Skip to main content

Advertisement

SpringerLink
Log in

Combined telovelar posterolateral (far lateral) approach for the resection of a large posterior fossa ependymoma: how I do it

  • How I Do it
  • Published:
Acta Neurochirurgica Aims and scope Submit manuscript

Abstract

Background

Ependymomas are glial cell tumors whose recommended treatment, according to the recent European guidelines, is surgical. Patient outcomes, in terms of progression-free survival and overall survival, are strongly related to the extent of resection. However, in some cases, critical locations and/or large dimensions could make a gross total resection challenging. In this article, we describe the surgical anatomy and technique of a combined telovelar-posterolateral approach for the resection of a giant posterior fossa ependymoma.

Methods

A 24-year-old patient who presented to our institution complaining of a 3-month history of headache, vertigo, and imbalance. Preoperative MRI scans showed a large mass within the fourth ventricle, extending towards the left cerebellopontine angle and perimedullary space through the homolateral Luschka foramen. Surgical treatment was proposed with the aims of releasing the preoperative symptoms, obtaining the tumor’s histopathological and molecular definition, and preventing any future neurological deterioration. The patient gave his written consent for surgery and consented to the publication of his images. A combined telovelar-posterolateral approach was then performed to maximize the tumor’s exposure and resection. Surgical technique and anatomical exposure have been extensively described, and a 2-dimensional operative video has been included.

Results

The postoperative MRI scan demonstrated an almost complete resection of the lesion, with only a millimetric tumor remnant infiltrating the uppermost portion of the inferior medullary velum. Histo-molecular analysis revealed a grade 2 ependymoma. The patient was discharged home neurologically intact.

Conclusions

The combined telovelar-posterolateral approach allowed to achieve a near total resection of a giant multicompartimental mass within the posterior fossa in a single surgical stage.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5

Similar content being viewed by others

Abbreviations

CSF:

Cerebrospinal fluid

CPA:

Cerebellopontine angle

FLAIR:

Fluid inversion recovery

MIB1:

Mindbomb E3 ubiquitin protein ligase 1

MRI:

Magnetic resonance imaging

PICA:

Posterior inferior cerebellar artery

PF-EPN NOS:

Posterior fossa ependymoma not otherwise specified

VA:

Vertebral artery

2-D :

2-dimensional

CN :

Cranial nerve

CPA :

Cerebellopontine angle

CSF :

Cerebrospinal fluid

CT :

Computed tomography

ER :

Emergency room

EVD :

External ventricular drainage

EPN :

Ependymoma

MRI :

Magnetic resonance imaging

PF :

Posterior fossa

PICA :

Posterior inferior cerebellar artery

RT :

Radiotherapy

VA :

Vertebral artery

References

  1. Armstrong TS, Vera-Bolanos E, Gilbert MR (2011) Clinical course of adult patients with ependymoma: results of the Adult Ependymoma Outcomes Project. Cancer 117(22):5133–5141. https://doi.org/10.1002/cncr.26181

    Article  PubMed  Google Scholar 

  2. Ghali MGZ (2021) Telovelar surgical approach. Neurosurg Rev 44(1):61–76. https://doi.org/10.1007/s10143-019-01190-5

    Article  PubMed  Google Scholar 

  3. Liu JK, Dodson VN (2019) Telovelar approach for microsurgical resection of fourth ventricular subependymoma arising from rhomboid fossa: operative video and technical nuances. Neurosurg Focus Video 1(2):V5. https://doi.org/10.3171/2019.10.FocusVid.19452

    Article  PubMed  PubMed Central  Google Scholar 

  4. Louis DN, Perry A, Wesseling P et al (2021) The 2021 WHO Classification of Tumors of the Central Nervous System: a summary. Neuro Oncol 23(8):1231–1251. https://doi.org/10.1093/neuonc/noab106

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  5. Mussi AC, Rhoton AL Jr (2000) Telovelar approach to the fourth ventricle: microsurgical anatomy. J Neurosurg 92(5):812–823. https://doi.org/10.3171/jns.2000.92.5.0812

    Article  CAS  PubMed  Google Scholar 

  6. Pajtler KW, Mack SC, Ramaswamy V et al (2017) The current consensus on the clinical management of intracranial ependymoma and its distinct molecular variants. Acta Neuropathol 133(1):5–12. https://doi.org/10.1007/s00401-016-1643-0

    Article  CAS  PubMed  Google Scholar 

  7. Rhoton AL Jr (2000) The far-lateral approach and its transcondylar, supracondylar, and paracondylar extensions. Neurosurgery 47(3 Suppl):S195–S209. https://doi.org/10.1097/00006123-200009001-00020

    Article  PubMed  Google Scholar 

  8. Ruda R, Reifenberger G, Frappaz D et al (2018) EANO guidelines for the diagnosis and treatment of ependymal tumors. Neuro Oncol 20(4):445–456. https://doi.org/10.1093/neuonc/nox166

    Article  PubMed  Google Scholar 

  9. Vera-Bolanos E, Aldape K, Yuan Y et al (2015) Clinical course and progression-free survival of adult intracranial and spinal ependymoma patients. Neuro Oncol 17(3):440–447. https://doi.org/10.1093/neuonc/nou162

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Pieve Emanuele, Milan, Italy

    Beatrice C. Bono, Marco Riva & Federico Pessina

  2. Neurosurgery Department, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Milan, Italy

    Beatrice C. Bono, Marco Riva & Federico Pessina

Authors
  1. Beatrice C. Bono
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Marco Riva
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Federico Pessina
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

BCB, second surgeon, conceptualization, data curation, original draft preparation, writing—reviewing, and video editing. MR, second surgeon and reviewing of the final manuscript version. FP, first surgeon, conceptualization, supervision, video voice-over, and reviewing of the final manuscript version.

Corresponding author

Correspondence to Beatrice C. Bono.

Ethics declarations

Ethics approval and consent to participate

The patient was treated in accordance with the principles of the Helsinki Declaration. The patient gave written consent for the surgical procedure and the use of his data for scientific purposes.

Conflict of interest

The authors declare no competing interests. The authors did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Additional information

Summary of key points

1. Ependymomas are glial cell tumors, usually located within the ventricular system and sometimes involving multiple anatomical compartments.

2. Surgery is the first-line treatment in cases of radiologically suspected ependymomas, and histo-molecular classification is mandatory to establish proper follow-up timing and adjuvant treatments.

3. The aim of surgical treatment should be maximal safe resection, as the extent of resection is one of the main prognostic factors influencing patient outcomes.

4. Large fourth ventricular lesions with multicompartmental extension can be challenging to approach, as they could require multiple surgical steps.

5. The combined suboccipital telovelar-posterolateral approach allows for exposing three anatomical compartments in a single surgical stage: the fourth ventricle, the anterolateral perimedullary space, and the cerebellopontine angle.

6. Patient positioning should be carefully planned, keeping in mind that very different surgical corridors must be accessed during the resection stages. The lateral position is relatively well-tolerated by the patient, and it also allows for easy exposure of the lateral foramen magnum and CPA regions. Head rotation and downward tilting allow, instead, to expose the suboccipital telovelar area and reach the proper inferior-to-superior working angle towards the uppermost portion of the fourth ventricle.

7. A wide dissection of the basal cisterns is mandatory to achieve proper cerebellar relaxation; this allows the surgeon to maximize the working angles while avoiding fixed retractors, which could lead to cerebellar contusion and infarction.

8. External ventricular drainage positioning, neuronavigation, doppler ultrasound, and intraoperative are used to minimize the risk of any perioperative complication.

9. An accurate and careful dissection technique is required especially during tumor removal from the lower cranial nerves to minimize the risk of postoperative dysphonia/dysphagia.

10. Tumors involving multiple anatomical compartments are challenging to approach and resect completely, as they could require sequential or combined surgeries. In this regard, the use of an endoscope would have allowed us to better visualize the small tumor remnant, thus maximizing the chances of achieving a gross total resection.

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary information

(MP4 90842 kb)

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Bono, B.C., Riva, M. & Pessina, F. Combined telovelar posterolateral (far lateral) approach for the resection of a large posterior fossa ependymoma: how I do it. Acta Neurochir 165, 2513–2518 (2023). https://doi.org/10.1007/s00701-023-05632-4

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00701-023-05632-4

Keywords

Search

Navigation