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Interhemispheric Subrostral Translamina Terminalis Approach to a Teratoma of the Anterior third Ventricle
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The video describes the unusual interhemispheric subrostral approach to a teratoma of the anterior third ventricle. A five year old girl was referred to another hospital for diabetes insipidus. MRI showed a small enhancing mass in the anterior third ventricle and the patient was referred to our center for endoscopic biopsy that revealed immature teratoma. The lesion was resistant to chemotherapy because its size increased after three cycles, and the patient was referred again two months after endoscopic biopsy for surgical removal of the lesion.
The different steps of the procedure are described: bilateral opening of the dura, section of the sagittal sinus, section of the falx, anterior interhemispheric dissection to reach the anterior communicating artery and the A2 complex, gentle lateral retraction of both A2 tracts to reveal the lamina terminalis, incision and opening of the lamina terminalis, dissection, debulking and removal of the tumor from the anterior third ventricle.
MRI shows no residual tumor or regrowth at two-year follow up.
Introduction
This video shows the midline interhemispheric route as a valid option to perform a translamina terminalis approach to the third ventricle
About The Authors
Giuseppe Cinalli started the residency program in Neurosurgery at the “Federico II” University in Naples, and completed it at the Department of Pediatric Neurosurgery of the Hôpital Necker Enfants Malades in Paris, France. In 1993 he spent 5 months as visiting fellow in the Department of Pediatric Neurosurgery of the New York University Medical Center directed by Fred Epstein, and 3 months at the Department of Pediatric Neurosurgery of the Primary Children’s Medical Center of Salt Lake City directed by Marion “Jack” Walker.
On November 1st, 1993 he started his University career in France first as Chef de Clinique-Assistant (1993-1997) and then Practicien Hospitalier-Universitaire (1997-1998.) In October 1999 he started to work at the Department of Pediatric Neurosurgery of the Santobono-Pausilipon Children’s Hospital of Naples, where he became chief of the Department of Pediatric Neurosurgery in 2007 and head of the Department of Neurosciences in 2016. He is active member of 7 scientific societies, wrote 116 indexed papers, editor of four books (3 published with Springer), founding member of the International Study Group on Neuro Endoscopy (ISGNE) later transformed in International Federation of NeuroEndoscopy (IFNE), of which he became President in November 2017 for a two-year term.
Dr Nicola Onorini is a resident in Neurosurgery at the University of Milan, working at the Department of Neurosurgery, University of Brescia, Italy.
About this video
- Author(s)
- Giuseppe Cinalli
- Nicola Onorini
- DOI
- https://doi.org/10.1007/978-3-030-74230-0
- Online ISBN
- 978-3-030-74230-0
- Total duration
- 24 min
- Publisher
- Springer, Cham
- Copyright information
- © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2021
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Video Transcript
[MUSIC PLAYING]
In this video, we will present the interhemispheric subrostral trans-lamina terminalis approach to a teratoma of the third ventricle. I’m Giueseppe Cinalli from Santobono-Pausilipon Children’s Hospital in Naples, Italy. Five-year-old girl presented with polyuria and polydipsia. Laboratory test confirmed a diagnosis of central diabetes insipidus. Serum and CSF tumor markers were negative. MRI showed a small enhancing mass in the anterior third ventricle, and the patient was referred to our center for endoscopic biopsy that revealed an immature teratoma.
This is the trajectory that we plan to perform an endoscopic biopsy with a normal ventricle of the lesion, which is the video of the foraminal Monro and this is the fragments of the tumor that were assembled into the third ventricle. In order to exclude the presence of normal chemo-sensitive tumor, different samples were taken by the biopsy forceps during the endoscopic biopsy. As you can see, this is a very tough tumor without significant bleeding. And samples is a relatively difficult because of the texture of the tumor that is relatively firm. And this is the video after the biopsy.
The lesion was resistant to chemotherapy because its size increased after three cycles. The patient was referred again two months later after endoscopic biopsy for removal of the tumor. This is the MRI showing the lesion of the anterior third ventricle immediately behind lamina terminalis without ventricular dilatation. Sagittal T2 MRI shows the lesion that is very anterior into the third ventricle, with a large cystic component in the posterior part of the third ventricle. And this is the coronal image showing that the lesion is completely below the anterior commissure.
The surgical approach. And interhemispheric transcallosal transforaminal would not be ideal because the most anterior part would be difficult to visualize through the foraminal Monro. The subfrontal translamina terminalis would be suitable, but the upper part would not be very visible because of the prevalent vertical axis. And so we decided to perform an anterior interhemispheric trans-laminal terminalis approach. Because subcallosal area above the anterior communicating artery was quite large. And this is the trajectory visible during the pre-surgical planning of the lesion through the interhemispheric fissure. The lumbar CSF drainage is placed preoperatively to decrease brain swelling. The patient is resting supine with the head and horseshoe headrest in neutral position slightly extended.