The Use of Semitranslucent Rubber Pledgets During Microsurgical Dissection of Cerebellopontine Angle Tumors: Technical Note

2017 ◽  
Vol 14 (1) ◽  
pp. 6-9
Author(s):  
Marcus D Mazur ◽  
Richard Gurgel ◽  
Joel D MacDonald
Keyword(s):  
Cerebellopontine Angle ◽  
Cranial Nerves ◽  
Technical Note ◽  
Anatomical Structures ◽  
Tumor Capsule ◽  
Latex Gloves ◽  
Neural Tissues ◽  
Brain Interface ◽  
Surgical Field ◽  
The Brain

Abstract BACKGROUND AND IMPORTANCE Dissection of cerebellopontine angle (CPA) tumors that abut or adhere to the brainstem or cranial nerves can be a challenging surgical endeavor. We describe the use of semitranslucent latex rubber pledgets in the tumor–brain interface as a method to improve visualization and protection of vital tissue during microsurgical dissection of CPA masses. The rubber pledgets are fashioned by cutting circular discs out of the cuff portion of talc-free, partially opaque latex gloves. These pledgets provide a semitranslucent, nonadherent membrane that can be placed between vital neural tissues and a tumor capsule to minimize trauma during dissection. The semitranslucent latex enables visualization of the underlying anatomical structures while also providing a protective surface onto which a suction device can be rested to facilitate clearance of the surgical field. CLINICAL PRESENTATION A 56-yr-old woman with left ear tinnitus presented with a 3-cm CPA meningioma. During microsurgical dissection, rubber pledgets were used to preserve the interface between the brain stem, cranial nerves, and tumor capsule. The use of the rubber pledgets appeared to secure the interface between to tumor and the brain while at the same time protecting the cranial nerves, brainstem, and cerebellum. CONCLUSION Semitranslucent rubber pledgets may facilitate microsurgical dissection of CPA tumors.

Surgical management of cerebellopontine angle and petrous lesions

2019 ◽  
pp. 281-296
Author(s):  
Nicholas Hall ◽  
Yuval Sufaro ◽  
Andrew Kaye
Keyword(s):  
Skull Base ◽  
Cerebellopontine Angle ◽  
Surgical Techniques ◽  
Operating Microscope ◽  
Critical Function ◽  
Anatomical Structures ◽  
Nerve Monitoring ◽  
Mortality And Morbidity ◽  
Harvey Cushing ◽  
The Brain

At the turn of the twentieth century Harvey Cushing, the father of neurosurgery, described the cerebellopontine angle (CPA) region of the brain as ‘the gloomy corner of neurosurgery’, famously comparing this anatomical region with the bloody fence corner of the Gettysburg. With limited magnification and illumination, a modern skull base subspecialist neurosurgeon can understand the huge technical challenges that pioneers such as Cushing would have faced treating large tumours with major pre-existing morbidity in this location. At that stage Cushing advocated subtotal tumour debulking as the only rational strategy, however, shortly after that Dandy began to advocate safe total removal of cerebellopontine angle tumours. Since these early days introduction of more sophisticated anaesthesia, perioperative antibiotic prophylaxis, the operating microscope, and cranial nerve monitoring techniques have all resulted in significant advances in cerebellopontine angle surgery. The concentration of cases in subspecialty centres and the recognition of the importance of experience and meticulous technique has transformed skull base surgery into a subspecialty field with consequent reductions in mortality and morbidity. Although fragile and tenuous anatomical structures, supplying critical function, will always make treatment of pathology in this region a high-risk challenge, frequently, curative outcomes are now achieved with minimal morbidity for patients. This chapter aims to outline the anatomy and pathology of the cerebellopontine angle. The chapter describes the presentation of patients and investigations needed to make diagnoses for the different pathologies in this region, and the surgical techniques, approaches, and outcomes that we use to treat these lesions.

scholarly journals Endoscopic Resection of a Cerebellopontine Angle Meningioma via a Retrosigmoid Approach

2019 ◽  
Vol 80 (S 03) ◽  
pp. S310-S310
Author(s):  
Frederick Luke Hitti ◽  
John Y.K. Lee
Keyword(s):  
Cerebellopontine Angle ◽  
Brain Mri ◽  
Cranial Nerves ◽  
Vascular Supply ◽  
Retrosigmoid Approach ◽  
Tumor Capsule ◽  
Imaging Characteristics ◽  
Adjacent Structures ◽  
Patient Reported ◽  
The Right

A variety of lesions may arise within the cerebellopontine angle (CPA). Schwannomas and meningiomas are most commonly found in this location. Imaging characteristics of meningiomas include hyperdensity on head computed tomography (CT) and avid contrast enhancement on T1-weighted postcontrast magnetic resonance imaging (MRI). Here, we present the case of a 49-year-old woman with enlarging right CPA meningioma. The patient reported mild hearing loss on the right but her neurological exam was otherwise benign. Since the lesion was enlarging and symptomatic, the patient was offered resection of the mass for diagnosis and treatment via an endoscopic retrosigmoid approach. We provide a video that illustrates the steps taken to resect this mass endoscopically. After cerebrospinal fluid (CSF) was drained to achieve brain relaxation, the tumor was visualized. The tumor had a rich vascular supply and had the appearance of a typical meningioma. The bipolar was used to cauterize the tumor's vascular supply. The tumor capsule was then opened with the microscissors. The round knife, suction, and ultrasonic tissue debrider were used to debulk the tumor. After internal debulking of the tumor, the capsule was dissected off the cerebellum and mobilized. A combination of blunt and sharp dissection was done to free the tumor capsule from the adjacent structures. Inferiorly, the lower cranial nerves were visualized. Tissue pathology confirmed a diagnosis of grade I meningioma. A gross total resection was achieved and the patient remained neurologically stable, postoperatively. Furthermore, T1-weighted postcontrast brain MRI, 1 year after surgery, showed no residual.The link to the video can be found at: https://youtu.be/X9c_inLp-So.

scholarly journals Endoscopic Assistance in the Deep and Narrow Spaces of the Brain—Microscopic Tumor Surgery Supported by the New Micro-Inspection Tool QEVO® (Technical Note)

2021 ◽  
Vol 8 ◽  
Author(s):  
Karl-Michael Schebesch ◽  
Christian Doenitz ◽  
Julius Höhne ◽  
Amer Haj ◽  
Nils Ole Schmidt
Keyword(s):  
Time Frame ◽  
Foramen Magnum ◽  
Technical Note ◽  
Intracranial Lesions ◽  
Endoscopic Assistance ◽  
Surgical Field ◽  
Rhomboid Fossa ◽  
The Brain ◽  
Anatomical Area ◽  
Endoscopic Device

Introduction: To evaluate the feasibility and efficacy of the innovative micro-inspection tool QEVO® (Carl Zeiss Meditec, Oberkochen, Germany) as an endoscopic adjunct to microscopes for better visualization of the surgical field in complex deep-seated intracranial tumors in infants and adults.Materials and Methods: We retrospectively assessed the surgical videos of 25 consecutive patients with 26 complex intracranial lesions (time frame 2018–2020). Lesions were classified according to their anatomical area: 1 = sellar region (n = 6), 2 = intra-ventricular (except IV.ventricle, n = 9), 3 = IV.ventricle and rhomboid fossa (n = 4), and 4 = cerebellopontine angle (CPA) and foramen magnum (n = 7). Indications to use the QEVO® tool were divided into five “QEVO® categories”: A = target localization, B = tailoring of the approach, C = looking beyond the lesion, D = resection control, and E = inspection of remote areas.Results: Overall, the most frequent indications for using the QEVO® tool were categories D (n = 19), C (n = 17), and E (n = 16). QEVO® categories B (n = 8) and A (n = 5) were mainly applied to intra-ventricular procedures (anatomical area 2).Discussion: The new micro-inspection tool QEVO® is a powerful endoscopic device to support the comprehensive visualization of complex intracranial lesions and thus instantly increases intraoperative morphological understanding. However, its use is restricted to the specific properties of the respective anatomical area.

scholarly journals Resection of Cerebellopontine Angle Meningioma via Retrosigmoid Approach Aiming for Hearing Improvement

2019 ◽  
Vol 80 (S 03) ◽  
pp. S302-S303
Author(s):  
Yuki Shinya ◽  
Hideaki Ono ◽  
Tomohiro Inoue ◽  
Akira Tamura
Keyword(s):  
Cerebellopontine Angle ◽  
Cranial Nerves ◽  
Auditory Brainstem ◽  
Retrosigmoid Approach ◽  
Maximum Diameter ◽  
Hearing Improvement ◽  
Female Case ◽  
Brainstem Response ◽  
The Brain ◽  
Preoperative Examination

We present a 71-year-old female case of left cerebellopontine angle (CPA) meningioma who presented with progressive hearing loss. The tumor was 35 mm in maximum diameter, obviously compressed the brain stem and cerebellum, and also displaced cranial nerves 7th and 8th anteriorly (Fig. 1). Retrosigmoid approach was chosen to resect the tumor aiming for hearing improvement. We performed dissection of the tumor from cranial nerves 7th and 8th gently and resection of the tumor except for the part adhesive to these cranial nerves (Fig. 2). Postoperative course was good without any new neurological deficit. Postoperative examination also showed improvement of high-frequency hearing of the left side, and auditory brainstem response demonstrated wave 2 to 5, which was not identify on preoperative examination. These procedures enabled safe and effective resection of the tumor and contributed to hearing improvement.The link to the video can be found at: https://youtu.be/hkRSCxtV3bY.

Partial labyrinthectomy presigmoid transpetrosal resection of petroclival meningioma

2014 ◽  
Vol 36 (v1supplement) ◽  
pp. 1 ◽  
Author(s):  
Shaun D. Rodgers ◽  
Sean O. McMenomey ◽  
Chandranath Sen
Keyword(s):  
Brain Stem ◽  
Cerebellopontine Angle ◽  
Tumor Resection ◽  
Cranial Nerves ◽  
Hearing Preservation ◽  
Petrous Bone ◽  
Line Of Sight ◽  
Petroclival Meningioma ◽  
Partial Labyrinthectomy ◽  
The Brain

A petroclival meningioma represents a challenging tumor to resect in the cerebellopontine angle and ventral to the brain stem. Multiple cranial nerves and blood vessels may be intimately involved with the tumor. A partial labyrinthectomy presigmoid transpetrosal approach can facilitate resection while preserving hearing. This approach allows for a direct line of sight along the petrous bone while sealing the canals can preserve hearing. In this video operative manuscript, we demonstrate a step-by-step illustration of a partial labyrinthectomy presigmoid transpetrosal resection of a petroclival meningioma. This approach affords the best chance of hearing preservation and an opportunity for maximum tumor resection.The video can be found here: http://youtu.be/29I4KEXz1vY.

Utility of depth electrode placement in the neurosurgical management of bottom-of-sulcus lesions: technical note

2019 ◽  
Vol 24 (3) ◽  
pp. 284-292
Author(s):  
Eisha A. Christian ◽  
Elysa Widjaja ◽  
Ayako Ochi ◽  
Hiroshi Otsubo ◽  
Stephanie Holowka ◽  
...  
Keyword(s):  
Pediatric Patients ◽  
Focal Cortical Dysplasia ◽  
Target Identification ◽  
Cortical Dysplasia ◽  
Technical Note ◽  
Electrode Placement ◽  
Electrode Implantation ◽  
Depth Electrodes ◽  
Intracranial Electrode ◽  
The Brain

OBJECTIVESmall lesions at the depth of the sulcus, such as with bottom-of-sulcus focal cortical dysplasia, are not visible from the surface of the brain and can therefore be technically challenging to resect. In this technical note, the authors describe their method of using depth electrodes as landmarks for the subsequent resection of these exacting lesions.METHODSA retrospective review was performed on pediatric patients who had undergone invasive electroencephalography with depth electrodes that were subsequently used as guides for resection in the period between July 2015 and June 2017.RESULTSTen patients (3–15 years old) met the criteria for this study. At the same time as invasive subdural grid and/or strip insertion, between 2 and 4 depth electrodes were placed using a hand-held frameless neuronavigation technique. Of the total 28 depth electrodes inserted, all were found within the targeted locations on postoperative imaging. There was 1 patient in whom an asymptomatic subarachnoid hemorrhage was demonstrated on postprocedural imaging. Depth electrodes aided in target identification in all 10 cases.CONCLUSIONSDepth electrodes placed at the time of invasive intracranial electrode implantation can be used to help localize, target, and resect primary zones of epileptogenesis caused by bottom-of-sulcus lesions.

scholarly journals A Simple Method to Avoid Brain Shift during Neuronavigation: Technical Note

2020 ◽  
Author(s):  
Jair Leopoldo Raso
Keyword(s):  
Dura Mater ◽  
Brain Area ◽  
Conventional Technique ◽  
Technical Note ◽  
Cortical Surface ◽  
Brain Shift ◽  
Simple Method ◽  
Cortex Area ◽  
Neuronavigation System ◽  
The Brain

Abstract Introduction The precise identification of anatomical structures and lesions in the brain is the main objective of neuronavigation systems. Brain shift, displacement of the brain after opening the cisterns and draining cerebrospinal fluid, is one of the limitations of such systems. Objective To describe a simple method to avoid brain shift in craniotomies for subcortical lesions. Method We used the surgical technique hereby described in five patients with subcortical neoplasms. We performed the neuronavigation-guided craniotomies with the conventional technique. After opening the dura and exposing the cortical surface, we placed two or three arachnoid anchoring sutures to the dura mater, close to the edges of the exposed cortical surface. We placed these anchoring sutures under microscopy, using a 6–0 mononylon wire. With this technique, the cortex surface was kept close to the dura mater, minimizing its displacement during the approach to the subcortical lesion. In these five cases we operated, the cortical surface remained close to the dura, anchored by the arachnoid sutures. All the lesions were located with a good correlation between the handpiece tip inserted in the desired brain area and the display on the navigation system. Conclusion Arachnoid anchoring sutures to the dura mater on the edges of the cortex area exposed by craniotomy constitute a simple method to minimize brain displacement (brain-shift) in craniotomies for subcortical injuries, optimizing the use of the neuronavigation system.

Arteriovenous malformations in the posterior fossa

1977 ◽  
Vol 47 (1) ◽  
pp. 50-56 ◽  
Author(s):  
Hiroshi Matsumura ◽  
Yasumasa Makita ◽  
Kuniyuki Someda ◽  
Akinori Kondo
Keyword(s):  
Arteriovenous Malformation ◽  
Brain Stem ◽  
Posterior Fossa ◽  
Arteriovenous Malformations ◽  
Cerebellopontine Angle ◽  
Anterior Part ◽  
Content Type ◽  
The Brain ◽  
Fine Print

✓ We have operated on 12 of 14 cases of arteriovenous malformation (AVM) in the posterior fossa since 1968, with one death. The lesions were in the cerebellum in 10 cases (three anteromedial, one central, three lateral, and three posteromedial), and in the cerebellopontine angle in two; in two cases the lesions were directly related to the brain stem. The AVM's in the anterior part of the cerebellum were operated on through a transtentorial occipital approach.

Preservation of cranial nerves during removal of the brain for an enhanced student experience in neuroanatomy classes

2013 ◽  
Vol 27 (1) ◽  
pp. 20-24 ◽  
Author(s):  
Jennifer Long ◽  
David J.H. Roberts ◽  
James D. Pickering
Keyword(s):  
Cranial Nerves ◽  
Student Experience ◽  
The Brain

Giant syringobulbia associated with cerebellopontine angle arachnoid cyst and hydrocephalus

2011 ◽  
Vol 8 (1) ◽  
pp. 30-34 ◽  
Author(s):  
Ai Muroi ◽  
Nigel Peter Syms ◽  
Shizuo Oi
Keyword(s):  
Arachnoid Cyst ◽  
Head Circumference ◽  
Lateral Ventricle ◽  
Cerebellopontine Angle ◽  
External Ventricular Drainage ◽  
Magnetic Resonance Images ◽  
Ventricular Catheter ◽  
Cerebrospinal Fluid Diversion ◽  
Left Lateral Ventricle ◽  
The Brain

The aim in reporting this case was to discuss the pathophysiology and treatment issues in an infant with a giant syringobulbia associated with a right cerebellopontine angle (CPA) arachnoid cyst causing noncommunicating hydrocephalus. This 7-month-old infant presented to the hospital with a history of delayed milestones and an abnormal increase in head circumference. Magnetic resonance images and CT scans of the brain showed a large CSF cavity involving the entire brainstem and a right CPA arachnoid cyst causing obstruction of the fourth ventricle and dilation of the lateral and third ventricles. Cerebrospinal fluid diversion was performed by direct communication from the syringobulbia cavity to the left lateral ventricle and from the left lateral ventricle through another ventricular catheter; external ventricular drainage was performed temporarily for 5 days. Communication between the syrinx and arachnoid cyst was confirmed. Clinically, there was a reduction in head circumference, and serial MR imaging of the brain showed a decrease in the size of the syrinx cavity and the ventricle along with opening of the normal CSF pathways. The postoperative course was uneventful, and no further intervention was necessary. On follow-up of the child at 3 years, his developmental milestones were normal. Surgical intervention for this condition is mandatory. The appropriate type of surgery should be performed on the basis of the pathophysiology of the developing syringobulbia.

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