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.

Atypical pediatric ganglioglioma is common and associated with a less favorable clinical course

2016 ◽  
Vol 17 (1) ◽  
pp. 41-48 ◽  
Author(s):  
Mohana Rao Patibandla ◽  
Thomas Ridder ◽  
Kathleen Dorris ◽  
Michelle R. Torok ◽  
Arthur K. Liu ◽  
...  
Keyword(s):  
Temporal Lobe ◽  
Clinical Course ◽  
Oncological Outcome ◽  
Tumor Location ◽  
Complete Resection ◽  
Low Grade ◽  
Imaging Features ◽  
Total Resection ◽  
Brainstem Death

OBJECT Ganglioglioma (GG) is commonly recognized as a low-grade tumor located in the temporal lobe, often presenting with seizures. Most are amenable to complete resection and are associated with excellent oncological outcome. The authors encountered several GGs in various locations, which seem to have a less favorable clinical course than GGs in the temporal lobe. METHODS The authors performed a single-center retrospective review of all children with a histological diagnosis of GG who were treated at Children’s Hospital Colorado between 1997 and 2013. Each tumor was categorized by 2 pediatric neuroradiologists as typical or atypical based on preoperative MRI appearance. Typical lesions were cortically based, within a single cerebral lobe, well-circumscribed, and solid or mixed solid/cystic. The treatment and clinical course of each patient was analyzed. RESULTS Thirty-seven children were identified, with a median age at presentation of 8.2 years and median follow-up of 38.0 months. Eighteen tumors (48.6%) were typical and 19 (51.4%) were atypical. All typical lesions presented with seizures, whereas no atypical lesions did so. Sixteen (88.9%) typical lesions were located in the temporal lobe. In the atypical group, tumor location was variable, including 11 (57.9%) in the brainstem. Death during follow-up was statistically more common in the atypical group (31.6% vs 0%, p = 0.02). Gross-total resection (GTR) was achieved for 15 of 16 typical tumors (93.8%), compared with 3 atypical tumors (15.8%, p < 0.0001). Presentation with seizure or non-brainstem location were each associated with survival (p = 0.02 and 0.004, respectively). The presence of mutation in BRAF exon 15 did not differ between the 2 groups. CONCLUSIONS Pediatric GG with typical imaging features is associated with excellent rates of GTR and overall survival. Atypical GG is commonly encountered, less amenable to GTR, and associated with a worse outcome. This may relate to anatomical or biological characteristics and merits further investigation.

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.

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 Suprasellar Craniopharyngioma—Technical Purview

2018 ◽  
Vol 79 (S 03) ◽  
pp. S247-S248 ◽  
Author(s):  
Anil Nanda ◽  
Vinayak Narayan ◽  
Nasser Mohammed ◽  
Amey Savardekar ◽  
Devi Patra
Keyword(s):  
Optic Nerve ◽  
Residual Tumor ◽  
Blind Spot ◽  
Complete Resection ◽  
Complete Excision ◽  
Best Management ◽  
Excessive Sleepiness ◽  
History Of ◽  
Perforator Vessels ◽  
Microsurgical Resection

Objectives Complete surgical resection is an important prognostic factor for recurrence and is the best management for craniopharyngioma. This operative video demonstrates the technical nuances in achieving complete resection of a suprasellar craniopharyngioma. Design and Setting The surgery was performed in a middle-aged lady who presented with the history of progressive bitemporal hemianopia and excessive sleepiness over 8 months. On imaging, suprasellar craniopharyngioma was identified. The tumor was approached through opticocarotid cistern and lamina terminalis. Exposure of bilateral optic nerves, right internal carotid artery, anterior cerebral artery, and its perforator branches was then afforded and the tumor was gross totally resected. Results The author demonstrates step-by-step technique of microsurgical resection of suprasellar craniopharyngioma. The narrow corridor to deeper structures, intricacies of multiple perforator vessels, and the technique of arachnoid and capsule dissection are the main challenging factors for the gross total resection of craniopharyngioma. The tumor portion which lies under the ipsilateral optic nerve is a blind spot region with a high chance of leaving residual tumor. Mobilization of optic nerve may endanger visual function too. The use of handheld mirror [‘mirror-technique’] helps in better visualization of this blind spot and achieve complete excision. Conclusions The technical pearls of craniopharyngioma surgery include the optimum utilization of translamina terminalis route, wide opening of the cisterns, meticulous separation of deep perforator vessels, capsular mobilization/traction avoidance, and the use of “mirror-technique” for blind-spot visualization. These surgical strategies help to achieve complete resection without causing neurological deficit.The link to the video can be found at: https://youtu.be/9wHJ4AUpG50.

Posterior Fossa Ependymomas: Report of 30 Cases and Review of the Literature

Neurosurgery ◽  
1991 ◽  
Vol 28 (5) ◽  
pp. 659-665 ◽  
Author(s):  
Mark K. Lyons ◽  
Patrick J. Kelly
Keyword(s):  
Posterior Fossa ◽  
Survival Rates ◽  
Residual Tumor ◽  
Gross Total Resection ◽  
Subtotal Resection ◽  
Low Grade ◽  
Significant Prognostic Factor ◽  
Median Dose ◽  
Total Resection ◽  
Male Patients

Abstract Thirty patients with histologically confirmed posterior fossa ependymomas operated on between January 1976 and December 1988 were reviewed. The median age was 44 years (range, 1-69 yr). There were 7 children (aged 5 yr or younger) and 23 adults (aged 16 yr or older). There were 18 female patients and 12 male patients. Headache, nausea and vomiting, and disequilibrium were the most frequent symptoms. The most common findings were ataxia and nystagmus. Gross total resection was performed in 8 patients (27%), subtotal resection in 21 patients (70%), and biopsy in only 1 patient (3%), Tumors were low grade in 73% and high grade in 27%. Twenty-seven patients underwent posterior fossa radiotherapy (median dose, 5400 cGy). Fourteen patients also underwent spinal irradiation (median dose, 3520 cGy). Age was the only significant prognostic factor identified (P &lt;0.01). The 5-year survival rates were 76% for adults and 14% for children. All 14 patients who died had recurrent or residual tumor at the primary site. This review suggests that in patients with primary posterior fossa ependymomas the following is true: 1) the young patient (5 yr old or younger) has a poor prognosis: 2) there was a trend toward a better 5-year survival rate with a gross total resection; 3) if recurrence occurs, it will be at the primary intracranial site; and 4) symptomatic spinal seeding does not occur frequently.

Efficacy of facial nerve–sparing approach in patients with vestibular schwannomas

2011 ◽  
Vol 115 (5) ◽  
pp. 917-923 ◽  
Author(s):  
Raqeeb Haque ◽  
Teresa J. Wojtasiewicz ◽  
Paul R. Gigante ◽  
Mark A. Attiah ◽  
Brendan Huang ◽  
...  
Keyword(s):  
Facial Nerve ◽  
Residual Tumor ◽  
Subtotal Resection ◽  
Nerve Sparing ◽  
Nerve Function ◽  
Facial Nerve Function ◽  
Total Resection ◽  
Nerve Preservation ◽  
Facial Nerve Preservation ◽  
Microsurgical Resection

Object The goal of this article was to show that a combination of facial nerve–sparing microsurgical resection and Gamma Knife surgery (GKS) for expansion of any residual tumor can preserve good facial nerve function in patients with recurrent vestibular schwannoma (VS). Methods Records of individuals treated by a single surgeon with a facial nerve–sparing technique for a VS between 1998 and 2009 were retrospectively analyzed for tumor recurrence. Of the 383 patients treated for VS, 151 underwent microsurgical resection, and 20 (13.2%) of these patients required postoperative retreatment for a significant expansion of residual tumor after microsurgery. These 20 patients were re-treated with GKS. Results The rate of preservation of good facial nerve function (Grade I or II on the House-Brackmann scale) in patients treated with microsurgery for VS was 97%. Both subtotal and gross-total resection had excellent facial nerve preservation rates (97% vs 96%), although subtotal resection carried a higher risk that patients would require retreatment. In patients re-treated with GKS after microsurgery, the rate of facial nerve preservation was 95%. Conclusions In patients with tumors that cannot be managed with radiosurgery alone, a facial nerve–sparing resection followed by GKS for any significant regrowth provides excellent facial nerve preservation rates.

scholarly journals Microsurgical Resection of Low-Grade Spinal Cord Astrocytoma: 2-Dimensional Operative Video

2018 ◽  
Vol 17 (3) ◽  
pp. E107-E108
Author(s):  
Mirza Pojskić ◽  
Kenan I Arnautović
Keyword(s):  
Spinal Cord ◽  
Motor Evoked Potentials ◽  
Prognostic Significance ◽  
Neurological Function ◽  
Intramedullary Tumor ◽  
Low Grade ◽  
Thoracic Spinal Cord ◽  
Thoracic Spinal ◽  
Microsurgical Resection ◽  
Spinal Cord Astrocytoma

Abstract This video demonstrates microsurgical resection of low-grade (Grade I) thoracic spinal cord astrocytoma. Astrocytomas are the most common pediatric intramedullary tumors and occur secondary to ependymomas in adults.1,2 The treatment goal should be radical gross total resection while preserving neurological function with intraoperative neuromonitoring.2-4 To our knowledge, this is the first video report on microsurgical resection of low-grade spinal cord astrocytoma.  A 58-yr-old female presented with gait disturbances has been featured in this video. A spinal MRI revealed T1/T2 hyperintense intramedullary tumor at T4, suggesting spinal cord astrocytoma versus ependymoma. Dura was opened in the midline and tacked to the surrounding muscle tissue with tacking sutures. The arachnoid was opened separately with microscissors, keeping it intact for closure at the end of surgery. Liga clips were applied to hold the arachnoid to the dura. Myelotomy was done in the midline,5 opening the posterior median sulcus over the length of the tumor and extending proximally and distally a few millimeters beyond the tumor.3,5 The tumor reduction was achieved by coagulation or debulking. Once sufficient debulking was achieved, dissection of the tumor margins toward surrounding cord was performed. Preoperative recording of motor-evoked potentials (MEPs) compared with continuous intraoperative MEPs were essential for preserving the neurological function and quality of life. The intraoperative finding of a clear tumor plane of resection carries positive prognostic significance and reduces the risk of complications.2,3,6  A pathohistological diagnosis showed a low-grade (Grade I) spinal cord astrocytoma (pilocytic). Follow-up MRI showed no sign of tumor or recurrence. The patient recovered fully and was neurologically intact. Written consent was obtained directly from the patient.

Primary Gastrointestinal Non-Hodgkin’s Lymphoma: II. Combined Surgical and Conservative or Conservative Management Only in Localized Gastric Lymphoma—Results of the Prospective German Multicenter Study GIT NHL 01/92

2001 ◽  
Vol 19 (18) ◽  
pp. 3874-3883 ◽  
Author(s):  
Peter Koch ◽  
Francisco del Valle ◽  
Wolfgang E. Berdel ◽  
Normann A. Willich ◽  
Berthold Reers ◽  
...  
Keyword(s):  
Conservative Treatment ◽  
Gastric Lymphoma ◽  
Residual Tumor ◽  
Complete Resection ◽  
Low Grade ◽  
Incomplete Resection ◽  
Treatment Results ◽  
Extended Field ◽  
Hodgkin's Lymphomas ◽  
Involved Field

PURPOSE: The aim of the study was to obtain data on anatomic and histologic distribution, clinical features, and treatment results of patients with primary gastrointestinal non-Hodgkin’s lymphomas, particularly combined surgical and conservative treatment (CSCT) versus conservative treatment (CT) alone for primary gastric lymphoma (PGL) in localized stages. PATIENTS AND METHODS: Whether the treatment included surgery was left to the discretion of each participating center. Radiotherapy (Rx) and chemotherapy were stratified according to histologic grading, stage, and the inclusion or omission of surgery as follows: patients with low-grade PGL were treated with extended-field (EF) Rx (30 Gy). In case of residual tumor after surgery or in case of CT only (in stage IIE after six cycles of cyclophosphamide, vincristine, and prednisone), an additional boost of 10 Gy was given. All patients with high-grade PGL were treated with four (stage IE) or six (stage IIE) cycles of cyclophosphamide, doxorubicin, vincristine, and prednisone followed by EF Rx (stage IE) or involved-field (IF) Rx (stage IIE). Rx dosage corresponded to low-grade NHL. RESULTS: Between October 1992 and November 1996, 106 patients had CT only. The survival rate (SR) after 5 years was 84.4% and was influenced neither by patients’ characteristics nor by stage or histologic grade. Seventy-nine patients had CSCT. Their SR was 82.0%. Complete resection of the tumor (R0) was prognostic for the overall survival (P = .0165) as compared with incomplete resection. CONCLUSION: Although the study was not randomized, a stomach-conserving approach may be favored.

Clinical outcomes and prognostic factors for cavernous hemangiomas of the spinal cord: a retrospective cohort study

2019 ◽  
Vol 31 (2) ◽  
pp. 271-278 ◽  
Author(s):  
Narihito Nagoshi ◽  
Osahiko Tsuji ◽  
Daisuke Nakashima ◽  
Ayano Takeuchi ◽  
Kaori Kameyama ◽  
...  
Keyword(s):  
Conservative Treatment ◽  
Surgical Intervention ◽  
Lesion Size ◽  
Sudden Onset ◽  
Neurological Function ◽  
Neurological Injury ◽  
Prognostic Indicators ◽  
Asymptomatic Patients ◽  
Surgical Data ◽  
Unstable Gait

OBJECTIVEIntramedullary cavernous hemangioma (CH) is a rare vascular lesion that is mainly characterized by the sudden onset of hemorrhage in young, asymptomatic patients, who then experience serious neurological deterioration. Despite the severity of this condition, the therapeutic approach and timing of intervention for CH remain matters of debate. The aim of this study was to evaluate the clinical characteristics of CH patients before and after surgery and to identify prognostic indicators that affect neurological function in these patients.METHODSThis single-center retrospective study included 66 patients who were treated for intramedullary CH. Among them, 57 underwent surgery and 9 patients received conservative treatment. The authors collected demographic, symptomology, imaging, neurological, and surgical data. Univariate and multivariate logistic regression analyses were performed to identify the prognostic indicators for neurological function.RESULTSWhen comparing patients with stable and unstable gait prior to surgery, patients with unstable gait had a higher frequency of hemorrhagic episodes (52.4% vs 19.4%, p = 0.010), as assessed by the modified McCormick Scale. The lesion was significantly smaller in patients who underwent conservative treatment compared with surgery (2.5 ± 1.5 mm vs 5.9 ± 4.1 mm, respectively; p = 0.024). Overall, the patients experienced significant neurological recovery after surgery, but a worse preoperative neurological status was identified as an indicator affecting surgical outcomes by multivariate analysis (OR 10.77, 95% CI 2.88–40.36, p < 0.001). In addition, a larger lesion size was significantly associated with poor functional recovery in patients who had an unstable gait prior to surgery (8.6 ± 4.5 mm vs 3.5 ± 1.6 mm, p = 0.011).CONCLUSIONSOnce a hemorrhage occurs, surgical intervention should be considered to avoid recurrence of the bleeding and further neurological injury. In contrast, if the patients with larger lesion presented with worse preoperative functional status, surgical intervention could have a risk for aggravating the functional deficiencies by damaging the thinning cord parenchyma. Conservative treatment may be selected if the lesion is small, but regular neurological examination by MRI is needed for assessment of a change in lesion size and for detection of functional deterioration.

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.

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