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Giant Tuberculum Sella Meningioma

October 06, 2015

Transcript

This video refers to resection of a large tuberculum sella meningioma via the transcranial and, more specifically, pterional approach. This is a 41 year old male who presented after a seizure, was noted to be suffering from a large tuberculum sella meningioma herniating into the area of the sella. There is evidence of hyperostosis at the area of the tuberculum sella and playing on the sphenoidalis. You can see the vicinity and potential encasement of the anterior cerebral arteries at the posterior aspect of the tumor. Importantly, there's evidence of tumor infiltration into both optic canals. You can see the optic nerve displace more laterally and the tumor entering to the frame and more medially. A similar finding is evident on the right side. This is the typical location for tumor infiltration for tuberculum sella meningiomas as there is evidence of a potential space, just medial to the nerve at the level of the optic canal. There's also some edema associated with the tumor. Due to the large size of the tumor and it's very lateral extension, this patient underwent a transcranial approach versus a transnasal endoscopic route. A left-sided craniotomy was completed. The floor of the anterior cranial fossa was drilled flat with the orbital roof. The latter aspect of the sphenoid wing was resected and a partial clinoidectomy was completed. You can see the superior orbital fissure located here. The dura was open at coronal enfashion. The anterior limb of the sylvian fissure was dissected and the optic nerve and the carotid artery were first identified. Next the tumor was heavily devascularized along its base. And clotting was limited to the level of the midline to avoid any heat injury to the posteriorly located neurovascular structures. Tumor was also de-bulked. Early identification of the cerebrovascular structures at posterior level of the capsule keeps these structures out of harm's way. Use of dynamic retraction to decompress the tumor. Here's the optic nerve. Some tumor, again, herniating through the medial aspect of the nerve into the optic foramen. A Carlin blade knife is used to open the falciform ligament over the area of the tumor. This maneuver releases the nerve and adds to the exposure necessary to remove the tumor herniating into the canal. Can see the tumor has been pulled out of the potential space along the medial aspect of the nerve. Any heat injury to the nerve is obviously avoided. The tumors is de-bulked so we can more easily manipulate it. Here's the portion of the tumor that is herniating into the sella. This portion of the tumor is also de-bulked. Higher magnification reveals evidence of adherence of the tumor to the medial aspect of the nerve. I continue to de-bulk the tumor so that the tumor can be displaced away from the nerve. Here's the more superior capsule of the tumor that is being delivered into our resection cavity. The arteries that are in passage and are traveling over the capsule of the tumor, are protected. Again, tumor is removed piecemeal. Here's a tumor against the contralateral optic nerve. Mobilizing the tumor away from the nerve. Here's the ipsilateral optic nerve, contralateral optic nerve. Tumor de-bulking continues. Here's part of the tumor herniating into the medial part of the canal, compressing the contralateral optic nerve. So the contralateral nerve is generously decompressed. Now I continue to work on the ipsilateral nerve so it's generously decompressed. A blind to hook it's used to investigate the proximal portion of the canal. No evidence of compression is evident. Here is the chiasm contralateral optic nerve, ipsilateral optic nerve. A calm complex tumor herniating into the solitar skull was also removed. Here's part of the tumor along the planum. Some high proptosis is evident. This portion of the dura was heavily coagulated to minimize the risk of future occurrence, in the area of the high proptosis there. Here's the final result. Hemostasis was secured. And post-operative MRI revealed gross total resection of the mass, including the part of the tumor that was herniating into the sella turcica. The optic nerves were generously decompressed and this patient's vision significantly improved after surgery. Thank you.

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