Resection of a Pontine Cavernous Malformation via an Endoscopic Endonasal Approach

2012 ◽  
Vol 71 (suppl_1) ◽  
pp. onsE186-onsE194 ◽  
Author(s):  
Matthew M. Kimball ◽  
Stephen B. Lewis ◽  
John W. Werning ◽  
J D. Mocco
Keyword(s):  
Skull Base ◽  
Surgical Resection ◽  
Conservative Management ◽  
Cavernous Malformation ◽  
Gross Total Resection ◽  
Total Resection ◽  
Transnasal Approach ◽  
Acute Hemorrhage ◽  
Cavernous Malformations ◽  
Endoscopic Transnasal Approach

Abstract BACKGROUND AND IMPORTANCE: Cavernous malformations of the brainstem are a dilemma in terms of deciding when to operate, and they remain difficult to access surgically. We present a novel approach for the resection of a brainstem cavernous malformation CLINICAL PRESENTATION: A 59-year-old woman presented with a 1-month history of intermittent dysarthria, right facial weakness, and left arm and leg weakness. A magnetic resonance image revealed a 2-cm mass in the pons with blood products of differing ages, consistent with a cavernous malformation. We discussed with her the risks of surgical resection and conservative management. She decided to pursue conservative management. Two weeks later, she returned to the emergency room with diplopia and left-sided hemiplegia. Acute hemorrhage within the right pons was seen. She then chose to undergo surgical resection. CONCLUSION: The patient underwent an endoscopic transnasal approach for resection of a pontine cavernous malformation. Image guidance was used to identify key anatomic landmarks. A gross total resection was achieved without new neurological deficits. With physical and occupational therapy, the patient developed antigravity strength in her left upper and lower extremities before discharge. At her 4-week follow-up, she was ambulating independently with the assistance of a cane. We report the successful gross total resection of a pontine cavernous malformation via an endoscopic transnasal approach. This patient had improvement in neurological symptoms after surgical resection with minimal surgical morbidity. Technologic advances in endoscopic skull base approaches have provided access to lesions of the skull base previously requiring more invasive approaches.

Endoscopic Resection of Hemorrhaged Third Ventricle Cavernous Malformation: 2-Dimensional Operative Video

2018 ◽  
Vol 16 (2) ◽  
pp. E51-E51
Author(s):  
Giorgio Palandri ◽  
Thomas Sorenson ◽  
Mino Zucchelli ◽  
Nicola Acciarri ◽  
Paolo Mantovani ◽  
...  
Keyword(s):  
Gold Standard ◽  
Intraventricular Hemorrhage ◽  
Cavernous Malformation ◽  
Third Ventricle ◽  
Gross Total Resection ◽  
Vascular Lesions ◽  
Total Resection ◽  
Cavernous Malformations ◽  
The Third

Abstract Cavernous malformations of the third ventricle are uncommon vascular lesions. Evidence suggests that cavernous malformations in this location might have a more aggressive natural history due to their risk of intraventricular hemorrhage and hydrocephalus.1 The gold standard of treatment is considered to be microsurgical gross total resection of the lesion. However, with progressive improvement in endoscopic capabilities, several authors have recently advocated for the role of minimally-invasive neuroendoscopy for resecting intraventricular cavernous malformations.2-4 In this timely intraoperative video, we demonstrate the gross total resection of a third ventricle cavernous malformation that presented with hemorrhage via a right-sided trans-frontal neuroendoscopic approach.

scholarly journals Use of Virtual Reality Platforms in the Preoperative Planning and Intraoperative Navigation of Deep-Seated Cavernomas

Neurosurgery ◽  
2019 ◽  
Vol 66 (Supplement_1) ◽  
Author(s):  
Carolina Gesteira Benjamin ◽  
Monica Mureb ◽  
Keiji Drysdale ◽  
Timothy M Shepherd ◽  
John G Golfinos ◽  
...  
Keyword(s):  
Virtual Reality ◽  
Surgical Resection ◽  
Diffusion Tensor ◽  
Neurologic Deficit ◽  
Gross Total Resection ◽  
Total Resection ◽  
Cavernous Malformations ◽  
Advantages And Disadvantages ◽  
Advanced Planning ◽  
Eloquent Cortex

Abstract INTRODUCTION Cavernous malformations in deep-seated eloquent cortex pose significant management challenges. Surgical resection, when indicated, carries a high risk of postoperative neurologic deficit. Obtaining safe surgical access is highly dependent upon location and the patient's clinical status. Three-dimensional (3D) virtual reality platforms, neuronavigation, and advanced neuroimaging can be used as adjuncts to determine and perform the safest surgical approach. METHODS Five patients who underwent surgical resection of deep seated cavernomas in eloquent cortex were included. 3D images were created from Diffusion Tensor MR Imaging (DTI) using a 360 Virtual Reality planning software (Surgical Theater SRP, Version7.4.0, Cleveland, Ohio). The Surgical Theater system was integrated with the neuronavigation system (Brainlab AG Version 3.0.5, Feldkirchen, Germany) to allow for real time evaluation of the 3D tractography. The 360°VR model was used to assess the location of the cavernoma and relevant anatomy, map multiple trajectories, and compare the advantages and disadvantages of each. SRP and Brainlab projections were used to determine the limits of the cavernoma, guide the placement of the tubular retractor, and confirm the approach vector intraoperatively. RESULTS Locations of the cavernomas included left caudate head, right superior colliculus, right posteroinferior thalamus, right insula, and left medulla. All patients underwent craniotomy and microsurgical resection. Two patients who presented with a neurologic deficit partially improved after prolonged rehabilitation. Three patients who were neurologically intact on presentation remained so post-op. Gross-total resection was obtained in all patients. CONCLUSION Virtual segmentation allows for better understanding of complex anatomic relationships between the lesion and surrounding critical structures. Advanced planning familiarizes surgeons to the patient in the context of the surgical field, increasing spatial and positional orientation. 3D virtual reality planning platforms in conjunction with neuronavigation and DTI can assist in choosing the optimal surgical corridor to achieve gross-total resection of deep-seated cavernomas while minimizing neurologic risk.

Transsylvian Transuncal Approach for an Anterior Midbrain Cavernous Malformation Resection: A Case Report

2017 ◽  
Vol 14 (3) ◽  
pp. E38-E43
Author(s):  
Julien Delaunois ◽  
Géraldo Vaz ◽  
Christian Raftopoulos
Keyword(s):  
Diffusion Tensor ◽  
Gross Total Resection ◽  
Direct Access ◽  
Cerebral Peduncle ◽  
Left Hemiparesis ◽  
Facial Paresis ◽  
Total Resection ◽  
Acute Hemorrhage ◽  
Cavernous Malformations ◽  
Holmes Tremor

Abstract BACKGROUND AND IMPORTANCE Cavernous malformations (CMs) are vascular abnormalities with a hemorrhage risk of 0.2% to 5% per year, according to their location. Brainstem CMs seem to have a greater hemorrhagic risk and represent a neurosurgical challenge. We report here the first transsylvian transuncal (TS-TU) approach for an anteromedial mesencephalic CM resection. CLINICAL PRESENTATION A 29-yr-old female suddenly presented a left hemiparesis and central facial paresis with a diplopia in the upward gaze. A cerebral imagery revealed an 18-mm right cerebral peduncle CM with signs of acute hemorrhage. Two months later, she rebleed while pregnant. The pregnancy was interrupted. Five months later, a 3.0 Tesla magnetic resonance imaging (MRI) with diffusion tensor imaging sequences was realized for preoperative planning followed by a gross total resection of the CM through a TS-TU approach to avoid the perforating arteries of the anterior perforated substance. The patient presented postoperatively again a left hemiparesis and central facial paresis with a right oculomotor nerve paresis. On the tenth postsurgical day, she developed a Holmes’ tremor of the left upper limb, for which a Levodopa treatment was initiated. Three months postoperative, MRI showed a gross total resection of the mesencephalic CM without complications. A complete clinical recovery was observed 1 yr later. CONCLUSION We describe here the first performance of a TS-TU approach for an anterior mesencephalic CM resection. This surgical approach allowed direct access to the CM, avoiding the vascularization of the anterior perforated substance.

scholarly journals Giant Cervical Cavernous Malformation: 2-Dimensional Operative Video

2019 ◽  
Vol 17 (4) ◽  
pp. E153-E153
Author(s):  
Benjamin K Hendricks ◽  
Robert F Spetzler
Keyword(s):  
Spinal Cord ◽  
Cavernous Malformation ◽  
Cervical Spinal Cord ◽  
Video Recording ◽  
Gross Total Resection ◽  
Cervical Cord ◽  
Total Resection ◽  
Cavernous Malformations ◽  
Institutional Review ◽  
High Cervical

Abstract Cervical spinal cord cavernous malformations are rare but can be neurologically devastating lesions and, when symptomatic, are best treated with gross total resection to prevent progressive neurologic decline related to recurrent hemorrhage. This patient had a large high cervical cord cavernous malformation with evidence of recent hemorrhage. A midline myelotomy was utilized to enter the cavernous malformation. The cavernous malformation was then circumferentially separated from the spinal parenchyma and removed in a piecemeal manner. Postoperative imaging confirmed gross total resection of the lesion with preservation of the surrounding spinal cord. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

scholarly journals Transcavernous Resection of a Giant Extensive Chondrosarcoma with Endoscopic Assistance

2021 ◽  
Author(s):  
Walid Elshamy ◽  
Burcak Soylemez ◽  
Sima Sayyahmelli ◽  
Nese Keser ◽  
Mustafa K. Baskaya
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Skull Base ◽  
Internal Carotid ◽  
Gross Total Resection ◽  
Petrous Apex ◽  
Left Internal Carotid Artery ◽  
Total Resection ◽  
Complete Occlusion ◽  
Grade Ii

AbstractChondrosarcomas are one of the major malignant neoplasms which occur at the skull base. These tumors are locally invasive. Gross total resection of chondrosarcomas is associated with longer progression-free survival rates. The patient is a 55-year-old man with a history of dysphagia, left eye dryness, hearing loss, and left-sided facial pain. Magnetic resonance imaging (MRI) showed a giant heterogeneously enhancing left-sided skull base mass within the cavernous sinus and the petrous apex with extension into the sphenoid bone, clivus, and the cerebellopontine angle, with associated displacement of the brainstem (Fig. 1). An endoscopic endonasal biopsy revealed a grade-II chondrosarcoma. The patient was then referred for surgical resection. Computed tomography (CT) scan and CT angiogram of the head and neck showed a left-sided skull base mass, partial destruction of the petrous apex, and complete or near-complete occlusion of the left internal carotid artery. Digital subtraction angiography confirmed complete occlusion of the left internal carotid artery with cortical, vertebrobasilar, and leptomeningeal collateral development. The decision was made to proceed with a left-sided transcavernous approach with possible petrous apex drilling. During surgery, minimal petrous apex drilling was necessary due to autopetrosectomy by the tumor. Endoscopy was used to assist achieving gross total resection (Fig. 2). Surgery and postoperative course were uneventful. MRI confirmed gross total resection of the tumor. The histopathology was a grade-II chondrosarcoma. The patient received proton therapy and continues to do well without recurrence at 4-year follow-up. This video demonstrates steps of the combined microsurgical skull base approaches for resection of these challenging tumors.The link to the video can be found at: https://youtu.be/WlmCP_-i57s.

scholarly journals Transcavernous Approach for Gross Total Resection of a Dumbbell-Shaped Giant Trigeminal Schwannoma

2021 ◽  
Author(s):  
Sima Sayyahmelli ◽  
Emel Avci ◽  
Burak Ozaydin ◽  
Mustafa K. Başkaya
Keyword(s):  
Skull Base ◽  
Cavernous Sinus ◽  
Tumor Resection ◽  
Mass Effect ◽  
World Health ◽  
Gross Total Resection ◽  
Petrous Apex ◽  
Total Resection ◽  
Who Grade ◽  
Trigeminal Schwannoma

AbstractTrigeminal schwannomas are rare nerve sheet tumors that represent the second most common intracranial site of occurrence after vestibular nerve origins. Microsurgical resection of giant dumbbell-shaped trigeminal schwannomas often requires complex skull base approaches. The extradural transcavernous approach is effective for the resection of these giant tumors involving the cavernous sinus.The patient is a 72-year-old man with headache, dizziness, imbalance, and cognitive decline. Neurological examination revealed left-sided sixth nerve palsy, a diminished corneal reflex, and wasting of temporalis muscle. Magnetic resonance imaging (MRI) showed a giant homogeneously enhancing dumbbell-shaped extra-axial mass centered within the left cavernous sinus, Meckel's cave, and the petrous apex, with extension to the cerebellopontine angle. There was a significant mass effect on the brain stem causing hydrocephalus. Computed tomography (CT) scan showed erosion of the petrous apex resulting in partial anterior autopetrosectomy (Figs. 1 and 2).The decision was made to proceed with tumor resection using a transcavernous approach. Gross total resection was achieved. The surgery and postoperative course were uneventful, and the patient woke up the same as in the preoperative period. MRI confirmed gross total resection of the tumor. The histopathology was a trigeminal schwannoma, World Health Organization (WHO) grade I. The patient continues to do well without any recurrence at 15-month follow-up.This video demonstrates important steps of the microsurgical skull base techniques for resection of these challenging tumors.The link to the video can be found at https://youtu.be/TMK5363836M

Ossifying fibromyxoid tumour of the sphenoid sinus

2009 ◽  
Vol 124 (4) ◽  
pp. 437-440
Author(s):  
S D Shetty ◽  
R J Salib ◽  
S B Nair ◽  
N Mathad ◽  
J Theaker
Keyword(s):  
Skull Base ◽  
Sphenoid Sinus ◽  
Neoplastic Disease ◽  
Clinical Effects ◽  
Soft Tissue Neoplasm ◽  
Transnasal Approach ◽  
Fibrous Stroma ◽  
Neuroectodermal Origin ◽  
Endoscopic Transnasal Approach

AbstractIntroduction:Ossifying fibromyxoid tumour is a recently described, rare but morphologically distinctive soft tissue neoplasm characterised by a combination of myxoid and/or fibrous stroma with areas of ossification. Although most authors postulate a neuroectodermal origin for this peculiar tumour, there is no agreement in the literature regarding its histopathogenesis. To our knowledge, this is the first reported case of ossifying fibromyxoid tumour involving the sphenoid sinus.Histological findings:Tumour of low cell density, composed of small, spindle-shaped or stellate cells with small, irregular nuclei set in a fibromyxoid stroma.Management:Following discussion at the skull base multidisciplinary team meeting, a combined surgical team including an otorhinolaryngologist and a neurosurgeon carried out resection of the lesion, using an endoscopic transnasal approach, followed by reconstruction of the defect.Conclusions:An awareness of the distinctive histopathological features of ossifying fibromyxoid tumour, and of its clinical effects, is crucial to establishing a definitive diagnosis and thereby instituting appropriate management. This case report also reinforces the evolving role of the endoscopic transnasal approach in the management of inflammatory and neoplastic disease involving the skull base. This is increasingly being made possible by close collaboration between multiple surgical specialties, including otorhinolaryngology and neurosurgery.

scholarly journals 795 Trends in Cerebrospinal Fluid Leak Rates Following the Extended Endoscopic Endonasal Approach for Anterior Skull Base Meningioma: A Meta-Analysis Over the Last 20 Years

2021 ◽  
Vol 108 (Supplement_2) ◽  
Author(s):  
A H Zamanipoor Najafabadi ◽  
D Z Khan ◽  
I S Muskens ◽  
M L D Broekman ◽  
N L Dorward ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Skull Base ◽  
Arterial Injury ◽  
Gross Total Resection ◽  
Csf Leak ◽  
Total Resection ◽  
Visual Improvement ◽  
The Impact ◽  
Reconstructive Techniques ◽  
Over Time

Abstract Introduction The extended endoscopic approach (EEA) provides direct access for resection of tuberculum sellae (TSM) and olfactory groove meningiomas (OGM) but is associated with cerebrospinal fluid (CSF) leak in up to 25% of patients. To evaluate the impact of improved skull base reconstructive techniques, we assessed published CSF leak percentages in EEA over the last two decades. Method Random-effects meta-analyses were performed for studies published between 2004-2020. Outcomes assessed were CSF leak, gross total resection, visual improvement, intraoperative arterial injury and 30-day mortality. For the main analyses, publications were pragmatically grouped based on publication year in three categories: 2004-2010, 2011-2015, and 2016-2020. Results We included 29 studies describing 540 TSM and 115 OGM patients. CSF leak incidence dropped over time from 22% (95% CI: 6-43%) in studies published between 2004 and 2010, to 16% (95% CI: 11-23%) between 2011 and 2015, and 4% (95% CI: 1-9%) between 2016 and 2020. Outcomes of gross total resection, visual improvement, intraoperative arterial injury, and 30-day mortality remained stable over time Conclusions We report a noticeable decrease in CSF leak over time, which might be attributed to the development of reconstructive techniques (e.g., hadad bassagasteguy flap, and gasket seal), refined multilayer repair protocols, and selected lumbar drain usage.

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

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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