Transcortical surgery for lateral ventricular tumors

Comparative Analysis of Supratentorial Intraventricular Tumors in Adults and Pediatrics in a Developing Country: Clinicopathological Features, Surgical Management, and Outcomes

BACKGROUND

 Supratentorial intraventricular tumors, encompassing lateral and third ventricular tumors, are uncommon intracranial neoplasms, typically slow-growing and benign, manifesting symptoms only upon reaching a substantial size. This study aims to identify optimal surgical approaches, assess the prevalence and characteristics of these tumors, and evaluate postoperative outcomes among pediatric and adult age groups.

METHODS

 A retrospective comparative study at a tertiary care hospital from January 2014 to June 2020 included 165 patients (68 pediatrics, 97 adults) meeting inclusion criteria for intraventricular tumor management. Data covered demographic factors, clinical history, neurological assessments, neuroimaging, surgical approaches, histopathological diagnoses, immunohistochemical features, adjuvant therapies, follow-up status, postoperative complications, and morbidity/mortality.

RESULTS

 Ventricular tumor incidence showed male preponderance in both adults (M:F = 1.2:1) and pediatrics (M:F = 3:1). Lateral ventricles were the most common location. Pediatric cases exhibited more frequent calcifications on computed tomography scans (35.6% vs. 29.5%). Grade II and III tumors were more prevalent in adults within the lateral ventricle (27.1 and 1.9%) compared with pediatrics (6.5 and 8.4%). The third ventricle predominantly featured benign lesions, with pediatric patients experiencing significantly longer hospital stays (16.12 ± 21.94 days vs. 9.58 ± 6.21 days) (p = 0.006). Adults and pediatric patients showed a significant difference in high-grade lateral ventricle tumors (p-value = 0.002*).

CONCLUSIONS

 Supratentorial ventricular tumors are relatively more prevalent in children than adults, presenting challenges due to size and bleeding risks. Surgical resection is the primary treatment, with a focus on the optimal approach for gross total excision to reduce recurrence risk.

Stereotactic radiosurgery for intraventricular meningioma: a systematic review and meta-analysis

BACKGROUND

Intraventricular meningioma (IVM) is a rare subtype of intracranial meningioma, accounting for 9.8 to 14% of all intraventricular tumors. Currently, there is no clear consensus on which patients with IVM should receive conservative treatment, surgery, or stereotactic radiosurgery (SRS). This research aims to analyze the outcomes, including survival and recurrence rates of patients who undergo SRS for IVM as a primary or adjuvant treatment.

METHODS

A systematic search was conducted in Scopus, Web of Science, PubMed, and Embase till June 5th 2023. Screening and data extraction were performed by two independent authors. Random-effect meta-analysis was performed to determine the tumor control proportion of IVM cases treated with SRS. Individual patient data (IPD) meta-analysis was performed for the progression-free survival (PFS) of the patients in the follow-up time. All analyses were performed using the R programming language.

RESULTS

Out of the overall 132 records, 14 were included in our study, of which only 7 had enough data for the meta-analysis. The tumor control proportion was 0.92 (95% CI, 0.69-0.98) in patients who underwent SRS for primary IVM. The overall tumor control in both primary and adjuvant cases was 0.87 (95% CI, 0.34-0.99). the heterogeneity was not significant in both meta-analyses (P = 0.73 and P = 0.92, respectively). Post-SRS perifocal edema occurred in 16 out of 71 cases (0.16; 95% CI, 0.03-0.56), with no significant heterogeneity (P = 0.32). IPD meta-analysis showed a PFS of 94.70% in a 2-year follow-up. Log-rank test showed better PFS in primary SRS compared to adjuvant SRS (P < 0.01).

CONCLUSIONS

According to this study, patients with IVM can achieve high rates of tumor control with a low risk of complications when treated with SRS, regardless of whether they have received prior treatment. Although SRS could be a promising first-line treatment option for asymptomatic IVM, its efficacy in symptomatic patients and its comparison with resection require further investigation.

Resection of the tumor in the trigone of the lateral ventricle via the contralateral posterior interhemispheric transfalcine transprecuneus approach with multi-modern neurosurgery technology: a case report

Choroid plexus papilloma (CPP) is a rare benign intracranial tumor origin that predominantly manifests in the lateral ventricle in children, accounting for 0.3%-0.6% of all primary intracranial tumors. It is extremely rare to have the CPP in the trigone of the lateral ventricle through the contralateral posterior interhemispheric transfalcine transprecuneus approach (PITTA). Herein, we report this rare case. A 7-year-old girl presented with headache. Magnetic resonance imaging of the brain showed periatrial lesions, and histopathological examination confirmed CPP (WHO grade I). The contralateral PITTA is a safe, effective, reasonable, and appropriate for some lesions in the trigone of the lateral ventricle. It provides a wider surgical angle (especially for the lateral extension) and reduces the risk of disturbance of the optic radiation compared with the conventional approaches. The use of multiple modern neurosurgical techniques, including interventional embolization, intraoperative navigation, microscope, and electrophysiological monitoring, make the procedure much easier and more accurate, and the neuroendoscope adds to the visualization of the microscope and can reduce surgical complications.

Cortical incisions and transcortical approaches for intra-axial and intraventricular lesions: A scoping review

Background

Transcortical approaches, encompassing various surgical corridors, have been employed to treat an array of intraparenchymal or intraventricular brain pathologies, including tumors, vascular malformations, infections, intracerebral hematomas, and epileptic surgery. Designing cortical incisions relies on the lesion location and characteristics, knowledge of eloquent functional anatomy, and advanced imaging such as tractography. Despite their widespread use in neurosurgery, there is a noticeable lack of systematic studies examining their common lobe access points, associated complications, and prevalent pathologies. This scoping review assesses current evidence to guide the selection of transcortical approaches for treating a variety of intracranial pathologies.

Methods

A scoping review was conducted using the PRISMA-ScR guidelines, searching PubMed, EMBASE, Scopus, and Web of Science. Studies were included if ≥5 patients operated on using transcortical approaches, with reported data on clinical features, treatments, and outcomes. Data analysis and synthesis were performed.

Results

A total of 50 articles encompassing 2604 patients were included in the study. The most common primary pathology was brain tumors (60.6%), particularly gliomas (87.4%). The transcortical-transtemporal approach was the most frequently identified cortical approach (70.48%), and the temporal lobe was the most accessed brain lobe (55.68%). The postoperative course outcomes were reported as good (55.52%), poor (28.38%), and death (14.62%).

Conclusion

Transcortical approaches are crucial techniques for managing a wide range of intracranial lesions, with the transcortical-transtemporal approach being the most common. According to the current literature, the selective choice of cortical incision and surgical corridor based on the lesion's pathology and anatomic-functional location correlates with acceptable functional outcomes.

Intraventricular Tumors: Surgical Considerations in Lateral and Third Ventricular Tumors

Management of lateral and third ventricular tumors has been a challenge for neurosurgeons. Advances in imaging and pathology have helped in a better understanding of the treatment options. Technical refinement of microsurgical technique and addition of endoscopy has enabled more radical excision of tumors, when indicated, and added more safety.A proper understanding of the pathology at various ages and treatment options is continuously evolving. Many pediatric tumors are amenable to conservative surgical methods with effective complementary treatments. However, radical surgery is required in many adults as the main treatment and for many benign tumors. Various intraventricular lesions encountered and their surgical management is reviewed here for their efficacy, safety, and outcome, encompassing changes in our practice over the last 20 years.

The Anterior Interhemispheric Transcallosal Approach to the Ventricles: How We Do It

Intraventricular tumors of the lateral and third ventricles are relatively rare, accounting for 1-2% of all primary brain tumors in most large series [1-4]. They can be uniquely challenging to approach due to their deep location, propensity to become large before they are discovered, and association with hydrocephalus [5, 6]. The surgeon's goal is to develop a route to these deep lesions that will cause the least morbidity, provide adequate working space, and achieve a complete resection. This must be performed with minimal manipulation of the neural structures encircling the ventricles, avoiding functional cortical areas, and acquiring early control of feeding vessels [7, 8].

Clinical Results and Quality of Life After Transcortical Versus Transcallosal Resection of Adult Lateral and Third Ventricle Lesions: Long-Term Outcome

BACKGROUND

Resection of intraventricular tumors can be achieved using 2 main operative approaches: transcallosal or transcortical. This study aims to describe preoperative and postoperative factors as well as quality of life (QoL) based on long-term results in these patients.

METHODS

Patients underwent surgery of primary intraventricular lesions between 2007 and 2020 via a transcortical (group A) or transcallosal (group B) route. The main clinical parameters were completeness of resection, overall survival, surgical complications, postoperative neurologic deficits, and seizure rates. QoL was assessed using a modified questionnaire Short-Form 36 inventory.

RESULTS

Forty patients (19 women and 21 men) met the inclusion criteria. Group A consisted of 26 patients (12 women and 14 men; median age 45.5 years ± 16.7 standard deviation) and had lower preoperative tumor volume (confounder) compared with group B (7 women and 7 men; age 50.0 ± 17.4 years). Gross total resection was achieved in 65% in group A and 71% in group B. Follow-up was 7.8 ± 3.9 years. New seizures/permanent neurologic deficits occurred in 27%/15% (group A) and 29%/29% (group B) and surgical complications in 23% of patients. Group B had a higher degree of memory impairment (21%) compared with group A (10%). QoL impairment was present in both groups mainly regarding physical role function and mental health index.

CONCLUSIONS

Keeping in mind the limitations, transcallosal surgery was associated with a higher probability of neurologic deficits and memory impairment in our series. However, it had fewer surgical complications with similar gross total resection and seizure rates.

Application of endoport-assisted neuroendoscopic techniques in lateral ventricular tumor surgery

Objective

The objective of this study was to investigate the clinical experience and therapeutic efficiency of Endoport-assisted neuroendoscopic surgery for resection of lateral ventricular tumors. The key points and application value of this surgical technique were additionally discussed.

Methods

A retrospective analysis was conducted on the clinical and follow-up data of 16 patients who underwent endoport-assisted neuroendoscopic surgery for lateral ventricular tumors at the Department of Neurosurgery, Nanjing Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medical School, between January 2018 and September 2020. The surgical procedures, complications and outcomes were analyzed.

Results

The study included a total of 16 patients (5 males and 11 females) with lateral ventricular tumors, with a mean age of 43.2 years (18-70 years old). The tumors were distributed as follows: 5 cases involved the body of the lateral ventricle, 3 involved the frontal horn and body, 3 involved the occipital horn, 2 involved the trigone, 2 involved the frontal horn, and 1 case involved the occipital horn and body. Perioperative complications were analyzed, revealing 1 case of intraoperative acute epidural hematoma intraoperative and 2 cases of postoperative obstructive hydrocephalus. All complications were promptly managed. Postoperative MRI revealed that 14 cases (88%) achieved total resection, while 2 cases (12%) achieved subtotal resection. During the follow-up of 6-38 months, no recurrence was observed. The patient diagnosed with glioblastoma died 16 months after surgery (GOS=1), while the remaining patients have successfully resumed to normal daily life with a GOS score of 5.

Conclusion

In conclusion, endoport-assisted neuroendoscopic surgery proved to be a minimally invasive and effective technique for resecting lateral ventricular tumors, with acceptable complications. It effectively utilizes the benefits of close observation, comprehensive exposure, and reduced tissue damage. Therefore, endoport-assisted neuroendoscopic surgery is suitable for the resection of lateral ventricular tumors.

Paramedian transparietal approach to a dominant hemisphere intraventricular meningioma: illustrative case

BACKGROUND

Meningiomas of the atrium of the lateral ventricle present a unique operative challenge. Parietal transcortical approaches have been described with an oblique approach, but a strictly paramedian approach may offer advantages in a dominant hemisphere atrial meningioma.

OBSERVATIONS

The patient presented with several weeks of intermittent headaches. Magnetic resonance imaging (MRI) showed an enhancing intraventricular mass in the atrium of the left lateral ventricle. Three-dimensional reconstructions were created from a preoperative MRI, with 1-mm slices for neuronavigation. Diffusion tensor imaging (DTI) was obtained, and tracts were reconstructed in the patient’s three-dimensional brainspace. DTI tractography delineated a paramedian transparietal corridor devoid of functional white matter tracks. The patient was positioned supine, in a semislouch position. A left parietal craniotomy was performed. Neuronavigation identified a gyrus posterior to the sensory cortex, anterior to the optic radiations and medial to superior longitudinal and arcuate fasciculus fiber tracts. The tumor was debulked to allow mobilization to coagulate capsular blood supply. Gross total resection was achieved. The patient was discharged postoperatively on day 3 without neurological deficits.

LESSONS

A paramedian transparietal approach to a dominant hemisphere meningioma of the lateral ventricle can be a safe and effective way to resect tumors in this anatomically unique operative corridor.

Microsurgical endoportal MRI/US-navigated approach for the resection of large intraventricular tumours: a 20-consecutive patients case series

OBJECTIVES

Deep lesions located in lateral and third ventricles can be accessed thorough interhemispheric transcallosal or transcortical trans-ventricular approaches. Traditional brain retractors are made by 'non-cerebral engineered' spatulas, which do not equally distribute pressure on surrounding structures damaging brain. In this paper, we present a series of 20 intraventricular tumours resected through a MRI/US-navigated microscopic transcortical endoportal approach.

PATIENTS AND METHODS

Between January 2014 and December 2017, 20 patients underwent US-MRI neuronavigated (Esaote^®, Genova, Italy) transcortical endoportal (Vycor^® Viewsite Brain Access System TC Model, Vycor^® Medical Inc., Boca Raton, FL) surgery for intraventricular deep-seated lesions with the intent to reach maximal safe resection.

RESULTS

Gross total removal was achieved in 14 patients (70%). The only prognostic factor that resulted in statistical significance related to surgical radicality from multivariate analysis was white matter infiltration (p = 0.043), regardless of other tumour (dimensions, origin and location inside ventricular system, histopathology) and patient (age, gender, clinical presentation) characteristics. The mean duration of surgery was 225.9 min (± 59). Neither critical events, nor major bleedings, nor intraoperative deaths occurred during surgery. One case of postoperative CSF infection (5%) was registered. Six patients (30%) required permanent CSF drainage system (Ommaya reservoir, VP shunt) in the postoperative period. The mean Functional Independence Measure (FIM) score at last follow-up was 105 (range: 65-124).

CONCLUSIONS

Transcortical transventricular endoportal surgery seems to be a valuable alternative to transcallosal surgery, although further prospective multicentre studies with larger number of patients, evaluation of pre- and post-operative neuropsychological outcomes and achievement of postoperative DTI and f-MRI are needed to confirm our results.

Customising the surgical management for intraventricular meningiomas - 'one size doesn't fit all'

BACKGROUND

Intraventricular meningiomas are uncommon and gross total resection is the recommended treatment. However, total resection may not always be possible, especially in locations in which the lesions are adherent to veins and neural structures. We share our experience with intraventricular meningiomas, focusing on the management strategies and outcomes.

PATIENTS AND METHODS

We describe the data of 7 patients with intraventricular meningiomas operated at our institute over the last 9 years. Three patients had a third ventricular tumor of which two had lesions straddling across the foramen of Monro. The remaining 4 patients had trigonal mass. The clinico-radiological features, management strategies and outcomes have been elaborated with a mean follow-up of 57 months.

RESULTS

The common clinical presentations were raised intracranial pressure symptoms, visual field defects and memory deficits. One patient had multiple meningiomas. Total excision was achieved in all except in 2 patients in whom the lesion straddled across the foramen of Monro with dense adhesions to veins and neural structures. Staged resection was required in one patient with a large trigonal mass. All patients had a low-grade lesion. The tumor recurred in one patient (post-pregnancy) after partial resection. All the patients improved neurologically, and none had added deficits.

CONCLUSIONS

Gross total resection of intraventricular meningiomas although desirable may not be possible in certain cases in which the risks outweigh the benefits. These tumors often are of low histological grade and the treatment strategies should be individualized. Regular follow-up is warranted as these tumors may recur despite a low histological grade.

Supracerebellar infratentorial inverted subchoroidal approach to lateral ventricle lesions: Anatomical study and illustrative case

Background:

This study provides an anatomical description of a novel supracerebellar infratentorial inverted subchoroidal (SIIS) approach to the lateral ventricle. An illustrative case is presented in which this approach was used to simultaneously resect two tumors residing in the posterior fossa and lateral ventricle.

Methods:

The SIIS approach was performed on five cadaveric heads using microsurgical and endoscopic techniques. Target points were defined in the lateral ventricle, and quantitative analysis was performed to assess limits of exposure within the lateral ventricle. Two coronal reference planes corresponding to the anterior and posterior margins of the lateral ventricle body were defined. Distances from target points to reference planes were measured, and an imaging-based predicting system was provided according to obtained measurements to guide preoperative approach selection.

Results:

Mean (standard deviation) distances between the predefined target points indicating the anterior limits and the anterior plane were 9 (7.0) mm, 11 (5.8) mm, and 7 (5.1) mm; posterior limits had distances of 8 (3.0) mm, 17 (9.2) mm, 15 (9.2) mm, and 9 (7.2) mm to the posterior plane. Limiting factors of the choroidal fissure dissection were the venous angle anteriorly and thalamocaudate vein posteriorly. The position of the venous angle had a high negative correlation with the anterior exposure limit (r = –0.87, P < 0.001; r = –0.92, P < 0.001).

Conclusion:

A step-by-step anatomical description of a new SIIS approach is given, and a quantitative description of the limits of the exposure is provided to evaluate the application of this approach.

Surgical approaches for resection of third ventricle colloid cysts: meta-analysis

Although outcome studies and systematic reviews have been published on the surgical treatment of third ventricle colloid cysts (TVCC), there are no meta-analyses that compare the outcomes for various surgical approaches. This meta-analysis assesses the outcomes and complications for transcortical, transcallosal, and endoscopic surgical approaches used to excise TVCCs. A meta-analysis of surgically excised TVCCs was performed with an assessment of outcome for transcortical, transcallosal, and endoscopic approaches. A random-effects model analyzed the extent of surgical excision. The analysis included reports that compared at least two of these surgical approaches, for a total of 11 studies comprising a population of 301 patients. The transcortical approach was associated with a higher incidence of complete excision compared to the endoscopic approach (OR = 0.137, p = 0.041), with no significant differences observed between transcortical and transcallosal approaches, and between transcallosal and endoscopic approaches. Comparison between endoscopic and pooled microsurgical approaches was also insignificant (OR = 0.22, p = 1). The risk of motor weakness was increased with the transcortical approach compared to the endoscopic approach (OR = 6.10, p = 0.018). There were no significant differences between transcortical and transcallosal approaches regarding newly onset seizures, and no significant mortality differences between all three approaches. This study demonstrates that microsurgical approaches are associated with a greater extent of resection compared to endoscopic approaches; however, best results are likely achieved based on the surgeon's expertise, flexibility, and case review.

Anatomic Correlates and Surgical Experience with Goel Orbital Cortical Approach to Caudate Head Tumors

OBJECTIVE

We analyzed cortical landmarks, trajectory of approach, and various fiber tracts in the vicinity of our earlier described approach through the orbital/basal surface of the frontal lobe to access tumors located in the region of the caudate nucleus. We also present a new lateral orbital trajectory to approach these tumors.

METHODS

The orbital surfaces of 3 formalin fixed and frozen cadaveric brain specimens were dissected to decipher the white fibers in the region of the caudate nucleus. Safe trajectories to lesions of the head of the caudate nucleus were identified, and the anatomic landmarks of the approach were evaluated. Three patients with caudate head tumors were operated using this approach.

RESULTS

The caudate head lies at an average distance of 34 mm from the tip of the frontal pole, 24 mm from the basal medial orbital surface of the frontal lobe, 35 mm from the basal lateral orbital surface, and 37 mm from the superior surface of the frontal lobe. Two avenues were identified to approach the caudate head: one by making a cortical incision in the lateral orbital gyrus (lateral orbital approach), and the second by making a corticectomy in the medial orbital gyrus (medial orbital approach) in line with the temporal pole. All 3 patients were operated successfully using this approach.

CONCLUSIONS

Surgical approach to the caudate head through the orbital surface of the frontal lobe as described by us provides the shortest trajectory and safe surgical route to access tumors of the caudate nucleus.

Transcortical Approach to Deep-Seated Intraventricular and Intra-axial Tumors Using a Tubular Retractor System: A Technical Note and Review of the Literature

BACKGROUND

 Retraction of white matter overlying a brain lesion can be difficult without causing significant trauma especially when using traditional methods of bladed retractors. These conventional retractors can produce regions of focal pressure resulting in contusions and areas of infarct.

METHODS

 In this article, we present a retrospective case series of six patients with deep-seated intraventricular and intra-axial tumors that were approached using a ViewSite Brain Access System (tubular retractor). The authors describe a unique method of creating a pathway using a dilated glove. We shall also review the relevant literature that reports this type of surgery. Cases included three cases with third ventricular colloid cysts, one case of a third ventricular arachnoid cyst, one case with a lateral ventricular neurocytoma, and a case with a deeply seated intra-axial metastatic tumor.

RESULTS

 Gross total resection was achieved in five cases with small residual in the central neurocytoma operation, with no documented neurological deficit in any case. One case had persistent memory problems and one case had continuing decline from the metastatic disease.

CONCLUSION

 The introduction of tubular-shaped retractor systems has offered the advantage of reducing retraction pressures and distributing any remaining force in a more even and larger distributed area, thus reducing the risk of previous associated morbidity while also permitting great visualization of the target lesion.

Transcallosal Removal of a Choroid Plexus Tumor From the Lateral Ventricle in a Dog. Case Report

A 6-years-old female Staffordshire terrier was referred for periodic generalized seizures and asymmetric visual deficits. Magnetic resonance imaging revealed a 23.2 × 19.3 × 23.0 mm soft tissue mass within the right lateral ventricle and consequential dilatation of the lateral ventricles. Surgically, an interhemispheric approach was performed next to the marginal gyrus after a right parieto-parasagittal craniotomy, and a large choroid plexus tumor was transcallosally removed. After 3 days, the dog was discharged to home, and supportive treatment was continued. Histology revealed a choroid plexus papilloma, which was also confirmed by immunohistochemistry. One month after surgery, a control MRI showed that the ventricles were still dilated, but there was no sign of recurrent tumor. The dog had two additional seizures at home during the month following the intervention and one more grand mal episode was observed 4 months after the surgery. Nine months after the surgery, the dog showed no seizure activity, but her vision had not yet returned.

Intraventricular neuroepithelial tumors: surgical outcome, technical considerations and review of literature

Background

Intraventricular neuroepithelial tumors (IVT) are rare lesions and comprise different pathological entities such as ependymomas, subependymomas and central neurocytomas. The treatment of choice is neurosurgical resection, which can be challenging due to their intraventricular location. Different surgical approaches to the ventricles are described. Here we report a large series of IVTs, its postoperative outcome at a single tertiary center and discuss suitable surgical approaches.

Methods

We performed a retrospective chart review at a single tertiary neurosurgical center between 03/2009–05/2019. We included patients that underwent resection of an IVT emphasizing on surgical approach, extent of resection, clinical outcome and postoperative complications.

Results

Forty five IVTs were resected from 03/2009 to 05/2019, 13 ependymomas, 21 subependymomas, 10 central neurocytomas and one glioependymal cyst. Median age was 52,5 years with 55.6% (25) male and 44.4% (20) female patients. Gross total resection was achieved in 93.3% (42/45). 84.6% (11/13) of ependymomas, 100% (12/21) of subependymomas, 90% (9/10) of central neurocytomas and one glioependymal cyst were completely removed. Postoperative rate of new neurological deficits was 26.6% (12/45). Postoperative new permanent cranial nerve deficits occurred in one case with 4th ventricle subependymoma and one in 4th ventricle ependymoma. Postoperative KPSS was 90% (IR 80–100). 31.1% of the patients improved in KPSS, 48.9% remained unchanged and 20% declined. Postoperative adverse events rate was 20.0%. Surgery-related mortality was 2.2%. The rate of shunt/cisternostomy-dependent hydrocephalus was 13.3% (6/45). 15.4% of resected ependymomas underwent adjuvant radiotherapy. Mean follow-up was 26,9 (±30.1) months.

Conclusion

Our surgical findings emphasize satisfactory complete resection throughout all entities. Surgical treatment can remain feasible, if institutional experience is given. Satisfying long-term survival and cure is possible by complete removal. Gross total resection should always be performed under function-remaining aspects due to mostly benign or slow growing nature of IVTs. Further data is needed to evaluate standard of care and alternative therapy options in rare cases of tumor recurrence or in case of patient collective not suitable for operative resection.

The interhemispheric fissure-surgical outcome of interhemispheric approaches

Exposure of the anterior skull base is challenging due to strategic structures. The interhemispheric approach (IHA) has turned out to be a feasible technique. We report our experience with IHAs in patients with extraaxial lesions (EAL). We performed a retrospective chart review at a tertiary neurosurgical center between April 2009 and March 2020. We included patients with resection of EAL through IHAs concentrating on surgical technique, complete resection rate, postoperative outcome, and complications. Seventy-four patients resected by an IHA were included: 49 (66.2%) frontal (FIA), nine (12.1%) parietooccipital (PIA), and 16 (21.6%) frontobasal IHAs (FBIAs). Median age at time of surgery was 59 years (range 16–88 years), 47 (63.5%) female and 27 (36.5%) male. Complete resection rate was 83.8% (FIA 89.8%, PIA 55.6%, FBIA 81.3%). Rate of new minor deficits was 17.6%, rate of major deficits 5.4%, total rate 23.0%. 51 (68.9%) WHO°I meningiomas, ten (13.5%) WHO°II meningiomas, two (2.7%) WHO°III meningiomas, nine (12.2%) metastases, one (1.4%) sarcoma, and one (1.4%) local adenocarcinoma were resected. Total complication rate was 27.0%. Rate of major complications requiring intervention was 9.6%. Mean follow-up was 34.2 (± 33.2) months. In patients with lesions of the interhemispheric fissure, overall morbidity and complications are comparatively high. Extensions of IHAs with potential even higher morbidity are not necessary though; we support the use of standardized IHAs. Our findings suggest regular usage of relatively feasible IHAs for a satisfying outcome. Invasive, complicated, or contralateral trajectories were not needed.

White Matter Relationships Examined by Transillumination Technique Using a Lateral Transcortical Parietal Approach to the Atrium: Three-Dimensional Images and Surgical Considerations

BACKGROUND

Numerous lesions are found in the ventricular atrium (VA). Access is gained through many white matter tracts with great relevance and specific neurologic functions. It is important to understand the configuration of the most relevant structures surrounding this zone and, thus, select the safest entry zone on the lateral cerebral surface.

OBJECTIVE

We studied the white matter layers traversed in the lateral transcortical parietal approach through the intraparietal sulcus (IPS), adding a transillumination technique. With this knowledge, we selected the safest highway to improve this particular approach.

METHODS

An in-depth study of the white matter tracts was performed on 24 cerebral hemispheres (12 human whole brains). The Klingler technique and microsurgical dissection techniques were used under ×6 to ×40 magnification. The transillumination technique (torch illuminating the ventricular cavity) was used to expose the layers surrounding the VA and, thus, guide the dissection.

RESULTS

Taking the IPS on the cerebral surface as a reference, we identified the following white matter layers ordered from the surface to the ependyma: U fibers, superior longitudinal fascicle, arcuate fascicle, vertical occipital fascicle, sagittal stratum with the optic radiations, and tapetum fibers. The transillumination technique allowed for the easier identification of the white matter deep periventricular layers.

CONCLUSIONS

Knowledge of the main fascicles in the path and neighborhood of the VA allowed us to understand how certain neurologic functions can be affected by lesions at this level and to select the most appropriate way to avoid damaging relevant fascicles.

Tumors of the lateral and third ventricle: surgical management and outcome analysis in 42 cases

Objectives:

To discuss the clinical presentation, pathological diagnosis, and surgical outcome for a series of 42 consecutive patients treated for lateral and third ventricular tumors.

Methods:

This is a retrospective series study conducted between 2001 and 2015 and included 42 patients (mean age: 25 years; range: 2 months-65 years) with lateral and third ventricle tumors surgically treated at King Khaled University Hospital, Riyadh, Kingdom of Saudi Arabia. Demographic, clinical, radiological, surgical, histopathological, and follow up data were analyzed.

Results:

The most common symptoms at presentation included headache (69%), nausea/vomiting (38%), visual deficits (24%), and seizures (17%). Lesions were located in the lateral ventricle in 15 patients, third ventricle in 20 patients, and involved both the lateral and third ventricles in 7 patients. The most common tumor types in the overall cohort were colloid cysts (n=6) and pineal tumors (n=6). The postoperative complication rate was 36%. The most common postoperative complications were seizure and hydrocephalus (n=5 each, 12%). Surgical mortality was 5%.

Conclusion:

The selection of the surgical approach for intraventricular tumor resection is fundamentally dependent on the surgeon’s experience and preference. We recommend that this decision be based on the anatomic considerations that provide the best and safest access to the mass, rather than on the risk of seizure following transcortical approach.

Cognitive function assessment and comparison on lateral ventricular tumors resection by the frontal transcortical approach and anterior transcallosal approach respectively in children

Currently, there are few studies on cognitive impairment caused by neurosurgery, and there have been no studies on cognitive impairment after resection of lateral ventricular tumors in children. Previously, our research team has reported that the frontal transcortical approach can impair cognitive function. In this study, we explored which functions would be damaged by the transcallosal approach and compared the cognitive function changes caused by the two surgical approaches, so as to provide a theoretical basis for the selection of pre-operative surgical approaches. The authors prospectively collected pediatric patients with lateral ventricular tumors who had undergone surgical resection through the frontal transcortical approach and anterior transcallosal approach in Beijing Tiantan Hospital from November 2012 to May 2017. The inclusion criteria according to the Children Wechsler Scale requirements and clinical performance were formulated. Wechsler Intelligence Scale for Children®-fourth edition: Chinese version (WISC-IV) was adopted for general intelligence and cognitive function assessment in the study. In addition, the resting-state functional magnetic resonance imaging (resting-state fMRI) and diffusion tensor imaging (DTI) were carried out to measure the level of co-activation and to explore the functional connectivity between the brain regions at the pre-operative period and 6-month follow-up in post-operation. A total of 30 patients were enrolled. Gross total resection was achieved in all patients, and no severe post-operative complications were observed. The frontal transcortical approach was applied in 19 patients, and the transcallosal approach was conducted for 11 patients. Compared with the pre-operative indices of WISC-IV, patients generally had a lower level of indices of the WISC-IV in post-operation. In patients accepting lateral ventricular tumors resection through the anterior transcallosal approach, the total IQ was declined to M = 84.82, SD = 8.072 from M = 93.27, SD = 6.635 within the 6-month convalescence. The data of working memory (t = - 2.990, p = 0.002) and total IQ (t = - 2.205, p = 0.028) pre- and post-operative showed statistical significance. But in the comparison of two surgical approaches, it was found that IQ had no statistical difference in WISC-IV tasks data. Previous studies suggest that the frontal transcortical approach impair perceptual reasoning, processing speed, and IQ, while this study indicates that the anterior transcallosal approach impairs patients' working memory and IQ. Both approaches make equal damage to IQ. Through comparing the two surgical approaches, it can be known that the anterior transcallosal approach cannot replace the frontal transcortical approach. The protection of cognitive function should be considered as one of the bases for neurosurgeons to select the operative approach before the operation. However, in an actual situation, the specific approach should be carefully selected by comprehensive consideration.

Structure of corona radiata and tapetum fibers in ventricular surgery

In this study the three-dimensional anatomy of the corona radiata and tapetum via the fiber dissection and diffusion tensor imaging of the brain for ventricular surgery was demonstrated. Ten formalin-fixed cerebral hemispheres were dissected for corona radiata and tapetum via Klingler's fiber dissection method under an operating microscope. The corona radiata and tapetum were dissected through lateral and medial surfaces of the cerebral hemisphere, respectively. All surgical routes for ventricular lesions were evaluated for white matter fibers during and after dissections. Corona radiata and tapetum fibers were demonstrated by dissecting hemispheres through lateral and medial aspects of the brain. The internal capsule contains all fibers that extend from thalamus to cortex and cortex to thalamus, brainstem, and spinal cord. These fan-shaped fibers extending from cortex to internal capsule were named the corona radiata. The corona radiata is not a specific pathway, and it is composed of several different fiber pathways. The tapetum contains splenium and body fibers of the corpus callosum. Tapetum is located immediately medial to the ependymal line of the ventricular wall and forms a fiber layer in the medial optical radiation on the coronal and axial sections. Surgical planning for ventricular lesions requires detailed information regarding white matter fibers that can be obtained by the fiber dissection and diffusion tensor imaging of the brain to decrease surgical complications.

Natural history of intraventricular meningiomas: systematic review

Review the data published on the subject to create a more comprehensive natural history of intraventricular meningiomas (IVMs). A Medline search up to March 2018 using "intraventricular meningioma" returned 98 papers. As a first selection step, we adopted the following inclusion criteria: series and case reports about IVMs, as well as papers written in other languages, but abstracts written in English were evaluated. Six hundred eighty-one tumors were evaluated from 98 papers. The majority of the tumors were located in the lateral ventricles (602-88.4%), fourth ventricle (59-8.7%), and third ventricle (20-2.9%). These tumors accounted for a mortality rate of 4.0% (25 deaths) and a recurrence rate of 5.3% (26 recurrences). The majority of the tumors were grade I (89.8%) and consisted of the following subtypes: fibrous, 39.7% (n = 171); transitional, 22.0% (n = 95); meningothelial, 18.6% (n = 80); angiomatosus, 3.2% (n = 14); psammomatous, 2.6% (n = 11); and others, 13.9% (n = 60). Forty-five patients (7.4%) presented with grade II (GII) tumors, and 17 patients (2.8%) presented with grade III (GIII) tumors. These tumors follow the histopathological distribution of meningiomas in general, with the exception of the higher prevalence of the fibrous subtype, possibly due to its embryonic origin. Recurrence and mortality were lower than in other localizations likely due to a complete surgical resection rate than in the convexity and skull base, which suggests that GTR is the gold standard for the management of IVMs.

Flexible Neuroendoscopic Diagnosis and Management of Ventricular Tumors: A Retrospective Cohort Study

BACKGROUND

Ventricular tumors (VTs) represent approximately 10% of intracranial lesions and are associated with hydrocephalus in 73.9%-100% of patients. We present our experience using flexible neuroendoscopy as a diagnostic and hydrocephalus-related treatment strategy for paraventricular and intraventricular tumors.

METHODS

This retrospective cohort included 27 pediatric and 21 adult patients with paraventricular or intraventricular tumors treated with flexible neuroendoscopy. Terminally ill patients and patients with incomplete data were excluded.

RESULTS

Male and female patients comprised 52% and 48% of the population, respectively. Mean patient age was 20.45 years (±18.65 SD). The most common tumor location was the thalamic and pineal region. Conclusive pathologic diagnosis was obtained in 40 patients (83.3%); the most common type of tumor was astrocytoma. Hydrocephalus was present in 38 (79.1%) patients, who were treated successfully with endoscopic procedures. There were no major complications.

CONCLUSIONS

Flexible neuroendoscopy is a strategic tool for diagnosis of VTs, especially in patients with associated hydrocephalus and VTs unreachable by other means. Flexible neuroendoscopy has a high rate of definitive diagnosis with low associated complications. More studies evaluating the long-term efficacy of flexible neuroendoscopy for hydrocephalus associated with VTs are needed.

Selection of Surgical Approach for Trigonal Meningiomas in Consideration of Visual Outcome

OBJECTIVES

We report the surgical outcome of trigonal meningiomas through 3 different approaches with attention to visual outcomes.

METHODS

Between 1994 and 2017, 23 patients underwent resection of trigonal meningiomas. We performed tumor removal using 3 different surgical approaches through the superior parietal lobule, middle temporal gyrus (MTG), and modified MTG. The patients were retrospectively identified, and surgical results including visual outcome were analyzed.

RESULTS

Twenty-three patients with a mean age of 45 years formed the study group. The most common symptom and sign were headache (N = 14, 60.9%) and visual disturbance (N = 6, 26.1%). All patients underwent surgical resection, 6 via a translateral approach through MTG, 8 via a translateral approach through modified MTG, and 9 via a transparietal approach through the superior parietal lobule (SPL). Gross total resection was achieved in all patients. We found that visual preservation rate was 25% (1/4) in the MTG group, 62.5% (5/8) in the modified MTG group, and 100% (7/7) in the SPL group, respectively (P = 0.044). Permanent complication rate was 50% (3/6) in the MTG group, 50% (n = 4/8) in the modified MTG group, and 11.1% (n = 1/9) in the SPL group.

CONCLUSIONS

The superior parietal lobule approach is a safe and applicable procedure with a great visual preservation and an acceptable risk of morbidity for trigonal meningiomas when there is a chance of visual recovery or preservation.

Postoperative Seizure Rate After Transcortical Resection of Subcortical Brain Tumors and Colloid Cysts: A Single Surgeon's Experience

When deciding on a surgical route to reach subcortical brain tumors and colloid cysts, many surgeons advocate the use of transcallosal, transsulcal, or skull base approaches over transcortical approaches due to a high reported incidence of postoperative seizures. We have retrospectively analyzed all patients operated upon by a senior neurosurgeon (Ricardo J. Komotar) who undertook transcortical approaches for the resection of subcortical brain tumors and colloid cysts. We have also performed a comprehensive review of the literature to estimate postoperative seizure risk after transcortical approaches for the resection of deep tumors and colloid cysts. Of 27 patients who underwent transcortical approaches for the resection of subcortical brain tumors and colloid cysts, zero had postoperative seizures. A comprehensive review of the literature shows an 8.3% postoperative risk of seizures after the transcortical approach. Our institution has never experienced a postoperative seizure following the transcortical approach for the resection of deep tumors and colloid cysts. For this reason, we advocate selecting a surgical approach that obtains adequate lesion exposure and minimizes the violation and retraction of eloquent cortex, venous structures, and white matter tracts, rather than on presumed postoperative seizure risk.

Clinical features and neurosurgical treatment of trigonal cavernous malformations

The goals of this study were to analyze the incidence, clinical manifestations, neuroimaging findings, surgical treatments, and neurological outcomes of trigonal cavernous malformations (TCMs). Among 1395 cases of intracranial and intraspinal cavernous malformations (CMs) surgically treated between 2003 and 2016 at Beijing Tiantan Hospital, a series of 12 patients with TCM was chosen for analysis and their records were reviewed. We also performed an exhaustive literature search using PubMed to identify all previously reported cases in the literatures. TCMs accounted for 0.86% of the entire series of the central nervous system (CNS) CMs. The case series consisted of five male and seven female patients (ratio 1:1.4), with an average age at presentation of 32.9 years (7-53 years). In all the cases, headache was the most common initial symptom (66.7%). Complete resection without surgical mortality was achieved in all the cases. Postoperative complications included fever, lower limb weakness, sensory aphasia, and calculational capacity declination. Follow-up period after diagnosis was 15 to 74 months (mean 48.3 months); no patient was lost to follow-up. All the patients were considered to be in excellent clinical condition. TCMs are rare lesions; they can reach large size, and their symptoms and signs commonly resulted from mass effect. Surgical intervention is the treatment of choice for TCMs; patients can obtain favorable neurological outcomes after complete resection.

Cognitive performance change of pediatric patients after conducting frontal transcortical approach to treat lateral ventricular tumor

OBJECTIVE

Applying frontal transcortical approach to treat lateral ventricular tumor is one of the most common neurosurgical manipulations. The frontal transcortical approach generally passes through the middle frontal gyrus in which there is no major function involved in the traditional sense. However, current researches have suggested that the prefrontal cortex (PFC) plays a central role in the whole network of the brain cognitive frame. In addition, cognitive function is crucial in growing and developmental stages and essential for the educational achievement, especially for children. Based on this, the authors in this study analyzed cognitive performance change of pediatric patients who had accepted frontal transcortical operation in 1-year follow-up and discussed the possibility of higher cognitive functions of the damaged region.

PATIENTS AND METHODS

In this single-center study, 15 pediatric patients (median age at surgery, 9.21 years old; range, 6.42-14.17 years old) who had been treated with frontal transcortical approach for lateral ventricular tumors were selected as research objects. The cognitive function assessment was conducting by adopting the revised Wechsler Intelligence Scale for Children-fourth edition (WISC-IV). In addition, the resting-state functional magnetic resonance imaging (resting-state fMRI) and diffusion tensor imaging (DTI) were carried out to measure the level of co-activation and to explore the functional connectivity between the brain regions at the preoperative period and 1-year follow-up after surgery.

RESULTS

GTR was achieved in all patients, and all patients were in good condition after surgery. Compared to the preoperative indices of WISC-IV, patients generally had a lower level of indices of the WISC-IV after surgery, for example, the total IQ was declined to M = 83.60, SD = 9.500 from M = 95.33, SD = 13.844 within 1 year convalescence. The data of perceptual reasoning (t = - 2.392, p = 0.016), processing speed (t = - 2.121, p = 0.033), and total IQ (t = -2.638, p = 0.008) before and after surgery showed statistically significance. Furthermore, decreased functional connectivity and disconnected neural fasciculus were revealed by the size of activation regions in the resting-state fMRI and the reconstruction of three-dimensional images of white matter tracts in the DTI pre- and post-operative.

CONCLUSION

The PFC was not regarded as a major functional area in the past, but the researches at present have shown that the interactions between PFC and other posterior brain regions serve as the basis of the higher cognitive functions. According to imaging manifestations and WISC-IV tasks in this paper, we found that the PFC injury caused by the frontal transcortical approach led to damaged brain structure and impaired the performance of cognitive function. On this basis, we detected that the perceptual reasoning and processing speed maybe have more extensive connections with the middle frontal gyrus.

Quantitative anatomical comparison of the ipsilateral and contralateral interhemispheric transcallosal approaches to the lateral ventricle

OBJECTIVE The best approach to deep-seated lateral and third ventricle lesions is a function of lesion characteristics, location, and relationship to the ventricles. The authors sought to examine and compare angles of attack and surgical freedom of anterior ipsilateral and contralateral interhemispheric transcallosal approaches to the frontal horn of the lateral ventricle using human cadaveric head dissections. Illustrative clinical experiences with a contralateral interhemispheric transcallosal approach and an anterior interhemispheric transcallosal transchoroidal approach are also related. METHODS Five formalin-fixed human cadaveric heads (10 sides) were examined microsurgically. CT and MRI scans obtained before dissection were uploaded and fused into the navigation system. The authors performed contralateral and ipsilateral transcallosal approaches to the lateral ventricle. Using the navigation system, they measured areas of exposure, surgical freedom, angles of attack, and angle of view to the surgical surface. Two clinical cases are described. RESULTS The exposed areas of the ipsilateral (mean [± SD] 313.8 ± 85.0 mm²) and contralateral (344 ± 87.73 mm²) interhemispheric approaches were not significantly different (p = 0.12). Surgical freedom and vertical angles of attack were significantly larger for the contralateral approach to the most midsuperior reachable point (p = 0.02 and p = 0.01, respectively) and to the posterosuperior (p = 0.02 and p = 0.04) and central (p = 0.04 and p = 0.02) regions of the lateral wall of the lateral ventricle. Surgical freedom and vertical angles of attack to central and anterior points on the floor of the lateral ventricle did not differ significantly with approach. The angle to the surface of the caudate head region was less steep for the contralateral (135.6° ± 15.6°) than for the ipsilateral (152.0° ± 13.6°) approach (p = 0.02). CONCLUSIONS The anterior contralateral interhemispheric transcallosal approach provided a more expansive exposure to the lower two-thirds of the lateral ventricle and striothalamocapsular region. In normal-sized ventricles, the foramen of Monro and the choroidal fissure were better visualized through the lateral ventricle ipsilateral to the craniotomy than through the contralateral approach.

Resection of tumors of the third ventricle involving the hypothalamus: effects on body mass index using a dedicated surgical approach

Resection of large lesions growing into the third ventricle is considered nowadays still a demanding surgery, due to the high risk of severe endocrine and neurological complications. Some neurosurgical approaches were considered in the past the procedures of choice to access the third ventricle, however they were burden by endocrine and neurological consequences, like memory loss and epilepsy. We report here the endocrine and functional results in a series of patients operated with a recently developed approach specifically tailored for the resection of large lesions growing into the third ventricle. Authors conducted a retrospective analysis on 10 patients, operated between 2011 and 2012, for the resection of large tumors growing into the third ventricle. Total resection was achieved in all patients. No perioperative deaths were recorded and all patients were alive after the follow-up. One year after surgery 8/10 patients had an excellent outcome with a Karnofsky Performance Status of 100 and a Glasgow Outcome score of 5, with 8 patients experiencing an improvement of the Body Mass Index. Modern neurosurgery allows a safe and effective treatment of large lesions growing into the third ventricle with a postoperative good functional status.

The white matter tracts of the cerebrum in ventricular surgery and hydrocephalus

OBJECTIVE The relationship of the white matter tracts to the lateral ventricles is important when planning surgical approaches to the ventricles and in understanding the symptoms of hydrocephalus. The authors' aim was to explore the relationship of the white matter tracts of the cerebrum to the lateral ventricles using fiber dissection technique and MR tractography and to discuss these findings in relation to approaches to ventricular lesions. METHODS Forty adult human formalin-fixed cadaveric hemispheres (20 brains) and 3 whole heads were examined using fiber dissection technique. The dissections were performed from lateral to medial, medial to lateral, superior to inferior, and inferior to superior. MR tractography showing the lateral ventricles aided in the understanding of the 3D relationships of the white matter tracts with the lateral ventricles. RESULTS The relationship between the lateral ventricles and the superior longitudinal I, II, and III, arcuate, vertical occipital, middle longitudinal, inferior longitudinal, inferior frontooccipital, uncinate, sledge runner, and lingular amygdaloidal fasciculi; and the anterior commissure fibers, optic radiations, internal capsule, corona radiata, thalamic radiations, cingulum, corpus callosum, fornix, caudate nucleus, thalamus, stria terminalis, and stria medullaris thalami were defined anatomically and radiologically. These fibers and structures have a consistent relationship to the lateral ventricles. CONCLUSIONS Knowledge of the relationship of the white matter tracts of the cerebrum to the lateral ventricles should aid in planning more accurate surgery for lesions within the lateral ventricles.

Microsurgical resection of tumors of the lateral and third ventricles: operative corridors for difficult-to-reach lesions

Tumors of the lateral and third ventricles are cradled on all sides by vital vascular and eloquent neural structures. Microsurgical resection, which always requires attentive planning, plays a critical role in the contemporary management of these lesions. This article provides an overview of the open microsurgical approaches to the region highlighting key clinical perspectives.

Trigone ventricular meningiomas: Is it possible to achieve good results even in the absence of high tech tools?

BACKGROUND

Intraventricular meningiomas constitute 2% of intracranial meningiomas, representing a challenging disease for neurosurgeons; we report our experience through a case series, emphasizing surgical approaches and results.

METHODS

Between 2009 and 2012, four patients underwent microsurgical resection in our department. Clinical and imaging findings, surgical approaches, outcomes, and follow-up were analyzed.

RESULTS

Four patients (three females and one male) were included and the signs of intracranial hypertension were the main clinical presentation in all cases. The parietal approach through intraparietal sulcus was performed in 3 cases and parieto-occipital interhemispheric surgical route in 1 case. Gross total resection was achieved in all the patients without additional deficits and without the aid of neuronavigation, intraoperative monitoring, and intraoperative magnetic resonance imaging.

CONCLUSION

Gross total resection is the gold standard treatment for such tumors and the intraparietal sulcus approach is an excellent choice for most of the cases. Careful anatomical knowledge contributes to a safer procedure even in the absence of high tech equipment assistance.

The cerebral isthmus: fiber tract anatomy, functional significance, and surgical considerations

OBJECTIVE

The cerebral isthmus is the white matter area located between the periinsular sulcus and the lateral ventricle. Studies demonstrating the fiber tract and topographic anatomy of this entity are lacking in current neurosurgical literature. Hence, the authors' primary aim was to describe the microsurgical white matter anatomy of the cerebral isthmus by using the fiber dissection technique, and they discuss its functional significance. In addition, they sought to investigate its possible surgical utility in approaching lesions located in or adjacent to the lateral ventricle.

METHODS

This study was divided into 2 parts and included 30 formalin-fixed cerebral hemispheres, 5 of which were injected with colored silicone. In the first part, 15 uncolored specimens underwent the Klinger's procedure and were dissected in a lateromedial direction at the level of the superior, inferior, and anterior isthmuses, and 10 were used for coronal and axial cuts. In the second part, the injected specimens were used to investigate the surgical significance of the superior isthmus in accessing the frontal horn of the lateral ventricle.

RESULTS

The microsurgical anatomy of the anterior, superior, and inferior cerebral isthmuses was carefully studied and recorded both in terms of topographic and fiber tract anatomy. In addition, the potential role of the proximal part of the superior isthmus as an alternative safe surgical corridor to the anterior part of the lateral ventricle was investigated.

CONCLUSIONS

Using the fiber dissection technique along with coronal and axial cuts in cadaveric brain specimens remains a cornerstone in the acquisition of thorough anatomical knowledge of narrow white matter areas such as the cerebral isthmus. The surgical significance of the superior isthmus in approaching the frontal horn of the lateral ventricle is stressed, but further studies must be carried out to elucidate its role in ventricular surgery.

Superior parietal lobule approach for choroid plexus papillomas without preoperative embolization in very young children

OBJECT Choroid plexus papillomas (CPPs) are rare neoplasms, often found in the atrium of the lateral ventricle of infants, and cause overproduction hydrocephalus. The extensive vascularity and medially located blood supply of these tumors, coupled with the young age of the patients, can make prevention of blood loss challenging. Preoperative embolization has been advocated to reduce blood loss and prevent the need for transfusion, but this mandates radiation exposure and the additional risks of vessel injury and stroke. For these reasons, the authors present their experience using the superior parietal lobule approach to CPPs of the atrium without adjunct therapy. METHODS A retrospective review was conducted of all children who presented to Columbia University/Morgan Stanley Children's Hospital of New York with a CPP in the atrium of the lateral ventricle and who underwent surgery using a superior parietal lobule approach without preoperative embolization. RESULTS Nine children were included, with a median age of 7 months. There were no perioperative complications or new neurological deficits. All patients had intraoperative blood loss of less than 100 ml, with a mean minimum hematocrit of 26.9% (range 19.6%-36.2%). No patients required a blood transfusion. The median follow-up was 39 months, during which time no patient demonstrated residual or recurrent tumor on MRI, nor did any have an increase in ventricular size or require CSF diversion. CONCLUSIONS The superior parietal lobule approach is safe and effective for very young children with CPPs in the atrium of the lateral ventricle. The results suggest that preoperative embolization is not essential to avoid transfusion or achieve overall good outcomes in these patients. This management strategy avoids radiation exposure and the additional risks associated with embolization.

A Purely Endoscopic and Simultaneous Transsphenoidal and Transcranial Keyhole Approach for Giant Pituitary Adenoma Resection: A Technical Case Report

A combined transsphenoidal-transcranial approach for the resection of pituitary adenomas has previously been reported. While this approach is useful for specific types of pituitary adenomas, it is an invasive technique. To reduce the invasiveness of this approach, we adopted the keyhole concept for pituitary adenoma resection. A 23-year-old man presented at a local hospital with a 6-month history of bilateral hemianopia. Magnetic resonance imaging revealed a large pituitary adenoma extending from the sella turcica toward the right frontal lobe. Endoscopic transsphenoidal surgery was planned at a local hospital; however, the operation was abandoned at the start of the resection because of the firm and fibrous nature of the tumor. The patient was subsequently referred to our hospital for additional surgery. The tumor was removed purely endoscopically via a transsphenoidal and transcranial route. Keyhole craniotomy, 3 cm in diameter, was performed, and a tubular retractor was used to achieve a wider surgical corridor; this enabled better visualization and dissection from the surrounding brain and provided enough room for the use of surgical instruments under endoscopic view. The tumor was successfully removed without complication. This is the first case report to describe the resection of a giant pituitary adenoma using a purely endoscopic and simultaneous transsphenoidal and transcranial keyhole approach.

The 6 thalamic regions: surgical approaches to thalamic cavernous malformations, operative results, and clinical outcomes

OBJECT

The ideal surgical approach to thalamic cavernous malformations (CMs) varies according to their location within the thalamus. To standardize surgical approaches, the authors have divided the thalamus into 6 different regions and matched them with the corresponding surgical approach.

METHODS

The regions were defined as Region 1 (anteroinferior), Region 2 (medial), Region 3 (lateral), Region 4 (posterosuperior), Region 5 (lateral posteroinferior), and Region 6 (medial posteroinferior). The senior author's surgical experience with 46 thalamic CMs was reviewed according to this classification. An orbitozygomatic approach was used for Region 1; anterior ipsilateral transcallosal for Region 2; anterior contralateral transcallosal for Region 3; posterior transcallosal for Region 4; parietooccipital transventricularfor Region 5; and supracerebellar-infratentorial for Region 6.

RESULTS

Region 3 was the most common location (17 [37%]). There were 5 CMs in Region 1 (11%), 9 in Region 2 (20%), 17 in Region 3 (37%), 3 in Region 4 (6%), 4 in Region 5 (9%), and 8 in Region 6 (17%). Complete resection was achieved in all patients except for 2, who required a second-stage operation. The mean follow-up period was 1.7 years (range 6 months-9 years). At the last clinical follow-up, 40 patients (87%) had an excellent or good outcome (modified Rankin Scale [mRS] scores 0-2) and 6 (13%) had poor outcome (mRS scores 3-4). Relative to their preoperative condition, 42 patients (91%) were unchanged or improved, and 4 (9%) were worse.

CONCLUSIONS

The authors have presented the largest series reported to date of surgically treated thalamic CMs, achieving excellent results using this methodology. In the authors' experience, conceptually dividing the thalamus into 6 different regions aids in the selection of the ideal surgical approach fora specific region.

Posterior interhemispheric transfalcine transprecuneus approach for microsurgical resection of periatrial lesions: indications, technique, and outcomes

OBJECT

Surgical exposure of the peritrigonal or periatrial region has been challenging due to the depth of the region and overlying important functional cortices and white matter tracts. The authors demonstrate the operative feasibility of a contralateral posterior interhemispheric transfalcine transprecuneus approach (PITTA) to this region and present a series of patients treated via this operative route.

METHODS

Fourteen consecutive patients underwent the PITTA and were included in this study. Pre- and postoperative clinical and radiological data points were retrospectively collected. Complications and extent of resection were reviewed.

RESULTS

The mean age of patients at the time of surgery was 39 years (range 11-64 years). Six of the 14 patients were female. The mean duration of follow-up was 4.6 months (range 0.5-19.6 months). Pathology included 6 arteriovenous malformations, 4 gliomas, 2 meningiomas, 1 metastatic lesion, and 1 gray matter heterotopia. Based on the results shown on postoperative MRI, 1 lesion (7%) was intentionally subtotally resected, but ≥ 95% resection was achieved in all others (93%) and gross-total resection was accomplished in 7 (54%) of 13. One patient (7%) experienced a temporary approach-related complication. At last follow-up, 1 patient (7%) had died due to complications of his underlying malignancy unrelated to his cranial surgery, 2 (14%) demonstrated a Glasgow Outcome Scale (GOS) score of 4, and 11 (79%) manifested a GOS score of 5.

CONCLUSIONS

Based on this patient series, the contralateral PITTA potentially offers numerous advantages, including a wider, safer operative corridor, minimal need for ipsilateral brain manipulation, and better intraoperative navigation and working angles.

Thalamic arteriovenous malformation fed by the artery of Percheron originating from the contralateral posterior cerebral artery in a child

PURPOSE

Artery of Percheron (AOP) is a rare variant of thalamoperforating artery with a single common trunk feeding both thalami and with or without contribution to the rostral midbrain. We report the first case of thalamic arteriovenous malformation (AVM) fed by AOP with hemorrhagic onset.

METHODS

A 12-month-old girl suddenly weakened and developed coma. Left thalamic hemorrhage was detected with the third and both lateral ventricles' hematoma. Thalamic AVM was discovered to be fed by an AOP originating from the contralateral posterior cerebral artery.

RESULTS

Endovascular embolization of AVM was impossible due to a risk of bilateral thalamic infarction and anatomical inaccessibility. Thalamic AVM was removed by high superior parietal approach without new neurological symptoms.

CONCLUSION

The first case of thalamic AVM fed by AOP originating from the contralateral posterior cerebral artery is reported. Surgical removal of AVM would be at the heart of treatment in order to avoid bilateral thalamic infarction.

Quantifying sulcal and gyral topography in relation to deep seated and ventricular lesions: cadaveric study for basing surgical approaches and review of literature

OBJECTIVE

Numerical implication of sulcal and gyral topography for surgical approaches has not been studied.

METHODS

Percentage gain of distance using sulci as compared to that of gyri was calculated by measuring distances toward the ventricles in 15 hemispheres.

RESULTS

Superior frontal sulcus was closest proving greater than 50% gain in distance compared to superior frontal gyrus; inferior temporal sulcus provided greater gain in the temporal lobe.

CONCLUSION

Sulci provide upto 58% distance gain. For trans-gyral approaches, MFG and ITG were found closer to the respective ventricular area.

[Liponeurocytoma in the left lateral ventricle. Presentation of the first case reported in Spain and literature review]

Supratentorial liponeurocytoma is a rare tumor, predominantly appearing in young males. It most commonly affects the lateral ventricles, with involvement of the third ventricle being exceptional. It is defined as a low-grade neuroglial tumor, with areas of associated lipomatosis. The most common clinical manifestation is that resulting from the presence of secondary intracranial hypertension and hydrocephalus. We present the first case reported in Spain of this tumor type and one of the few appearing in the literature so far. We report the case of a 33-year-old male patient, suffering from crural sensitive symptoms and recent onset headache. The radiographic study revealed the presence of a large supratentorial tumor; intraventricular, multicystic, heterogeneous and with areas of associated lipomatosis. The patient underwent surgery and complete tumor resection was achieved. The definitive diagnosis was of supratentorial liponeurocytoma. The presence of a supratentorial intraventricular tumor with areas of fatty degeneration should lead us to consider this type of tumor in the differential diagnosis. Complete tumor resection is considered to be the treatment of choice.

Outcomes after surgery for central neurocytoma: results of a French multicentre retrospective study

OBJECTIVE

Central neurocytoma (CN) is a rare intraventricular tumour. Surgery has been highly recommended for CN, although it entails a significant chance to harm the patient. We aimed to provide new data that would support surgical decision-making and optimise patient information about outcomes after surgery.

METHOD

Under the auspices of the French Society of Neurosurgery, we conducted a multi-institutional database search in 23 academic hospitals. In all, we reviewed the relevant clinical and radiological data of 82 patients who were operated on for CN between 1984 and 2008, and had their diagnosis confirmed by central pathological review.

RESULTS

The median follow-up was 61 months (range, 6-96 months). Gross total resection (GTR) was achieved in 48 % of the patients, and subtotal resection (STR) in 52 %. The 5-year overall survival rate was 93.8 % (95 % CI, 93.7-93.9). The 5-year progression-free survival rate was 92.1 % (95 % CI, 91.90-92.2) in patients who underwent GTR, compared with 55.3 % (95 % CI, 55.1-55.5) in patients who had STR (p = 0.01). The overall perioperative complication rate was 66 %. The main causes of postoperative disability were some degree of postoperative paresis and/or aphasia (39 %), memory difficulties (29 %) and temporary hydrocephalus (26 %). GTR was not associated with an increased rate of postoperative complications compared with STR. At last follow-up, Karnofsky Performance Score was at least equal to 80 for 90.6 % of the tested patients.

CONCLUSION

Our series emphasised that maximal surgical resection of CNs offers favourable benefit-risk ratio. These data are of importance to properly counsel patients regarding expected outcomes, and to plan relevant preoperative and postoperative investigations like language and memory function evaluation.