Name:
10.3171/2025.1.FOCVID24183
Description:
10.3171/2025.1.FOCVID24183
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/42428cdb-29f0-4b0f-8608-acb9670d0a1d/videoscrubberimages/Scrubber_348.jpg
Duration:
T00H07M16S
Embed URL:
https://stream.cadmore.media/v10.3171/2025.1.FOCVID24183
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/42428cdb-29f0-4b0f-8608-acb9670d0a1d/15. 24-183.mp4?sv=2019-02-02&sr=c&sig=kLehXZMRe%2FJ582CX18bz%2FA5YoB7fVI3xYCfxdJxWu%2BE%3D&st=2026-04-05T03%3A48%3A32Z&se=2026-04-05T05%3A53%3A32Z&sp=r
Upload Date:
2025-02-18T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
[MUSIC PLAYING]
SPEAKER: Endoscopic transorbital removal of a temporomesial cavernous hemangioma. This is a case of a 47-year-old woman with no relevant past medical history. Symptoms started in March 2023 with episodes of confusion, altered spatial and temporal awareness, and dizziness. Anti-epileptic drugs were started and further imaging investigation were performed. As you can see in these images, there is a left medial temporal lesion that showed signs of recent bleeding, possibly a cavernous angioma.
SPEAKER: Since the lesion was right behind the orbit, we decided to make a lateral endoscopic transorbital approach. The endoscopic transorbital approach has many benefits. First, it allows to reach deep-seated lesions without manipulating the temporal lobe, its eloquent areas, and Sylvian vessels. It also avoids corticectomy, which is often needed in microsurgical transcranial techniques and avoids large scalp and temporary muscle incision. Furthermore, compared to anterior microsurgical techniques such as lateral canthotomy, it allows to have a better view without bone removal and reconstruction. Finally, this technique has great cosmetic outcomes and less pain for the patient.
SPEAKER: The main risks are due to the limited space that makes it difficult for a surgeon to control bleeding or unexpected events during surgery. Also, there is a long learning curve for this technique, which can be a disadvantage in the first surgeries. The middle cranial fossa and the temporal lobe have been traditionally reached through open microsurgical transcranial approaches, and these techniques are valid and used nowadays for the majority of pathologies of these regions.
SPEAKER: Temporomesial hemangiomas can clearly be reached with these techniques or the anterior lateral canthotomy as an alternative. In this case, being right behind the sphenoid wing, the lesion can be resected through an endoscopic transorbital approach, and as anticipated before, this technique can limit potential damage to the brain parenchyma or to the Sylvian vessels.
SPEAKER: Furthermore, cosmetic outcomes are better with the endoscopic approach. First of all, the patient is in a supine position with the head pinned in a neutral fashion. The registration of the neuronavigation is then performed and the eyelid and orbit are prepped and draped. The following steps are later described in the video: the skin incision, the periorbital dissection, the meningo-orbital band coagulation and incision, the neuronavigation check, the sphenoid wing drill, the dura opening, the lesion resection, hemostasis, the dura closure, and the subcutaneous and skin closure.
SPEAKER: The incision is right below the eyebrow, aiming directly at the orbital rim, where the orbital blend with the frontalis muscle. Once the bone is reached, we proceed with blunt dissection of the periorbita in a craniocaudal and lateromedial fashion. As we can see, early coagulation of a lateral periorbital feeder is necessary, and we can continue with the dissection until we reach an important landmark, which is the meningo-orbital band, that we must coagulate and cut. This allows us to obtain a better manipulation of the orbit and a larger workspace. Once we have reached the posterolateral aspect of the orbit with ease, we introduce the drill and we can make an opening through the greater sphenoid wing reaching the middle cranial fossa. We can also use Kerrison rongeur to avoid damaging surrounding structures.
SPEAKER: And then we refine the opening with the drill once again. After we make sure of the position with the neuronavigation, we open the dura. We introduce cottonoids to be more delicate on the cerebral parenchyma, and we identify where the angioma breaks through the surface. At this point, we use dynamic retraction, using the aspirator. Using the aspirator, grasping forceps, and even a curette, we remove the angioma and the hemosiderin around it.
SPEAKER: Here you can see the total removal of the hemosiderin with the curette and then with grasping forceps. After we make sure that we have removed the whole lesion, we do a hemostasis with a hemostatic agent. We then introduce synthetic dura.
SPEAKER: We do a bilayered reconstruction below and above the approximated flaps of the dura. Finally, we only suture the subcutaneous layer of the incision while the skin is approximated and fixed with synthetic glue in order to obtain a better cosmetic outcome.
SPEAKER: After surgery, there wasn't any new deficit. Only little eyelid edema that regressed spontaneously. After neurological follow up, we were able to discontinue antiepileptic drugs with no recurrence. MRI at 3 months showed complete removal of the hemangioma.
SPEAKER: Lastly, here is shown the good cosmetic result at follow-up.
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