Transclival Approach for Resection of a Pontine Cavernous Malformation: 2-Dimensional Operative Video

2020 ◽  
Vol 19 (4) ◽  
pp. E413-E413
Author(s):  
Dennis London ◽  
Seth Lieberman ◽  
Omar Tanweer ◽  
Donato Pacione
Keyword(s):  
Cavernous Malformation ◽  
Case Reports ◽  
Abducens Nerve ◽  
Petrous Bone ◽  
Fat Graft ◽  
Csf Leak ◽  
Endoscopic Endonasal ◽  
Cavernous Malformations ◽  
Lumbar Drain ◽  
Magnetic Resonance Imaging Mri

Abstract Cerebral cavernous malformations are common vascular anomalies consisting of a cluster of capillaries without intervening brain tissue.1 A variety of approaches for resection have been undertaken,2 and a handful of case reports have described the endoscopic, endonasal, transclival approach.3 We present a case of a 51-yr-old woman with lupus and hepatitis B-associated cirrhosis who presented with diplopia, dysphagia, and ataxia. She had a left abducens nerve palsy and magnetic resonance imaging (MRI) showed a left pontine cavernous malformation. After a repeat hemorrhage, she consented to surgical resection. The lesion appeared to come to the medial pontine pial surface. Tractography indicated a rightward displacement of the left corticospinal tract. Therefore, an endoscopic, transnasal, transclival approach was chosen. A lumbar drain was placed preoperatively. The clivus and ventral petrous bone were drilled using the vidian canal to help identify the anterior genu of the petrous carotid artery. The clival dura was opened, revealing the abducens nerve exiting the ventral pons. The cavernoma was visible on the surface lateral to the nerve. It was removed using blunt dissection and the remaining cavity inspected. The skull base was reconstructed using an abdominal dermal-fat graft and Alloderm covered by a nasoseptal flap. Postoperatively she had transient swallowing difficulty. The lumbar drain was kept open for 5 d. Cerebrospinal fluid (CSF) leak was ruled out using an intrathecal fluorescein injection. She was discharged home, but presented 2 wk postoperatively with aseptic meningitis, which was treated supportively. Postoperative imaging did not show residual cavernoma.

scholarly journals Endoscopic Endonasal Transclival Approach to Ventral Pontine Cavernous Malformation: Case Report

2021 ◽  
Vol 8 ◽  
Author(s):  
Xiao Dong ◽  
Xiaoyu Wang ◽  
Anwen Shao ◽  
Jianmin Zhang ◽  
Yuan Hong
Keyword(s):  
Case Report ◽  
High Risk ◽  
Cavernous Malformation ◽  
Csf Leak ◽  
Endoscopic Endonasal Approach ◽  
Endonasal Approach ◽  
Dorsal Approach ◽  
Endoscopic Endonasal ◽  
Cavernous Malformations ◽  
Individualized Approach

Ventral medial pontine cavernous malformations are challenging due to the location in eloquent tissue, surrounding critical anatomy, and potential symptomatic bleeding. Conventional approaches, such as anterolateral, lateral and dorsal approach, are associated with high risk of deleterious consequences due to excessive traction and damage to the surrounding tissues. The authors present an endoscopic endonasal approach for the resection of midline ventral pontine cavernous malformations, which follows principles of optimal access to brainstem cavernous malformations as the “two-point method.” No CSF leak or any other complications are obtained. The successful outcomes indicate that an individualized approach should be chosen before the surgery for brainstem cavernous malformations. With the advance of techniques, endoscopic endonasal approach could provide the most direct route to ventral pontine lesions with safety and efficiency.

Endoscopic Endonasal Excision of an Optic Pathway Cavernous Malformation: Technical Case Report

2021 ◽  
Author(s):  
Biren Khimji Patel ◽  
A Jaypalsinh Gohil ◽  
Prakash Nair ◽  
Easwer H.V. ◽  
Deepti A.N.
Keyword(s):  
Clinical Presentation ◽  
Cavernous Malformation ◽  
Vascular Malformations ◽  
Low Flow ◽  
Visual Field Defects ◽  
Optic Pathway ◽  
Endoscopic Endonasal ◽  
Cavernous Malformations ◽  
Magnetic Resonance Imaging Mri ◽  
Bitemporal Hemianopia

Abstract BACKGROUND AND IMPORTANCE Cavernous malformations (CMs) are angiographically occult low-flow vascular malformations that infrequently involve the optic pathway and the hypothalamus (OPH). CLINICAL PRESENTATION A 23-yr-old male presented with bitemporal hemianopia due to chaismal apoplexy. Imaging revealed a CM involving the OPH. The CM was resected by an extended endonasal approach. The patient had improvement in his visual field defects, and postoperative magnetic resonance imaging (MRI) revealed a gross total resection of the CM. CONCLUSION This case demonstrates the surgical technique of endoscopic endonasal resection of a CM involving the optic pathway.

scholarly journals Endoscopic endonasal transclival approach for resection of a pontine cavernous malformation

2019 ◽  
Vol 1 (1) ◽  
pp. V3
Author(s):  
Lucas Ramos Lima ◽  
Jarbas Carvalhais Reis ◽  
Gerival Vieira Junior ◽  
Tiago Fraga Vieira ◽  
Lucidio Duarte de Souza Filho ◽  
...  
Keyword(s):  
Cavernous Malformation ◽  
Brain Mri ◽  
Complete Resection ◽  
Csf Leak ◽  
Motor Deficit ◽  
Ventral Region ◽  
Endoscopic Endonasal ◽  
Cavernous Malformations ◽  
Prepontine Cistern ◽  
History Of

Symptomatic cavernous malformations in the ventral region of the pons are difficult to access surgically. The authors present a case of a 46-year-old woman with a 10-year history of sudden and transitory diplopia and right hemiparesis, followed by five more episodes of mild right hemiparesis. Brain MRI showed a 2.6-cm cavernous malformation in the pons with an exophytic portion in the prepontine cistern. The patient underwent an endoscopic endonasal transclival approach for a complete resection of the lesion. CSF leak was noted and corrected on the sixth postoperative day. The patient progressed with complete motor deficit recovery.The video can be found here: https://youtu.be/ePgpyij2Wpo.

scholarly journals Stepwise Algorithm for Skull Base Reconstruction in Endoscopic Endonasal Surgery: From the Simple to the Complex

Neurosurgery ◽  
2019 ◽  
Vol 66 (Supplement_1) ◽  
Author(s):  
Maria Belen Vega ◽  
Philippe Lavigne ◽  
Vanessa Hernandez-Hernandez ◽  
Aldo Eguiluz-Menendez ◽  
Eric Wang ◽  
...  
Keyword(s):  
Skull Base ◽  
Posterior Fossa ◽  
Free Flaps ◽  
Fat Graft ◽  
Csf Leak ◽  
Endoscopic Endonasal Surgery ◽  
Endonasal Surgery ◽  
Endoscopic Endonasal ◽  
Skull Base Reconstruction ◽  
Skull Base Defects

Abstract INTRODUCTION The most frequent complication of endoscopic endonasal surgery (EES) is postoperative cerebrospinal fluid (CSF) leak. This study was designed to develop a step-wise algorithm for EES reconstruction across the spectrum of skull base defects: from free mucosal graft for uncomplicated pituitary adenomas to free flaps in complex cases with recurrent leaks. METHODS All patients with skull base pathologies who underwent EES between January 2017 and December 2018 were included and retrospectively analyzed. Tumor location, reconstruction method and postoperative CSF leak were reviewed and a step-wise algorithm based on size and location of defect was developed. RESULTS Location of skull base defects was categorized as follows: anterior fossa, suprasellar, sellar and posterior fossa. For all nonsellar sites, we performed a multilayer (collagen matrix + /- fascia lata + /− fat graft + vascularized flap) reconstruction. The nasoseptal flap (NSF) was the first choice for vascularized reconstruction when available. For all sellar lesions we employed a free mucosal graft unless a high-flow CSF leak was present, in which case a single-layer reconstruction with NSF was performed. When the NSF was not available, alternative local (lateral nasal wall flap) and regional (extracranial pericranial flap) pedicled flaps were successful choices. When patients failed multiple attempts at repair, regional or microvascular free flaps were options. Lumbar spinal drainage was employed for large anterior and posterior fossa defects and during secondary repair of postoperative CSF leaks. Of 347 patients, 4.6% had a postoperative CSF leak. Of 158 patients with an intraoperative leak (45.5%), 10.1% developed a postoperative CSF leak: 7.8% for sellar/suprasellar defects and 13% for anterior/posterior fossa defects. CONCLUSION This algorithm provides a standardized, stepwise approach to the reconstruction of all skull base defects after EES based on location.

scholarly journals Does lumbar drainage reduce postoperative cerebrospinal fluid leak after endoscopic endonasal skull base surgery? A prospective, randomized controlled trial

2019 ◽  
Vol 131 (4) ◽  
pp. 1172-1178 ◽  
Author(s):  
Nathan T. Zwagerman ◽  
Eric W. Wang ◽  
Samuel S. Shin ◽  
Yue-Fang Chang ◽  
Juan C. Fernandez-Miranda ◽  
...  
Keyword(s):  
Skull Base ◽  
Skull Base Surgery ◽  
Controlled Trial ◽  
Csf Leak ◽  
Inclusion Criteria ◽  
Endoscopic Endonasal ◽  
Randomized Controlled ◽  
Lumbar Drain ◽  
Prospective Randomized Controlled Trial ◽  
Csf Leaks

OBJECTIVEBased on a null hypothesis that the use of short-term lumbar drainage (LD) after endoscopic endonasal surgery (EES) for intradural pathology does not prevent postoperative CSF leaks, a trial was conducted to assess the effect of postoperative LD on postoperative CSF leak following standard reconstruction.METHODSA prospective, randomized controlled trial of lumbar drain placement after endoscopic endonasal skull base surgery was performed from February 2011 to March 2015. All patients had 3-month follow-up data. Surgeons were blinded to which patients would or would not receive the drain until after closure was completed. An a priori power analysis calculation assuming 80% of power, 5% postoperative CSF leak rate in the no-LD group, and 16% in the LD group determined a planned sample size of 186 patients. A routine data and safety check was performed with every 50 patients being recruited to ensure the efficacy of randomization and safety. These interim tests were run by a statistician who was not blinded to the arms they were evaluating. This study accrued 230 consecutive adult patients with skull base pathology who were eligible for endoscopic endonasal resection. Inclusion criteria (high-flow leak) were dural defect greater than 1 cm2 (mandatory), extensive arachnoid dissection, and/or dissection into a ventricle or cistern. Sixty patients were excluded because they did not meet the inclusion criteria. One hundred seventy patients were randomized to either receive or not receive a lumbar drain.RESULTSOne hundred seventy patients were randomized, with a mean age of 51.6 years (range 19–86 years) and 38% were male. The mean BMI for the entire cohort was 28.1 kg/m2. The experimental cohort with postoperative LD had an 8.2% rate of CSF leak compared to a 21.2% rate in the control group (odds ratio 3.0, 95% confidence interval 1.2–7.6, p = 0.017). In 106 patients in whom defect size was measured intraoperatively, a larger defect was associated with postoperative CSF leak (6.2 vs 2.9 cm2, p = 0.03). No significant difference was identified in BMI between those with (mean 28.4 ± 4.3 kg/m2) and without (mean 28.1 ± 5.6 kg/m2) postoperative CSF leak (p = 0.79). Furthermore, when patients were grouped based on BMI < 25, 25–29.9, and > 30 kg/m2, no difference was noted in the rates of CSF fistula (p = 0.97).CONCLUSIONSAmong patients undergoing intradural EES judged to be at high risk for CSF leak as defined by the study’s inclusion criteria, perioperative LD used in the context of vascularized nasoseptal flap closure significantly reduced the rate of postoperative CSF leaks.Clinical trial registration no.: NCT03163134 (clinicaltrials.gov).

Left retrosigmoid craniotomy for cavernous malformation of the middle cerebellar peduncle

2014 ◽  
Vol 36 (v1supplement) ◽  
pp. 1 ◽  
Author(s):  
Jonathan Russin ◽  
David J. Fusco ◽  
Robert F. Spetzler
Keyword(s):  
Cerebrospinal Fluid ◽  
Cavernous Malformation ◽  
Lateral Wall ◽  
Petrous Bone ◽  
Sigmoid Sinus ◽  
Middle Cerebellar Peduncle ◽  
Cavernous Malformations ◽  
Lateral Border ◽  
History Of ◽  
Cerebellar Peduncle

We present a 25-year-old female with a history of multiple intracranial cavernous malformations complaining of vertigo. Imaging is significant for increasing size of a lesion in her left cerebellar peduncle. Given the proximity to the lateral border of the cerebellar peduncle, a retrosigmoid approach was chosen. After performing a craniotomy that exposed the transverse-sigmoid sinus junction, the dura was open and reflected. The arachnoid was sharply opened and cerebrospinal fluid was aspirated to allow the cerebellum to fall away from the petrous bone. The cerebellopontine fissure was then opened to visualize the lateral wall of the cerebellar peduncle. The cavernous malformation was entered and resected.The video can be found here: http://youtu.be/P7mpVbaCiJE.

scholarly journals An Occipital Headache as the First Presentation of Multiple Third, Fourth, and Lateral Ventricular Cavernous Malformations: A Case Report and Review of Literature

2017 ◽  
Vol 6 (1) ◽  
pp. 61-65
Author(s):  
Alireza Vakilian ◽  
Amir Moghadam Ahmadi ◽  
Habib Farahmand
Keyword(s):  
Surgical Intervention ◽  
Cavernous Malformation ◽  
Vascular Malformations ◽  
Case Reports ◽  
Review Of Literature ◽  
Rare Presentation ◽  
Cavernous Malformations ◽  
Cavernous Hemangiomas ◽  
Occipital Headache ◽  
Tomography Scan

Background: Cavernous hemangiomas are common benign vascular malformations. Their existence in the intraventricular region is very rare. Case Reports: A 43-year old woman with an occipital headache was admitted to the emergency ward. Brain computed tomography scan showed mild hydrocephalus and multiple intraventricular isodense lesions. Imaging findings, especially of Gradient Resonance Echo imaging, were in favor of multiple intraventricular cavernous malformations. Conclusion: This is a rare presentation of multiple cavernous malformation as occipital headache without needing surgical intervention in this phase. Coexistence of periventricular plaques like Radiologically isolated syndrome of Multiple sclerosis is another unique aspect in this report. [GMJ.2017;6(1):61-65]

Surgical Experience in Prevention of Postoperative CSF Leaks Using Abdominal Fat Grafts in Endoscopic Endonasal Transsphenoidal Surgery for Pituitary Adenomas

2020 ◽  
Author(s):  
Stephen Ahn ◽  
Jae-Sung Park ◽  
Do H. Kim ◽  
Sung W. Kim ◽  
Sin-Soo Jeun
Keyword(s):  
Pituitary Adenomas ◽  
Case Series ◽  
Abdominal Fat ◽  
Fat Graft ◽  
Csf Leak ◽  
Endoscopic Endonasal ◽  
Tertiary Referral Center ◽  
Fat Grafts ◽  
Sellar Floor ◽  
Csf Leaks

Abstract Objective Cerebrospinal fluid (CSF) leaks are the most common complication during endonasal endoscopic transsphenoidal approach (EETSA) and prevention of postoperative CSF leaks is critical. In this study, we report a single surgeon's experience of sellar floor reconstruction using abdominal fat grafts for prevention of postoperative CSF leaks in EETSA for pituitary adenomas. Design This study is presented as case series with retrospective chart review. Setting Present study was conducted at tertiary referral center. Participants A total of 216 patients who underwent surgery via EETSA for pituitary adenomas between 2008 and 2018 at our institution were evaluated. When an intraoperative CSF leak occurred, sellar floor reconstruction was performed using a fat graft harvested from the abdomen via a 2-cm skin incision. Main Outcome Measures Primary outcome and measures of this study was postoperative CSF leaks. Results A total of 53 patients showed intraoperative CSF leaks (24.5%) and 2 patients showed postoperative CSF leaks (0.93%). There were no postoperative CSF leaks in any patients who showed intraoperative CSF leaks and received sellar floor reconstruction using fat grafts. There were also no postoperative CSF leaks in 12 patients who received preventative sellar floor reconstruction using fat grafts due to extensive arachnoid herniation without intraoperative CSF leaks. However, there were two postoperative CSF leaks in patients who did not show intraoperative CSF leaks and did not receive sellar floor reconstruction. Conclusion The effectiveness of sellar floor reconstruction using abdominal fat grafts in patients receiving EETSA for pituitary adenoma was reported. We suggest that identification of intraoperative CSF leaks is important and preventive sellar floor reconstruction without evidence of intraoperative CSF leaks can also be beneficial.

S241 – Acoustic Neuroma Surgery: Hydroxyapatite Cement Cranioplasty

2008 ◽  
Vol 139 (2_suppl) ◽  
pp. P156-P156 ◽  
Author(s):  
Emma A. Kruger ◽  
Moises A Arriaga ◽  
Douglas Chen ◽  
Todd Hillman
Keyword(s):  
Acoustic Neuroma ◽  
Bone Substitute ◽  
Abdominal Fat ◽  
Fat Graft ◽  
Csf Leak ◽  
Wound Complications ◽  
Reconstruction Technique ◽  
Lumbar Drain ◽  
Acoustic Neuroma Surgery ◽  
Hydroxyapatite Cement

Objectives To review the outcome of hydroxyapatite cement cranioplasy in acoustic neuroma surgery using trans-labyrinthine and retrosigmoid approaches. Methods Retrospective chart review of the cases of acoustic neuroma resection performed in our institution from January 1, 2007, until November 1, 2007, using 2 separate types of hydroxyapatite cranioplasty in wound closure. Abdominal fat graft in case of translabyrinthine approach and either abdominal fat graft or duragen were covered using Hydrset (Stryker) or Bonesouce (Stryker) hydroxyapatitie cement bone substitute. Translabyrinthine and Retrosigmoid resections were included in the review. The rate of postoperative cerebrospinal fluid leak, lumbar drain use, and early wound complications were recorded. Results There were 33 cases of acoustic neuroma resection over a period of 10 months using hydroxyapatite cranioplasty. Hydroset bone substitue was used in 16 cases and no CSF leak was observed. Bonesource bone substitute was used in 17 cases and 1 case of CSF leak was observed. The leak was managed with lumbar drain placement and resolved without any additional interventions. In the Hydroset group no drains were used, and in the Bonsource group drains were placed at the completeion of a procedure and removed 12 hours postoperatively. There were no wound complications seen at the completeion of the review. No other adverse outcomes were noted. Conclusions Both forms of hydroxyapatite cranioplasty are reliable methods to avoid CSF leak in acoustic neuroma surgery. The handling characteristics and no need for drain with Hydroset may make it preferable as a bone reconstruction technique in acoustic neuroma surgery.

scholarly journals Contralateral Transmaxillary Approach for Resection of Chondrosarcoma of the Petrous Apex: A Case Report

2021 ◽  
pp. 014556132098216
Author(s):  
Jesse D. Lawrence ◽  
Robert Marsh ◽  
Meghan T. Turner
Keyword(s):  
Abducens Nerve ◽  
Petrous Apex ◽  
Lytic Lesion ◽  
Adjuvant Radiation ◽  
Low Grade ◽  
Endoscopic Endonasal ◽  
Postoperative Mri ◽  
Novel Approach ◽  
Magnetic Resonance Imaging Mri

Background: Deep location and neurovascular structures make access to lesions of the petrous apex a significant challenge. A novel approach for these tumors is the contralateral transmaxillary approach. Clinical Presentation: A 31-year-old male was evaluated for left abducens nerve palsy. Magnetic resonance imaging (MRI) and computed tomography revealed an enhancing, lytic lesion of the petrous apex with extension to the cavernous sinus and petroclival junction. The patient underwent a combined endoscopic contralateral transmaxillary and endoscopic endonasal transclival approach for resection of the lesion. No new or worsening neurologic deficits were noted following the procedure. Pathology revealed low-grade chondrosarcoma (grade I). Postoperative MRI revealed gross total resection of the lesion. Patient underwent adjuvant radiation therapy at the discretion of radiation oncology. Conclusion: The contralateral transmaxillary approach to the petrous apex allows for resection of lesions of the petrous apex with the ability to extend the dissection laterally. Excellent results achieved by institutions with advanced extended endoscopic endonasal experience can be reproduced in institutions with less experience. Further characterization of the risks and benefits of this approach is needed.

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