September 03, 2015
This video is a good example of an adherent and fibrous tuberculum sella meningioma and the pitfalls associated with aggressive manipulation of the perforating vessels along the ACoA complex. This is 62 year-old male who presented with visual decline and was diagnosed with a typical tuberculum sella meningioma causing optic apparatus compression. An endonasal approach was selected. You can see the exposure of the sella in the tuberculum. After the removal of the entire face of the sella and portion of the tuberculum, the tumor was exposed. Bony removal was extended more anteriorly. The tumor was noted to be slightly calcified at least along its base based on preoperative CT. We used special Rongeurs to remove the bone over the area of the tuberculum and be able to expose the most anterior margin of the tumor. This is often the most challenging part of bony removal to make sure the acute angle is overcome to be able to remove enough of the tuberculum and the posterior plenum to expose the anterior and posterior extent of the tumor. More laterally bony remove all was extended toward the areas of the cavernous sinuses, and bleeding was controlled using FloSeal and gentle tamponade from a piece of Cottonoid. Tumor appears relatively well exposed. Neuronavigation confirmed our extent of bony exposure. Next, the tumor is being debulked. Parts of the tumor relatively soft. Here's part of the tumor just underneath the chiasm. Often the more accessible plane is the plane between the pituitary gland stalk and the posterior part of the capsule. Therefore, here is the stalk. The chiasm. The tumor was relatively dissectable, at least at this portion of the dissection. However, as I continue dissection more anteriorly, the tumor was extremely adherent specially to the left optic nerve as it entered its foramen. Continue the dissection. More on the right side because the tumor appeared to be more easily manipulable. Here is removal of the tumor on the left side using ring curettes. Again, you can see the tumor is not easily mobilizable. This is a three-hand technique so more microsurgical techniques can be employed. Here is the carotid artery that was evident at the tip of my arrow on the left side. Attempting to dissect the tumor as safely as possible using sharp dissection techniques. Here you can see the optic nerve entering in its foramen. Tumor is very adherent to the peel surface of the optic nerve. I did not want to cause any injury to the cerebral vasculature of the nerve, therefore small part of the tumor was left behind over the nerve. Here you can see how adherent the tumor is to the sheath of the nerve. Optic nerve. Carotid artery. Continuing my dissection. Using sharp dissection techniques as much as possible. I continue further manipulation over the left optic nerve, left A1. And the tumor is very adherent to the optic nerve in this area. I attempt to skip a piece of tumor over the nerve and continue dissecting underneath there. A1 complex, as well as the ACoA. Here's part of the tumor over the right optic nerve as the nerve enters the foramen. This part of dissection appeared more doable as the portion of the tumor entering the foramen was mobilizable. Using the debrider to decompress and remove part of the tumor along the midline so dissection of the tumor from the ACoA complex can be performed under direct vision. Unfortunately, as you can see, the A1 was again engulfed within the tumor just as the left optic nerve was. I attempted to gentle dissection, preserving the artery. Again, the tumor appears to be adherent. There's no easy planes between the artery and the tumor that can be entered. Diverting my attention to the right side, you can see the right A1. This plane is further developed. The perforating vessels are carefully protected. I continue to persist. Since losing the plane at this junction would definitely make gross total removal of the tumor very difficult. Again, further dissection along the contralateral A1. Some of the perforating vessels are evident here. reaching to find the ACoA complex and protecting the artery of Huebner. Again, you can see part of the tumor left over the left optic nerve. Here's one of the perforating vessels off of the left A1. Here's the perforating vessel, appears healthy. Maybe the manipulation was relatively excessive, however an attempt was made to remove as much of the tumor as possible. Especially in older patients, these perforating vessels can be quite sensitive to any slight maneuver leading to their dissection and potentially postoperative ischemia in their distribution. Here's that perforating vessels, which is the center of attention. The tumor is awfully adherent to the ACoA complex. No easy planes can be found. Various instruments were used to develop a plane of dissection. Another perforating vessels off of the right A2. Now I divert my attention to where the final area, where the dissection plane was developed, hoping that coming from anterior to posterior direction, I can develop a reasonable plane between the arteries and the tumor. Here, you can see the A2 branch. The anterior ramus of fissure. The tumor remains very adherent to the ACoA complex. Although very small piece of the tumor is left, I continued to debulk the tumor knowing by now the fact that gross total removal is not achievable and a small piece of tumor has to be left behind on the ACoA complex just that was left behind over the left optic nerve. Here, you can see the dissection from anterior to posterior direction. Here is the A2. This is a nice view of how adherent the tumor is to the ACoA complex. Even after this plane was developed, unfortunately, this part of the artery appears very adherent to the tumor capsule. Further debulking was elected Here, you can see how adherent the tumor is to the ACoA-A2 junction. Part of the tumor was left at this area. Here, again, is the adherent piece of the tumor. Perforating vessels just lateral to the left A1. Those vessels are also very adherent to the posterior capsule of the tumor. Continuing with additional tumor debulking, the left optic nerve was unroofed and additional attempt for tumor removal deemed reasonable. Small part of the tumor was delivered. However, this piece of the tumor remained very adherent to the peel surface of the nerve. Here is the three-hand technique with two surgeons and three instruments working at the same time. Very small and thin sheet of tumor was left over the left optic nerve. The right optic nerve was generously decompressed through its foramen. The shunt tumor was removed over the optic nerve on the right side. There are small piece of the tumor over the left ACoA complex and A2 was left behind. It was quite coagulated to avoid and minimize the chance of future recurrence. Closure was completed using the casket technique. Piece of dural allograft, preferably a softer one, was used. As you can see here, piece of prosthesis to create the countersink effect. The nasal septal flap completed the closure. Post-operative MRI demonstrated a small residual tumor anteriorly. Unfortunately, this patient suffered from a cardiac stroke, most likely related to over manipulation of the perforating vessels coming off of the left A1 and A2. This important lesson signifies avoidance of significant manipulation of these perforating vessels, especially in all their patients. Although these perforating vessels appeared intact at the end of the operation, obviously some injury occurred to them which led to ischemia in the area of the caudate. Nonetheless, this patient made an excellent recovery at three months, including neurocognitively, and his vision continues to improve after surgery. Thank you.
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