Name:
10.3171/2025.1.FOCVID24196
Description:
10.3171/2025.1.FOCVID24196
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/f5f5f7af-e163-481a-bae5-a0bea6661558/videoscrubberimages/Scrubber_459.jpg
Duration:
T00H09M30S
Embed URL:
https://stream.cadmore.media/player/f5f5f7af-e163-481a-bae5-a0bea6661558
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/f5f5f7af-e163-481a-bae5-a0bea6661558/12. 24-196.mp4?sv=2019-02-02&sr=c&sig=0qaWXAwc6J%2F%2FiImzmTP3qGNGbygFw18L1igieZMQl6Q%3D&st=2026-02-02T15%3A51%3A09Z&se=2026-02-02T17%3A56%3A09Z&sp=r
Upload Date:
2025-02-18T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
[MUSIC PLAYING]
SPEAKER: This video will represent an endoscopic transorbital approach with ECOG for resection of an anterior temporal lobe mass. This is a 32-year-old female with past medical history of partial complex seizures since the age of 18, who was referred to neurosurgery clinic for change in semiology, with increase in frequency and duration of her seizures. Her neurological exam was remarkable for slight right proptosis. Prior imaging shows a 2004 CT scan of a right middle fossa hypodensity that on repeat imaging, in 2011 and 2014, was stable. MRI was not available from that time point.
SPEAKER: New MRI was obtained, which shows an enhancing mass in the right anterior temporal pole, with no surrounding vasogenic edema. Patient's case was discussed in a multidisciplinary rounds, was offered medical management versus surgical intervention. We offered a pterional craniotomy versus a transorbital approach. That would allow for more direct pathway to the pathology, less brain manipulation, and obtaining ECOG for intraoperative recording. Our set up for a transorbital approach requires two IVs, arterial line, Foley, neuromonitoring for ECOG, antiepileptics as determined by neurology, neuronavigation, and Mayfield pins in a neutral position. We don't routinely use lumbar drain or fat graft.
SPEAKER: Lateral upper eyelid crease was marked. Silastic corneal shield with lubricant placed. Skin and periosteum was infiltrated with 1% lidocaine with 1/100,000 epinephrine; 15 blade was used to cut through skin and the orbicularis muscle, and then preseptal dissection is used. We then followed by monopolar to then get to the subperiosteal dissection. After the lateral orbital rim has been isolated as fishhooks are applied, we like to instrument the bone prior to the orbitotomy. A sagittal or oscillating saw is used with protection of the globe and temporalis muscle.
SPEAKER: An osteotome can be used to facilitate a cosmetic fracture, with a rongeur ultimately used to fracture the bone. Further drilling is performed with a high-speed drill with copious irrigation until the dura is appreciated. We like to use dynamic retraction at times when we can avoid retraction of the globe. Kerrison punches can be used to help complete the exposure, and the dura is appreciated in the depth here, with the greater sphenoid wing underneath the sucker.
SPEAKER: Hemostasis is achieved prior to opening of the dura. Neuronavigation is used to confirm localization of the dural opening. A C-shaped incision was marked out with a bipolar. And 11 blade was used to perform the dural opening with microscissors.
SPEAKER: As the dura is opened, you can appreciate the normal brain with a vessel in the sulcus that separates the tumor from the surrounding brain. A four-contact platinum strip is then placed in different directions for ECOG testing prior to tumor removal. These results were unremarkable. For surgical approach, resection, and closure, an endoscope is usually used.
SPEAKER: However, for illustrative purposes, the microscope is used for publication purposes. Using standard microsurgical techniques, the tumor is coagulated and we define the plane between the tumor and the sulcus. Microscissors are used for sharp dissection, frozen sent off, confirming a glial tumor.
SPEAKER: The goal in surgical approach was to isolate the tumor and circumscribe it to define anatomical landmarks. The medial superior plane was identified and the arachnoid was coagulated and cut and patty was placed. Further debulking of the tumor to aid in manipulation and identifying of anatomical landmarks.
SPEAKER: Oculoplastics routinely removed any malleable retractors and visualized the pupil to ensure no prolonged retraction. The tumor is very soft and had a purplish appearance. It was not vascular and was easy to define a plane between the brain and the tumor. Here, we can see us manipulating it away and further debulking.
SPEAKER: The tumor then was manipulated and lateralized. So we can see the medial white matter that is showing that we are around the tumor.
SPEAKER: White matter can be appreciated now in the depth as the tumor is now being manipulated with a ring curette. Once the tumor is completely free, the last amount of tumor is then removed.
SPEAKER: Further inspection is performed to ensure no residual. Copious irrigation is used and hemostasis achieved. Postoperative ECOG is then performed in different directions and in the cavity to ensure no further epileptic activity. In the future, we could consider placing the strip far around the anterior temporal tip and also consider attempting to reach the hippocampus.
SPEAKER: Reconstruction and closures performed and 4-0 Nurolon is used to approximate the dura. Gelfoam and Surgicel is placed over the dural opening, followed by fibrin glue and a collagen matrix dural substitute. We only use fat as an overlay when there is a large dural defect, like in meningioma resections. But it is not unreasonable to place for a multilayer closure. Further fibrin glue is placed.
SPEAKER: The lateral orbital rim was placed back with 4-mm screws. The periosteum and temporalis muscle was reapproximated with interrupted 3-0 Vicryl. 6-0 Prolene was then use in a running fashion to close the skin. Prolene sutures are removed in oculoplastics clinic postop day 5.
SPEAKER: CT scan 3D reconstruction shows lateral orbital plating and greater sphenoid wing drilling. Top three panels show preop CT with the bottom three postop. Postop MRI in the bottom three panels shows gross-total resection. Final pathology shows a pilocytic astrocytoma, WHO grade 1. Postop day 10 clinic visit shows normal extraocular movements.
SPEAKER: Six month follow-up shows no seizures, no change in antiepileptics, no recurrence on MRI, and improvement in proptosis.
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