Staged microsurgical removal of a thalamo-peduncular tumor via trans-temporal approach in a pediatric patient
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The video illustrates the microsurgical technique via a trans-temporal approach adopted by authors to approach a large left thalamo-peduncular pilocytic astrocytoma. The patient affected was a 14-month baby girl, suffering from a slowly progressive postural instability and a two-months history of right hemiparesis, without intracranial hypertension (thalamo-peduncular syndrome). An MRI showed a large tumor in the left hemisphere, at the thalamo-peduncular interface, with third ventricle obliteration and upper-anterior dislocation of the third floor structures associated with poster-medial displacement of the cortico-spinal tract. Left lateral involvement of the optic chiasm was also evident.
This video can help the neurosurgeon to better understand the most effective surgical strategy and the main pitfalls that can arise from the removal of such a rare tumour as thalamus-peduncularis in the paediatric population.
This video describes the most effective surgical strategy to remove a thalamus-peduncularis tumor in the paediatric population.
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, 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).”
Dr. Vincenzo Meglio is a fourth-year neurosurgical resident at the Division of Neurosurgery, Department of Neurosciences, Reproductive Sciences and Dentistry, University of Naples “Federico II”, Naples, Italy. He is at the moment in a 4-month rotation in the Department of Pediatric Neurosurgery at the Santobono-Pausilipon Children’s Hospital.
About this video
- Giuseppe Cinalli
- Vincenzo Meglio
- Online ISBN
- Total duration
- 1 hr 17 min
- Springer, Cham
- Copyright information
- © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
In this video, we will present the staged microsurgical removal of thalamo-peduncular tumor through a trans-temporal approach. I’m Giuseppe Cinalli, director of Pediatric Neurosurgery at Santobono-Pausillipon Children’s Hospital.
It’s a 22-month female child with a two-month history of progressive postural instability, acute right-sided hemiparesis without cranial hypertension, signaling a thalamo-peduncular syndrome. The cranial CT showed a giant lesion deep-seated at left thalamo-peduncular interface with heterogeneous density and perilesional edema.
This is the CT scan, showing the hypodense mass in the left hemisphere, thalamo-peduncular localization. A contrast-enhanced encephalic MRI confirmed the presence of the lesion in the temporal lobe, with optic chiasm involvement, anterior displacement of the A1 and M1 cerebral arteries, and posterior dislocation of P1 and P2. Spectroscopy showed a picture of heteroplastic proliferation with high proliferation rate of glial cell-line. And DTI sequences with tractography revealed the posteromedial dislocation of the left corticospinal tract, which is unusual according to the literature.
These are the images of the axial T1 injected MRI, showing the mass in the left thalamus and the peduncle. This is the sagittal image, showing the same mass under sagittal point of view. And this is the coronal, showing how deep the thalamic mass goes inside the peduncle and the temporal extension.
This is the overall aspect of the injected MRI of the patient. Subtemporal approach was feasible, but the upper part would have been less easy to control. Instead, it was chosen a transtemporal approach because of better tumor control, especially in the upper part of the tumor.
This is the overall imaging of the setup, with the support below the head in order to avoid excessive pressure of the pins and allow the head to be also supported by the cushion below. Trichotomy and draping was made as usual. And an inverted U-shaped incision located by navigation was carried out–
This is the craniotomy, frontotemporal, centered on the lesion, planned by neuronavigation. This is the incision of the cortex at the level of the inferior temporal gyrus. Opening, you can see the silhouette of the tumor in the background. Labbe vein was spared, of course. This section of the corticotomy, deepening to expose the tumor. This is the internal debulking of the tumor, with the perspective of the subtotal removal in order to have a decompressive effect and histology, in order to possibly achieve a complete removal in two stage, trying to limit as much as possible the risks of neurological deficits.
This is to give an idea of the texture of the tumor. This is the boundaries that has been reached during the first surgery. Again, removal of the lower interface of the tumor, within the temporal horn. And this is the intermediate MRI, showing partial removal. Unfortunately, this was a pilomyxoid astrocytoma, so an immediate regrowth was observed at only one month after surgery, with significant increase of the residual volume and obliging the surgeons to perform a second procedure very rapidly, without waiting for chemotherapy.
That was the original plan. We were obliged to complete the resection in order to offer to the oncologists the possibility to perform a neoadjuvant therapy. And this is the result after the second surgery.