Endoscopic Endonasal Resection of Olfactory Groove Meningioma
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Let's discuss resection of large olfactory groove meningiomas via the endoscopic transnasal transcript reform technique. This is a 32 year-old female, who presented with progressive personality change. MRI evaluation revealed a large olfactory groove meningiomas. Evidence of significant high prosthesis along the anterior cranial base. Also significant amount of edema along the bilateral funnel lobes. You can see the tumor extends all the way to the mid-section of the orbit. This is the farthest the tumor can get, in terms of its girth to be a good candidate for endonasal resection methods. If the tumor extends beyond the mid portion of the orbit, it should be removed via the transcranial routes. Let's go ahead and review the operative events for removal of this tumor. Bilateral nasal septal flaps were elevated on both sides of the septum. Partial sphenoidotomy and bilateral total ethmoidectomy's were completed. You can see the posterior wall of the funnel. Sinus pony removal extended all the way from the posterior wall of the frontal sinus to the area of the tuberculum sellae. The craniectomy also extended bilaterally toward the lamina propecia. And in fact part of the laminar was removed to expose their medial part of the orbit. Here's the craniectomy. The drilling allows removal the bone again, all the way from the posterior wall of the frontal sinus extending to the area of the tuberculum cellar. Circumferential bony removal disconnects the area of the high prosdosis and accomplishes the transcrib reform corridor for removal of this tumor. Part of the ethmoid bone is left behind. This is the part that is associated with hypostasis from the tumor. Importantly the anterior and posterior ethmoidal arteries are coagulated on to de-vascularized the tumor aggressively. Subsequently the high prosthetic bone is removed. As you can see here and the tumor is aggressively debulked. You can see the narrow operative corridor piece of tumor can actually get stuck in the naries. However, eventually should be able to be removed. I continue tumor removal and debulking. After the debulking is complete the tumor capsule is dissected from the surrounding brain. In this case, the significant amount of edema led me to believe that peel invasion is very likely. You can see the branches of the frontal polar arteries that are involved in the tumor and actually are tumor feeding vessels. These arteries were carefully coagulated and cut. Subsequently, I focus my attention to the posterior capsule of the tumor. The optic nerves are identified and again the tumor is micro surgically dissected away from this cerebrovascular structures along the posterior capsule of the tumor. You can see the olfactory nerve, which was very much engulfed in the tumor and had to be sacrificed. I continue microsurgical mobilization of the tumor from the parenchyma. Carotenoid patties are used to wipe the brain away from the tumor. You can see this important maneuver of mobilizing the tumor away while leaving a carotenoid patty to create the dissection plan between the parenchyma and the tumor capsule. And note this important maneuver of gently pulling on the tumor and then leaving a carotenoid patty to create a dissection plains. Falx cerebri is coagulated and cut along the anterior aspect of the tumor. I continue to debulk the tumor aggressively using the ultrasonic aspirator. It is important not to limit the exposure and remove the bone all the way to the area of the laminate apprecia. So the lateral margins of the capsule are readily identifiable. You saw a brief view of the ACA just a moment ago. This time the tumor got again stuck at the nose but eventually was removed. Here's the resection cavity carefully inspected using a 45 degree angled scope. No residual tumor is apparent. All the edges of the dura appear clean. Again, this maneuver allows a simpson one resection that may not be feasible via the transcranial approaches. A piece of allograft dura was used to reconstruct the dural defect as the first layer. Large pieces of fat were also left behind to additionally create more reconstruction material. And other piece of allograph dura was also inserted and tucked in along the edges of the craniectomy. Subsequently, the two large nasoseptal flaps were recruited all the way to the funnel sinus so that this skull-based defect can be adequately covered. Again, one has to remember to harvest very long nasoseptal flaps so that ages can reach the frontal sinus. In this case, postoperative MRI revealed gross total removal of the tumor, the edema has essentially resolved. This patient's personality has significantly improved and she has recovered from the surgery without any complications. Thank you.
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