Name:
10.3171/2023.1.FOCVID22129
Description:
10.3171/2023.1.FOCVID22129
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/6c10ec4f-f2b6-4750-8778-caafd1a37215/videoscrubberimages/Scrubber_95.jpg
Duration:
T00H05M45S
Embed URL:
https://stream.cadmore.media/player/6c10ec4f-f2b6-4750-8778-caafd1a37215
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/6c10ec4f-f2b6-4750-8778-caafd1a37215/2. 22-129.mp4?sv=2019-02-02&sr=c&sig=%2FebeRztevPDAV%2B6wAZJfgKo%2FScA4xJ2gwQvobZW%2FJwM%3D&st=2025-05-11T10%3A25%3A26Z&se=2025-05-11T12%3A30%3A26Z&sp=r
Upload Date:
2023-02-20T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
SPEAKER 1: This is a surgical video demonstrating endoscopic fenestration of an enlarging right occipital arachnoid cyst in a lady in her 40s with worsening headaches, as well as visual field loss and optic disc swelling. The cyst measured approximately 8 cm with progressive enlargement over the years between 2010 and 2021 where it started causing significant mass effect and displacement of the ventricular system, as well as of the occipital and temporal lobes.
SPEAKER 1: Given her worsening symptoms, the cyst, which is now being seen in different views, including the axial, coronal, and sagittal views, was considered for surgical intervention. And the options considered were placement of a cystoperitoneal shunt, craniotomy for release of the cyst contents, as well as endoscopic fenestration. The shunt was not the first choice, given the need to leave permanent hardware.
SPEAKER 1: The surgical plan included having the patient prone, the use of stereotactic navigation, and using an endoscope on a preplanned trajectory, as shown below, to navigate down to the ventricle and to fenestrate the cyst. Here, the endoscope is being introduced through the burr hole. And we're using electrocautery to find the spot based on navigation where the cyst contents come closest to the ventricular system.
SPEAKER 1: After using electrocautery to create an entry point, alligator forceps are used to enlarge the opening of the cyst to create the maximal opening and connection between the cyst as well as the ventricular system. This is a technique that is used sequentially to provide the biggest window of access. And after the first entry point, we use electrocautery, joining the area to further increase the size of this fenestration site, which is being seen over here.
SPEAKER 1: After electrocautery, we will follow that up with an alligator forceps clamp to further enlarge the created opening. And irrigation is constantly used, which provides a visual and tactile feel of the success of the fenestration, depending on the billowing and movement of the cyst wall contents, which often indicates flow of fluid and creation of a connection.
SPEAKER 1: Microscissors are here being used to take down additional tissue between the two areas of electrocautery and the site of fenestration to maximize the creation of a bigger opening and chances of success. And again, this is the irrigation that is demonstrating the movement of the cyst walls from the flow of fluid from the cyst into the ventricular system.
SPEAKER 1: It is hard to understand the anatomy when inside a giant occipital arachnoid cyst, given the lack of anatomic landmarks. And using navigation is helpful in understanding these locations. These thin cyst walls are further being divided with the use of microscissors to continue enlarging the site of opening at the fenestration. This further highlights the need for high-resolution endoscopy and accurate targeting in completion of some of this endoscopic microsurgical work that allows us to create these passages of fenestration for these lesions.
SPEAKER 1: Hemostasis is achieved with constant irrigation to stop any bleeding and to promote formation of blood clot. And a ventricular drain is placed under vision through the area of fenestration, which helps in the clearance of blood products, for keeping the fenestration opening in the first 24 hours, and also for monitoring of postoperative intracranial pressures at the site of the fenestration.
SPEAKER 1: And placement of this ventricular drain under vision allows for safe, accurate placement of these monitoring devices. This is the imaging preoperatively and postoperatively, approximately 3 months apart, that demonstrates decrease in the size of the cyst and reconstitution of normal ventricular anatomy. The patient was discharged the next postoperative day, had improvement of headaches. And the visual improvement continued at 2 years' follow-up with improvement in the optic disc edema, as well as the visual fields seen by the ophthalmologist.
SPEAKER 1: The occipital arachnoid cysts are rare lesions. But they can be symptomatic especially with massive enlargement, as in this case. The treatment can be very targeted and precise using stereotactic navigation and high-resolution endoscopy, which allows us to make a large enough opening for accurate rerouting of cyst fluid into the ventricular system. And use of an external ventricular drain is useful for the reasons mentioned before.
SPEAKER 1: These are the references. Thank you.
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