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Removal of midbrain tumor via interhemispheric transcallosal-transchoroidal approach
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The video describes the surgical strategy for approaching a midbrain periaqueductal tumor in an adolescent girl. Hydrocephalus secondary to aqueductal/midbrain tumor was diagnosed at the age of 6 and hydrocephalus was successfully treated by endoscopic third ventriculostomy. The tumor slowly progressed over years. A biopsy of the tumor was attempted through a second endoscopic approach, at the age of 15, but it was inconclusive. Therefore, maximum possible safe resection was planned through microsurgical interhemispheric approach. A transcallosal/transchoroidal route was selected: the rationale for choosing this approach comes from a careful analysis of pre-operative MRI scans on high definition sagittal images, which show how the tumor is located at the entrance of the sylvian aqueduct. The patient was positioned supine with the head in neutral position with 15° flexion in 3-pin head rest. Skin incision was in a horse-shoe fashion to include previous scar from endoscopic biopsy, a bone flap exposing the midline and controlling the sagittal sinus was elevated, a ventricular catheter was placed in the right lateral ventricle under electromagnetic neuronavigation control, before opening the dura. After obtaining adequate brain relaxation, the dura was opened and the interhemispheric fissure was dissected, under microscopicmagnification. The calloso-maginal arteries and the pericallosal arteries were identified and protected. Corpus callosum was exposed and opened. The right lateral ventricle was entered: choroid plexus, thalamo-striate vein and foramen of Monro were identified. The choroid plexus along the choroidal fissure was coagulated. The anterior septal vein was coagulated and cut. The exposed choroidal fissure was dissected and opened form the foramen of Monro. The third ventricle was entered, interthalamic adhesion was coagulated and divided. The superior aspect of the midbrain was exposed, the upper pole of the tumor bulging from the ependyma as grayish, gelatinous mass was recognised. The tumor was biopsied and then removed with ultrasonic aspirator, under neurophysiological monitoring. A post-operative MRI showed near total removal of the tumor, that the histology confirmed as pilocytic astrocytoma. The patient presented conjugate eye movement disturbances that recovered significantly following 6-month rehabilitation.
Introduction
This video describes the surgical strategy for the removal of midbrain tumor via interhemispheric transcallosal-transchoroidal approach
About The Authors
Dr. Giuseppe Cinalli is Chief of the Department of Pediatric Neurosurgery and of the Department of Neurosciences at the Santobono-Pausilipon Children’s Hospital, where he began working in October 1999. He 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 a period as a visiting fellow at the Department of Pediatric Neurosurgery of the New York University Medical Center directed by Fred Epstein, and at the Department of Pediatric Neurosurgery of the Primary Children’s Medical Center of Salt Lake City directed by Marion “Jack” Walker. In the same year he began his University career in France as Chef de Clinique-Assistant and later as Praticien Hospitalo-Universitaire. He is an active member of 7 scientific societies, has written 116 indexed papers, edited 4 books, and is a founding member of the International Study Group on Neuro Endoscopy (ISGNE), which later became the International Federation of Neuroendoscopy (IFNE). In 2017 he was elected President of the IFNE for a two-year term.
Dr. Pietro Spennato is neurosurgeon at Department of Pediatric Neurosurgery at the Santobono-Pausilipon Children’s Hospital, where he began working in March 2007. He started the residency program in Neurosurgery at the “Vanvitelli” University in Naples. In 2003 he spent a period as a visiting fellow in neurosurgery and pediatric Neurosurgery Dpt of Neurosurgery, Royal Liverpool Children’s Hospital NHS Trust, Alder Hey, Eaton Road and Walton Centre for Neurology and Neurosurgery NHS Trust, Liverpool UK.
About this video
- Author(s)
- Giuseppe Cinalli
- Pietro Spennato
- DOI
- https://doi.org/10.1007/978-3-030-95506-9
- Online ISBN
- 978-3-030-95506-9
- Total duration
- 37 min
- Publisher
- Springer, Cham
- Copyright information
- © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2022
Video Transcript
[MUSIC PLAYING]
In this video, we will present the removal of a midbrain tumor via interhemispheric transcallosal transchoroidal approach. I am Giuseppe Cinalli, director of the Department of Neurosciences, Division of Pediatric Neurosurgery at Santobono-Pausilipon Children’s Hospital in Naples, Italy. The clinical case is of a 16-year-old girl– aqueductal stenosis secondary to an aqueductal/midbrain tumor, diagnosed at the age of six and treated with the endoscopic third ventriculostomy. MRI shows slow progression of the tumor over years.
These are the MRIs taken in 2008, 2013, 2017 showing, in 2008, the effects of endoscopic third ventriculostomy that granted the resolution of hydrocephalus at the beginning of the clinical history. But progressive tumor growth until dimensions in 2017– that prompted a surgical operation. A coronal MRI showed a ventricle that had a significantly larger size than normal and a tumor that is immediately below the floor of the third ventricle in the aqueductal area.
A neuronavigated endoscopic biopsy was organized. This is the planning of the biopsy with a very anterior bur hole in order to cannulate adequately the foramen of Monro You can see the endoscopic-biopsy incision is much more anterior if compared to the old incision of the endoscopic third ventriculostomy.
This is the endoscopic vision of the right foramen of Monro with the septal vein and the choroid plexus, advancing the endoscope into the foramen of Monro to see the floor of the third ventricle. We can see that the aqueductal area is not recognizable. We can recognize the mammilary bodies, but the more posteriorly [INAUDIBLE] the inlet of the aquaduct cannot be recognized.
We identify the tumor with electromagnetic and neuronavigation during endoscopic exploration. And we forward biopsy forceps in order to sample the area that is recognized under magnetic neuronavigation as a tumor. Endoscopic biopsy was not diagnostic. Maximum possible safe removal via interhemispheric transcallosal, transchoroidal approach was planned. Preoperative MRI shows the presence of a small right perimedian-enhancing lesion in the periaquaductal region– the relationship with the corticospinal tract and the tract to follow to access the tumor through a transcallosal transchoroidal approach following the surgical planning.
And the patient positioning is in supine, with the head in neutral position, with 15-degree flexion in a 3-pin head rest. A horseshoe skin incision was decided to include the previous incision for an endoscopic biopsy. And the standard bone flap exposed the midline to control the sagittal sinus.