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Endoscopic approaches to brainstem cavernous malformations: Case series and review of the literature.

Nayak NR, Thawani JP, Sanborn MR, Storm PB, Lee JY - Surg Neurol Int (2015)

Bottom Line: Three of the four patients maintained stable or improved neurological examinations following surgery, while one patient experienced ipsilateral palsies of cranial nerves VII and VIII.The first transclival approach resulted in a symptomatic cerebrospinal fluid leak requiring re-operation, but the second did not.It allows the surgeon to achieve well-illuminated, panoramic views, and by combining approaches, can provide minimally invasive access to most regions of the brainstem.

View Article: PubMed Central - PubMed

Affiliation: Department of Neurosurgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, Silverstein Pavilion 3, Philadelphia, PA 19104.

ABSTRACT

Background: Symptomatic cavernous malformations involving the brainstem are frequently difficult to access via traditional methods. Conventional skull-base approaches require significant brain retraction or bone removal to provide an adequate operative corridor. While there has been a trend toward limited employment of the most invasive surgical approaches, recent advances in endoscopic technology may complement existing methods to access these difficult to reach areas.

Case descriptions: Four consecutive patients were treated for symptomatic, hemorrhagic brainstem cavernous malformations via fully endoscopic approaches (endonasal, transclival; retrosigmoid; lateral supracerebellar, infratentorial; endonasal, transclival). Together, these lesions encompassed all three segments of the brainstem. Three of the patients had complete resection of the cavernous malformation, while one patient had stable residual at long-term follow up. Associated developmental venous anomalies were preserved in the two patients where one was identified preoperatively. Three of the four patients maintained stable or improved neurological examinations following surgery, while one patient experienced ipsilateral palsies of cranial nerves VII and VIII. The first transclival approach resulted in a symptomatic cerebrospinal fluid leak requiring re-operation, but the second did not. Although there are challenges associated with endoscopic approaches, relative to our prior microsurgical experience with similar cases, visualization and illumination of the surgical corridors were superior without significant limitations on operative mobility.

Conclusion: The endoscope is a promising adjunct to the neurosurgeon's ability to approach difficult to access brainstem cavernous malformations. It allows the surgeon to achieve well-illuminated, panoramic views, and by combining approaches, can provide minimally invasive access to most regions of the brainstem.

No MeSH data available.


Related in: MedlinePlus

Endoscopic view of surgical field demonstrating hemorrhagic staining of the left posterolateral midbrain (a); Resection of the cavernous malformation following pial opening (b)
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Figure 5: Endoscopic view of surgical field demonstrating hemorrhagic staining of the left posterolateral midbrain (a); Resection of the cavernous malformation following pial opening (b)

Mentions: The endoscope was then inserted along the tentorium, taking care to identify, cauterize, and divide bridging veins. The Mitaka pneumatic holding arm (Mitaka Kohki, Tokyo, Japan) was used to stabilize the endoscope, and standard bimanual techniques were used to dissect the arachnoid adhesions. The 4th cranial nerve was identified and followed to its origin at the midbrain. The arachnoid over the tentorial edge on the lateral aspect of the midbrain was opened, exposing hemorrhagic staining of the leptomeninges on the lateral midbrain immediately under the tentorium and above the 4th cranial nerve [Figure 5a]. A significant amount of blood clot was evacuated with suction and bipolar electrocautery. Next, a round knife was used to dissect the capsule of the lesion and cupped forceps were used to resect the malformation [Figure 5b]. After hemostasis was obtained, the dura was closed primarily with interrupted sutures, and a muscle autograft was placed over the dural closure. Collagen allograft was placed over the muscle, and gelfoam was placed over the allograft. The bone flap was replaced and augmented with a titanium mesh cranioplasty.


Endoscopic approaches to brainstem cavernous malformations: Case series and review of the literature.

Nayak NR, Thawani JP, Sanborn MR, Storm PB, Lee JY - Surg Neurol Int (2015)

Endoscopic view of surgical field demonstrating hemorrhagic staining of the left posterolateral midbrain (a); Resection of the cavernous malformation following pial opening (b)
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4418103&req=5

Figure 5: Endoscopic view of surgical field demonstrating hemorrhagic staining of the left posterolateral midbrain (a); Resection of the cavernous malformation following pial opening (b)
Mentions: The endoscope was then inserted along the tentorium, taking care to identify, cauterize, and divide bridging veins. The Mitaka pneumatic holding arm (Mitaka Kohki, Tokyo, Japan) was used to stabilize the endoscope, and standard bimanual techniques were used to dissect the arachnoid adhesions. The 4th cranial nerve was identified and followed to its origin at the midbrain. The arachnoid over the tentorial edge on the lateral aspect of the midbrain was opened, exposing hemorrhagic staining of the leptomeninges on the lateral midbrain immediately under the tentorium and above the 4th cranial nerve [Figure 5a]. A significant amount of blood clot was evacuated with suction and bipolar electrocautery. Next, a round knife was used to dissect the capsule of the lesion and cupped forceps were used to resect the malformation [Figure 5b]. After hemostasis was obtained, the dura was closed primarily with interrupted sutures, and a muscle autograft was placed over the dural closure. Collagen allograft was placed over the muscle, and gelfoam was placed over the allograft. The bone flap was replaced and augmented with a titanium mesh cranioplasty.

Bottom Line: Three of the four patients maintained stable or improved neurological examinations following surgery, while one patient experienced ipsilateral palsies of cranial nerves VII and VIII.The first transclival approach resulted in a symptomatic cerebrospinal fluid leak requiring re-operation, but the second did not.It allows the surgeon to achieve well-illuminated, panoramic views, and by combining approaches, can provide minimally invasive access to most regions of the brainstem.

View Article: PubMed Central - PubMed

Affiliation: Department of Neurosurgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, Silverstein Pavilion 3, Philadelphia, PA 19104.

ABSTRACT

Background: Symptomatic cavernous malformations involving the brainstem are frequently difficult to access via traditional methods. Conventional skull-base approaches require significant brain retraction or bone removal to provide an adequate operative corridor. While there has been a trend toward limited employment of the most invasive surgical approaches, recent advances in endoscopic technology may complement existing methods to access these difficult to reach areas.

Case descriptions: Four consecutive patients were treated for symptomatic, hemorrhagic brainstem cavernous malformations via fully endoscopic approaches (endonasal, transclival; retrosigmoid; lateral supracerebellar, infratentorial; endonasal, transclival). Together, these lesions encompassed all three segments of the brainstem. Three of the patients had complete resection of the cavernous malformation, while one patient had stable residual at long-term follow up. Associated developmental venous anomalies were preserved in the two patients where one was identified preoperatively. Three of the four patients maintained stable or improved neurological examinations following surgery, while one patient experienced ipsilateral palsies of cranial nerves VII and VIII. The first transclival approach resulted in a symptomatic cerebrospinal fluid leak requiring re-operation, but the second did not. Although there are challenges associated with endoscopic approaches, relative to our prior microsurgical experience with similar cases, visualization and illumination of the surgical corridors were superior without significant limitations on operative mobility.

Conclusion: The endoscope is a promising adjunct to the neurosurgeon's ability to approach difficult to access brainstem cavernous malformations. It allows the surgeon to achieve well-illuminated, panoramic views, and by combining approaches, can provide minimally invasive access to most regions of the brainstem.

No MeSH data available.


Related in: MedlinePlus