Suboccipital Microsurgical Resection of Pediatric Ependymoma in the Foramen of Luschka: 2-Dimensional Operative Video

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.

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

Neurosurgical Focus: Video ◽

10.3171/2019.10.focusvid.19465 ◽

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.

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Microsurgical resection of a glioblastoma multiforme of the medulla oblongata with intraoperative subcortical stimulation and mapping

Neurosurgical Focus: Video ◽

10.3171/2019.10.focusvid.19405 ◽

2019 ◽

Vol 1 (2) ◽

pp. V1

Author(s):

Sima Sayyahmelli ◽

Jian Ruan ◽

Bryan Wheeler ◽

Mustafa K. Başkaya

Keyword(s):

Glioblastoma Multiforme ◽

Surgical Resection ◽

Medulla Oblongata ◽

Cranial Nerves ◽

The Body ◽

Fine Motor ◽

Surgical Video ◽

Inferior Aspect ◽

Hyperintense Signal ◽

Microsurgical Resection

Primary glioblastoma multiforme tumors of the medulla oblongata are rare, especially in the adult population. Perhaps due to this rarity, we are not aware of any previous reports addressing the resection of these tumors or their clinical outcomes.In this surgical video, we present a 43-year-old man with a 1-month history of left-sided paresthesia. The paresthesia initiated in the left hand, along with weakness and reduced fine motor control, and then spread to the entire left side of the body. He had recent weight loss, imbalance, difficulty in swallowing, and hoarseness in his voice. He also had a diminished gag reflex, and significant atrophy of the right side of the tongue with an accompanying deviation of the uvula and fasciculations of the tongue. MRI showed an infiltrative expansile mass within the medulla with peripheral enhancement and central necrosis. In T2/FLAIR sequences, a hyperintense signal extended superiorly into the left inferior aspect of the pons and left inferior cerebellar peduncle and inferiorly into the upper cervical cord.The decision was made to proceed with surgical resection. The patient underwent a midline suboccipital craniotomy with C1 laminectomy for surgical resection of this infiltrative expansile intrinsic mass in the medulla oblongata, with concurrent monitoring of motor and somatosensory evoked potentials and monitoring of lower cranial nerves IX, X, XI, and XII. A gross-total resection of the enhancing portion of the tumor was performed, along with a subtotal resection of the nonenhancing portion. The surgery and postoperative course were uneventful. Histopathology revealed a grade IV astrocytoma. The patient received radiation therapy.In this surgical video, we demonstrate important steps for the microsurgical resection of this challenging glioblastoma multiforme of the medulla oblongata.The video can be found here: https://youtu.be/QHbOVxdxbeU.

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EPEN-21. IMPAIRED NEURONAL-GLIAL FATE SPECIFICATION IN PEDIATRIC EPENDYMOMA REVEALED BY SINGLE-CELL RNA-SEQ

Neuro-Oncology ◽

10.1093/neuonc/noaa222.158 ◽

2020 ◽

Vol 22 (Supplement_3) ◽

pp. iii311-iii312

Author(s):

Bernhard Englinger ◽

Johannes Gojo ◽

Li Jiang ◽

Jens M Hübner ◽

McKenzie L Shaw ◽

...

Keyword(s):

Dna Methylation ◽

Single Cell ◽

Regulatory Networks ◽

Target Genes ◽

Target Identification ◽

Rna Seq ◽

Cell Models ◽

Pediatric Ependymoma ◽

Glial Fate ◽

Anatomic Locations

Abstract Ependymoma represents a heterogeneous disease affecting the entire neuraxis. Extensive molecular profiling efforts have identified molecular ependymoma subgroups based on DNA methylation. However, the intratumoral heterogeneity and developmental origins of these groups are only partially understood, and effective treatments are still lacking for about 50% of patients with high-risk tumors. We interrogated the cellular architecture of ependymoma using single cell/nucleus RNA-sequencing to analyze 24 tumor specimens across major molecular subgroups and anatomic locations. We additionally analyzed ten patient-derived ependymoma cell models and two patient-derived xenografts (PDXs). Interestingly, we identified an analogous cellular hierarchy across all ependymoma groups, originating from undifferentiated neural stem cell-like populations towards different degrees of impaired differentiation states comprising neuronal precursor-like, astro-glial-like, and ependymal-like tumor cells. While prognostically favorable ependymoma groups predominantly harbored differentiated cell populations, aggressive groups were enriched for undifferentiated subpopulations. Projection of transcriptomic signatures onto an independent bulk RNA-seq cohort stratified patient survival even within known molecular groups, thus refining the prognostic power of DNA methylation-based profiling. Furthermore, we identified novel potentially druggable targets including IGF- and FGF-signaling within poorly prognostic transcriptional programs. Ependymoma-derived cell models/PDXs widely recapitulated the transcriptional programs identified within fresh tumors and are leveraged to validate identified target genes in functional follow-up analyses. Taken together, our analyses reveal a developmental hierarchy and transcriptomic context underlying the biologically and clinically distinct behavior of ependymoma groups. The newly characterized cellular states and underlying regulatory networks could serve as basis for future therapeutic target identification and reveal biomarkers for clinical trials.

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Resection of a Lower Clival Meningioma via Posterolateral Approach: Two-Dimensional Operative Video

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0040-1714407 ◽

2020 ◽

Author(s):

Pinar E. Ocak ◽

Selcuk Yilmazlar

Keyword(s):

Cranial Nerve ◽

Cranial Nerves ◽

Posterolateral Approach ◽

Left Vertebral Artery ◽

Posterior Arch ◽

Upper Cervical Spine ◽

Two Dimensional ◽

Lower Cranial Nerve ◽

Complex Anatomy ◽

Microsurgical Resection

Abstract Objectives This study aimed to demonstrate resection of a craniovertebral junction (CVJ) meningioma via the posterolateral approach. Design The study is designed with a two-dimensional operative video. Setting This study is conducted at department of neurosurgery in a university hospital. Participants A 50-year-old woman who presented with lower cranial nerve findings due to a left-sided lower clival meningioma (Fig. 1). Main Outcome Measures Microsurgical resection of the meningioma and preservation of the neurovascular structures. Results The patient was placed in park-bench position and a left-sided retrosigmoid suboccipital craniotomy, followed by C1 hemilaminectomy and unroofing the lip of the foramen magnum, was performed. The dural incision extended from the suboccipital region down to the posterior arch of C2 (Fig. 2). The arachnoid overlying the tumor was incised, revealing the course of the cranial nerve (CN) XI on the dorsolateral aspect of the tumor. The left vertebral artery (VA) was encased by the tumor which was originating from the dura below the jugular foramen. The mass was resected in a piecemeal fashion eventually. At the end of the procedure, all relevant cranial nerves and adjacent vascular structures were intact. Postoperative magnetic resonance imaging (MRI) confirmed total resection and the patient was discharged home on postoperative day 3 safely. Conclusions Microsurgical resection of the lesions of the CVJ are challenging as this transition zone between the cranium and upper cervical spine has a complex anatomy. Since adequate exposure of the extradural and intradural segments of the VA can be obtained by the posterolateral approach, this approach can be preferred in cases with tumors anterior to the VA or when the artery is encased by the tumor.The link to the video can be found at: https://youtu.be/d3u5Qrc-zlM.

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