Translamina Terminalis Approach Research Articles

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.

Transcortical–transforaminal microscopic approach for purely intraventricular craniopharyngioma

Purely intraventricular craniopharyngiomas are rare and pose particular surgical challenges. The two main surgical approaches to these lesions based in the anterior third ventricle are the frontal transventricular approach (through a transcortical or transcallosal approach) and the trans-lamina terminalis approach. The authors note that the pituitary stalk in many of these cases is located in a normal position, which suggests that the third ventricular floor is intact. In such cases, the senior author chooses an approach to avoid disruption of the floor of the third ventricle. Specifically, a traditional frontotemporal approach is not used; we have found that in such cases, a frontal transventricular approach through the usually dilated foramen of Monro provides an optimal visualization of the tumor while minimizing the risks of injury to the hypothalamus and pituitary stalk. The endoscope can be very helpful in exploring blind angles, hidden from the microscopic view. Recognition of this rare location variant of craniopharyngioma is helpful in preoperative planning in an effort to reduce hypothalamic pituitary axis damage. Two patients presenting with craniopharyngiomas that were entirely intraventricular are shown in the video. The patients underwent removal of their tumors without incurring new long-term endocrine deficits. The video can be found here: http://youtu.be/VFlhm_lsrGY. (http://thejns.org/doi/abs/10.3171/2013.V1.FOCUS12347)

Trans-Lamina Terminalis Approach to Third Ventricle using Supraorbital Craniotomy: Technique Description and Literature Review for Outcome Comparison with Anterior, Lateral and Trans-Sphenoidal Corridors

The trans-lamina terminalis approach has been described to remove third ventricular tumors. Various surgical corridors for this approach include anterior (via bifrontal craniotomy), anterolateral (via supra-orbital craniotomy), lateral (via pterional craniotomy) and trans-sphenoidal corridors. Supra-orbital craniotomy offers a minimally invasive access for resection of third ventricular tumors. The trans-lamina terminalis technique through a supra-orbital craniotomy is described. Also, a literature review of clinical outcome data was performed for the comparison of different surgical corridors (anterior, antero-lateral, lateral, and trans-sphenoidal). The operative steps and anatomic landmarks for supra-orbital craniotomy are discussed, along with 3 representative cases and respective outcomes. Gross total resection was achieved in 2 patients, and one patient required reoperation for recurrence. Based on the current literature, the clinical outcomes after supra-orbital craniotomy for trans-lamina terminalis approach are comparable to other surgical corridors. The supra-orbital craniotomy for trans-lamina terminalis approach is a valid surgical choice for third ventricular tumors. The major strengths of this approach include minimal brain retraction and direct end-on view; however, the long working distance is a major limitation. The clinical outcomes are comparable to other surgical corridors. Sound understanding of major strengths, limitations, and strategies for complication avoidance is necessary for its safe and effective application.

Chordoid Glioma

chordoid glioma is a rare tumor (World Health Organization grade II) with both glial and chordoid features, often located in the suprasellar region and anterior third ventricle. It was first described by Brat in 1998. Because there is no detailed information available from the clinical perspective, we reviewed the literature. a literature search through PUBMED and CNKI revealed 64 cases of chordoid glioma. Information on the clinical course was very limited. We reviewed the literature and studied the pathologic and imaging features, postoperative mortality and morbidity in relation to surgical extension and approaches, and the importance of adjuvant treatment. mortality in the immediate postoperative period is 28%, and postoperative morbidity is 60%, which are statistically higher after gross total resection as compared with subtotal resection. Translamina terminalis approach is considered to be the best approach. The current study cannot document that patients have longer survival and higher quality of life after gross total resection than subtotal resection. The role of postoperative radiotherapy is uncertain and there is no report on the use of chemotherapy. More information about the optimal treatment strategy is needed.

Surgical nuances for removal of retrochiasmatic craniopharyngiomas via the transbasal subfrontal translamina terminalis approach

Giant craniopharyngiomas in the retrochiasmatic space are challenging tumors, given the location and surrounding vital structures. Surgical removal remains the first line of therapy and offers the best chance of cure. For tumors with extension into the retrochiasmatic space, the authors use the translamina terminalis corridor via the transbasal subfrontal approach. Although the lamina terminalis can be accessed via anterolateral approaches (pterional or orbitozygomatic), the surgical view of the optic chiasm is oblique and prevents adequate visualization of the ipsilateral wall of the third ventricle. The transbasal subfrontal approach, on the other hand, offers the major advantage of direct midline orientation and access to the third ventricle through the lamina terminalis. This provides the significant advantage of visualization of both walls of the third ventricle and hypothalamus as well as inferior midline access to the interpeduncular cistern to permit safe neurovascular dissection and total tumor removal. In this report, the authors describe the transbasal subfrontal translamina terminalis approach, with specific emphasis on technical surgical nuances in removing retrochiasmatic craniopharyngiomas. An illustrative video demonstrating the technique is also presented.

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.

The translamina terminalis approach for microsurgical resection of anterochiasmatic sellar tumour

Objective To study the operative approach and microsurgical technique of translamina terminalis approach on anterochiasmatic sellar tumour. Methods The clinical data and the follow-up result of 23 patients with anterochiasmatic sellar tumour who were treated surgically through translamina terminalis approach were analyzed retrospectively from February 2001 to May 2007. Results Among 23 patients, total resection was performed in 13 cases,secondary resection in 6 cases, partial resection in 4 cases. All patients had good results without operation death. Three recurred cases were found during the follow-up period of 6 months to 4 years. Conclusions The translamina terminalis approach for microsurgical resection of anterochiasmatic sellar tumour is an effective method by mastering anatomy characteristics of saddle area interspaces. Perfect microsurgical skill, protection of important structures in saddle area and treatment of complication in time ware the basement of achieving fine curative effect. Key words: Skull base neoplasms; Anterochiasmatic sellar turnout; Translamina terminalis approach; Microsurgery

Chordoid glioma of the third ventricle attached to the optic chiasm: Successful removal through a trans-lamina terminalis approach

Chordoid glioma of the third ventricle constitutes a rare, very recently recognized histological entity. Most reports of this neoplasm, focused on its distinct histological features, have hypothesized about a probable origin of the lesion at the third ventricle floor and/or the lamina terminalis. We report on a new case, presenting neuroradiological and intraoperative pictorial evidences of the tumoral attachment, limited to the chiasm-lamina terminalis junction. A 53-year-old woman debuted with acute symptoms of obstructive hydrocephalus, visual disturbances and confusion. MRI investigation showed a large solid-cystic third ventricle mass bulging through the lamina terminalis and ventricular floor. After placing a ventriculoperitoneal shunt, the tumor was completely removed through a trans-lamina terminalis approach. A tight tumoral attachment to the junction of the posterior chiasm to the lamina terminalis was identified and dissected. No other adhesions to the third ventricle boundaries were found. A chordoid glioma was diagnosed on histological examination. One year after the surgical procedure the patient does not present new neurological deficits, and there are no signs of tumoral regrowth on the follow-up postoperative MRI. Chordoid glioma should be included in the differential diagnosis of third ventricle tumors. Preoperative neuroradiological suspicion of this lesion should alert the neurosurgeon about the presence of a tight tumoral adherence at the level of the chiasm-lamina terminalis junction. The trans-lamina terminalis approach provides a suitable route for an early control of this attachment under direct vision, allowing a safe dissection of the mass from the third ventricle.

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.

Endoscopy-Assisted Microsurgical Removal of Giant Craniopharyngioma in Childhood

Sixty-nine children suffering from craniopharyngioma were operated on between 1996 and 2004. Twenty-three of those children had very large tumors (diameter > 50 mm). Radical total microsurgical resection assisted by endoscopy was attempted in 19 patients. We performed in these cases a minimal pterionosubfrontal flap. The translamina terminalis approach was used for the retrochiasmatic tumors and the anterior/lateral subchiasmatic approach for prechiasmatic tumors. The success of our total resection of the tumor was evaluated by CT scan and MRI. None of the patients received radiotherapy postoperatively. The follow-up period ranged between 18 months and 4 years. Only 3 patients showed recurrences. Despite the fact that total removal was performed, we only witnessed 2 cases of postoperative neurological aggravation. Transient diabetes insipidus was seen in all cases. Hydrocephalus was present in 15 cases; only 5 required shunting. We hereby present our techniques and results. We conclude that good knowledge of the surgical and endoscopic anatomy of giant craniopharyngioma make total removal of these tumors possible with minimal complications, if any.

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.

Intraventricular craniopharyngiomas: topographical classification and surgical approach selection based on an extensive overview.

This retrospective study analyzes the clinical, neuroradiological, pathological and surgical characteristics of well-described intraventricular craniopharyngiomas with the aims of: (i) critically to review the criteria used to affirm the diagnosis of an intraventricular location (ii) defining more accurately this topographical diagnosis preoperatively, and (iii) to investigate factors influencing the surgical outcome. Clinical, neuroradiological, pathological and surgical objective data of 104 well-described intraventricular craniopharyngiomas (IVC) reported in the literature, in addition to a new case, were analyzed. On the basis of the proofs provided for third ventricle intactness, a new topographical classification for IVC was developed, distinguishing between: (i) strict IVC, with a proved third ventricle floor integrity and (ii) non-strict IVC, without any reliable proof confirming the intactness of the third ventricle floor. Following this classification, clinical features, pathology and surgical outcome for strictly and non-strictly IVC were compared. For 105 IVC compiled, 36 belonged to the strictly group and 69 to the non-strictly group. Two pathological features were associated with the non-strictly IVC group: a preferentially adamantinomatous pattern (p=0.106) and wider and tighter adherences to third ventricle margins (p=0.01). The non-strict topography was also associated with a worse postoperative outcome (p=0.046). There was a significant relationship between the surgical approach and the final outcome (p=0.05), being the translamina terminalis approach associated with the best outcome. Two different topographies might be considered among IVC: strict and non-strict intraventricular location. Non-strictly IVC have wider and tighter adhesions to third ventricle boundaries and this subtype is associated with a worse outcome.

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.

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.

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.

Third ventricular chordoid glioma: case report and review of the literature

Background Chordoid glioma of the third ventricle is a rare type of brain tumor that was recently characterized as a novel tumor entity. We present a case and review of the literature. Case report A 49-year-old woman presented with progressive headache, memory impairment and urinary incontinence. MRI showed a large well-circumscribed tumor in the third ventricle. The tumor was partially removed via a trans-lamina terminalis approach. The histologic findings indicated chordoid glioma. Residual tumor was treated by stereotactic radiosurgery and showed no regrowth at 2-year follow-up. Conclusions The ideal therapy is total removal of the tumor. However, according to the literature, total removal of the tumor carries a high risk because of its location, and conventional radiation therapy has little effect on the residual tumor. On the other hand, stereotactic radiosurgery appears more promising, and to date, no regrowth has been reported after γ-knife therapy.

Morphometry of the anterior third ventricle region as a guide for the subfrontal (translaminaterminalis) approach.

The anterior third ventricle region acquires clinical significance in benign and malignant tumors and cyst formations, of which craniopharyngiomas and gliomas are the most common. The subfrontal approach is one of the most preferred approaches for removing these tumors. In this study, the microsurgical anatomy of 81 Turkish, adult cadaveric hemispheres was examined to provide morphometric data of the region. These measurements from the anterior third ventricle region serve as a guide for neurosurgeons during surgical approach for removing anterior third ventricle tumors.

Endoscopic surgery of the third ventricle: the subfrontal trans-lamina terminalis approach.

The authors describe an endoscopic approach to the anterior aspect of the third ventricle and demonstrate its use in the cadaver. This technique consists of a small supraorbital craniotomy and a subfrontal trans-lamina terminalis approach to the third ventricle. It may be helpful in the management of refractory third ventricular lesions that cannot be easily accessed endoscopically through the foramina of Monro.

Craniopharyngiomas of the third ventricle: trans-lamina terminalis approach.

Craniopharyngiomas usually grow on the cisternal surface of the hypothalamic region; these tumors can also grow from the infundibulum or tuber cinereum on the floor of the third ventricle, developing exclusively into the third ventricle. The aim of the present work was to establish the usefulness of the pterional trans-lamina terminalis approach for the removal of these tumors. Eight patients who were surgically treated for craniopharyngiomas located exclusively within the third ventricle were considered. The initial symptoms were acute hydrocephalus in two cases, psychological disturbances in two, amenorrhea in two, headaches in one, and hypopituitarism in one. The diagnoses were established, in all cases except one, with magnetic resonance imaging. In all cases, the tumor completely filled the third ventricle. Total removal of the lesion was achieved in seven cases. One patient underwent partial removal. In the immediate postoperative period, no major complications were observed. Five patients required replacement hormonal therapy. All patients returned to a normal life. Many months after surgery, two patients exhibited psychological disturbances and died, the first because of voluntary withdrawal of replacement therapy (12 mo after surgery) and the second because of a severe imbalance in body fluids and electrolytes, with a subsequent hyperosmolar coma (27 mo after surgery). Only one patient who underwent initial total removal experienced a small recurrence of the lesion (30 mo after surgery); after 3 years, the lesion exhibited unchanged size. In our experience, the trans-lamina terminalis approach is a valid choice for the removal of purely intraventricular craniopharyngiomas. These tumors can be removed without significant sequelae related to the surgical approach. The proximity to the hypothalamus requires accurate neuroendocrine and electrolyte control in the postoperative period, in some cases even years after surgery.

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.