Removal of Giant Intraventricular Meningioma in a Child Using Radiofrequency Bipolar Sealer

  • Giuseppe Cinalli
  • Francesca Vitulli

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The video offers the step-by-step description of the transcortical approach for the removal of a giant intraventricular tumor. Meningiomas are relatively rare in children, and are more likely to be intraventricular and cystic, with malignant behavior and multiplicity. Gross total removal is associated with the most favorable outcome; furthermore, size and extension of these lesions often make total removal impossible in one step. The risk of intraoperative death from uncontrollable hemorrhage is not negligible. Viewers will have the occasion to watch the use of a new technique, the saline-cooled radiofrequency coagulation (Aquamantys®), a novel bipolar coagulation device that incorporates a new bipolar coagulation technique, combining radiofrequency energy and saline to provide hemostatic sealing by collagen fibers denaturation. This technique has been so far only once described in literature in adult patients.

Introduction

The video offers the step-by-step description of the transcortical approach for the removal of a giant intraventricular tumor.

About The Authors

Giuseppe Cinalli

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, is author of 244 scientific works (190 indexed), has a h-index of 47, has edited 4 books, Past President of the International Federation of Neuroendoscopy (IFNE), Vice-President of the Italian Society of Neurosurgery (SINCH).”

 
Francesca Vitulli

Dr. Francesca Vitulli is a neurosurgical resident at the Department of Pediatric Neurosurgery at the Santobono-Pausilipon Children’s Hospital.

 

About this video

Author(s)
Giuseppe Cinalli
Francesca Vitulli
DOI
https://doi.org/10.1007/978-3-031-47804-8
Online ISBN
978-3-031-47804-8
Total duration
59 min
Publisher
Springer, Cham
Copyright information
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2023

Video Transcript

[MUSIC PLAYING]

In this video we will describe the removal of a giant intraventricular meningioma in a child using a radio frequency bipolar sealer. I’m Giuseppe Cinalli, Director of the Department of Neurosciences and Pediatric Neurosurgery at Santobono-Pausilipon Children Hospital. And I was helped in video making by Dr. Francesca Vitulli, resident at Federico II University, in rotation at that time.

Introduction– case presentation– this video describes the case of a 10-year-old girl admitted for headache history during the last three months. Fundoscopy revealed papilledema. She had no focal motor deficits.

Radiology showed a contrast-enhanced MRI, giant left intraventricular lesion associated with dilatation of lateral ventricle and significant mass effect. Very large draining veins were evident inside the tumor draining in the thalamostriate and internal cerebral vein complex. Angiography revealed multiple feeders coming mainly from branches of the posterior left choroidal artery with distal afferences that could not be embolized. Left parietal transcortical approach was therefore decided.

MRI with contrast injection showed the significant mass with the huge venous circulation inside the tumor. The big venous collateral drains straight inside the internal veins complex. And feeders are not large enough to be embolized. They are many, numerous, and the vascularization is very significant. But unfortunately, embolization is not possible.

Surgical Planning– position skin incision were in right lateral position with the head fixed in a three-pin holder and rotated on the right. Electromagnetic navigation was used plus intraoperative monitoring, left parietal linear skin incision, left parietal bone flap, and dura open in an X fashion.

We start with corticotomy, initial dissection, and biopsy– standard parietal corticotomy. Here we are opening the small posterior tumor cyst that was evident. Some CSF mixed to tumor cyst fluid is coming out. And here, these are the superficial veins that are on the surface that it is important not to break during the approach to keep the surgical field clean. They can be sacrificed and must be sacrificed with impunity.

And at this point, we start to use the bipolar radio frequency sealer at low power at this point. And we check the reliability of this sealer that is expanding the bipolar coagulation very effectively all around the area and limiting its action only to the surface of the tumor.

Tumor coagulation and debulking– the bleeding that was observed previously is easily controlled with the bipolar sealer. It is very evident how quick and how effective is this device. We continue with the bipolar radio frequency sealer.

Not very precise nor elegant movements, but extremely effective to coagulate in the depth and helping our ultrasonic aspirator to cut through the tumor in a completely avascular fashion.

Here, we can identify an area with a very large vessel very adjacent to the tumor inside the ventricular cavity. There are big veins that need to be coagulated and divided. Draining the posterior pole of the tumor and keeping it attached, and make it impossible the removal. So we decide to sacrifice this vessel. And this proved to be an excellent decision.

Removing more and more tumor mass. We are approaching the end of the surgery. At the end of this part of the surgery, we will see much better the tumor location area.

The ultrasonic aspirator is finishing its job. This is the postoperative MRI. And this is the coronal section, where you can see the complete removal of the tumor without subdural collection.