Interhemispheric Translamina Terminalis Approach Research Articles

Impact of three surgical approaches on the therapeutic efficacy of intraventricular craniopharyngiomas: a single-center retrospective analysis.

This study aimed to investigate the therapeutic efficacy of three different surgical approaches for the treatment of intraventricular craniopharyngiomas (IVCs). The three surgical approaches investigated in this study were the endoscopic endonasal approach (EEA), pterional trans-lamina terminalis approach (PTA), and interhemispheric trans-lamina terminalis approach (ITA). Patient demographics, preoperative symptoms, endocrine and hypothalamic status, tumor characteristics, and surgical outcomes were analyzed and compared among the different surgical groups. A total of 31 patients with IVCs were included in the analysis, with 12 patients in the EEA group, 8 patients in the ITA group, and 11 patients in the PTA group. The mean follow-up time was 39 ± 23months. Statistical analysis of the data revealed significant differences in the gross total resection (GTR) rate among the three surgical groups (P = 0.033). The GTR rate for the EEA group was 100%, that for the ITA group was 88%, and that for the PTA group was 64%, which was the lowest rate observed. After surgery, only 8.3% of the patients in the EEA group did not experience new postoperative hypopituitarism, while the percentages in the ITA and PTA groups were 75% and 73%, respectively (P = 0.012). Finally, we found that postoperative hypopituitarism may be related to the transection of the pituitary stalk during the operation (P = 0.020). Based on the results of this study, we recommend using the EEA and the ITA instead of the PTA for the surgical resection of IVCs. Furthermore, the appropriate surgical approach should be selected based on the tumor's growth pattern.

Proposed System for Selection of Surgical Approaches for Craniopharyngiomas Based on the Optic Recess Displacement Pattern

Craniopharyngiomas remain surgically challenging because of the strong adhesion to vital neurovascular structures. We propose a system for the selection of surgical approaches based on the optic recess (OR) displacement pattern to facilitate the surgical planning and obtain the optimum visual and endocrinological outcomes. Craniopharyngiomas were divided into three types based on the OR displacement pattern: superior, anterior, and involvement types. Selected surgical approaches and patient outcome were retrospectively reviewed according to these classifications. Visual and endocrinological outcomes were compared between the groups. This study included 26 patients with primary craniopharyngiomas who underwent surgery at our institution, classified into 11 anterior, 11 superior, and 4 involvement types. Extended endoscopic endonasal approach provided excellent exposure infero-dorsal aspect of the chiasm for manipulation of the dissection plane in the anterior and superior types with midline location. Unilateral subfrontal approach was required for tumor of the superior type with lateral extension. Interhemispheric translamina terminalis approach (TLA) could provide safe dissection under direct vision of strong adhesion at the superior aspect of the chiasm in the involvement type. Visual and endocrinological outcomes were better in the involvement type compared with the superior and anterior types. Visual outcome was significantly correlated with preoperative visual function. Craniopharyngiomas with the involvement type are indicated for TLA to achieve the best visual and endocrinological outcome. Our classification of OR displacement pattern is useful to select the optimal surgical approach for craniopharyngiomas more accurately and concisely, especially in cases with third ventricular extension.

SURG-24. NOVEL MALLEABLE FORCIPES FOR ENDOSCOPIC ASSISTED TECHNIQUE IN PEDIATRIC BRAIN TUMORS

Recent advances in optical devices and surgical instruments have been applied to neurosurgery. Even with modifications, one of the most serious risks is injury of neuronal and vascular structure caused by operation of surgical instruments in a narrow surgical field. Fixed instruments are not practical for pediatric brain tumor surgeries because the length of the curved or angled tip portion is limited because of the narrow entrance. We developed a novel malleable forceps to resolve the difficulties related to microsurgical procedures. The malleable forceps has two shafts with a sharp cup at the tip. The entire forceps was made of stainless steel, with a silver and nickel alloy inserted between 10 and 40 mm from the tip. In the alloy part, the surgeon can flex the forceps freely using a special cylinder. The special cylinder is useful to prevent from slipping of the cups of tip. The maximum angle that can be bent is 70 degrees vertically. We also developed a monoshaft malleable forceps. We used these flexible forcipes in the case of various pediatric brain tumors including craniopharyngioma. We performed tumor resection by anterior interhemispheric trans-lamina terminalis approach. After procedure of tumor resection using microscope, endoscope inserted around the pituitary stalk. The piece of calcified tumor could be easily removed without any complications. These forcipes can be deformed to an appropriate angle and can be applied to various cases, especially pediatric brain tumors.

Anterior communicating artery division in the endoscopic endonasal translamina terminalis approach to the third ventricle: an anatomical feasibility study.

Endonasal endoscopic approaches (EEA) to the third ventricle are well described but generally use an infrachiasmatic route since the suprachiasmatic translamina terminalis corridor is blocked by the anterior communicating artery (AComA). The bifrontal basal interhemispheric translamina terminalis approach has been facilitated with transection of the AComA. The aim of the study is to describe the anatomical feasibility and limitations of the EEA translamina terminalis approach to the third ventricle augmented with AComA surgical ligation. Endoscopic dissections were performed on five cadaveric heads injected with colored latex using rod lens endoscopes attached to a high-definition camera and a digital video recorder system. A stepwise anatomical dissection of the endoscopic endonasal transtuberculum, transplanum, translamina terminalis approach to the third ventricle was performed. Measurements were performed before and after AComA elevation and transection using a millimeter flexible caliper. Multiple comparison statistical analysis revealed a statistically significant difference in vertical exposure between the control condition and after AComA elevation, between the control condition and after AComA division and between the AComA elevation and division (p < 0.05). The mean difference in exposed surgical area was statistically significant between the control and after AComA division and between elevation and AComA division (p < 0.01), whereas it was not statistically significant between the control condition and AComA elevation (NS). The anatomical feasibility of clipping and dividing the AComA through an EEA has been demonstrated in all the cadaveric specimens. The approach facilitates exposure of the suprachiasmatic optic recess within the third ventricle that may be a blind spot during an infrachiasmatic approach.

Combined Interhemispheric and Transsylvian Approach for Resection of Craniopharyngioma.

We present a 37-year-old male case of cystic suprasellar huge craniopharyngioma, who presented with significant memory disturbance due to obstructive hydrocephalus. Combined interhemispheric and pterional approach was chosen to resect huge suprasellar tumor. Interhemispheric trans-lamina terminalis approach was quite effective to resect third ventricular tumor, while pterional approach was useful to dissect tumor out of basilar perforators and stalk. The link to the video can be found at: https://youtu.be/BoYIPa96kdo .

Radical resection of a craniopharyngioma via the extradural anterior temporal approach with zygomatic arch osteotomy.

Background:Though the extradural anterior temporal approach (EDATA) with zygomatic osteotomy is useful, there are only few reports of this approach being used for craniopharyngioma resection. Herein, we report our surgical case series and the technical importance of EDATA for the radical removal of a craniopharyngioma.Methods:We report 7 cases of craniopharyngiomas treated surgically between April 1999 and October 2015. The surgical approaches, clinical presentation, pre and postoperative radiographic examination results, surgical outcomes, and morbidity were analyzed.Results:The mean follow-up period was 89.1 months. The surgical approach was EDATA with zygomatic osteotomy in 4, combined interhemispheric translamina terminalis approach (IHTLA) and trans-sylvian anterior temporal approach (ATA) in 2, and IHTLA in 1 patient. Complete tumor resection was achieved in all cases, without any recurrence during the follow-up period. Transient morbidities were oculomotor nerve palsy in 2, and meningitis and hydrocephalus in 1 patient. There was 1 case of permanent morbidity due to hydrocephalus that needed a ventriculoperitoneal shunt, and 1 case of blindness on the operative side. Visual acuity and visual field improved in 4 cases, showed no change in 2 cases, and deteriorated in 1 case. Though the pituitary stalk was preserved in 2 cases, all 7 cases needed total hormone replacement therapy.Conclusion:EDATA with zygomatic osteotomy ensures sufficient mobility of the internal carotid artery, and provides a good lateral and look up operative view. Hence, it can be used effectively for radical resection of craniopharyngiomas through the opticocarotid space and retrocarotid space.

Anterior callosal section is useful for the removal of large tumors invading the dorsal part of the anterior third ventricle: operative technique and results

Large tumors invading the dorsal part of the anterior third ventricle are difficult to manage. The anterior transcallosal approach is usually used to manage these tumors. In our clinic, anterior callosal section was combined with the anterior interhemispheric (AIH) translamina terminalis approach for these tumors with excellent results. The AIH approach is useful for removing tumors in and around the anterior part of the third ventricle. However, AIH alone is insufficient for large tumors invading the dorsal part of the anterior third ventricle. In such situations, simple anterior callosal section enables the neurosurgeon to extirpate the caudal part of the tumors deeply hidden from operative field, sparing the foramen of Monro, fornix, etc. We treated four large tumors (malignant teratoma, recurrent chordoid glioma, recurrent papillary tumor of pineal region occupying the third ventricle, and paraventricular meningioma) without major complications. The malignant teratoma case exhibited no recurrence with >10years follow-up. The chordoid glioma and papillary tumor of pineal region were totally removed. The meningioma was subtotally removed except only a small tumor around the bilateral anterior cerebral artery. This simple technique is a new way to manage difficult large lesions in and around the third ventricle.

The transventricular preforniceal approach for exophytic chiasmatic/hypothalamic astrocytomas extending into the anterior third ventricle

Surgical treatment of large exophytic chiasmatic/hypothalamic astrocytomas extending into the anterior third ventricle remains a challenging task for neurosurgeons. In particular, when the tumor extends from the chiasmatic region upward to the foramen of Monro, damage to the fornix and other neurovascular structures is a major concern. To describe the technique used in the transventricular preforniceal surgical approach to remove the superior and superoposterior part of the tumor in the third ventricle for treatment of exophytic chiasmatic/hypothalamic astrocytoma. The transventricular preforniceal approach was used in two cases of exophytic chiasmatic/hypothalamic astrocytoma. The approach is summarized in 4 procedures: 1) exposure of the anterior horn of the lateral ventricle by the transcallosal approach, 2) identification of the foramen of Monro and the fornix, 3) incision of the septum pellucidum or the wall of the lateral ventricle, in front of the columns of the fornix, and 4) removal of the tumor through the space between the anterior commissure and the columns of the fornix. Because the tumor compressed the foramen of Monro posteriorly and stretched the space between the anterior commissure and the columns of the fornix, the posterosuperior part of the tumor in the third ventricle was successfully removed through the surgical corridor in front of the columns of the fornix. In both cases, tumors were successfully removed using this approach without damaging the fornix and the anterior commissure. Residual tumor was removed using an anterior interhemispheric translamina terminalis approach in a two-stage surgery. The transventricular preforniceal approach can be applied for removing the superior part of exophytic chiasmatic/hypothalamic astrocytomas, because the space between the anterior commissure and the fornix is stretched by the tumor, providing an appropriate surgical corridor.

Rare primary tumours of the hypothalamus in adults: clinical course and surgical treatment

Background and purposeThe paper presents the operative technique and the results of treatment of adult patients with primary tumours of the hypothalamus, including rare ones. The aim of the study was to show the possibility of safe surgical treatment of rare tumours of the hypothalamus through a bifrontal basal interhemispheric trans-lamina terminalis approach. Material and methodsFive patients with tumours of the hypothalamus were operated on in the Neurosurgical Clinic in Sosnowiec between 1990 and 2008. There were 2 patients with craniopharyngiomas located exclusively in the third ventricle, and single patients with gemistocytic astrocytoma, Langerhans cell histiocytosis X and hamartoma of the hypothalamus each. The patients were treated surgically with a bifrontal basal interhemispheric trans-lamina terminalis approach. In two cases, the neuronavigation system with the use of tractography (DTI) was used to determine the location of the lamina terminalis, the posterior surface of the optic chiasm and the optic tracts. ResultsAll lesions were resected totally, except for partially resected hamartoma of the hypothalamus. The most common postoperative complication was diabetes insipidus, which was transient in two cases. A long-lasting follow-up of all the patients operated on did not reveal regrowth of the lesion. ConclusionsThe bifrontal basal interhemispheric trans-lamina terminalis approach allows for radical resection of primary tumours of the hypothalamus while avoiding serious postoperative deficits. This approach enabled the preservation of the olfactory bulb and tract and prevented damage of the frontal lobes. The use of DTI helped to establish the location and borders of the lamina terminalis, to establish the posterior surface of the optic chiasm and the optic tracts, and to save the anterior and lateral wall of the hypothalamus.

Ganglioglioma in the third ventricle: report on two cases

Gangliogliomas are uncommon central nervous system (CNS) tumors composed of a mixture of glial and neuronal elements. Although these tumors can occur in any portion of the central nervous system, involvement of the ventricular system is rare. We herein report on two cases of gangliogliomas in the third ventricle in a 34-year-old woman and in a 52-year-old man. One patient presented only with headaches, and the other presented symptoms associated with panhypopituitarism and diabetes insipidus. In the first case the tumor in the middle portion of the third ventricle was successfully removed by a transcallosal subchoroidal approach. In the second case the hemorrhagic tumor was located in the anterior floor of the third ventricle and was removed by an anterior inter-hemispheric trans-lamina terminalis approach. To date, follow-ups of both patients have involved no adjuvant therapy, and there have been no signs of tumor recurrence on magnetic resonance images. The nature, radiological findings, and treatments of these tumors are discussed.

Spontaneous Resolution of Diabetes Insipidus After Pituitary Stalk Sectioning During Surgery for Large Craniopharyngioma-Endocrinological Evaluation and Clinical Implications for Surgical Strategy-

The mechanism of spontaneous resolution of diabetes insipidus (DI) was investigated after surgery for large craniopharyngioma. Twenty-two adult patients (mean age 48.9 years old), who underwent surgery via the anterior interhemispheric trans-lamina terminalis approach, were divided into three groups: Group I, the entire pituitary stalk was preserved (n = 2); Group II, the stalk was dissected distally from the tumor but ultimately sacrificed (n = 9); Group III, the stalk was not identified and was sacrificed (n = 11). All patients were discharged without neurological deficits 1 month after surgery. Four patients underwent gamma-knife treatment for residual tumor or recurrence. Postoperative endocrinological functions were normal in Group I, and no replacement therapy was required. Hormonal replacement for pan-hypopituitarism and DI was necessary in Groups II and III (mean follow-up period 5.9 years). DI resolved at 2.7 +/- 1.3 years after surgery in four patients in Group II, and a hypertonic saline infusion test revealed production of small amounts of intrinsic antidiuretic hormone (ADH). Urine osmolarity was high in the morning, and a significant increase in urinary osmolarity was noted after Pitressin injection. These results indicate induction of hypersensitivity of the distal renal tubules to small amounts of intrinsic ADH, resulting in decreased urinary output. Recovery from DI can be expected, despite permanent impairment of anterior pituitary function, if the pituitary stalk is dissected as distally as possible.

Surgical experiences of 45 consecutive craniopharyngiomas

Object: The aim of the present study was to assess the outcome of surgical management in 45 consecutive patients harboring craniopharyngiomas treated between January 1986 and December 2002. Methods: In 45 patients undergoing surgery, the transsphenoidal approach was most frequently adopted as the primary procedure (20 patients), followed by the interhemispheric trans-lamina terminalis approach (13 patients), and by the pterional approach (9 patients), and finally endoscopic surgery (3 patients). Total tumor removal was finally achieved in 32 patients (71.1%), subtotal removal in 13 cases followed by conventional radiotherapy or gamma knife radiosurgery. In 15 patients, more than two of the surgical treatments were required to accomplish total tumor removal. In 8 of these 15 cases, the tumor recurred after initial surgical treatment by another neurosurgeon after which the patient was referred to us. The operative mortality is zero in all 45 cases. One 4-year-old boy died suddenly one and half years after the final operation, caused by the parents' poor medical coverage. Postmortem examination revealed a small fragment of residual tumor sticking to the anterior hypothalamic wall. Conclusion: Total tumor removal, while avoiding hazardous intraoperative manipulation, provided favorable results and a high rate of long-term control in craniopharyngiomas.

Intra-third ventricular craniopharyngiomas: imaging characteristics, histopathology and successful trans-lamina terminalis approach

Craniopharyngiomas usually grow from remnants of Rathkes' pouch and frequently locate on the cisternal surface of the hypothalamic region. However, this tumor can grow exclusively within the third ventricle. During the past 18 years, five purely intra-third ventricular craniopharyngiomas were experienced in our institute. Four patients were male and the patient ages ranged from 13 to 52 years. Presenting clinical symptoms and signs included visual impairments in three, mental deterioration in two, headache and pituitary insufficiency in two. The histopathology was papillary and squamous in three and adamontimomatous in two. Precise tumor location and morphology were established with CT and MRI. The mass was solid and well enhanced in two patients, mainly solid with small rim enhancing cysts in two and multi-cystic with calcification in one. Hypothalamic brain edema was observed in a huge tumor of a papillary type. Spotty or massive calcification was noted in each of the two tumors of an adamantinomatous type. Although there are several surgical approaches available to resect an intra-third ventricular tumor, all our cases were operated through an interhemispheric trans-lamina terminalis approach. Gross total resection was performed in all cases at the initial surgery. Microsurgical findings revealed: (1) little or no tumor adhesion to the ventricular walls and the roof, (2) firm attachment to the floor of the ventricle around the vicinity of the tuber cinereum. The origin seemed to be the floor, (3) another important finding was small feeders coming from the anterior part of the circle of Willis. In order to get a direct view of the most delicate part of the tumor dissection, the trans-lamina terminalis approach was a valid choice. Recurrence was noted 8 months later in one patient followed by a total resection using the same route. No radiotherapy was applied in all patients. In the post-operative period, precise assessment of body fluid and hormone is mandatory and accurate replacement treatments are needed even months or years. All patients returned to their previous activity.

Neonatal craniopharyngioma and inference of tumor inception time: case report and review of the literature

Background Craniopharyngioma is a rare neonatal tumor, although it is the most common tumor of the parasellar region in childhood. Only a few cases have been antenatally diagnosed. We report a case of neonatal craniopharyngioma surgically treated after birth and its inferred tumor inception time. Case description A routine ultrasound at 33 weeks of gestation revealed a high echoic mass at the center of the head in this fetus. The baby was delivered normally at 40 weeks with no abnormal appearance of its body surface. Hypotonicity of her lower limbs was observed. The tumor was totally removed uneventfully by an interhemispheric translaminaterminalis approach at 8 months after birth. Conclusion A kinetic study of the tumor showed that tumor inception time was on the 45.6th day of gestation. The present case is the fourth successful resection of neonatal craniopharyngioma. The literature is reviewed.

Microsurgical anatomy and clinical significance of the anterior communicating artery and its perforating branches.

Precise identification of the anomalous anterior communicating artery (ACoA) or the perforating branches of the ACoA is usually difficult on preoperative angiograms because of the vascular complexity around the ACoA and its small-caliber branches. The purpose of this study was to review the microsurgical anatomy of the ACoA and its branches to show their importance for the interhemispheric trans-lamina terminalis approach and ACoA aneurysmal surgery. In 30 cadaver brains, the ACoA and its branches were examined under magnification using a surgical microscope. The ACoA was evident in all specimens and had variations consisting of plexiform (33%), dimple (33%), fenestration (21%), duplication (18%), string (18%), fusion (12%), median artery of the corpus callosum (6%), and azygous anterior cerebral artery (3%). The perforating branches were also observed in all cadaver brains. They were classified into subcallosal, hypothalamic, and chiasmatic branches according to their vascular territories. The subcallosal branch, usually single and the largest, supplied the bilateral subcallosal areas, branching off to the hypothalamic area. The hypothalamic branches, multiple and of small caliber, terminated in the hypothalamic area. The incidence of anomalous ACoA was higher than has been previously reported, and any segment of the anomalous ACoA may have perforating branches regardless of diameter. Among the three branches, the subcallosal branch is the most important because it feeds bilateral subcallosal areas branching to the hypothalamic area.

Third ventricle cavernous angioma: Report of two cases

Cavernous angioma arising in the third ventricle is an extremely rare disease. We have reviewed five cases previously reported, as well as our own two cases, and discuss the clinical characteristics of and surgical approach to cavernous angioma at this site. The bifrontal craniotomy and interhemispheric translamina terminalis approach minimize the damage to the brain and allow for an approach to the third ventricle in a wide operative field with minimal compression of the brain itself. We have found this approach to be suitable for surgery on angiomas of the anterior half of the third ventricle.

A pitfall in the interhemispheric translamina terminalis approach for the removal of a craniopharyngioma. Significance of preserving draining veins. Part I. Clinical study

The interhemispheric translamina terminalis approach has made total removal of a craniopharyngioma less risky. Nevertheless, one of the pitfalls of this approach is cutting of the draining veins combined with retraction. A case of craniopharyngioma in which a subcortical hematoma developed is reported. The divided draining veins and the 60-minute retraction period were thought to have caused this complication. We therefore determined the clinical effect of cutting the draining veins and retraction on the regional cerebral blood flow and the motor nerve action potential. There were marked changes and a hematoma occurred mostly when the veins were divided and retraction was applied over the area.

A pitfall in the interhemispheric translamina terminalis approach for the removal of a craniopharyngioma. Significance of preserving draining veins. Part II. Experimental study

The authors have reported a case of a craniopharyngioma removed by the interhemispheric translamina terminalis approach, and the postoperative development of a subcortical hematoma. We suspected that the cause of the subcortical hematoma was dividing the bridging veins and applying a retractor over them. In this paper, we report our experimental study, using dogs and monkeys, to evaluate the effect of cutting the vein and applying a retractor over it. The incidence of a subcortical hematoma was highest (60%) when the veins were cut and the retraction was applied. Vein occlusion only did not cause hematoma to develop, and the retraction alone caused 13% of the hematomas. This clearly indicated that the clinical case reported in Part I developed the subcortical hematoma postoperatively because the frontal bridging vein was cut and a retractor was applied for 60 minutes over the cut vein.