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Giant Biventricular Epidermoid: Endoscopic Assisted

August 17, 2016


This is a challenging case of a Giant Posterior Biventricular Epidermoid tumor. This is a 32 year old male who presented with intractable, headaches and progressive memory difficulty. MRI evaluation, as you can see demonstrates this very large epidermoid mass, within the posterior biventricular area. Further, images demonstrate the extent of the tumor all the way to the area of the pineal region. The most challenging part of the tumor is the lateral extents of the tumor that are within the operative, blind spot of the surgeon. If the tumor is approach, via a posterior callosotomy. In this case, I did use a posterior callosotomy or trans-splenium approach for removal of the tumor coming from the right side, a lot more drain was used for brain decompression. Patient was placed in the lateral position. A linear incision was used over the posterior bridal area, crossing the midline, and a right-sided power sagittal craniotomy was elevated, with on roofing of the superior sagittal sinus. Here's a superior sagittal sinus, very small craniotomy, anterior transcortical approach. You can see gravity retraction, provides humble amount of space without the use of fixed retractor blades. The parasagittal veins were released, so that the lobe can be mobilized. Here's the exposure of the splenium, already affected by the tumor. The thin layer of overlying splenium, was transected, so the bulk of the tumor along the midline is exposed. The callosotomy was extended slightly posteriorly, so that humble amount of operative viewing, is available for tumor removal. As expected the tumor is, quite suckable, tumor debulking continues. Pituitary rongeurs are used to further debulk the tumor. You can see removing the lateral part, of the tumor is quite challenging. Dynamic retraction is used, the walls of the ventricle are carefully protected. However there is plenty more tumor more laterally, that has to be extracted. Part of the tumor, can actually hide underneath the ependymoma. Those pieces that are readily available, can be safely removed. Tumor fragments that are very adherent, to the neurovascular structures are left behind, to avoid the risk of neurologic morbidity. Again the operative blind spot is the very lateral pole of the tumor. Further resection can be supported via, additional visualization, through the endoscopic assistance. For now, I remove most of the tumor that was available along the midline and on the right side, next I complete the trans versing approach. A T-shaped incision is completed, within the falx. The leaflets of the falx are mobilized. It's important to, be very careful and not injure the straight sinus. Here's a view of the trans versing approach, the opening within the falx, allows mobilization of the contralateral hemisphere, and removal the tumor hiding underneath the splenium. And that's a very prominent operative blind spot, the portion of the tumor along the superior pole, of the tumor just underneath the splenium. Walls of the ventricle are apparent, and pulmonary irrigation is used to further dislodge, the pearls of the tumor. Here's the foramen of Monro more anteriorly choroid plexus. I continue to inspect, the surrounding neurovascular structures, to see if, removal of the small pieces of the tumor are safely, permissible. Again looking around the edges of the resection cavity, with this large sized tumor, it's unavoidable that some of the tumor fragments will be embedded, within the ventricular wall and not, necessarily safe to remove. It's important to leave some carotenoids, along the edges of the ventricle to avoid, movement of the tumor pearls into remote aspects, of the ventricular system and avoid a septic meningitis or encephalitis. Here's the use of the endoscope, to look more posteriorly, here are some of the tumor fragments, that are being removed. These were not, at all visible via the, trans colossal approach. By manual dissection can be completed, with their system, holding the endoscope. I attempt to remove as much of the tumor capsule as safely possible, to decrease their future risk of tumor return in this very young patient, you can see how adherent power the capsule of his tumor is to the surrounding ventricles, really complicating, any attempt at gross total resection of this mass. Sharp dissection may be used, to cut away some of the, tumor capsule when possible. Again here is called plexus within the atrium, mobilizing another sizeable fragment, of the epidermoid cyst. Curettes maybe used, to gently dislodge, and mobilize some of the tumor fragments, in the goal of the operation can not be gross store removal, because of the large size of the mass, which indicates significant adherence, of part of the tumor fragments, to the ventricular wall. Here's part of the tumor that's very embedded, on the left lateral pole of the tumor. These tumor fragments are quite embedded, within the ventricular wall. Angled suction is used to further maximize, removal of these pearls. Some of these fragments can be mobilized readily. Some of them are quite embedded, within the ventricular wall. Here's one of the final views of the operative cavity via the endoscope. And the three months MRI revealed, more than 95% radical subtotal, removal of the tumor without any complicating features. Here are the diffusion sequences, that are very sensitive in detection of the epidermal cyst. You can see small tumor fragments, that were left behind, underneath the ependymoma, to avoid any risk of neurological morbidity, and this patient made an excellent recovery. Thank you.

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