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Transtuberculum Approach to Third Ventricular Choroid Plexus Papilloma

April 21, 2016


This video examines resection of the third ventricular choroid plexus papilloma through the expanded transsphenoidal transtuberculum approach. This video also tests the reach and capability of the transnasal approach for a highly vascular tumor, such as a choroid plexus papilloma, primarily located within the third ventricle with minimal reach toward the suprasellar space. This is a 42 year-old female who presented with visual dysfunction, and papilledema. She has previously undergone resection of her choroid plexus papilloma from the right atrium. Let's go ahead and review the imaging in this case. The tumor is predominantly within the third ventricle. Minimal extension through the lamina terminalis and the retrochiasmatic space toward the suprasellar area. Here you can see the location of the pituitary gland, most likely the stalk is displaced more posteriorly. The transnasal transsphenoidal transtuberculum approach was utilized. Preoperative visual fields are also available for review. Here's the elevation of the nasal septal flap, exposure of the tuberculum sellae. Transtuberculum approach was completed. The entire face of the sellar was not removed, only the anterior half of it was resected. Here's the dural opening. Cruciate incision within the dura, neuronavigation was used so that the bone opening extends from one cavernous sinus to the other. The chiasm was immediately apparent. The tumor is extending through the retrochiasmatic surface, the leaflets of the dura are coagulated and reduced, Most of the perforating vessels to, or the underneath surface of the chiasm are protected. Here is the tumor. Go ahead and expand our operative corridor, and then continue to debulk the center of the tumor. As expected, this tumor was vascular. As the center of the tumor is debulked, I hope to mobilize the superior polar capsule, away from the chiasm, and deliver it into our resection cavity. Angled endoscopes accompanied by angled dissectors facilitate dissection of the superior pole of the tumor from the third ventricle. Here's the most difficult part of the operation is to make the superior aspect of the tumor to be mobilized into our resection cavity. Some of the septations had to be sharply dissected. Here's a portion of the tumor that is being delivered. Continue our sharp dissection strategies. Part of the hypothalamus and the wall of the third ventricle is apparent. Here's the use of the 45 degree angled endoscope to dissect the superior pole of the tumor from the walls of the third ventricle. After dissection of the wall of the tumor, large portion of the tumor was delivered. Here you can see the third ventricular space by lateral foramen of Monro. Now I divert my attention to where the portion of the tumor that is adherent to the lamina terminalis. You can see most of the tumor essentially removed from the walls of the third ventricle. No residual tumor is apparent. Postoperative MRI demonstrated gross total removal of the mass. Pituitary stalk remains intact, and this patient's vision improved after surgery. Thank you.

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