Name:
10.3171/2023.10.FOCVID23161
Description:
10.3171/2023.10.FOCVID23161
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/4a4e8bca-153a-44cf-b264-9f1bf5d708ac/videoscrubberimages/Scrubber_397.jpg
Duration:
T00H10M24S
Embed URL:
https://stream.cadmore.media/player/4a4e8bca-153a-44cf-b264-9f1bf5d708ac
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/4a4e8bca-153a-44cf-b264-9f1bf5d708ac/16. 23-161.mp4?sv=2019-02-02&sr=c&sig=H2d8%2FF8hROvcgECqePdm8v89rboUMRxcfwDXxiaczdM%3D&st=2025-10-19T10%3A46%3A31Z&se=2025-10-19T12%3A51%3A31Z&sp=r
Upload Date:
2023-12-05T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
[THEME MUSIC]
SPEAKER: This video highlights the benefits of the use of exoscope visualization in difficult patient positioning, in particular, pineal region pathology. Benefits of exoscope visualization include surgeon ergonomics. Surgeon ergonomics are improved once the visualization device is no longer attached to the surgeon. Increased magnification: exoscope devices not only have the ability for optical zoom, but also digital zoom.
SPEAKER: Due to the independence of the visualization device from the surgeon, a wide range of approach angles are possible while maintaining surgeon ergonomics. In this example, we demonstrate the ability to visualize and perform adequate microdissection work without changing patient positioning and maintaining the ergonomics of the surgeon. This is a 66-year-old male who presents with 3 days of altered mental status confusion.
SPEAKER: On examination, he was intact besides confusion and bilateral upgaze palsy. CT of the head, without contrast, reveals a hyperdense lesion in the pineal region, concerning for a hemorrhagic pineal mass. MRI of the brain, with and without contrast, demonstrated similar findings.
SPEAKER: The patient underwent placement of external ventricular drain for hydrocephalus on arrival. The patient's confusion improved, but the upgaze palsy persisted until after surgery. Cerebrospinal fluid was sent for diagnosis of the pathology, but was unremarkable. Given the CSF findings and the lack of a diagnosis, operative intervention was offered. Risks of the procedure were discussed with the patient and family.
SPEAKER: Risks include, but are not exclusive to, stroke, hemorrhage, infection, coma, and death. Benefits include the ability to obtain tissue diagnosis, resection of the mass, and potentially, treatment of hydrocephalus from decompression of the cerebral aqueduct. Multiple surgical options were discussed. Endoscopic biopsy and third ventriculostomy were deferred, given the low diagnostic yield of biopsy in the setting of intralesional hemorrhage.
SPEAKER: Third ventriculostomy was also deferred, given the anatomy of a high-riding posterior cerebral artery and basilar artery. An infratentorial supracerebellar approach was also considered, but deferred given the angle of the tentorium. The patient was positioned in a three-point fixation device in a three-quarter prone or park-bench position, with the right side facing down.
SPEAKER: An occipital craniotomy with exposure to the superior sagittal sinus was performed. A transtentorial approach was utilized for resection of the pineal mass. Here is a bird's-eye view of the operative setup. Each 3D TV can be placed at the surgeon and surgeon assist's discretion. The camera arm lies over the shoulder or over the head of the surgeon.
SPEAKER: The operator can adjust around the camera accordingly as well as the 3D TVs' position be placed in the line of sight of the surgeon. When comparing the traditional microscope and exoscope, surgeon ergonomics are improved as the visualization device is no longer attached to the surgeon. Due to the independence of the visualization device from the surgeon, a wide range of visualization angles are possible, while maintaining the ergonomics of the surgeon.
SPEAKER: As demonstrated here, the independence of the camera from the surgeon allows the surgeon to remain in relatively the same position, while allowing the camera to move according to the pathology at hand. Also, the 3D TVs can be placed in accordance to the surgeon's preference, independent of the camera. Several factors were taken into account in choice of approach and positioning.
SPEAKER: These include the angle of the tentorium, location of deep venous drainage in relation to the lesion, neck thickness, and neck mobility. The venous drainage in this case was typical for pineal gland–based pathology. Hence, a supracerebellar approach was ideal for improved avoidance of injury to deep venous structures. The angle of the tentorium on this patient is relatively steep.
SPEAKER: Considerations of a Concorde position and seated position were considered. Although possible, a Concorde position or seated position may improve the angle of approach, but would not eliminate the steep angle of approach in this patient. Of note, we have used exoscopes in the past with these approaches and continue to find them beneficial over traditional microscopes.
SPEAKER: The transtentorial approach improves the steep angle of exposure, but allows the benefits of a supracerebellar approach when considering the avoidance of injury to the deep venous structures. A seated or Concorde approach with the transtentorial approach, as noted here, becomes unnecessary or even becomes more challenging when compared to a park-bench approach, as the approach with the seated or Concorde positioning approaches from an inferior to superior direction.
SPEAKER: Whereas in this case, the approach is more vertically oriented. Neck thickness and mobility is also taken into consideration. Excessive neck flexion of patients with shorter, thicker necks and necks with fusions or decreased mobility from autofusion is not without risk of airway compromise, vascular compromise, and increased venous congestion. Although the transtentorial approach can be somewhat disorienting, orientation is achieved with the identification of the transverse sinus, straight sinus, and tentorial edge.
SPEAKER: Neuronavigation is helpful in these circumstances, utilizing MRI and CT venogram. Once the sagittal sinus is identified for the inter- hemispheric approach, identifying the transverse sinus, straight sinus, and tentorial edge orients the surgeon to the proper dural opening, which in this case is taken lateral to the straight sinus, from a posterior to anterior approach, to assist in identifying the deep drainage systems.
SPEAKER: Patient is placed in a three-quarter prone position and registered. Patient and surgeon ergonomics are noted. An inter-hemispheric approach is utilized via drainage of CSF from the cisterns and external ventricular drain. Identification of the straight sinus, transverse sinus, falx, and tentorium was performed.
SPEAKER: The tentorium was cauterized in a safe location and opened up toward the incisura. The tentorial leaflet is tacked up. Arachnoid is opened over the supracerebellar cistern.
SPEAKER: Arachnoid planes were maintained, identifying the pineal mass. An opening, one is made in the mass, and the mass was debulked. The ventricular portion of the tumor was identified.
SPEAKER: The mass was then dissected over the tectal plate. Further mobilization of the tumor was then performed, carefully identifying any venous structures through the dissection.
SPEAKER: The mass was then amputated and the final remnants removed. Visualization of the foramen Monro from the third ventricle were made. And also, visualization of the aqueduct was performed.
SPEAKER: Both of these areas were free of clot and debris. Patient was extubated after surgery, with improved confusion and resolved upgaze palsy. At 1-month follow- up, the patient was intact with expected wound healing. Postoperative MRI demonstrates gross-total resection. Postoperative CT venogram demonstrates patent venous sinuses as well as deep venous drainage system.
SPEAKER: Final pathology revealed the hemorrhagic pineal cyst.
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