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Peri-atrial Glioma: Awake Mapping and Transfalcine Approach

February 12, 2016


This is a unique video describing the techniques of the transfalcine approach, and mapping strategies for resection of a posterior frontal and peri-atrial tumor. This is a 41 year old male who presented with seizures and an MRI evaluation was diagnosed with a posterior medial frontal as well as an anterior medial pridal low grade glioma affecting the inferior aspect of their central labial. Anatomically, heres the location of the central labial, here's the marginal sulcus, functionally MRI confirms the location of the motor cortex draped over the tumor. DTI imaging also demonstrates displacement of the descending motor tracks by the tumor and the periatrial location of the mass is demonstrated here. Importantly, there is a branch of the peri co-sell artery traveling within the heart of the tumor. There are various traditional approaches to resect this tumor, the medial interim is ferric ipsilateral approach would place the central labial under significant retraction pressure. So the operator can reach the lateral pore of the tumor. I do believe this amount of retraction most likely would leave to significant amount of hemiparesis. Therefore, I chose a contralateral interhemispheric transfalcine approach in this case so that the cross core trajectory can disclose the lateral portal, the tumor with our significant retraction on the ipsilateral central labial. Furthermore mapping was used to localize the somatosensory association and areas anteriorly as well as the central labial ipsy laterally so that the contralateral central labial over the tumor can be estimated. Let's illustrate these concepts with the review of their surgical video and awake craniotomy was employed. Regional scalp anesthesia is ideal for the occipital supraorbital and supra troll clear nerves to provide additional comfort for the patient. Here's the incision draping for an awake craniotomy. A pair of sagittal craniotomy was completed the brain was noted to be relatively tight and therefore an external ventricular drain was implanted early. The Douro was open and a currently a fashion based over the super satchel sinus that is unroofed here. Two sutures were placed in the superior aspect of the falx mobilizing the superior sagittal sinus control laterally. Let's review the findings through neuro navigation here. You can see the falx neuro navigation identifies the ideal transfalcine scene trajectory to reach the tumor without significant retraction of the ipsilateral hemisphere. Obviously the central lobby was draped over the tumor and any retraction of the cortex over the pool of the tumor can place the central labial at significant risk. Next, the falx is incised in a T-shaped fashion. The subdural strip is implanted in preparation for mapping, you can see that the SMA area is mapped. No function was detected. Furthermore the ipsilateral or the central labial cortex of the normal hemisphere or unaffected hemisphere series mapped. And the leg area on the right side was noted to demonstrate motor activity. Again mapping the unaffected central labial can estimate the location of the central labial over the tumor. You can see the motor activity, the leg area. Next I stimulated slightly more anterior to the margin of the tumor along the medial aspect of the affected hemisphere and was able to trigger complex movements in the left upper extremity. Again, a characteristic of the function in their SMA cortex after mapping the function of SMA the tumor was entered the bulked, the ventricle and the temporal horn, or the try going area was also identified. You can see a vessel transfer seeing the section field. This vessel was carefully preserved and working channels on both sides of the vessel were employed to remove the tumor effectively. Postoperative MRI demonstrates a reasonable resection of the mass. The central labial was protected and this patient did not suffer from any postoperative neurological deficit. Thank you.

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