April 29, 2016
This video describes techniques for a section of brainstem cystic hemangioblastomas, and also review some of the advantages of fluorescein fluorescence for studying these tumors. This is a 41 year-old male who presented with left-sided facial numbness. MRI evaluation demonstrated a cystic mass over the left lateral aspect of the medulla oblongata with an associated enhancing nodule. This lesion was suspected to be a hemangioblastoma. Patient underwent a midline suboccipital craniotomy, and a C1 laminectomy. Head positioning and the midline incision is demonstrated. The bone exposure involved only a minimal midline suboccipital craniotomy. The majority of the bone removal centered over C1 laminectomy and superior C2 bone removal. The dura was incised in the midline. You can see there, arachnoid layer is preserved. Retention sutures. The encasing arachnoid planes were opened and ultimately the cystic nodule was widely exposed. Here, you can see the nodule, the feeding arteries and draining veins leading to the hemangioblastoma. Here is a closer view of the malformation and a small draining vein. Flouricine can study the hemodynamics of the vessels within this tumor. You can see the early arterial phase, here is the draining vein. The arterialized vein that is filling ahead of other normal veins in the surrounding neural structures. These lesions essentially act like simple arteriovenous malformations. Due to critical location of this mass, I attempted its removal while staying as close to the tumor as possible, preserving as much of the neural tissue as is safely possible. So the small arterial feeders to the tumor were carefully exposed. Forceps and bipolar arterial cautery was used on very low amplitude to avoid any thermal injury to the surrounding structures. En passage vessels were carefully protected. You can see the tumor is being circumferentially devascularized. Irrigation is used. Microdissection disconnects the capsule of the lesion from the surrounding neural tissue. High magnification is used. Slight amount of bleeding is tolerated, if necessary, to avoid aggressive coagulation. I continued to work around the circumference of the mass. Its capsule is also coagulated. Ultimately, the cyst will be entered. You can see I'm staying very close to the capsule of the tumor. The section planes continue to be developed. Here is partial entry into the cystic cavity Inferior pole of the tumor is now disconnected. Now the nodule appears to be more mobilizable. Its being gently pulled out of its resection cavity. The cyst should be punctured momentarily. Here is the final attachments to the surrounding neural tissue. The cyst is apparent. Obviously the walls of the cyst or not pathologic and should be left intact. You can see the thick lytic margin around the capsule of the lesion. The lesion is now completely disconnected and extracted. Here is the final piece of the lesion. Look into the cyst. No residual tumor is left behind. Final look at the operative corridor. And postoperative MRI demonstrates decompression of the cyst and gross total removal of the enhancing nodule, and this patient recovered from his surgery effectively and his numbness resolved. Thank you.
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