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Peri-atrial Metastasis-Transfalcine Approach

January 19, 2016


Let's discuss the use of the transfalcine approach for resection of peri-atrial or splenial GBMs. This is a 52 year old female who presented with very minor visual dysfunction and was found to have this relatively homogeneously solid mass in a inferior and medial wall of the atrium. You can see the lesion is also infiltrating part of the splenium is closely related to the vein of Galen and his straight sinus destructor should be considered and carefully protected during their fall scene incisions. The patient undergo a resection in the lateral position using a Lamar drain. You can see the normal hemisphere was placed down or in the dependent position. Gravity retraction was exploited. The first incision is parallel to the superior sagittal sinus. Because this tumor is somewhat more posteriorly located. The T-shaped incision is modified. In other words, the limb of incision is conducted in an oblique fashion. You can see the splenium, at the depth of our disssection cavity. So the reason the second incision is in the oblique fashion is to protect the venous lakes around the straight sinus. You can see that the flap of the falx is mobilized, and here is the part of the falx joining the tentorium containing the venous lakes of the straight sinus. dissection is continued the splenium is recognized. The draining veins toward the vein of Galen are protected. Navigation guides via extent of dissection in the posterior direction. You can see this portion of the falx is not excised or transected to protect the important venous structures within the falx. Next, a small over the tumor is performed and the tumor is debulked and resected. So an important discussion in this case is the pattern of the falcine incisions to protect the posteriorly located the dural venous sinuses. I continue to stare around the capsule of the tumor. Remove the tumor piecemeal using pituitary rongeurs. You can see the capsule of the tumor that has been dissected from the surrounding white matter. A discolored mass is quite apparent. Piecemeal removal prevents undue traction on the surrounding structures. And ipsilateral in Acetract rec approach, which requires a significant retraction on the ipsilateral hemisphere to reach the lateral pore of the tumor. Obviously a transcortical approach would place the optic radiations at risk. This fact applies to the lateral transcortical approach. Here is the choroid plexus within the trigone. Here is the magnified view of the opera field towards the trigone. The crosscore trajectories illustrated. You can also you can appreciate the importance of venous structures around the falcotentorial junction. The use of gravity retraction to mobilize the normal hemisphere in the dependent position and also their small operative corridor and minimal cortical transgression required to reach the lesion. Postoperative MRI demonstrated reasonable resection of this tumor. This patient's preoperative visual deficits remain stable after the surgery. Thank you.

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