Name:
10.3171/2023.1.FOCVID22143
Description:
10.3171/2023.1.FOCVID22143
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/71144f42-c7f8-419d-80d5-9bb18c71df87/videoscrubberimages/Scrubber_58.jpg?sv=2019-02-02&sr=c&sig=2XuDLc6ZVA8w10dcpbKEFKvLPnZdZLcjqvjdLrj6zI0%3D&st=2025-05-10T23%3A02%3A35Z&se=2025-05-11T03%3A07%3A35Z&sp=r
Duration:
T00H08M11S
Embed URL:
https://stream.cadmore.media/player/71144f42-c7f8-419d-80d5-9bb18c71df87
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/71144f42-c7f8-419d-80d5-9bb18c71df87/6. 22-143.mp4?sv=2019-02-02&sr=c&sig=53F1rE6GgZNQE3sjFGsvIIxiisiq3IqS5q5xJ3FdbpA%3D&st=2025-05-10T23%3A02%3A35Z&se=2025-05-11T01%3A07%3A35Z&sp=r
Upload Date:
2023-02-27T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
[MUSIC PLAYING]
SPEAKER: In this video, we will present the endoscopic ultrasonic resection of calcified tumor of the third ventricle. Twelve-year-old boy, 1-week history of headache and drowsiness, and bilateral papilledema edema. Radiology showed a tumor inside the third ventricle blocking both foramina of Monro with hydrocephalus. Tumor was bulging into the right foramen of Monro and occupying completely the third ventricle, with the calcified core well visible at CT scan.
SPEAKER: This is the material that was used for the surgery. This is the trajectory that was chosen through the right the frontal horn where the tumor was bulging through the left foramen of Monro. And this is the final trajectory of the target. Right coronal skin incision was performed. Planned to be included in a bicoronal incision. This is the endoscopic vision, tumor is well visible, bulging inside the foramen of Monro.
SPEAKER: The foramen of Monro is enlarged by the tumor. And this is the introduction of the ultrasonic aspirator cannula that is approached to the tumor, and we started to test the texture of the tumor to see if it is feasible an extended resection with the endoscopic ultrasonic aspirator. You see that the tumor is not bleeding very much. Here, you can see the accidental aspiration of the choroid plexus that is better to coagulate before performing any kind of surgery at the level of the foramina of Monro, but you see that the bleeding is very, very limited.
SPEAKER: And this part of the tumor that is bulging inside the lateral ventricle is certainly not very hemorrhagic and very easy to remove in this way. The cavitron is used with a power that is not exceeding 50% or 60% of the sonication power, and the aspiration is usually left between the 20% and 30%. We don't want excessive aspiration of fluid in order to avoid sudden decrease in intraventricular pressure.
SPEAKER: And you can see that with the-- keeping the cannula just on the surface of the tumor without entering inside the tumor with the cannula, we can remain very safe also on the boundaries. The tumor is attracted inside the cannula and is occupying the aspirating surface of the cannula, so only the tumor is aspirated inside the cannula and is fragmented by the sonication inside the cannula lumen.
SPEAKER: And we don't take any risk. Here we are approaching the pillar of the fornix. The bleeding starts to become a little bit more important, but the large ventricular chamber helps us to keep the vision extremely acceptable throughout the procedure. And here we are removing the adhesion of the tumor at the level of the pillar of the fornix and very close to the choroid plexus and very close to the anterior septal vein.
SPEAKER: Here we are approaching the central calcified core. Central calcified core, we knew from the previous CT scan data, would have been the most difficult part because of the texture and because it is inside the lumen of the third ventricle. You can see very nicely the calcification. And we have to work much closer to the tumor in this area because of the more important bleeding that we can observe inside the calcified core.
SPEAKER: But working very, very close to the tumor, we can create a microchamber of continuous irrigation that keeps clean the fluid inside the microchamber of work ahead of the endoscope. And we can keep under very, very tight visual control the tip of our ultrasonic aspiration that you see is only remaining on the surface of the tumor. And just removing and the debulking progressively, the tumor very slowly-- and the calcified areas of the tumor are well visible.
SPEAKER: Fortunately, they are scattered throughout the tumor, so it is possible to create small fragments of tumor that can be aspirated separately. And although it is certainly more long than complicated than the friable part that was inside the ventricular lumen, here we can create, anyway, a very significant debulking of the central part of the tumor.
SPEAKER: And then we arrive to the deepest part of the tumor where the calcified core is finished. We find, again, another texture of tumor inside the lower part of the third ventricle. The color of the tumor and the consistency of the tumor is well recognizable if compared to the normal ependyma. At the end of the surgery, we remove some larger piece of tumor together with some clots that are visible inside the tumor.
SPEAKER: And now, we are approaching the boundaries of the tumor, both the boundaries that are below the pillar of the fornix. Some remnant of the calcified part that is still remaining and floating inside the third ventricle. Significant irrigation is necessary in order to have a good vision and avoid deepening the cannula inside healthy normal tissue, of course.
SPEAKER: And here you can see that some part is still attached to the anterior pillar of the fornix. We can do still some job, but the pillar of the fornix is visible and looks quite healthy. So we can just clean the boundaries of the pillar of the fornix, very nicely respecting the ependyma and respecting, certainly, the anterior pillar of the fornix that should not be injured by our ultrasonic aspirator.
SPEAKER: Here you can see the normal ependyma of the floor of the third ventricle. The tumor, fortunately, is easy to recognize and to detach from the normal ependyma. And here you can see the tumor cinereum below the tumor. And after some irrigation, we can see the floor of the third ventricle. We perform an endoscopic third ventriculostomy systematically to facilitate CSF circulation at the level of the third ventricle.
SPEAKER: Surgical operative time is 115 minutes. So these are the details. And this is the postoperative MRI showing a subtotal removal with just some very small remnants adherent below the tela choroidea. And even the calcified core of the tumor has been completely removed. Here you can see that the third ventricle is completely free of tumor, and this is the MRI also showing a very nice removal.
SPEAKER: In conclusion, endoscopic ultrasonic aspirator is a useful tool to resect tumor in the ventricular system. Presence of calcification within the tumor does not contraindicate endoscopic approach.
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