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Interhemispheric transcallosal transchoroidal approach to a pineal teratoma in a 15-year-old boy
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Interhemispheric transcallosal transchoroidal approach to a pineal teratoma in a 15-year-old boy
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https://cadmoremediastorage.blob.core.windows.net/7358fae9-cfa5-4849-a447-1afc632b10a0/videoscrubberimages/Scrubber_150.jpg
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T00H10M28S
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https://cadmoreoriginalmedia.blob.core.windows.net/7358fae9-cfa5-4849-a447-1afc632b10a0/21-26.mp4?sv=2019-02-02&sr=c&sig=AqPDEXBj9JK1dVdWid8waTMTPSgRA9gN2tE5XUXHssM%3D&st=2024-12-08T22%3A17%3A31Z&se=2024-12-09T00%3A22%3A31Z&sp=r
Upload Date:
2021-10-27T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
[MUSIC PLAYING]
SPEAKER 1: In this video, we present an interhemispheric transcallosal transchoroidal approach to a pineal teratoma in a 15-year-old boy. The patient presented a two-week history of headache. He was referred from another hospital after emergency ETV was performed for acute triventricular hydrocephalus due to a pineal mass. Neurological exam was normal. Craniospinal MRI shows the resolution of the triventricular hydrocephalus and the presence of an ETV track.
SPEAKER 1: The mass was evident in the pineal region and posterior third ventricle, without CSF seeding. Blood and CSF, alpha-fetoprotein, beta-HCG, and placental alkaline phosphatase were within normal limits. Endoscopic biopsy was performed through a more anterior burr hole, passing below the mass center medial, revealing immature teratoma. On the base of histology, surgical removal was decided.
SPEAKER 1: To select the approach, sagittal midline MRI image was chosen. The mass was located very high in the posterior third ventricle, hidden behind the splenium and the vein of Galen. The lowest point of the vein of Galen was identified, then the highest point of the third torcular Herophili was identified. The line drawn in these two points, the Herophilus-Galen line identifies the highest possible line of sight of a microscope when performing an occipital interhemispheric transtentorial OITA approach.
SPEAKER 1: In this case, the OITA approach would allow excellent control of the lower half of the tumor, but the upper half would remain hidden behind the splenium and the vein of Galen. 3D model showing the Herophilus-Galen line helps to understand how deep and hidden is the tumor behind the Galen complex, without improvements of lesion moving with microscope. This lesion was highly located in the posterior third ventricle. so an interhemispheric transcallosal approach, followed by a complete dissection of the whole choroidal fissure, would allow complete exposure of the tumor mass, to the line of sight of the operating microscope.
SPEAKER 1: 3D model helps to understand that the transcallosal approach with choroidal fissure dissection from above, working between the two internal cerebral veins, would allow complete control of the tumor from the anterior to the posterior pole. The more positive trajectories used to cross the posterior column of the fornix, but dissection of the choroidal fissure and the section of the anterior septal vein allows a very lateral displacement of the right internal cerebral vein, creating a very large operative corridor that allowed us to work always laterally, to the posterior column of the fornix, minimizing the risks to injure it.
SPEAKER 1: Position is supine with mild flexion of the head. The standard transcallosal approach is performed through a flap that is one-third behind the coronal, two-thirds anterior to the coronal, crossing the midline, allowing perfect visualization of the tumor. Interhemispheric approach allows visualization of the two cingulate gyri and of the two callosal marginal arteries.
SPEAKER 1: The two cingulate gyri can be very adherent. And this requires a very slow and careful dissection in order to avoid any injury to them. But with smooth and careful dissection, it is possible to expose in the depth the corpus callosum, that should be dissected for a length of at least 3 centimeters. Here, we see the corpus callosum, the left callosum marginal arteries, and the two cingulate gyri.
SPEAKER 1: The self-retaining retractor is repositioned deeper in order to expose correctly the corpus callosum, that is separated with bipolar coagulation until opening of the ependyma of the right lateral ventricle, showing the choroid plexus in the depth. After completion of the 2-centimeter callosotomy, the choroid plexus is evident, with the right thalamus side vein, the fornix, and the right thalamus.
SPEAKER 1: Choroid fissure is hidden below the choroid plexus that needs to be coagulated from the foramen of the Monro to the posterior aspect of the thalamus, in order to unveil the choroidal fissure that is below, dissecting the connections between the two internal cerebral veins, the thalamus side vein, and the anterior septal vein. These veins must be dissected carefully, but in a very clear way, in order to coagulate the anterior septal vein.
SPEAKER 1: Here you see that you are dissecting the internal cerebral vein from the fornix, discovering the choroid fissure below. We need to dissect properly the internal cerebral vein, because we have to pass between the internal cerebral vein and the body of the fornix. And this passage must be dissected clearly. Here you can see the taenia fornices, the right internal cerebral vein, the anterior septal vein, and the right thalamus.
SPEAKER 1: And further dissection is necessary for complete identification. At this point, the junction between the right thalamus side vein, the anterior septal vein, and the internal cerebral vein is more clear. Complete dissection of the anterior septal vein is necessary before coagulation. The sacrifice of this vein allows complete opening of the choroid fissure.
SPEAKER 1: Here you see that we spend a lot of time to separate this vein from the ependyma in order to avoid thermal injury to the underlying fornix at the moment of coagulation. This is the moment of dissection of the anterior septal vein that finally allows the complete opening of the anterior part of the choroid fissure, that at this moment is still covered by choroid plexus. We coagulate slowly the choroid plexus at the level of the foramen of Monro in order to have a complete vision of the anterior part of the third ventricle.
SPEAKER 1: You can see the tumor below, and repositioning of the self-retaining retractor allows a nice view of the more anterior part of the tumor. At this point, the dissection continues by coagulating and separating the small vessels that run between the two internal cerebral veins at the level of the tela choroidea on the third ventricle. You can clearly see the very thin layer of the tela choroidea with very small vessels that must be coagulated and the relationship of the internal cerebral vein, the tela choroidea, and the tumor underlying the tela choroidea.
SPEAKER 1: This dissection is the most careful part of the whole surgical procedure. You can see very nicely the third layer of the tela choroidea that needs to be opened progressively, with very thin vessels that need to be coagulated and separated before having access to the capsule of the tumor. This process is continued throughout the length of the choroidal fissure. The white capsule of the tumor is very evident below the last remnants of the tela choroidea, and at this time, we coagulate, we open the capsule, and do a biopsy of the inner part of the tumor.
SPEAKER 1: Then we start the internal decompression, with the ultrasonic surgical aspirator. It is clear the relationship with the Massa intermedia. And at this point, we dissect the anterior pole of the tumor from below the Massa intermedia. The adhesions are relatively loose, and the tumor can be easily dissected from the lower aspect of the Massa intermedia, until identification of the more anterior part of the third ventricle.
SPEAKER 1: Then, dissection continues on the right side, until we reach the posterior pole of the tumor. Here, the posterior pole is dissected from below the more posterior part of the tela choroidea. This is the relationship with the right internal cerebral vein, and the last remnant of tea choroidea are opened with scissors in order to expose the posterior pole or the tumor. Then we go laterally on the left side, dissecting the left lateral aspect of the tumor.
SPEAKER 1: And then we go back on the right side, in order to finally find the cavity of the third ventricle. And because of the significant reduction of the mass due to the internal debulking, we are finally able, following dissection of the posterior and lateral edges of the tumor, to dissect the tumor from the lateral wall of the third ventricle and find the cavity of the third ventricle. Then we continue the dissection anteriorly.
SPEAKER 1: We find the floor of the third ventricle, and we dissect the tumor from the floor of the third ventricle, until obtaining a complete freedom of the residual tumor inside the cavity. That can be fully and completely removed en bloc with the forceps. This is the immediate post-operative MRI, showing the approach and the complete removal of the tumor.
SPEAKER 1: The histology showed immature teratoma, with areas of germinoma. Adjuvant treatment was chemotherapy plus radiotherapy, according with SIOP CNS GCT II Protocol. Clinical outcome was a normal neurological exam, with no evidence of disease 24 months after surgery, as shown by the followup MRI at two years. In conclusion, pineal tumors predominantly invading the posterior third ventricle can be difficult to approach through the supracerebellar or interhemispheric transtentorial way.
SPEAKER 1: The Herophilus-Galen line of sight is helpful in choosing surgical approach. The interhemispheric transcallosal transchoroidal approach offers complete visual control of the third ventricle, from anterior commissure to the quadrigeminal cistern and is electively indicated for tumors of the posterior third ventricle.
Segment:0 .
[MUSIC PLAYING]
SPEAKER 1: In this video, we present an interhemispheric transcallosal transchoroidal approach to a pineal teratoma in a 15-year-old boy. The patient presented a two-week history of headache. He was referred from another hospital after emergency ETV was performed for acute triventricular hydrocephalus due to a pineal mass. Neurological exam was normal. Craniospinal MRI shows the resolution of the triventricular hydrocephalus and the presence of an ETV track.
SPEAKER 1: The mass was evident in the pineal region and posterior third ventricle, without CSF seeding. Blood and CSF, alpha-fetoprotein, beta-HCG, and placental alkaline phosphatase were within normal limits. Endoscopic biopsy was performed through a more anterior burr hole, passing below the mass center medial, revealing immature teratoma. On the base of histology, surgical removal was decided.
SPEAKER 1: To select the approach, sagittal midline MRI image was chosen. The mass was located very high in the posterior third ventricle, hidden behind the splenium and the vein of Galen. The lowest point of the vein of Galen was identified, then the highest point of the third torcular Herophili was identified. The line drawn in these two points, the Herophilus-Galen line identifies the highest possible line of sight of a microscope when performing an occipital interhemispheric transtentorial OITA approach.
SPEAKER 1: In this case, the OITA approach would allow excellent control of the lower half of the tumor, but the upper half would remain hidden behind the splenium and the vein of Galen. 3D model showing the Herophilus-Galen line helps to understand how deep and hidden is the tumor behind the Galen complex, without improvements of lesion moving with microscope. This lesion was highly located in the posterior third ventricle. so an interhemispheric transcallosal approach, followed by a complete dissection of the whole choroidal fissure, would allow complete exposure of the tumor mass, to the line of sight of the operating microscope.
SPEAKER 1: 3D model helps to understand that the transcallosal approach with choroidal fissure dissection from above, working between the two internal cerebral veins, would allow complete control of the tumor from the anterior to the posterior pole. The more positive trajectories used to cross the posterior column of the fornix, but dissection of the choroidal fissure and the section of the anterior septal vein allows a very lateral displacement of the right internal cerebral vein, creating a very large operative corridor that allowed us to work always laterally, to the posterior column of the fornix, minimizing the risks to injure it.
SPEAKER 1: Position is supine with mild flexion of the head. The standard transcallosal approach is performed through a flap that is one-third behind the coronal, two-thirds anterior to the coronal, crossing the midline, allowing perfect visualization of the tumor. Interhemispheric approach allows visualization of the two cingulate gyri and of the two callosal marginal arteries.
SPEAKER 1: The two cingulate gyri can be very adherent. And this requires a very slow and careful dissection in order to avoid any injury to them. But with smooth and careful dissection, it is possible to expose in the depth the corpus callosum, that should be dissected for a length of at least 3 centimeters. Here, we see the corpus callosum, the left callosum marginal arteries, and the two cingulate gyri.
SPEAKER 1: The self-retaining retractor is repositioned deeper in order to expose correctly the corpus callosum, that is separated with bipolar coagulation until opening of the ependyma of the right lateral ventricle, showing the choroid plexus in the depth. After completion of the 2-centimeter callosotomy, the choroid plexus is evident, with the right thalamus side vein, the fornix, and the right thalamus.
SPEAKER 1: Choroid fissure is hidden below the choroid plexus that needs to be coagulated from the foramen of the Monro to the posterior aspect of the thalamus, in order to unveil the choroidal fissure that is below, dissecting the connections between the two internal cerebral veins, the thalamus side vein, and the anterior septal vein. These veins must be dissected carefully, but in a very clear way, in order to coagulate the anterior septal vein.
SPEAKER 1: Here you see that you are dissecting the internal cerebral vein from the fornix, discovering the choroid fissure below. We need to dissect properly the internal cerebral vein, because we have to pass between the internal cerebral vein and the body of the fornix. And this passage must be dissected clearly. Here you can see the taenia fornices, the right internal cerebral vein, the anterior septal vein, and the right thalamus.
SPEAKER 1: And further dissection is necessary for complete identification. At this point, the junction between the right thalamus side vein, the anterior septal vein, and the internal cerebral vein is more clear. Complete dissection of the anterior septal vein is necessary before coagulation. The sacrifice of this vein allows complete opening of the choroid fissure.
SPEAKER 1: Here you see that we spend a lot of time to separate this vein from the ependyma in order to avoid thermal injury to the underlying fornix at the moment of coagulation. This is the moment of dissection of the anterior septal vein that finally allows the complete opening of the anterior part of the choroid fissure, that at this moment is still covered by choroid plexus. We coagulate slowly the choroid plexus at the level of the foramen of Monro in order to have a complete vision of the anterior part of the third ventricle.
SPEAKER 1: You can see the tumor below, and repositioning of the self-retaining retractor allows a nice view of the more anterior part of the tumor. At this point, the dissection continues by coagulating and separating the small vessels that run between the two internal cerebral veins at the level of the tela choroidea on the third ventricle. You can clearly see the very thin layer of the tela choroidea with very small vessels that must be coagulated and the relationship of the internal cerebral vein, the tela choroidea, and the tumor underlying the tela choroidea.
SPEAKER 1: This dissection is the most careful part of the whole surgical procedure. You can see very nicely the third layer of the tela choroidea that needs to be opened progressively, with very thin vessels that need to be coagulated and separated before having access to the capsule of the tumor. This process is continued throughout the length of the choroidal fissure. The white capsule of the tumor is very evident below the last remnants of the tela choroidea, and at this time, we coagulate, we open the capsule, and do a biopsy of the inner part of the tumor.
SPEAKER 1: Then we start the internal decompression, with the ultrasonic surgical aspirator. It is clear the relationship with the Massa intermedia. And at this point, we dissect the anterior pole of the tumor from below the Massa intermedia. The adhesions are relatively loose, and the tumor can be easily dissected from the lower aspect of the Massa intermedia, until identification of the more anterior part of the third ventricle.
SPEAKER 1: Then, dissection continues on the right side, until we reach the posterior pole of the tumor. Here, the posterior pole is dissected from below the more posterior part of the tela choroidea. This is the relationship with the right internal cerebral vein, and the last remnant of tea choroidea are opened with scissors in order to expose the posterior pole or the tumor. Then we go laterally on the left side, dissecting the left lateral aspect of the tumor.
SPEAKER 1: And then we go back on the right side, in order to finally find the cavity of the third ventricle. And because of the significant reduction of the mass due to the internal debulking, we are finally able, following dissection of the posterior and lateral edges of the tumor, to dissect the tumor from the lateral wall of the third ventricle and find the cavity of the third ventricle. Then we continue the dissection anteriorly.
SPEAKER 1: We find the floor of the third ventricle, and we dissect the tumor from the floor of the third ventricle, until obtaining a complete freedom of the residual tumor inside the cavity. That can be fully and completely removed en bloc with the forceps. This is the immediate post-operative MRI, showing the approach and the complete removal of the tumor.
SPEAKER 1: The histology showed immature teratoma, with areas of germinoma. Adjuvant treatment was chemotherapy plus radiotherapy, according with SIOP CNS GCT II Protocol. Clinical outcome was a normal neurological exam, with no evidence of disease 24 months after surgery, as shown by the followup MRI at two years. In conclusion, pineal tumors predominantly invading the posterior third ventricle can be difficult to approach through the supracerebellar or interhemispheric transtentorial way.
SPEAKER 1: The Herophilus-Galen line of sight is helpful in choosing surgical approach. The interhemispheric transcallosal transchoroidal approach offers complete visual control of the third ventricle, from anterior commissure to the quadrigeminal cistern and is electively indicated for tumors of the posterior third ventricle.
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