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GBM of the Lateral Ventricle

July 07, 2014

Transcript

Resection of Intraventricular GBM's can be challenging since the tumor most likely invades at least part of the wall of the ventricles. This is a 42 year-old male with history of progressive confusion. MRI evaluation revealed a heterogeneously enhancing mass based on septum pellucidum. The differential diagnosis also included a central neurocytoma. Patient underwent an anterior interhemispheric transcallosal craniotomy for resection of the tumor. You can see the linear incision and the location of the midline. Superior sagittal sinus was unroofed. A right frontal craniotomy is evident. Any tear within the lakes Lateral to the superior sagittal sinus is repaired primarily. Venous lakes can bleed profusely. After repair of this tear, the interhemispheric corridor was entered. I placed two sutures within the superior aspect of the falx. These sutures are placed under traction so that the superior sagittal sinus can be mobilized toward the contralateral side. This expands our interhemispheric corridor. Microsurgery separates the cinguli from each other. I look for the pericallosal arteries to direct me toward the corpus callosum. In fact, callosomarginal arteries can be used to direct one, toward the pericallosal arteries. Here are the two pericallosal arteries, the corpus callosum. We'll go ahead and complete a small callosotomy as guided by neuronavigation. It is best to dissect the cingulum as much as possible so aggressive refraction is not necessary to expand the operative space. Patient again, is in the supine position with the head in the neutral state. Small callosotomy is completed. Ventricle is entered. Here's a gelatinous tumor consistent with a GBM on pathological examination. The callosotomy is expanded more laterally. The tumor is entered and using Pituitary Rongeurs and a suction device, the tumor's enucleated. The blind spot of the surgeon is underneath both corpus callosums, laterally. Here's the use of a dissector to deliver the mass toward the midline. Bipolar forceps set at a higher magnitude or intensity are used to emulsify the tumor so that the suction device can evacuate that part of the tumor. Here's this rolling technique. As the tumor is debulked, the capsule, the mass is rolled toward the midline. And pituitary rongeurs continue to evacuate the GBM. Aggressive debulking is a key maneuver for easy mobilization of the capsule toward the midline. Here you can see, the right ventricle is entered. Here's the part of septum pellucidum affected by the tumor. We also move toward the left ventricle where the part of the septum pellucidum affected by the tumor is being removed. It's critical not to injure the walls of the ventricle. As you can see here on the right side, inadvertently. Here's the wall of the ventricle on the left side. Here's the septum pellucidum affected by the tumor. So both chambers are identified so that you're protected during tumor removal. After the more anterior part of the tumor and the affected part of the septum pellucidum is removed, I divert my attention more posteriorly, where the tumor fans out more laterally. Here you can see again, the more inferior aspect of the septum pellucidum affected by the tumor. I realized that colosstal removal is not possible. Here is foramen of Monro. The blood within the foramen is evacuated. Obviously, the internal cerebral veins are at the roof of the third ventricle and somewhat infiltrated by the tumor. These veins should be protected along the inferior pole, the mass. I continue tumor evacuation more posteriorly. Here, you can see that part of the tumor that is filling the lateral part of the body of the lateral ventricle. Choroid plexus in in view. Obviously, the choroid plexi on both sides have to be identified. So that the surgeon is not leaving tumor behind. Pituitary rongeurs remove the more fibrous part of the tumor that is not easily removed via the suction device. Bleeding is kept to minimum. Here you can see a vein on the wall of the lateral ventricle. Along the deep proportion of resection cavity you can see the bilateral deep structures, including the pair of internal cerebral veins. I continue removing the part of the tumor that is infiltrating the posterior aspect of the internal cerebral veins. Here's the arachnoid band over the veins. Here's another view, a de-magnified one for your orientation of our operative cavity. Here are the internal cerebral veins, more anteriorly. I'm diverting my attention more posteriorly, so that part of the tumor toward the atrium can be removed. You can see the wall of the left lateral ventricles infiltrated, partly by the tumor. Therefore, a complete resection of mass would not be safe in this area. You can see the vein is also affected. Here is that blind spot, just underneath the corpus callosum, where significant amount of tumor is hiding. This is particularly an important maneuver to make sure effective tumor de-bulking is achieved. Again, the tumor is quite heterogeneous. That's the depth of the resection cavity. Again, the roof of the third ventricle, the walls of the right lateral ventricle. Inspection in this area reveals the internal cerebral veins. Foramen of Monro is located there. It remains patent. Here's the contralateral foramen of Monro. Further inspection reveals only small amount of residual tumor that was adherent to the walls of the left lateral ventricle. Immaculate hemostasis is secured. Any part of the tumor that can be coagulated is coagulated. Further inspection posteriorly, reveals small amount of the tumor reaching toward the atrium. This part of the tumor was also removed. Final view of our operative corridor. Both foramen of Monro are patent. Post operative MRI demonstrated the expected findings. You can see small amount of residual tumor over the roof of the third ventricle, as well as small amount of tumor dot over the areas where the tumor was very adherent to the walls of the ventricle. Thank you.

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