Name:
10.3171/2022.1.FOCVID21209
Description:
10.3171/2022.1.FOCVID21209
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/8fa48e42-1a9f-4b33-8dbd-8bd1ad512f1e/videoscrubberimages/Scrubber_315.jpg
Duration:
T00H06M45S
Embed URL:
https://stream.cadmore.media/player/8fa48e42-1a9f-4b33-8dbd-8bd1ad512f1e
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/8fa48e42-1a9f-4b33-8dbd-8bd1ad512f1e/21-209.mov?sv=2019-02-02&sr=c&sig=BdCnlMMjUQhhaAPMH1wESfUJgAxhqKxYYyk3osniUtE%3D&st=2025-05-13T13%3A33%3A08Z&se=2025-05-13T15%3A38%3A08Z&sp=r
Upload Date:
2022-02-10T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
[MUSIC PLAYING]
SPEAKER: This video demonstrates an endoscopic endonasal transclival approach for resection of a petroclival meningioma. Patient was a 45-year-old lady who presented with one episode of whole-body numbness that fully recovered. And an MRI was performed to rule out a stroke that identified the presence of a dorsum clival petroclival meningioma. The initial recommendation was observation, and the patient came back 6 months later with an MRI demonstrating increase on the size of the tumor.
SPEAKER: The initial presentation had a small meningioma not causing major mass effect and 6 months later showed further distortion of the ventral aspect of the pons, and an increase of 5 mm in a lateral perspective of the tumor and 3 mm in the anterior-posterior dimension. In the sagittal MRI, one could see that the tumor was protruding above the level of the dorsum sellae, invading the inferior aspect of the interpeduncular fossa immediately below the level of the left third cranial nerve.
SPEAKER: The tumor was also immediately above the position of the left sixth cranial nerve. Due to this specific peculiar position, we indicated an endoscopic endonasal transclival transdorsal approach to resect this tumor that was specifically located below the left third cranial nerve and above the left sixth cranial nerve. Alternative approaches would be a retrosigmoid and the transpetrosal approaches.
SPEAKER: And all of them will require more manipulation of the neurovascular structures. An endoscopic endonasal approach was performed and a nasoseptal flap was elevated on the right side of the nose. The anterior wall of the sphenoid was drilled, and then all the septations of the sphenoid were drilled as well as the face of the sella. We then started drilling the clival bone immediately medial to the left internal carotid artery.
SPEAKER: The dura of the sella and the face of the cavernous sinus was exposed. And the dura was cut in the periosteal layer to allow for a interdural dissection and transposition of the pituitary gland. That maneuver allowed us to expose the posterior clinoid in the left side and a branch of the posterior meningohypophyseal trunk was dissected. And this very small vessel was attached to the posterior clinoid.
SPEAKER: Most likely, it was the dorsal meningeal that would dissect it away from the posterior clinoid, allowing for a resection of the medial aspect of the carotid canal on the left side and full exposure of the dura located posteriorly. Once the bony structures were removed, we opened the dura very inferiorly, and we inspected the prepontine cistern identifying the sixth cranial nerve immediately inferior to the tumor on the left side, as well as branches of the basilar artery and the basilar artery itself.
SPEAKER: We removed the dura progressively superiorly, and we used bipolar to coagulate the basilar plexus. And we were able then to go around the medial aspect of the tumor, following the basilar artery safely from inferior to superior. As we dissected laterally, we perform all the maneuvers with direct visualization of the left sixth cranial nerve inferiorly. And superiorly, we identify the position of the arachnoid and also the location of the left third cranial nerve.
SPEAKER: With the visualization of both those cranial nerves and the full understanding that the insertion of the tumor was located between the third and the sixth cranial nerve, we used a 90-degree curette to remove the insertion of the tumor that was immediately lateral and located immediately posterior to the left carotid artery. With this insertion, we were able to mobilize the tumor safely and protecting the left sixth cranial nerve and the left third cranial nerve.
SPEAKER: It was a complete resection of the tumor. And further visualization and inspection with a 45-degree endoscope proved to be a complete resection of the tumor with no residual on the lateral aspect. The reconstruction was performed with a collagen matrix, followed by what we call the soft gasket sealed with Gelfoam inside, fat graft, and utilization of the nasoseptal flap for full reconstruction of the skull base.
SPEAKER: The postoperative imaging shows the presence of the fat graft in the clival recess as well as the nasoseptal flap covering the entire skull base defect and complete resection of the tumor without any complications. After surgery, patient did very well and was discharged on the third day after surgery without any signs of leakage. Six days after surgery, patient came back with signs of hyponatremia that was treated, and patient was discharged doing very well with no neurological deficits, no CSF leakage, and no complications.
SPEAKER: As a note, we believe that the hyponatremia the patient presented on the postoperative period could have been related to the hemitransposition with intradural maneuver on the left side or from direct manipulation of the pituitary gland due to the lifting maneuvers to reach the posterior fossa. Patient was recently seen 6 months after surgery with a postoperative MRI confirming a total resection of the tumor, no residual, and no recurrence.
SPEAKER: And the patient is doing very well.
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