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Large Bifrontal Glioma

May 06, 2014


Let's review the methods for resection of Giant Medial Frontal Gliomas. This is a 51 year-old male who presented with personality change. MRI evaluation revealed a very sizeable medial frontal, more specifically on the right side glioma with areas of calcification and partial enhancement. You can see the extent of the tumor all the way to the base of the frontal lobe and deep structures through this sagittal T2 MR image. I used a parasagittal craniotomy from the left side to use a transfalcine cross-court route to remove the tumor. I believe this cross-court approach would provide an extended operative trajectory toward the right side to remove the more lateral pole of the tumor. Let's go ahead and review the intra-operative findings. In here's the falx. Going from the left toward the right or the calcium marginal and pericallosal arteries are carefully protected. You can see the sutures within the falx where the falx was cut. So they're falx in flaps are immobilized. I work within the windows among the arteries to remove this relatively soft tumor. The response of the tumor to bipolar coagulation is somewhat different than the response of normal brain. Can see this tumor is readily emulsifiable via the use of bipolar forceps. Prepared and soaked gel foam. Pledges are used to bathe the arteries so their vasospasm is relieved. I continued to my resection until I reached the ventricle. intraoperative navigation especially important for removal of this tumor. The operative blind spot is obviously toward the right side, underneath the lip of the medial frontal lobe. I just follow the pathway of the tumor. Tumor appears slightly discolored compared to the normal brain. Here's working within the ventricle to remove the part of the brain affected by the tumor. Obviously resection of the very deep part of the tumor affecting the thalamus and hypothalamus is not safe. And working between the pericallosal arteries, removing the part of the corpus callosum, affected by the tumor. Here's the removal of the posterior border of the tumor. Very large resection cavity. Removing the more inferior part of the tumor beyond the boundaries of the caudate. Can see the ventricle there, pericallosal arteries. Following the part of the tumor debts can be easily evacuated via this suction device. Choroid plexus. We're moving deeper and deeper, removing the part of the tumor that is safely deliverable. Patient is in the supine position. Now inspecting the posterior part of the resection and the body of the lateral ventricle is unroofed. Here's the atrium of the lateral ventricle. I make sure I'm not overlooking any pieces of tumor. On the lateral side is the aqueduct. Along the posterior aspect of the third ventricle. Generous resection. Here's the right lateral ventricle, choroid plexus. Left lateral ventricle is located here. And removal of part of the tumor along the posterior aspect of the corpus callosum. Tumor was very fibrous and the bipolar forceps had to be used on a higher intensity for emulsification of the tumor. Here's a piece of papaverin soaked gel foam used to relieve vasospasm on the vessels. And I continue to undermine the edges of the cortex on both sides to make sure I'm not leaving tumor behind inadvertently. All the vasculature are protected. No obvious tumor is apparent. And postoperative MRI revealed reasonable section of this giant mass without any complicating features. Thank you.

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