Posterior Fossa ◽

Pediatric Population ◽

Obstructive Hydrocephalus ◽

Foramen Magnum ◽

Csf Leak ◽

Low Grade ◽

Who Grade ◽

Lumbar Drain ◽

Primary Neoplasms ◽

Ct Brain

Abstract The posterior cranial fossa is part of the cranial cavity, located between the foramen magnum and tentorium cerebelli that houses the cerebellum, pons and medulla oblongata. Commonly, tumors arising from this region in adults are cerebellar metastases or schwannomas of the vestibular nerve – the incidence of primary neoplasms is uncommon and more reserved for the pediatric population. A 28 year old female was in her usual state of health until last year when she started experiencing recurrent headaches with associated vomiting and intermittent loss of consciousness. A CT brain was done upon presentation to the hospital that revealed a 4th ventricle mass with obstructive hydrocephalus. A ventriculoperitoneal (VP) shunt was done thereafter to decompress the ventricular system, in anticipation for further surgical intervention for mass. Occipital craniotomy and resection of tumor was done and patient managed in a multidisciplinary manner in the intensive care unit. Post-operative course was marked by occipital pseudomeningocele with an associated CSF leak; a lumbar drain was placed in situ until complete resolution of leak. Histological analysis showed WHO Grade II Astrocytoma. Adult primary posterior fossa tumors are rare and can present with a constellation of symptoms. Although patient presented with findings in keeping with the diagnosis of an ependymoma, close clinical follow up will be required henceforth due to the refractory nature of such a low grade astrocytoma post-resection. Radiotherapy can also be considered in further management of case.

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Foramen Magnum Meningioma: Microsurgical Endoscopic-Controlled Resection via a Lateral Suboccipital Retrocondylar Approach with Preservation of Posterior Arch of Atlas Integrity

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0039-1698822 ◽

2019 ◽

Vol 80 (S 04) ◽

pp. S352-S354

Author(s):

Hischam Bassiouni

Keyword(s):

Vertebral Artery ◽

Tumor Resection ◽

Cranial Nerves ◽

Radical Resection ◽

Craniocervical Junction ◽

Foramen Magnum ◽

Cervical Cord ◽

Posterior Arch ◽

Suboccipital Craniotomy ◽

Upper Cervical

Abstract Objective Surgical treatment of foramen magnum (FM) meningiomas is challenging due to proximity of the tumor to critical neurovascular structures, namely, the lower brainstem/upper cervical cord, vertebral artery, PICA, and lower cranial nerves. Controversies in microsurgical resection of meningiomas in this location include the necessity for condyle drilling and the need for vertebral artery mobilization. However, a laminectomy or hemilaminectomy of the C1 posterior arch is usually routinely performed. We herein present microsurgical, endoscopic-controlled resection of a FM meningioma via a posterolateral retrocondylar suboccipital craniotomy with preservation of the integrity of the posterior arch of the atlas. Setting Our patient, a 57-year-old patient, suffered from right-sided hemiparesis due to a right-sided ventrolateral FM meningioma compromising the medulla oblongata and upper cervical cord. The tumor at the craniocervical junction was resected through a posterolateral suboccipital retrocondylar craniotomy. Results Radical resection of the FM meningioma was accomplished via a lateral suboccipital retrocondylar craniotomy with preservation of posterior arch of atlas integrity. The postoperative course was uneventful with full preservation of neurological function. Preoperative hemiparesis subsided completely after surgery. Conclusion Anterior-laterally located FM meningiomas can be safely and completely resected via a suboccipital retrocondylar craniotomy. A laminectomy or hemilaminectomy of the posterior arch of C1 is not routinely required for complete and safe resection of these tumors at the craniocervical junction. Neuroendoscopy is beneficial for control of complete tumor resection.The link to the video can be found at: https://youtu.be/DBk6qoJ6OzQ.

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