Transcortical Approach Research Articles

Combined Staged Endoscopic and Microsurgical Approach of a Third Ventricular Choroid Plexus Papilloma in an Infant

Choroid plexus papillomas of the third ventricle in newborn infants are quite rare and present a significant surgical challenge. This case report illustrates the utility of endoscopy in facilitating tumor resection. A 6-week-old boy, born prematurely at a gestational age of 35 weeks, presented with hydrocephalus secondary to a choroid plexus papilloma in the third ventricle, extending to the aqueduct of Sylvius and into the fourth ventricle. On admission, he was found to have clinical signs of raised intracranial pressure. MRI revealed a homogeneously enhancing mass primarily in the third ventricle. The initial surgical procedure was insertion of a ventriculo-peritoneal shunt, followed by an endoscopic biopsy, which allowed the surgeons to mobilize the tumor into the right lateral ventricle. This facilitated a subsequent transcortical approach to completely remove the tumour. The authors present a case of choroid plexus papilloma in an uncommon location with a unique surgical approach and a successful outcome with no neurological deficits. We detail our surgical approach and the complexity of approaching a tumor located in the third ventricle of an infant.

Trigone ventricular meningiomas: surgical approaches

Report our experience with trigone ventricular meningiomas and review the surgical approaches to the trigone. From 1989 to 2006, six patients with meningiomas of the trigone of the lateral ventricles underwent microsurgical resection. Their clinical features, image, follow up, and surgical approaches were retrospectively analyzed. Five patients presented with large and one with small volume meningioma. Unspecific symptoms occurred in three patients; intracranial hypertension detected in three patients; homonymous hemianopsy in three; and motor deficit present in one patient. Three patients were operated by transparietal transcortical approach, two by middle temporal gyrus approach, and one by parieto-occipital interhemispheric precuneus approach. Total resection was achieved in all patients without additional deficits. Judicious preoperative plan, adequate knowledge of anatomy, and use of correct microsurgical techniques are fundamental in achieving complete resection of trigone meningioma with low morbidity.

Surgical management of tumors producing the thalamopeduncular syndrome of childhood

Thalamopeduncular tumors arise at the junction of the inferior thalamus and cerebral peduncle and present with a common clinical syndrome of progressive spastic hemiparesis. Pathologically, these lesions are usually juvenile pilocytic astrocytomas and are best treated with resection with the intent to cure. The goals of this study are to define a common clinical syndrome produced by thalamopeduncular tumors and to discuss imaging characteristics as well as surgical adjuncts, intraoperative nuances, and postoperative complications relating to the resection of these neoplasms. The authors present a retrospective review of their experience with 10 children presenting between 3 and 15 years of age with a thalamopeduncular syndrome. Formal preoperative MR imaging was obtained in all patients, and diffusion tensor (DT) imaging was performed in 9 patients. Postoperative MR imaging was obtained to evaluate the extent of tumor resection. A prospective analysis of clinical outcomes was then conducted by the senior author. Pilocytic astrocytoma was the pathological diagnosis in 9 cases, and the other was fibrillary astrocytoma. Seven of 9 pilocytic astrocytomas were completely resected. Radical surgery was avoided in 1 child after DT imaging revealed that the corticospinal tract (CST) coursed through the center of the tumor, consistent with the infiltrative nature of fibrillary astrocytoma as identified by stereotactic biopsy. In 8 patients, tractography served as an important adjunct for designing a surgical approach that spared the CST. In 6 cases the CSTs were pushed anterolaterally, making a transsylvian approach a poor choice, as was evidenced by the first patient in the series, who underwent operation prior to the advent of tractography, and who awoke with a dense contralateral hemiparesis. Thus, subsequent patients with this deviation pattern underwent a transcortical approach via the middle temporal gyrus. One patient exhibited medial deviation of the tracts and another had lateral deviation, facilitating a transtemporal and a transfrontal approach, respectively. The thalamopeduncular syndrome of progressive spastic hemiparesis presenting in children with or without symptoms of headache should alert the examiner to the possibility of a tumoral involvement of CSTs. Preoperative tractography is a useful adjunct to surgical planning in tumors that displace motor pathways. Gross-total resection of pilocytic astrocytomas usually results in cure, and therefore should be entertained when developing a treatment strategy for thalamopeduncular tumors of childhood.

Intraventricular Atypical Meningiomas

A rare case of intraventricular meningioma that arose in the atrium of the left lateral ventricle was identified in a 51-year-old woman. Gross total removal was performed by transcortical approach. Histopathological findings showed meningothelial meningioma with a focal atypical area which had 8% of Ki-67 labeling index (LI). A large recurrence extending into the ipsilateral quadrigeminal cistern and opposite medial occipital lobe developed approximately 41 months after the first operation. The specimens obtained from the second resection showed atypical meningioma with 20% of Ki-67 LI but there were no anaplastic area. The patient underwent fractionated stereotactic radiotherapy. However, multiple local distant metastases were found in the occipital and cerebellar cortex suggesting cerebrospinal fluid dissemination apparently 24 months after the second operation. This report presents chronological progression of a rare intraventricular atypical meningioma with more aggressive transformation.

前脈絡叢動脈をｆｅｅｄｅｒとする側脳室三角部脳動静脈奇形の摘出後，内包梗塞を生じた１例

We report a case of cerebral infarction in the internal capsule following a resection of AVM in the trigone of the left lateral ventricle fed by the anterior choroidal artery. A 61-year-old man presented with mild right hemiparesis and seizure. He had had an AVM in the trigone of the left lateral ventricle since 37 years before, and had experienced a seizure and cerebral hemorrhage. Cerebral angiography showed an AVM of Spetzler-Martin’s Grade 2 fed by the anterior choroidal artery in the trigone of the left lateral ventricle. An operation was performed by the transcortical approach using a former hemorrhagic cavity. The left anterior choroidal artery feeding the nidus was cut in the left lateral ventricle, and AVM was removed together with a choroid plexus. Right hemiparesis worsened postoperatively, and MRI revealed cerebral infarction in the left internal capsule. Although it is thought that the cutting of the anterior choroidal artery in the lateral ventricle is safe, care should be taken when cutting the anterior choroidal artery even in the lateral ventricle because the branch(es) originating from the plexal segment of the anterior choroidal artery could penetrate to the cerebral parenchyma and feed the internal capsule.

Tumors of the posterior third ventricular region in pediatric patients: The Indian perspective and a review of literature

Background:Diverse tumors in the posterior third ventricular region (TPTVR) frequently occur in children. A decade's experience with pediatric TPTVR is presented, focusing on the Indian perspective.Materials and Methods:25 children (age range: 3-18 years; mean age: 13.32 years; presentation range: 7 days-2.5 years) had clinico-radiological assessment with contrast computed tomography (CT) and magnetic resonance imaging (MRI). The ventricular/lumbar cerebrospinal fluid (CSF) alpha feto protein (AFP)/beta human chorionic gonadotrophin (HCG) estimation was done when radiological suspicion of a germ cell tumor was present. Extent of resection was deemed partial when some tumor mass remained at the end of surgery, near total when <10% was retained over vital neurovascular structures, and total when complete resection was attained.Results:Operations included infratentorial supracerebellar approach (n = 12), occipito-transtentorial approach (n = 2), endoscopic biopsy and third ventriculostomy (n = 1), frontal parasagittal craniotomy, interhemispheric transcallosal subchoroidal approach (n = 2), middle temporal gyrus transcortical transventricular approach (n = 1), fronto-temporo-zygomatic combined transylvian and subtemporal approach (n = 1) and right ventriculoperitoneal shunt and stereotactic biopsy (n = 1). Only CSF diversion was performed for five patients with a small TPTVR. CSF diversion was required in 12 (48%) patients. Tumor pathology included pinealoblastoma (n = 4; one with pineocytic differentiation), nongerminomatous germ cell tumor (NGGCT; n = 3), germinoma (n = 3), pilocytic astrocytoma (n = 2), epidermoid (n = 3) and primitive neuroectodermal tumor (PNET), fibrillary astrocytoma, glioblastoma, teratoma, and meningioma (n = 1, respectively). A patient with neurocysticercosis was diagnosed solely on MRI (four did not undergo biopsy). Fractionated radiotherapy was administered in 13 patients with primary pineal tumors, PNET, NGGCT, fibrillary astrocytoma and glioblastoma. Extent of excision was total in 10 (40%), near total in 5 (20%), partial in 3 (12%) and a biopsy in 2 (8%) patients.Conclusions:Histopathologic characterization of TPTVR is essential prior to their further management. Benign lesions often have a good prognosis following gross total surgical resection. Pure germinomas are highly susceptible to radiotherapy. NGGCTs often have malignant components that require adjuvant therapy following surgery. The advancements in microsurgical techniques have led to gratifying perioperative results in these deep-seated lesions.

Morbidity of Transcallosal and Transcortical Approaches to Lesions in and Around the Lateral and Third Ventricles: A Single-Institution Experience

Morbidity of Transcallosal and Transcortical Approaches to Lesions in and Around the Lateral and Third Ventricles: A Single-Institution Experience

Morbidity of Transcallosal and Transcortical Approaches to Lesions in and Around the Lateral and Third Ventricles: A Single-Institution Experience

Resection of an intraventricular mass can result in life-altering complications. Many advocate transcallosal rather than transcortical approaches to these lesions, citing differential postoperative seizure risk. To test the hypothesis that the complication rates and patient outcomes are no different between these ventricular approaches. The medical records of 127 patients (93 adults and 34 children) operated on for intraventricular lesions between 1996 and 2007 were retrospectively analyzed. Risk factors for specific postoperative complications and outcome were assessed by multivariate analysis. The transcallosal (59%) or transcortical (41%) approach was used. Gross or nearly total resection was achieved in 87% of cases. The permanent neurological complication rate determined by a staff neurologist was 23.6%. Seizure attributable to surgery occurred after 8% of transcortical and 25% of transcallosal operations (P=.01). After controlling for a variety of factors, the transcallosal approach carried a 4.4-fold increased risk of seizure (95% confidence interval, 1.3-18.9). The operative approach was not a risk factor for any other postoperative complication. One year after surgery, 72% of patients had excellent functional outcome (Karnofsky Performance Score≥70 and Glasgow Outcome Score=5). High tumor grade and impaired preoperative Karnofsky Performance Score predicted poor outcome. More than 90% of patients operated on for symptomatic colloid cysts (n=34) had an excellent outcome. Although the 2 traditional approaches to the ventricular system had similar major complication rates, the transcallosal approach was associated with significantly increased seizure risk. Accordingly, the chosen operative corridor should optimize tumor access and the protection of vulnerable neurovascular structures.

Spontaneous acute hemorrhage within a subependymoma of the lateral ventricle: successful emergent surgical removal through a frontal transcortical approach

Introduccion. Los subependimomas son neoplasias benignas que se desarrollan en estrecha relacion con el sistema ventricular y que excepcionalmente asocian fenomenos hemorragicos. Describimos el caso de un subependimoma localizado en el ventriculo lateral que presento una hemorragia intratumoral aguda de forma espontanea, como se evidencio en los estudios neurorradiologicos y patologicos realizados, incluyendo un analisis exhaustivo de los casos similares descritos en la literatura cientifica. Caso clinico. Se trata de un varon de 71 anos que recibia tratamiento anticoagulante, y que presento un cuadro brusco y progresivo de disminucion del nivel de conciencia. Los estudios de neuroimagen evidenciaron la presencia de una masa localizada en el ventriculo lateral izquierdo, con signos de hemorragia reciente en su seno, que producia hidrocefalia biventricular aguda. La lesion fue resecada en su totalidad de forma urgente mediante un abordaje frontal transcortical. El estudio patologico de la lesion demostro que se trataba de un subependimoma con focos hemorragicos. En el periodo postoperatorio, el paciente presento un deficit de memoria global, tanto anterograda como retrograda. Conclusiones. Los episodios de hemorragia espontanea aguda constituyen un fenomeno excepcional en el caso de los tumores de histologia benigna como los subependimomas, y pueden transformar un curso clinico asintomatico en una emergencia quirurgica debido al desarrollo de hidrocefalia aguda. La extirpacion completa de la lesion de forma urgente representa la opcion de manejo quirurgico mas apropiada, ya que permite un reestablecimiento inmediato de la circulacion de liquido cefalorraquideo y previene la aparicion de resangrado.

Giant intraventricular mass arising from the septum pellucidum

A 55-year-old male patient was admitted with complaints of headache for one month. The neurological examination was normal. MRI revealed an inhomogeneous lesion in the lateral ventricles, arising from the septum pellucidum. The mass was isointense with areas of hyperintensity on T1-weighted MRI, and it was heterogeneously hyperintense on T2-weighted MRI with minimal contrast enhancement (Fig. 1). There was evidence of intense blooming on gradient echo MRI (Fig. 2). A gross total surgical excision was performed by a right frontal transcortical approach. The patient had an uneventful postoperative course.

Comparison of clinical application of surgical approaches to the third ventricle

Objective To compare the application effect of several approaches to the third ventricle,and explore the optimal approach to resect the tumors located at the third ventricle. Methods Under the operative microscope thirty- five patients (prophase group) with the third ventricle tumors were operated via transcortical approach, trans - lamina terminalis approach or infratentorial supracerebellar approach, and twenty- one patients (anaphase group ) via transcallosal - interforniceal approach. Operative effect was observed and compared. Results Among the prophase group, the tumors were totally removed in 16 cases,subtotally in 6 cases and partially in 13 cases. Among the anaphase group, the total removal of tumor were obtained in 11 cases, subtotal in 8 cases and partial in 2 cases. Rate of total and subtotal tumor removal had significant difference between two groups. Rate of postoperative complications in anaphase group was lower than that in prophase group. Conclusion Transcallosal - interforniceal approach should be considered for treatment of tumors involving the middle and posterior portion of the third ventricle by providing a quite large operative field ,direct corridor, easier tumor resection and rare postoperative complication. Key words: Third ventricle; Transcallosal -interforniceal approach; Trans -lamina terminalis approach; Infratentorial supracerebellar approach

Removal of 11 Incompletely Erupted, Impacted Cheek Teeth in 10 Horses using a Dental Alveolar Transcortical Osteotomy and Buccotomy Approach

To describe surgical technique and outcome in 10 horses with impacted cheek teeth that were removed by a transcortical osteotomy and buccotomy technique. Case series. Horses (n=10) with impacted cheek teeth. Medical records (2002-2008) of horses with impacted cheek teeth requiring removal were reviewed; surgical technique and outcome were determined. Exodontia of 11 cheek teeth was performed surgically in 10 horses; 3 horses had complications (residual swelling of the mandible) that resolved and all horses returned to their previous use. Transcortical buccotomy technique is effective for removal of incompletely erupted impacted cheek teeth in horses and has a good long-term prognosis for remission of clinical signs. Transcortical buccotomy approach is an effective technique for removal of unerupted impacted equine cheek teeth.

Trigonal and peritrigonal lesions of the lateral ventricle—surgical considerations and outcome analysis of 20 patients

The aim of this study is to review the results and clinical outcome of patients with surgically treated lesions within the trigone of the lateral ventricle. This is a retrospective case series of 20 (eight male, 12 female) patients with lesions of the trigone of the lateral ventricle operated between 1998 and 2008. All lesions were removed via the transcortical temporal and transcortical parietal route. Surgical complications and outcome were assessed using the modified Rankin Scale (mRS). There were four children and 16 adults with a mean age of 42 ± 22years (min = 1, max = 74). Eight (40%) lesions grew within the trigone of the dominant hemisphere. In 17 cases, the lesion was purely intraventricular, and in three cases, a slight paraventricular extension was seen. The mean size was 4.5cm of maximal diameter. Surgical removal was achieved via the transcortical parietal route in 13 cases (65%) and the transcortical temporal route in seven cases (35%). In all cases, complete resection was possible. According to the mRS, 13 patients improved, five remained the same, and two were lost to follow-up. One patient had an increased visual field deficit postoperatively and new hemiparesis and aphasia, but returned to the preoperative level within a few weeks. In one patient, an acute myocardial infarction occurred due to previous cardiac stent placement and in-stent stenosis. Even large trigonal lesions can be resected with low morbidity using a transcortical approach depending on the peritrigonal extension of the tumor.

The diagnosis and treatment of subependymal giant cell astrocytoma combined with tuberous sclerosis

Subependymal giant cell astrocytoma develops in a small proportion of tuberous sclerosis patients. There are still several controversies on the early diagnosis of the tumor, treatment of hydrocephalus, and timing of operation, etc. From September 1996 to April 2006, 17 patients were admitted in neurosurgical department of "Beijing Tiantan Hospital". The authors analyzed medical records and followed up every case. There are 18 tumors out of 17 patients. One patient had double tumors. Sixteen patients except one underwent tumor resection 17 times. Fifteen tumors out of 17 were gross totally removed; two were partially removed. One patient died of brain infarction postoperatively. Three out of 13 patients with preoperative hydrocephalus still needed ventriculoperitoneal shunt after tumor resection. There was no recurrence after total resection. Diagnosis of tumor should be made by clinical criteria. Serial follow-up is essential for a suspected perimonro lesion to find tumor growth earlier. When there is growth, tumor should be removed as soon as possible. Hydrocephalus will resolve in most cases after tumor resection, while external drainage is suitable for emergent cases. Transcallosal and transcortical approaches are both effective to resect the tumor. Tumor will not recur after total removal.

Spontaneous acute hemorrhage within a subependymoma of the lateral ventricle: successful emergent surgical removal through a frontal transcortical approach

INTRODUCTION. Subependymomas are benign neoplasms intimately related to the ventricular system which only exceptionally associate hemorrhagic events. We present neuroradiological and pathological evidences of intratumoral hemorrhage within a single case of subependymoma operated on at our institution. Additionally we analyze retrospectively the well-defined reports of similar cases published in the scientific literature. CASE REPORT. A 71-year-old man on anticoagulant therapy presented with abrupt and progressive deterioration of his level of consciousness. Emergent computed tomography and magnetic resonance imaging evidenced signs of acute bleeding within a mass located at the frontal horn of the left lateral ventricle, producing obstructive biventricular hydrocephalus. The lesion was immediately and completely removed through a left frontal transcortical approach. Pathological diagnosis was consistent with subependymoma displaying areas of microhemorrhage. After surgery the patient developed global anterograde and retrograde amnesia. CONCLUSIONS. A spontaneous hemorrhagic event within an asymptomatic lateral ventricle subependymoma can result in a surgical emergence as a consequence of sudden obstruction of cerebrospinal fluid pathways. Prompt and radical surgical removal of the mass, which allows a rapid resolution of hydrocephalus and prevents the risk of rebleeding, may constitute the safest management strategy.

脳室内出血を伴う視床出血に対する前頭部小開頭血腫除去術

When thalamic hemorrhage is accompanied by severe intraventricular hematoma, the prognosis is poor. Spontaneous thalamic and intraventricular hemorrhage is usually treated by external ventricular drainage for obstructive hydrocephalus. However, drainage occlusion, meningitis and residual hematoma are often troublesome in actual clinical practice. For such severe cases, we performed direct hematoma evacuation by the frontal mini-craniotomy transcortical approach in recent years. The present study evaluated the outcome and complications in 14 patients with spontaneous thalamic and intraventricular hemorrhage treated by frontal mini-craniotomy hematoma evacuation with ventricular drainage and 16 patients treated by only external ventricular drainage. There were no significant differences between the 2 groups with respect to age, clinical grade, hematoma volume, hematoma location and postoperative epilepsy. There was also no significant difference in postoperative outcome between the 2 groups. However, patients treated by frontal mini-craniotomy were less likely to require days of ventricular drainage settlement, had suffered meningitis less frequently and had good hematoma evacuation rate compared with those undergoing only external ventricular drainage. Frontal mini-craniotomy is a simple and effective method for hematoma evacuation that causes fewer complications.

Visual Field Defects After Selective Amygdalohippocampectomy and Standard Temporal Lobectomy

Selective amygdalohippocampectomy (SelAH) is increasingly performed in patients with mesial temporal lobe epilepsy and hippocampal sclerosis. To determine whether visual field defects are less pronounced after SelAH than after standard temporal lobectomy (StTL), we retrospectively analyzed postoperative quantitative visual fields after the 2 procedures. Humphrey visual field analysis was obtained postoperatively in 18 patients who had undergone SelAH and in 33 patients who had undergone StTL. The SelAH was performed via a transcortical approach through the middle temporal gyrus and included the amygdala, 3 cm of the hippocampus, and the parahippocampal gyrus. The visual field pattern deviation was used for analysis. We considered a defect clinically significant if there were 3 contiguous coordinates affected at the 5% level or 2 at the 1% level. All but 2 of 18 patients who had undergone SelAH had homonymous superior quadrantic visual field defects contralateral to the side of the surgery. One patient had no defects by our criteria, and one had a mild defect that reached significance only in the ipsilateral eye. The averaged defect affected mostly coordinates close to the vertical meridian with relative sparing of points close to the horizontal meridian. All but 3 of the 33 patients who had undergone StTL had homonymous superior quadrantic visual field defects. One patient had no defects; 2 had defects that reached significance in only one eye. The averaged defect involved all points in the affected quadrant, but was also greater near the vertical meridian. Of 13 tested visual field coordinates, 4 were significantly less affected by SelAH in the ipsilateral eye and 3 in the contralateral eye. The coordinates close to the horizontal meridian were significantly spared by SelAH. Visual field defects are very common after SelAH but are significantly less pronounced than after StTL. In particular, the visual field close to the horizontal meridian is relatively spared in SelAH.

Gliomas of the cingulate gyrus: surgical management and functional outcome

In this paper, the authors' goal was to summarize their experience with the surgical treatment of gliomas arising from the cingulate gyrus. The authors analyzed preoperative data, surgical strategies, complications, and functional outcome in a series of 34 patients (mean age 42 years, range 12-69 years; 14 females) who underwent 38 operations between May 2001 and November 2008. In 7 cases (18%) the tumor was located in the posterior (parietal) part of the cingulate gyrus, and in 31 (82%) the tumor was in the anterior (frontal) part. In 10 cases (26%) the glioma was solely located in the cingulate gyrus, and in 28 cases (74%) the tumor extended to the supracingular frontal/parietal cortex. Most cases (23 [61%]) had seizures as the presenting symptom, 8 patients (24%) suffered from a hemiparesis/hemihypesthesia, and 4 patients (12%) had aphasic symptoms. The authors chose an interhemispheric approach for tumor resection in 11 (29%) and a transcortical approach in 27 (71%) cases; intraoperative electrophysiological monitoring was applied in 23 (61%) and neuronavigation in 15 (39%) cases. A > 90% resection was achieved in 32 (84%) and > 70% in another 5 (13%) cases. Tumors were classified as low-grade gliomas in 11 cases (29%). A glioblastoma multiforme (WHO Grade IV, 10 cases [26%]) and oligoastrocytoma (WHO Grade III, 9 cases [24%]) were the most frequent histopathological results. Postoperatively, patients in 13 cases suffered from a transient supplementary motor area syndrome (34%), all of whom had tumors in the anterior cingulate gyrus. In the early postoperative period (30 days) a new deficit occurred in 5 cases (13%, mild motor deficits or aphasic symptoms). One patient had a major bleeding episode 2 days after surgery and was in a persistent vegetative state. Gliomas arising from the cingulate gyrus are rare. A gross-total resection is often possible and acceptably safe; intraoperative monitoring and neuronavigation are helpful adjuncts. In case of resection of gliomas arising from the anterior cingulate gyrus a supplementary motor area syndrome has to be considered, particularly when the tumor extends to the supracingular cortex.

Morbidity of Transcallosal and Transcortical Approaches to Lesions in and around the Lateral and Third Ventricles

Neurosurgery: August 2009 - Volume 65 - Issue 2 - p 426-427 doi: 10.1227/01.neu.0000358750.78152.da

Tuberous sclerosis combined with subependymal giant cell astrocytoma

Objective To describe the clinical features, diagnosis and treatment of subependymal giant ceil astrocytoma. Method Out of 17 TSC patients admitted to Tiantan Hospital from September 1996 to April 2006, 17 tumors out of 16 patients were removed surgically. 11 tumors were surgically resected through transcallosal approach, 6 through frontal transcortical approach. Follow-up ranged from 3 months to 123 months. Results 1 case died 2 years later without operation. Out of 17 pathologically confirmed SEGAs from 16 patients, 15 tumors were totally removed,2 tumors were subtotally removed. 1 case died 3 months after operation, excellent outcomes occurred in other 15 patients without long-term complications. It was necessary to insert a postoperative shunt in only 3 patients. There were no recurrences of 15 SEGAs that were totally removed after a mean follow-up of 41.2 months. Radiotherapy was proved ineffective. Conclusions Surgical removal is the only effective treatment of SEGA. Transcallosal approach and frontal transcortical approach are both effective. Key words: Tuberous sclerosis; Subependymal giant cell astrocytoma; Diagnosis; Surgery