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Infratentorial supracerebellar approach to pineal and juxta-pineal region tumors in sitting position
S35
Video Presentations
Monday, 7 July 1997
V·1
14:00-16:30
Tumours of the eNS I
IV-1-1 I Transcallosal approach for removal of colloid cysts Ravi Ramamurthi, M.C.Vasudevan, K. Sridhar, B. Ramamurthi. II.H.S. Medical Centre, Madras, India Colloid cysts being potentially life threatening require definitive surgical treatment. The options that are available are the transcortical approach, the transcallosal approach, stereotactic aspiration and endoscopic procedures. During the period1988to 1996twenty-eight patients withcolloid cystshave beenoperated uponby a microsurgical transcallosal approach. Theapproach to thethirdventricle hasbeentransforaminal in the majority of patients, whilein two it was subfomicea!. The interfomiceal approach has not beenfound necessary. The boneflap is not carriedacrossthe midline. Therehas been no mortality and total excision has beenpossible in twentysix and near total in two. The complications have been minimal in the form of transient hemiparesis in one, post-operative seizures in one,threehad postoperative acute subdural haematoma which was evacuated successfully. There was no permanent memory loss or disconnection syndrome as the incision in the corpuscallosum is less than 2 ems. The transcallosal approach is excellent for the removal of colloid cysts. Therehas been no mortality and minimal morbidity. This videopresentation will highlightthe technique used by the authorin the successful removal of twenty eight colloidcysts.
IV-1-2!lnfratentorial supracerebellar approach to pineal and juxta-pineal region tumors in sitting position
JunkohYamashita, HisashiNitta. Department of Neurosurgery, Kanazawa University Schoolof Medicine, Kanazawa, Japan
Introduction: Twenty-seven cases of pineal and juxta-pineal region tumors were treatedsurgically in the past 8 years in our Department. All of them were operated through the infratentorial supracerebellar approach in sittingposition. The surgical results wereanalyzed. Methods: This series included germ cell tumors (14), astrocytomas (2), meningiomas (2), hemangioblastomas (2), metastases (2), medulloblastomas (1), symptomatic pinealcyst (1), dermoid cyst (1), epidermoid cyst (1) and AVM (1). Among germ cell tumors, there were 3 germinomas, 1 germinoma with STGC, 1 yolk sac tumor, 1 choriocarcinoma, 5 immature teratomas and3 mixed germ cell tumors. Main concem of this approach was air embolism. In order to preventair embolism, 1) systemic blood pressure, 2) cardiacmurmur by an esophageal stethoscope, 3) endotidal pC02 and 4) pulmonary artery wedge pressure were monitored. If intracardiac air was detected, it was removed by a Bunegine-Albin catheter. Results: In this approach, 1) there was little hemorrhage, 2) deep cerebral veins did not obstructthe operative field, and 3) anatomical relationship of the tumorand the third ventricle was straightforward. Therewas no operative mortality. Although air embolism was encountered in 2 cases, they were treated successfully without neurological sequelae. We experienced one case of serious morbidity of cervical cord flexion injury in a 9-year old boy with pineal choriocarcinoma. It was foundthat germinoma accounted for lessthanone half of all germcell tumors. Discussion and Conclusion: The infratentorial supracerebellar approach is a goodapproach to pinealregion tumors, if properpreventive measures for air embolism aretaken.The neck shouldnot be overflexed. Thedistance between the chin and the stemum should be more than 2-fingerbreadths. Histological diagnosis shouldbe obtained asa basisof optimal treatment ofgermcelltumors, whenever possible.
IV-1-31 Microsurgical reconstruction of the sinusand the veins in of parasagittal meningioma ~ridg!ng
c~se
Invading the supenorsagittal sinus
AkiraHakuba, Takashi Tsuruno, Yoshimi Matsuoka. Dept. of Neurosurgery, Osaka City University, Osaka, Japan '
Introduction: The parasagittal meningiomas must be totally removed. One should not be afraidto reconstruct the superiorsagittalsinus andveins. Methods: Since 1978, we have experience with 32 parasagittal meningiomas that invaded the venous sinuses. In our early series, the dura or a saphenous vein was used for reconstruction (10 cases); the partially invaded cases (one or two walls of the sinus are invaded: group A) 6 and the grossly Invaded cases (threewalls of the sinus are invaded: group B) 4. Patency was confirmed by postoperative angiography in 4 of 6 and the results of all cases weregoodin groupA. However, neitherpatency nor goodresults wereobtained ingroupB.Since1981, we haveusedtheextemaljugularveinfor reconstruction (18cases); 6 casesin groupA and 12 casesin groupB. Reconstructed bridging veins in 2 cases of group A and 8 cases of group B were patent. The sinuses werepatentin all 5 casesin groupA and 5 casesout of 7 in group B.The results of these 18 patients were good (including 8 with transient deficit) regardless of the patency of the sinuses. Discussion and Conclusion: After total excision of the portion of meningiomas that partially invade the sinus, the sinus must be repaired. When the sinus is grosslyinvaded, but still carries blood, or when the veins running on or through the tumor carry blood as collateral channels of the completely obstructed sinus,it is also bestto reconstruct the veins in order to preserve these collateral venous drainages. The detailsof operative techniques will be shown in a video.
IV-1-4! Twointriguing cases of parasellar meningioma Suresh Nair, Rajneesh Kachhara. SreeChitra Tirunallnstitute for Medical Sciences and Technology, Trivandrum, India Authors present their operative techniques of two cases of parasellar meningioma. The first patient was a 53 year old lady presenting with ptosis of 14 yearsduration whoon investigation was found to havea Gr. IV cavemous sinus meningioma. The second patient was a 43 year old man who presented with 11 years history of temporal lobe epilepsy who was detected to have clinoidal meningioma with an ophthalmic segment aneurysm embedded in the tumor. Thesecasesare beingpresented because of their technical difficulty. Bothcaseswereapproached, after obtaining proximal controlof the carotid artery in the neck, through a transsylvian approach. The cavemous sinus tumour which tumed out to be angioblastic meningioma was approached by a combined lateral and superior intradural approach. After decompressing the tumour, first through lateral and laterthrough superiorroute, the anteriorclinoid was removed and distal ring around C3 carotid excisedand ICA was followed back to cavemous sinus.Tumour couldbe near totally removed exceptfor the bitswhichwereadherent to the medial wallof C4 segment. Patienthad a stormy post-operative period with unexplained prolonged paralyticileus and atrial fibrillation from which patient made total recovery. Patient developed Vlth nerve palsypostoperatively. Thesecondcaseofclinoidal meningioma wastackledafterestablishing first a planeof dissection between tumourand temporal lobe. Once temporal tumour was decompressed MC branches could be identified and dissection carried proximally to ICbifurcation. After removing anteriorclinoidintradurally, distalC2 and C3 portion of ICA with the aneurysm was exposed. This aneurysm could not be Clipped because of calcification in its broadneckwhichwas extending to the wall of the carotid and hencewas wrapped with muscle. lastly the frontal side of the c1inoidal meningioma was removed. Patient was free of complex partial seizures postoperatively. Although technically demanding, with modem neurosurgical techniques these benign lesionscan be dissected from surrounding nerves and vessels with minimal morbidity.
Video Presentations
Monday, 7 July 1997
V·1
14:00-16:30
Tumours of the eNS I
IV-1-1 I Transcallosal approach for removal of colloid cysts Ravi Ramamurthi, M.C.Vasudevan, K. Sridhar, B. Ramamurthi. II.H.S. Medical Centre, Madras, India Colloid cysts being potentially life threatening require definitive surgical treatment. The options that are available are the transcortical approach, the transcallosal approach, stereotactic aspiration and endoscopic procedures. During the period1988to 1996twenty-eight patients withcolloid cystshave beenoperated uponby a microsurgical transcallosal approach. Theapproach to thethirdventricle hasbeentransforaminal in the majority of patients, whilein two it was subfomicea!. The interfomiceal approach has not beenfound necessary. The boneflap is not carriedacrossthe midline. Therehas been no mortality and total excision has beenpossible in twentysix and near total in two. The complications have been minimal in the form of transient hemiparesis in one, post-operative seizures in one,threehad postoperative acute subdural haematoma which was evacuated successfully. There was no permanent memory loss or disconnection syndrome as the incision in the corpuscallosum is less than 2 ems. The transcallosal approach is excellent for the removal of colloid cysts. Therehas been no mortality and minimal morbidity. This videopresentation will highlightthe technique used by the authorin the successful removal of twenty eight colloidcysts.
IV-1-2!lnfratentorial supracerebellar approach to pineal and juxta-pineal region tumors in sitting position
JunkohYamashita, HisashiNitta. Department of Neurosurgery, Kanazawa University Schoolof Medicine, Kanazawa, Japan
Introduction: Twenty-seven cases of pineal and juxta-pineal region tumors were treatedsurgically in the past 8 years in our Department. All of them were operated through the infratentorial supracerebellar approach in sittingposition. The surgical results wereanalyzed. Methods: This series included germ cell tumors (14), astrocytomas (2), meningiomas (2), hemangioblastomas (2), metastases (2), medulloblastomas (1), symptomatic pinealcyst (1), dermoid cyst (1), epidermoid cyst (1) and AVM (1). Among germ cell tumors, there were 3 germinomas, 1 germinoma with STGC, 1 yolk sac tumor, 1 choriocarcinoma, 5 immature teratomas and3 mixed germ cell tumors. Main concem of this approach was air embolism. In order to preventair embolism, 1) systemic blood pressure, 2) cardiacmurmur by an esophageal stethoscope, 3) endotidal pC02 and 4) pulmonary artery wedge pressure were monitored. If intracardiac air was detected, it was removed by a Bunegine-Albin catheter. Results: In this approach, 1) there was little hemorrhage, 2) deep cerebral veins did not obstructthe operative field, and 3) anatomical relationship of the tumorand the third ventricle was straightforward. Therewas no operative mortality. Although air embolism was encountered in 2 cases, they were treated successfully without neurological sequelae. We experienced one case of serious morbidity of cervical cord flexion injury in a 9-year old boy with pineal choriocarcinoma. It was foundthat germinoma accounted for lessthanone half of all germcell tumors. Discussion and Conclusion: The infratentorial supracerebellar approach is a goodapproach to pinealregion tumors, if properpreventive measures for air embolism aretaken.The neck shouldnot be overflexed. Thedistance between the chin and the stemum should be more than 2-fingerbreadths. Histological diagnosis shouldbe obtained asa basisof optimal treatment ofgermcelltumors, whenever possible.
IV-1-31 Microsurgical reconstruction of the sinusand the veins in of parasagittal meningioma ~ridg!ng
c~se
Invading the supenorsagittal sinus
AkiraHakuba, Takashi Tsuruno, Yoshimi Matsuoka. Dept. of Neurosurgery, Osaka City University, Osaka, Japan '
Introduction: The parasagittal meningiomas must be totally removed. One should not be afraidto reconstruct the superiorsagittalsinus andveins. Methods: Since 1978, we have experience with 32 parasagittal meningiomas that invaded the venous sinuses. In our early series, the dura or a saphenous vein was used for reconstruction (10 cases); the partially invaded cases (one or two walls of the sinus are invaded: group A) 6 and the grossly Invaded cases (threewalls of the sinus are invaded: group B) 4. Patency was confirmed by postoperative angiography in 4 of 6 and the results of all cases weregoodin groupA. However, neitherpatency nor goodresults wereobtained ingroupB.Since1981, we haveusedtheextemaljugularveinfor reconstruction (18cases); 6 casesin groupA and 12 casesin groupB. Reconstructed bridging veins in 2 cases of group A and 8 cases of group B were patent. The sinuses werepatentin all 5 casesin groupA and 5 casesout of 7 in group B.The results of these 18 patients were good (including 8 with transient deficit) regardless of the patency of the sinuses. Discussion and Conclusion: After total excision of the portion of meningiomas that partially invade the sinus, the sinus must be repaired. When the sinus is grosslyinvaded, but still carries blood, or when the veins running on or through the tumor carry blood as collateral channels of the completely obstructed sinus,it is also bestto reconstruct the veins in order to preserve these collateral venous drainages. The detailsof operative techniques will be shown in a video.
IV-1-4! Twointriguing cases of parasellar meningioma Suresh Nair, Rajneesh Kachhara. SreeChitra Tirunallnstitute for Medical Sciences and Technology, Trivandrum, India Authors present their operative techniques of two cases of parasellar meningioma. The first patient was a 53 year old lady presenting with ptosis of 14 yearsduration whoon investigation was found to havea Gr. IV cavemous sinus meningioma. The second patient was a 43 year old man who presented with 11 years history of temporal lobe epilepsy who was detected to have clinoidal meningioma with an ophthalmic segment aneurysm embedded in the tumor. Thesecasesare beingpresented because of their technical difficulty. Bothcaseswereapproached, after obtaining proximal controlof the carotid artery in the neck, through a transsylvian approach. The cavemous sinus tumour which tumed out to be angioblastic meningioma was approached by a combined lateral and superior intradural approach. After decompressing the tumour, first through lateral and laterthrough superiorroute, the anteriorclinoid was removed and distal ring around C3 carotid excisedand ICA was followed back to cavemous sinus.Tumour couldbe near totally removed exceptfor the bitswhichwereadherent to the medial wallof C4 segment. Patienthad a stormy post-operative period with unexplained prolonged paralyticileus and atrial fibrillation from which patient made total recovery. Patient developed Vlth nerve palsypostoperatively. Thesecondcaseofclinoidal meningioma wastackledafterestablishing first a planeof dissection between tumourand temporal lobe. Once temporal tumour was decompressed MC branches could be identified and dissection carried proximally to ICbifurcation. After removing anteriorclinoidintradurally, distalC2 and C3 portion of ICA with the aneurysm was exposed. This aneurysm could not be Clipped because of calcification in its broadneckwhichwas extending to the wall of the carotid and hencewas wrapped with muscle. lastly the frontal side of the c1inoidal meningioma was removed. Patient was free of complex partial seizures postoperatively. Although technically demanding, with modem neurosurgical techniques these benign lesionscan be dissected from surrounding nerves and vessels with minimal morbidity.