Name:
10.3171/2023.1.FOCVID2296
Description:
10.3171/2023.1.FOCVID2296
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/84c25122-b921-48f7-964a-62d655002cc4/videoscrubberimages/Scrubber_277.jpg
Duration:
T00H06M46S
Embed URL:
https://stream.cadmore.media/player/84c25122-b921-48f7-964a-62d655002cc4
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/84c25122-b921-48f7-964a-62d655002cc4/9. 22-96.mp4?sv=2019-02-02&sr=c&sig=MZJx5PwRkNalkg%2FE%2BhO7LeXB5APU%2F51G%2FeDJVRfiSXs%3D&st=2025-11-03T16%3A43%3A54Z&se=2025-11-03T18%3A48%3A54Z&sp=r
Upload Date:
2023-02-28T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
[MUSIC PLAYING]
SPEAKER 1: We presented the case of a 68-year-old woman who suffered of a persistent headache resistant to medical therapy. She underwent an MRI, which showed the presence of an intraventricular lesion in the left trigone, with a main suspicion of a meningioma. According to the size of the tumor and the symptoms' onset, surgery was indicated to avoid an acute hydrocephalus, intracranial hypertension, or development of neurological deficits.
SPEAKER 1: The risks of this procedure include eventual damages at the optic radiation, language areas, motor deficits, and Gerstmann's syndrome for the subcortical parietal areas. Gamma Knife and radiosurgery are rarely indicated except for patients who can't undergo general anesthesia or they refuse surgery. To avoid damages at near-eloquent areas, we performed a full endoscopic inferior parietal lobule transcortical approach with a lateromedial/ superoinferior direction.
SPEAKER 2: Based on the preoperative tractography.
SPEAKER 1: The patient was placed in a lateral position with the head turned three-quarters on the right side, fixed with Mayfield head holder. The equipment was made by the surgical endoscope, microsurgical tubular instruments, ultrasound aspirator, and neuronavigator, which allowed us to study the surgical trajectory.
SPEAKER 2: Four-hands surgical technique was performed, consisting in two surgeons as first operators, of which, in this case, one holds the endoscope and spatula, the other one the surgical instruments, such as ultrasound aspirator, suction, bipolar, dissector, and microscissor. Both hands of the surgeons move in a coordinated way to guarantee a complete surgical vision by reducing the dynamic retraction.
SPEAKER 1: A minimally invasive linear skin incision was performed centered on the mini-craniotomy, followed by the corticectomy. A retractor-less transcortical approach was made with the only use of a spatula and dissector, to make gentle dynamic retraction of the interested parenchyma to avoid iatrogenic cerebral contusions. Considering the minimally invasive approach and the surgical site, it's important to first debulk the lesion to easily find then its pedicle.
SPEAKER 1: Therefore, a mild debulking was performed through ultrasound aspirator. Usually, these lesions are characterized by a dura-like layer on the surface, which we could appreciate with some adherences between the ependyma and the tumor, already identified through the preoperative MRI, which have been gently detached. At first, the pedicle of the lesion was then seen attached to the choroidal plexus in its cranial aspect facing the anterior part of the atrium toward the middle sella and more anteriorly to the frontal horn.
SPEAKER 1: The vascular pedicle of the tumor should be identified and coagulated at the earliest possible time to avoid excessive bleeding from the ependymal surface, which can be challenging to control. We used bipolar forceps to coagulate and then cut it with microscissors to initially mobilize the tumor. After having partially moved the lesion, we could find the choroidal plexus on the occipital side, going downward to the temporal horn with a lateral-posterior left choroidal artery.
SPEAKER 1: Thanks to the endoscope surgical view, we could also appreciate the column of fornix in white, which turned around the thalamus on the anteromedial aspect. After having detached the lesion from the ependyma and rolling it on the surgical site, avoiding any retraction, we could also appreciate the choroidal plexus still kept the lesion adherent to this area. This kind of surgical vision was only possible, thanks to the endoscope.
SPEAKER 1: We continued to the debulk the lesion to better expose its base of implant, which we finally cauterized, avoiding the rupture of the small cicatricial synechiae and choroidal vessels associated. Otherwise, there may be small bleeding, which, although minimal, could compromise the ventricular system. The choroidal plexus was completely cauterized and cut with microscissor.
SPEAKER 1: We moved finally on the parieto-occipital portion of choroidal plexus to completely detach the meningioma. And exploration excluded any other portion of attachment. The lesion was rolled in the surgical cavity to allow the surgeon to see if beyond the lesion any vessels were attached. Then we gently removed the tumor, appreciating the corticectomy was smaller than the lesion itself.
SPEAKER 1: Interventricular meningiomas are rare tumors mainly located in the trigone of the lateral ventricle. They usually origin from the meningothelial inclusion bodies in the tela choroidea or the mesenchymal stroma of the choroidal plexus, often surrounded by a dura-like layer, as seen in this case. Because of their size, they usually become symptomatic due to the block of the CSF and their proximity to the eloquent areas.
SPEAKER 1: Surgery is indicated when symptomatic, and in literature are described different approaches according to the tumor position in the trigone and to avoid the nearby white matter fiber tracts with a microscopic view. The endoscopic approach gives a wider viewing range compared with the microscope and may reduce damage to normal brain tissue, facilitating total resection of the lesion and improving the surgical outcome.
SPEAKER 1: Surgical trajectory is based on the trigone tumor's relationship with the near white matter fiber tracts involved in the vision, language, motor functions, and integration of information. A postoperative CT scan excluded any complications. The patient underwent a postoperative MRI within 48 hours from surgery, which confirmed the gross- total resection of the lesion. She was discharged in her 6th postoperative day without neurological deficits.
SPEAKER 1: She repeated the MRI during the follow-up 2 months after surgery. The patient was in perfect condition without headache. The final diagnosis was grade I meningioma according to the WHO classification.
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