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Petroclival Chondrosarcoma: Transclival Transpetrosal Approach

April 28, 2016

Transcript

This video examines the reach of the endoscopic transnasal approach for resection of petroclival lesions and more, specifically chondrosarcoma's. This is a 52 year-old male who presented with intractable headaches and biopsy proven chondrosarcoma. You can see the location of the mass. Again, typical of a chondrosarcoma at the area of their spheno petroclival junction. These tumors are typically extradural, however, this tumor may have had some intradural component. We'll go ahead and examine this region very carefully during our resection. Endoscopic transnasal transpetroclival approach was attempted here where you can see the clivus petroclival region, the floor of the sphenoid sinus. CT guided neuro navigation was used in intraoperatively. Petroclival bone was targeted and drilling allowed exposure and unroofing of the tumor, obviously their paraclival carotid artery was avoided during the initial stages of the operation. You can see the soft tumor typical of chondrosarcoma's. Next I continued to unroof the portion of the paraclival carotid artery, it's early identification will keep it out of harm's way. You saw the dura a moment ago. Again, this tumor was primarily extradural. No transdural invasion was noted upon careful inspection of all the corners. Here you can see the protuberance of the paraclival ICA. I continue to drill the affected part of the bone by the tumor. Here, now I'm going to unroof the ICA, as it leads to the cavernous sinus. Again, the tumor often tracks along the carotid artery into the cavernous sinus, and therefore it's best to unroof the carotid artery, as you can see here, to be able to remove the tumor around the ICA. I continue to drill the soft affected bone. Again maximizing my chances of gross total resection of this tumor. Haemostasis can be readily managed using bipolar forceps if necessary. Now the tumor is being evacuated using pituitary rongeurs, importantly 45 degree angled endoscopes and angled instruments are used to remove the most lateral part of the tumor, getting close to jugular tubercle you can see the tumor is soft, really an excellent candidate for endoscopic approach, here is the paraclival carotid you saw a moment ago, I continue to remove the tumor until the dura of the petroclival region is apparent using angled suctions as well to inspect the dura of the lateral clavo region. This is the area where I thought the tumor could have violated the dura, but it did not. And continue to remove the tumor until the dura is encountered. You can see the hard bone is now apparent. Tumor is being delivered around the corners into our resection cavity and using the 45 degree endoscope to clearly inspect every corner. Now, the walls appear relatively clean, a little bit of tumor left here that we're going to remove and working around the bony edges. And then this is really a nice view, as you can see of the dura of the temporal fossa that paraclival carotid entering into the cavernous sinus. You can see the anatomy better, right where the carotid enters into the cavernous sinus area, the sellar. Really a nice approach for a section of these tumors, through a very minimally disruptive corridor. And there's the septal flap was used to cover our resection cavity, no obvious CSF leak is apparent and the post-operative MRI examination revealed gross total removal of the mass, even the portion that was sort of indenting and pushing the dura more posteriorly, and this patient made an excellent recovery. Thank you.

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