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Posterior Dominant Insular Tumor: Transsylvian Approach

October 28, 2019


This is another video describing resection of a Posterior dominant side Insular Tumor via the Transsylvian Approach. Let's see how we can extend the transsylvian route for the Posterior Insular Tumors. This is a 43 year old female who presented with a seizure. MRI evaluation revealed a relatively homogeneously enhancing mass in the posterior aspect of insula on the left side associated with some edema. You can also appreciate the relationship of this enhancing mass to the MCA branches that are overlying the tumor. Due to their relatively small size of this tumor, a Transsylvian Approach should be more than adequate to access the tumor. A left-sided frontotemporal craniotomy was completed. Here you can see the frontal lobe, temporal lobe, Sylvian fissure. A wide dissection of the fissure was completed. You can see the use of water in the syringe to expand this Sylvian fissure. The injection of the fluid expands the fissure and may facilitate easier split. The M2 branches are followed more posteriorly. Here you can see that, again frontal lobe, temporal lobe, wide fissure dissection. We'll go ahead and focus our attention to the posterior aspect of the insula. The M2 branches are mobilized. You can see the discolored insular cortex. Most likely overlying the tumor. It's critical to mobilize these MCA branches. There is some spasm often present during their manipulation and papaverine soaked gelfoam may be used to bathe these arteries with papaverine. As you can see here to relieve their spasm and decrease the chance of distal ischemia. Obviously neuronavigation is used during this entire procedure. A small corticotomy over the tumor is completed. We enter the tumor. We expect the tumor to be very discolored. Pituitary round jaws are used for the biopsy, which in this case was determined to be a high-grade glioma. We'll continue to remove additional tumor. Tissues collected for both pathology and research. Next we continue using the suction and high magnification in order to identify the margins of the tumor. Retractors are not used in this case. You can see how the tumor is delivered into the resection cavity. Next bipolar of the cautery is used to emulsify the tumor, after which the suction evacuates the emulsified tumor. Again as you can see, the tumor is relatively discolored. And now just about here, we're getting to relatively normal margins. Dynamic retraction is used. It's important to avoid any heat injury to the distal M2 branches. Work around the arteries to remove additional tumor, in this case, on the temporal side. We continued to use papaverine soaked gelfoam intermittently, to protect the vessels and relieve their vasospasm. Resection is continued until relatively normal margins are encountered. You can see the micro-Doppler probe is also used intermittently to confirm adequate flow within the vessels. Here's a more demagnified view of our resection cavity. You can see the brain and the opercula look relatively intact. And here is the postoperative CT scan, which revealed no evidence of ischemia, good resection of the tumor. And this patient made an excellent recovery without any neurological deficits. Again, this video demonstrates how wide split of the fissure more posteriorly and dynamic retraction can be used to access the tumors along the posterior aspect of the insula safely. Thank you.

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