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Grand Rounds-Tackling Challenging Cranial Cases

William Couldwell, Robert Spetzler, Rick Boop, Paul Gardner and Juan Fernandez-Miranda

August 12, 2015


- Ladies and gentlemen, my name is Aaron Cohen, thanks for being with us this afternoon. This is part one of our 3D series for managing difficult intracranial cases. We're gonna have the second session tomorrow, which would mostly focus on, complication management intraoperatively. Our speakers are Dr. Robert Spetzler, Dr. Rick Boop, Dr. Bill Couldwell, Dr. Paul Gardner and Dr. Juan Fernandez-Miranda. None of whom require any introduction. We're gonna go ahead and start with Dr. Robert Spetzler, who's been truly a mentor for so many of us, please.

- Thank you, Aaron. I think if you really want to see 3D best, it's always best to be toward the center, that way you have the maximum 3D visual effect. And I've put together a number of highly edited videos. We can go ahead and start if you don't mind. We're talking about a cavernous malformation, bled intraventricular leads right here and really the problem is, how are you best going to approach this? You can go ahead and let it run. Our own way of doing this is actually to go contralateral transingulate directly to the lesion. So here the patient is horizontal, the left side is down. We see the faux. You can see the trajectory, we opened the faux, we put the plate in and then pull the blade toward us. Now we have gravity retracting the left hemisphere, no retractors, opening the faux using some Yasargil scissors and with image guidance, then determining our trajectory, which is right here coming across the midline, going directly to the cavernous malformation, that allows us to really make a very, very small opening. We're now getting down to the ventricle and you can see right here as we're coming right down to the lesion and there's the cavernous malformation really sitting in the wall of the ventricle and that means no Richard retraction required direct access and then separating the cavernous malformation from the wall of the ventricle. I think in essence, these are all venous lesions. We see the venous connections to these cavernous malformations, interrupt them and take them out. I think cavernous malformations that are in the wall of the ventricle are really much more risky to the patient than when they're buried in the white matter, because when they bleed, they can fill the whole ventricular system and cast the ventricles and lead to maim. So here we're just using two tools, which is the retractor, light at bipolars to give us access into this deep location and then separating the lesion piece by pulling it back always with retraction, with the suction, you can pick up each little individual cavernous malformation. So here's the lesion, you can see very nice the trajectory. It's very hard to see from up here, but here it's nicely gone. The next case is for, cervical arterial venous malformation. This is a patient that had multiple episodes, was treated elsewhere, endovascularly with embolization. Keep going, just let it run. Here you see a lot of embolic material inside. Opening the dura, starting off with 2D as a comparison, and then switching over to 3D. You can see underneath the arachnoid, all the coil vessels and what has been such an interesting finding in these lesions here, you can see all the embolic material, which is extra vascular. The really neat finding for these lesions is that you can coagulate the vessels, which are part of the AVM and cut across them. Something that we really can't do in the intercranial space, because when we cut across an AVM, we are usually rewarded with the uncontrollable bleeding, but here, if we stay in the arachnoid plane... You see we're right in the plane, we try to preserve the little normal vessels. And we know that when we get to the AVM itself, you have U-fibers, you've vessels that go in and that come back out. Obviously very important you see all the Onyx that's lying around here, that's probably a small mbasedis spends worth of Onyx sitting in the extra vascular space, not surprising that the patient, this was done in Europe deteriorated after this injection. Although I'm very fond of Onyx as an embolic material and working with AVMs. And then again, just staying in this plane, being able to resect arterial venous malformation, which we've obviously published in journal on neurosurgery, but it really surprised us that can do this, when you know, there's going to be a portion of the AVM, that's still within the spinal cord itself. And then finally we've come around toward the last large draining vein. And then an ICG, just to make sure we don't have any shunting, a lot of abnormal vascularity, but you could see the mass itself is already gone. And here you see the spinal cord afterwards. There's no longer any shunting, in the late phase of the arteriogram. This is for a ICA aneurysm, basically after a rupture, basically to demonstrate that, just plain old retrosigmoid approach, is really more than adequate to get to these lesions, we don't need to do skull base approaches. We can really see the anatomy very well. So here through a retrosigmoid approach, no retractors, we're looking at the clivers here. We're looking at the sixth cranial nerve that's sitting right here. There's the aneurysm, brainstem is right here, seven and eight are right up here. So mobilizing the vessels, that's the neck of the aneurysm right here, that's aneurysm embedded in the brainstem. We see the basilor artery below. So we have proximal control, but we have very poor distal control of the basilor artery. And so this is ICA coming out and we have branch of ICA. And the key now will be to take this dome of the aneurysm and create a path between it and the brainstem. So it's embedded in the brainstem, the PS firmly adhered to the aneurysm. So taking scissors in order to create a cut in the attached pia-arachnoid, allows us to create a space, little bit awkward because we don't have distal control, so probably not a good idea to cut into the aneurysm, but here getting more and more space. We're separating. We're using our suction with slight retraction toward us and then a number six, to push away the vascularity. Separating a tiny little branch. Again seven and eight, six is lying right here, going to derail this canal right up here. and here just separating the brainstem. And as we separate the brainstem, thank you. As we separate the brainstem, we get to see better and better. So now here again, we see the basilor artery, we see ICA coming off, aneurysm sitting up here. Now we've created this pathway in between... Am blocking you? On the top, here's an overview, again you can see just with a little retrostigmoid approach, nothing special, then bringing in the clip. We've lifted six up, but now applying the clip, and obviously we have to be high enough on the next, so that we don't interfere with the flow of ICA. But you can see, you really have a very nice trajectory, a very nice view. And then we're going to do an ICG to make sure that our vessels that we have worked around are all patent. And so here again, you see the overview and you can see very nicely as you're looking down that ICA is very nicely patent, that's right here, lower cranial nerve's right there, six cranial nerve right there. And the post-op, you can see the aneurysm gone, clip sitting right here. Next one is a mini eyebrow approach for the clipping of an aneurysm. You can see the aneurysm sticking up from the internal carotid artery here, the approach. And coming down it's really the orbital bulb, and it's gone. It gives you those extra few millimeters angle of visualization, which I think is so important and the modified orbit a psychometric approach. Optic nerve, you can see the optic nerve lifted up over the dome of the aneurysm. Opening the arachnoid internal carotid artery down below, but you can see the mark distortion of the optic nerve, which accounts for the visual symptoms. In this case, it was hard to get to the neck without taking off a portion of the anterior clinoid. So cutting it off using the sucker to protect the knife in case it slipped some and then drilling off that anterior clinoid. And you can see again, no retractor. The flow seal which I call magic stuff, because it is just incredible in stopping any venous bleeding at all. Cutting a little bit of the ring, taking off just a little bit more of the bone so that we can slip the tine of the clip between the optic nerve. Problem here now we facing is that, this aneurysm has calcification in it. So the closing is gonna be very slowly to watch if it fractures or anything. So internal carotid artery, ophthalmic artery is coming off right there. And you can already see how decompress the optic nerve is. Nicely decompressed, that's the overview, plenty of room, despite the small opening and then the closure. The next one is left interhemispheric craniotomy. You could see a cavernous malformation, down deep para third ventricle in the thalamus. And I'll show you some other ones tomorrow where we have to open the choroidal fissure, but very often, if you line up the foramen of Monro. Again the patient is horizontal, that's just opening the septum pellucidum so that the CSF can drain out, so it doesn't fall down and obstruct your vision. We are looking through the foramen of Monro right at the cavernous malformation. So you can see the septal vein, you see the thalamus stride vein, and we can get right into it, choroid plexus sitting right here. Problem always is that the deeper we are, the darker it gets because our light doesn't come in at zero angle to give us a shadow, so now when we use a light at sucker, we can really see very nicely. Again using the suction as counter traction, little forceps that have teeth on them, I'm very fond of them because you can actually grab the cavernous malformation pretty well. and then just localizing it. This constant movement of the suction as counter traction on the normal tissue and the tooth forceps pulling on the pathology itself. Remember that above us, not visible here, naturally is the fornix and our goal is to keep that pristine. Here comes out part of the lesion and still see there's a good portion of the cavernous malformation behind, and we keep mobilizing it and then bringing it out. It's always nice to take it out in one piece, but that's more the exception than the rule and you can always tell the different ages of it. And then we spend a long time inside the cavity looking for any potential residual. So here it is, here's the fornix, you can see it's absolutely pristined. And there's the cavity where we were that's our trajectory. Little showing off. So this is a lesion that's based, meningioma that's based on the faux. We're coming in from the right side, patient again is horizontal. The right hemisphere is allowed to fall away just from gravity. And then in fact gravity brings in the tumor from the other side as well. So you really using gravity as your retractor for both access, as well as removal of the lesion and then just bringing it into your corridor. That's the faux cutting a little bit more of the faux to get full access. And then the bottom, obviously making sure that, the vessels on the bottom of the tumor aren't involving A3. Using ultrasonic aspirator in order to debulk the tumor. Bottom of the lesion, very nice a separation. Once we've cut the faux, separate the little vessels and then finally getting the last piece out. And again, really no requirement whatsoever for retraction. And you can see it's gone. Thank you very much for your attention.

- [Dr. Aaron] Thank you. Next I wanna introduce Dr. Rick Boop. Dr. Boop is without a question, the best pediatric neurosurgeon I have seen at work in terms of being a technical master and I've seen a lot of neurosurgeons at work during the my career. So I'm really proud to have somebody of his caliber here for the discussion of the cases, Rick please.

- [Dr. Rick] Thank you. So this first case is a child who is five-year old, who came up to us with a three-week history of progressive hemiparesis. And the phone call was we've got a posterior fossa tumor causing hydrocephalus. But if you look at the CT scan, it's not really a poster of faucet tumor. If you look on MRI, this is a tumor that is, I've only seen it in children, and I've seen it from age three to 15, but I've not seen it in older. They can be heterogeneous in their enhancement and sometimes radiologists may call them glioblastomas or high grade gliomas, but they're typically not, they're typically pile acidic and the children always present with, progressive spastic hemisparesis. So when I show it to the residents and say, how do you approach this? They'll say, well, it's a thalamic tumor, I'd go transcollosal to get to it. But if you look carefully, these are not, these we call Thalamopeduncular tumors and they arise under the thalamus at the lateral aspect of the p dunkle. And if you go transcallosal, you may go through a normal thalamus to get to tumor. Some people have advocated as subtemporal route, but you can't get to the superior aspect of the tumor and where along the p dunkle these tumors take their origin is variable and the extent to which they push up the thalamus is variable from case to case. So we'd written a paper a couple of years ago on a transtemporal approach because these tumors will cross the ambient cistern and apply enough pressure to the choroidal fissure, that they will rupture the fissure and then grow into the temporal horn of the lateral ventricle as this one has done and so that's a safe approach to it. The first time I saw one of these was before we had tractography and I went transsylvian and the patient woke up hemiplegic and in this paper of 10 cases, six out of 10, the corticospinal tract were pushed anterolateral so that a transsylvian approach takes you right through the corticospinal tract. The other structures that you have to be careful of here are the optic tract, the third and fourth nerves. And in this particular case, it extended down far enough into the posterior fossa that we didn't think we could get to the whole tumor from any one approach safely, so we ended up doing a staged operation. You can see here the tractography, Corticospinal tract are here and so we have a nice corridor. This is a glial cyst in the temporal horn, where the tumor has grown through the choroidal fissure. So we positioned the patient lateral mailer eminence to the ceiling and then using frameless stereotaxy, passive ventricular catheter into the tissue, into the ventricle when we get CSF, follow it down and get into the tumor there. And in this case, this is our Intraoperative MRI from stage one, where we took out the superior aspect of the tumor, relieved the hydrocephalus and then two, three weeks later came back from a retrosigmoid approach to take the rest of it out. Could we have the video please? So catheters past using frameless stereotaxy. This is superior temporal sulcus, so middle temporal gyrus, superior temporal gyrus. We're working with a binocular microscopes, so my fellow and I are standing opposite one another and that's why you'll often see four instruments in the field at once and this is a technique that we've enjoyed. So we follow the catheter down to the ventricle, just widening out the trajectory until it's wide enough to accept a half by three catenoid. And then you see the cyst of the tumor here in the temporal horn of the lateral ventricle. And since it's a neoplastic cyst, we can open that and then we'll be getting into, the solid portion of the tumor. So this leads into the ambient cyst which is all tumorous at this point. And that's where we have to be very careful about the optic tract. The third nerve as you know, is gonna be under the tentorial edge and in this case, we didn't get that far, but this sucker is retracting on the temporal lobe and the optic tract is there too and so we were very cautious to retract on a catenoid and try to be gentle with that. And as we cuss the typical gray fleshy appearance of a pilocytic astrocytoma and that's what the frozen section was, is distinctly different color and texture from the white matter tracks of the brainstem around it. So it's very easily identifiable, anatomically. This then is our retrosigmoid approach coming back two weeks later. And first thing we do is take petrosal vein, you can see the cyst of the tumor here underneath the vein and a cranial nerves come into view and adherent to the capsule but the sector way,. This I believe is five. And the cyst was almost like Pia, it was quite thick, but it dissected out quite nicely. You can see us opening the arachnoid over the cyst. And it's too billowy, then we'll next open the cyst and deflated so that we can dissect more easily. You can see we've dissected it out and then we've opened it to the typical zantac chronic fluid of a neoplastic cyst, and then coagulating the wall and removing it. And now we're starting to dissect the solid portion of the tumor away from the white brainstem fibers and as we go, we debulk with the coosa. Removing more of the cyst wall as it gets in our way. And debulking with the ultrasonic aspirator. His question is why go super tentorial first and then infratentorial. The patient presented with hydrocephalus and we wanted to debulk enough tumor, superiorly to alleviate the hydrocephalus and then we could come back for the posterior part later. And so you see the cisternal vessels is here, fourth nerve, and finally our debulking of tumor from the posterior approach meets our previous resection cavity. This is the only one out of a dozen children where we've actually used a staged approach, the rest of them we've been able to get a complete resection from a single approach transtemporal approach. So I think this is just drying up and cleaning up at the end. And if we could run this, this is just a cell phone video. Surgery was on Wednesday and this is on Sunday, four days later, just before discharge.

- [instructor] Walk down the hall away from me and come back again.

- [Dr. Rick] Sorry for turning you on your side, but you can still see he still as a circumduction gate and a clumsy arm, but for being four days post-op he's doing pretty well.

- [instructor] Now can you move it, stop right there for me.

- [instructor] Don't stop.

- [instructor] Now can you raise your arm up, raise your arms up, that's right. Hold up your hands and show me, can you do this with your fingers? Do it with your left hand. There you go, getting better by the day, aren't you.

- [instructor] Hi five. There you go.

- [Dr. Rick] If we could have the next case, please. This is a 13 year old who came to us from Albuquerque and her history is that in 2012, she presented with hydrocephalus, had an endoscopic third ventriculostomy and a biopsy of a third ventricular tumor. It was a very small piece and when our pathologist looked at it couple of months ago, they said they thought it was nondiagnostic, but it was called glioblastoma. And based on that, she had radiation and tumor zolomae tumor progressed. She went on to Avastin, tumor progressed and then the family came to us and she developed a movement disorder. She had no updates, no convergence at presentation. So this is her tumor and to me, it's got a well-defined margin. It's got a glial cyst, which is more typical of, to me, low grade tumors, difficult location. And then it was hard to tell in the surrounding area, whether that was radiation change or infiltrative tumor. You can see here her flare images and it was hypoperfused on profusion imaging. This is a Meth PET, which is a research protocol we have, it's not FDG PET, but on Met PET, it was very avid, which was concerning for a more metabolic tumor. But again, on these T1 weighted gadolinium enhanced images, it had a number of properties that made us think this might be a low grade tumor instead of a glioblastoma, not to mention she's two years out and it hasn't changed that much. So if we could have the video, please, this is a transcallosal approach. She's supine noticed that the bone flap goes across the midline and then with tenting stitches, we pull the faux over so that it's bowed and we can see straight down without any need for fixed attraction. We've got a good field of view down to the pericallosal vessels, down to the Corpus callosum, no fixture tractors. We're using frameless stereotactic guidance and you'll see that we use that to help decide the exact trajectory that the positioning of the bone flap and then the extent of the callosotomy as well. So here's our stereotactic probe, we put a piece of gel foam where the probe was, and that's just behind the genu of the Corpus callosum. And then another one more posteriorly at the mid body of the Corpus callosum centered over the foramen of Monroe. And then opening the Corpus callosum, taking care to cover the pericallosal vessels with catenoid so that we don't transfer any heat to the vessels keeping the bipolar tips perpendicular. Again, we've got opposing ocular, so we've got the first assistant able to assist the surgeon, taking the periventricular, subventricular veins on the way in and we're coming in on the right of the midline, so you see the septum collustrum coming into view over here. This is framing of Monroe, the choroid plexus, septal vein comes down just behind the frame and in this case and so we're opening up the choroidal fissure and here's the septal vein coming in into the internal septal veins there, so here's the fornix and we're taking care not to burn the fornix, but taking the septal vein and that gives us an opening into the whole third ventricle by opening the remainder of the choroidal fissure and being able to move more quickly, more posteriorly. As we open it up internal cerebral vein here and here, we're working between them and in the depths, you see the mass intermedia coming into view. You can see the cyst of the tumor trough the foramen of Monro and you can see the ependyma covering of the solid portion of the tumor more posteriorly. So here we're, coagulating the mass intermediate, the midline and the floor of the third ventricle is pushed up by the tumor underneath. And once we get there it dissects out like a fairly typical, low grade astrocytoma. So working now that we've sectioned a mass intermediate, we can work towards the posterior end of the third ventricle and we'll see the back wall of the tumor here and a normal ependyma behind it and then place a gel foam there over the aqueduct and then coose the tumor out in this case, because of prior radiation, the demarcation between the border of the tumor and the normal ependymal was not quite so easy in some places, but you can see here what looks like normal ependymal quite different than the tumor tissue. And once we got what looked like tumor out, then we dry up. I'll tell you that this case was a complication, She woke up just fine, but had a nuclear third nerve palsy on the right. And I think was, we were probably too deep in. This is the next case. We've got some slides to go with it before we start the video. I presented a similar case two years ago in the similar approach and it was a third ventricular low grade tumor that presented with a third nerve palsy and I'll just make the point that those fiber tracts are just under the floor of the third ventricle and in these tumors can either be violated by the tumor or by the surgeon. This next case is just kind of a fun congenital case. This is a child who came to us at the age of two with leukemia and was being treated for leukemia. When the hair fell out, the family noticed this lump on the back of the head and you can see discoloration of the skin here and I'm pulling up on the skin with my finger, which allows us to see this pit, which is typical of a dermal sinus tract. So this child went on to have this MRI and you can see on the MRI scan, the dermal sinus track coming through the skin, down the bone, just under the tentorial edge into a posterior fossa neoplasm that should be a dermoid. And here the child's prone on a horseshoe with an elliptical incision around it, the incision being extended down to open up the posterior fossa. Now the video, please. So we followed the tract down, you can see the portion of skin around the dermal sinus tract and we're making an opening with the drill just around the tract, following it through the defect in the bone and down to the dura. Histologically I'll tell you that this tract was full of hair and hair follicles when we send it to the pathologist. So here is the edge of the sinus, tracular right here and we took this out just to get it out of our way and then extended our bony exposure. This is a case that has an anatomical variant called a faux bellae in which the leaflets of the faux are split so instead of having one occipital sinus, we have two parallel occipital sinuses here and here and the stock going into the dura there. And so we're able to between the sinuses, the dura in this direction and expose a portion of the tumor this way. And you can see the transverse sinus there and there and the tracular right here and the stock coming right up underneath it, which is typical of this. And so this is the dermoid underneath the stock coming down into it, my fellow trying to dissect the tumor away from the edge of the sinus here. And you can see we get into the edge of it, but it's easily controllable with a bit of pressure and a stitch. So these dermal sinus tracts typically will enter adjacent to a sinus, whether it's on top of the head or at the back of the head, or even at the sacrum, I've seen them even split the sagittal sinus before and go right down through leaflets of the sinus, but they usually dissect away quite easily if you don't stick a hole in the sinus. About half these children present with infection and to miss these little skin lesions is a high source of lawsuits for pediatric neurosurgeons, at least in our country. And from there, we're able to dissect out the rest of the tract. So from this trajectory, we were able to get around the right side of the tumor, but on the left side, it extended over to about here, so we needed a bit more exposure to do this side. Trying to keep it intact so that we don't create a sterile meningitis in this infant. And opening the dura, taking this side of the occipital sinus so that we can get better exposure of this side of the dermal. And it just acts out quite easily then. So this is our specimen, I think that's the end of the video.

- Thank you.

- [Dr. Aaron] Thanks very much. Next we have Dr. Bill Couldwell from University of Utah. He's been a dear mentor of mine throughout my career and I really appreciate him as the master surgeon being here to say afternoon, thank you, Bill.

- [Dr. Bill] Thanks Aaron. So I really appreciate showing these videos and I appreciate Aaron and his technical expertise presenting this in such a great way. This is a variety of cases. This first one is a case of trigeminal nerve sheath tumor, a malignant one. And what we're gonna do is we're gonna take the tumor out from the cavernous sinus down into the jaw. So here you can see the tumors involving the third division here, extending up into the cavernous sinus. It also extends down into the jaw and the mandible and the mandibular nerve. So we're going to do a craniotomy and a neck dissection with our ENT colleagues. And then you'll see how we close with the myocutaneous flap. So this is a neck incision that we're using. And then we'll go ahead and dissect down to the mandible, it split the lower lip with this dissection. Now once we split the lower lip, we can dissect along the mandible. So this is on the left side and the mandible, this are mandibular nerve, as it comes out the foramen in the jaw. So now we can expose the mandibular nerve in its groove all the way along, where it's involved, you see it gets thicker here. And you can see this is tumor right in here in the mandibular nerve, extending down all the way down to this region. So we'll isolate the inferior part of it here. And then this is Jason Hahn, my ordinary oncology colleague, and he goes ahead and taps the screws for repairing the mandible split and he taps the screws before he divides the mandible. Go ahead, remove lymph nodes in place, and then follow the tumor up into the infratemporal fossa. And then, so we'll come in from above now and we'll take it out of the cavernous sinus and then release it through the foraminal valley. So here we are extra dural approach, middle fossa and I'm coming right down and I'm peeling the dura off the fifth nerve. So here's the foraminal valley, we're opening this up and now we're peeling it up and you can do this in the face of tumor, like a meningioma or in this case a nerve sheath tumor and I'm peeling up the lateral wall of the cavernous sinus. Here's the middle meningeal artery that we're dividing here and you can see all this nerve is involved. So what we'll do is we'll do it a resection of the fifth nerve itself, but leave the other nerves and the carotid intact below it. So we're at the top of the cavernous sinus now, we're up to where three and four is, in the top of the cavernous sinus. We've just peeled it up or extra dural the whole time. And then we'll go ahead and remove and amputate the nerve and lifted off the carotid here, you can see the carotid right here, we'll leave the rest of the nerves intact three and four. Now we'll take V1 'cause we wanna take more of a margin of V1 and we'll take it right out to the region where it goes through the superior orbital fissure. Now we're opening up foraminal valley here and we'll then disconnect the top of this tumor and then we'll plan to remove the rest of it from below. So once we've disconnected it from the region of the foraminal valley, you can see our ENT colleagues are working from below as well, helping us disconnecting. We'll go ahead and close the middle fossa skull base, we'll use fat graft here, a little bit of fiber and glue, and then go ahead and close the craniotomy 'cause we've isolated it now from the top, made poor cranioplasty. And now we'll go ahead and dissect it from below through the infratemporal fossa and remove the specimen. So now our auntie colleagues will go ahead and so a free flap in, we'll use a myocutaneous free flap here to get the closure because we've got, removed all the region of the posterior pharynx on the left side. Here's the free flap and part of this free flap goes in the oral cavity and part goes over top of the mandible. So the part is sewn in the oral cavity here to close that off into Infratemporal fossa. And then the mandible is repaired using a plate. Put the screws in that were drilled before the cut was made, so you get good occlusion and now we roll over the rest of the free flap into the extra oral space and then close the skin and lip. And you get a remarkably good cosmetic result with these types of dissections, it's really a pleasure to work with ENT colleagues in this. And this is what the scan looks like postoperatively, so we've done a complete resection of the lateral part of the cavernous sinus foraminal valley. So the next case is a foramen magnum meningioma. This was done with my partner, Phil Taussky. And this is a very large meningioma, a 59 year old woman. She presented with four years of swallowing difficulty and a typical foramen magnum meningioma with severe brainstem and upper cervical spine compromise, just perfect for a far lateral approach. It's really coming from the Jaeger tubercle in this case. So we'll do a lateral position and we do a simple incision, a linear incision in this case and then bring it down into the neck, down to about region of C4, this usually gives you enough exposure. And then do a direct dissection down on the C1 transverse process and disconnect the deep triangle muscles from the C1 transverse process. Identify the vertebral artery and then open up the dura, remove C1 laminate and you can see here's the back of the tubercle or the condyle. And we didn't do too much of a condyle removal in this case, was not necessary, but you can see when you open up the dura here, you're perfectly on the tumor, this is all tumor exposed right here. It gives you a perfect trajectory. Here's the attachment on the dura right there. So we'll pull up this flop of dura and then go ahead and then remove the center of the tumor, debulk it using the ultrasonic aspirator, SONOPET in this case. And then start our extra tumoral dissection and remove it carefully off the brainstem. We use these soft catenoids to help us sweep down the arachnoid and separated from the brainstem and the cranial nerves and then carefully dissected off the brainstem here and then we're able to mobilize the tumor and then bring it out like a swinging door and amputate the tumor. Once the tumor's removed at its attachment, then we'll focus on this area of dura. Here's the vertebral right here and we'll remove all the dura right up to the region of the vertebral artery you get a maximum Simpson grade resection. Here's a little bit more tumor here, so we'll remove some more bone, or remove the attachment and then go ahead and close, close the dura as best you can. It may be difficult to close is in this case, we had to put so a dural graft in because we removed much dura and I used some fat graft in here, it's perfect, it really reduces the risk of a pseudomeningocele when you use that. And here's our post-op scan. So the next case is a case of, a juvenile nasopharyngeal angiofibroma in a young boy. He's 13 years old, he presents with severe epistaxis. And these are difficult cases because they're very vascular. You can see the attachment here behind the maxillary sinus going into the through foraminal tandem rep to the region of the cavernous sinus in this case and right into this sphenoid sinus, middle fossa floor involved. So I like to isolate this tumor from above. I don't like to just pull it down from below when it's into the cavernous sinus like this, because we worry about attachment to the nerves. So what we'll do is we'll do a middle fossa approach, extra dural. And what we're doing is we're isolating the tumor here, here's V2 and V3 and here's the tumor between V2 and V3. Very vascular tumor, it was embolized before surgery, but it's still very vascular. The attachment takes a lot of time, you must drill it. And then we'll come in from below and do an endonasal endoscopic resection from below. Tissue debrider, beautiful instrument, takes away all the redundant mucosa that's in your way. Here's the superior turbinate, we'll remove the middle turbinate here and bring it out on block. And then we identify the attachment of the tumor, very vascular and start resecting the tumor. Now this approach allows you to work from both sides and so we're back in the head now and here's V3 and V2 is over here, and this is the junction between V2 and V3 and I'm isolating the tumor from the skull base attachment through the craniotomy here, got a beautiful view of the nerves in the cavernous sinus. And what I'm doing is I'm dissecting the tumor and then my ENT colleague is pulling down from below. So it allows you a by portal exposure, you can see them working from below and then we get around the tumor completely and then close it off, Just like I showed you in the last case with some fat graft to include the opening and the base of the skull, all extra dural, a no CSF leak. And here's his post-op scan, the middle fossa floor, all the tumor has been removed from the face from thepterygopalatine fossa and into the region. And you can see our fat grafts sitting here in the anterior temporal area where we've removed the middle fossa skull base. The next case is a more difficult and very complicated case. This is a salvage operation for a failed endovascular pipeline stent and to my knowledge, this is the first time that our pipeline stent's been removed surgically. This is a 58 year old woman who presents with a known giant ICA aneurysm. And here's the aneurysm. And you'll see the 3D reconstruction of the angiogram here. And what you see is the internal carotid artery coming up, middle cerebral coming out there and anterior celebral coming out there. So there was a, she failed her balloon occlusion tests, so we couldn't just trap it and so they put the pipeline stent through and what happened is the distal part fell out off the distal part of the losses purchase. And now it's like a garden hose loose inside the aneurysm giving that filling pattern. So what we'll do in this case is we'll trap the aneurysm and I'll remove the pipeline stent to enable the ophthalmic artery to feed directly from the carotid. And so we like to use a saphenous vein most of the time and the only reason is that it's simple to take, our fellows learn how to use this endoscopic harvest technique as well as you can size the artery to exactly match your carotid based on where you take it in the leg. So that's one advantage of using a saphenous vein over radial artery is you can size it directly. So it's brought out through a simple one centimeter incision in the leg after this endoscopic harvest. And here you see the vein brought out, it's prepared, we tie off the side branches and then proceed with setting up for the bypass. So what I'm gonna do is I'm gonna bypass from the external carotid in the neck to M2 in the head. So there's the hypoglossal nerve and carotid bifurcation standard frontotemporal craniotomy. And we'll go through the middle fossa, we'll bring the vein graft up directly under the mandible. And it's as simple thing to do. If you drill a hole about a centimeter in size, just lateral to foraminal valley. So here's spinosum here. There's the middle meningeal artery that I'm cauterizing right here. So there's foraminal valley spinal. Spinosum is just lateral and posterior valley and we'll go ahead and drill a hole, which goes directly into the infratemporal fossa here. It's about a centimeter in size and then we'll go ahead and prepare our distal recipient into vessel. So dissect out the fissure and isolate acceptable branch that you want to bypass into. And then we'll go ahead and prepare to do the bypass before we trap the aneurysm. So here I'm taking a tonsil clamp and I'm just passing in under the jaw and then the tonsil comes out just above the 12th nerve and it's easy, you just put your finger under the jaw and you can pass through the middle fossa directly there. I bring a chest tube up and then bring the graph through the test rube just like a shawn passer. Size the graft and then go ahead and prepare for the anastomosis. Now what we'll do in a case like this is... so I'm isolating the superior thyroid artery here, dissect out the bifurcation, we'll go from the external and we'll do this anastomosis first. So we don't have to clamp off the internal yet. And then we'll go to the M2, so we don't ever have to clamp off the lenticular strides during the bypass. So clean off the advent tissue off the vessel and do an end-to-end into the external carotid. I prefer interrupted sutures here just to avoid the risk of cinching the anastomosis site. So after we complete the proximal anastomosis, we'll bring up the graft and make it run straight up into the intracranial cavity and then we'll do the distal anastomosis. Size it bevel and then we'll go ahead and complete the anastomosis here and then document that the bypass is open. So we do this under burst suppression and mild hypothermia, little bit of methylene blue to help you see the vessel and go ahead and do your bypass. So we'll do an ICG as our next step, make sure that's open. And now we can go ahead and tackle the aneurysm directly. Now what I'm going to do, is we're gonna dissect down to the region of the aneurysm. So here's the aneurysm and here's the middle cerebral coming out of the aneurysm right there. So I'll go ahead and place a clip across there and then we'll open up the aneurysm, now the aneurysm has been trapped. You can see it's half filled with thrombus and this is the pipeline being removed. It's amazing because it collapses the pipeline when you pull on it and it just pulls out like butter. And then we'll go ahead and the reason I pulled the pipeline out is so I could clip the artery right there, because this is what the pipeline was going across, where the ophthalmic was taking off. I felt a better way of making sure that the ophthalmic would stay open. So we close and then we'll go ahead and perform a formal angiogram. Here's the closure, we make sure that we don't crimp, the graft with a closure and then the post-op angiogram and you can see what we've done. So here's the bypass feeding the middle cerebral and then we've clipped the artery just above the ophthalmic, so the native carotid is still filling the ophthalmic and the aneurysm itself has all its trapped right there, so. Now the final cases is a complicated case of a series of patients that I have and this operation has a fairly significant amount of morbidity, but I'm gonna show you how we have done en block resection of the cavernous sinus. This is unusual indication, 70 year old man who had fungal sinusitis that went up in through the cavernous sinus and the posterior orbit and he's failed medical therapy completely. It's all on the back of his orbit and in the cavernous sinus. So he has a non-functional right eye and he's progressed despite many months of fungal therapy. So we did this as a life-saving operation, you can see the extent of infection. He failed his balloon occlusion test, so we have to revascularize him. So what we'll do is we'll set up and we'll go ahead and do a bypass and do an en block resection of the cavernous sinus after the bypass has done. So here's the saphenous vein that we'll prepare and go ahead, standard frontal temporal craniotomy. And then again, we're gonna bring the bypass up through the middle fossa floor, this shortens the bypass by about half the length. So we'll go ahead and drill a hole in the middle fossa floor, just lateral to foraminal valley. It's very safe, you're away from the carotid there and it's a very easy pass to get down under the mandible. So here's a harvesting the saphenous vein, just like the last case. You can take as longer piece of graft as you need, usually we harvest about 20 centimeters when we do this. And then this is the only incision that's made. And then go ahead and perform the bypass, exactly like I showed you in the last case, we'll do an end to side, I think in this case and the only reason for that is because I didn't wanna embarrass any blood supply to the face given he had this infection. So we'll prepare our donor and recipient vessels for the bypass and then go ahead and perform the bypass. So we put the tonsil clamp down, bring the chest tube back, bring the graph through just like I showed you last time. And then sow in the graft. And decide. And then distally, we'll go into M2 again. And again if you use M2 as your distal anastomosis set of more approximately, you never have to clamp off the lindergill strides ever during the bypass procedure. So size the graft, trap the artery and then go ahead and prepare your arteriotomy. After we do this, then we'll do an ICG to document that everything is fine and make sure that the brain is living off the bypass fine. And we'll go ahead and then proceed with our resection of the cavernous sinus. Now we do a series of cuts in sequence here and I'll go through this with you on the video, but we start with the posterior orbit cut. So, here's the right side, right carotid right optic nerve. And we can now tie off the carotid because we've performed our bypass. We'll tie off the carotid to the neck, so that there's no petrous carotid filling. We'll amputate the optic nerve here, just anterior to the chiasm, remputated the carotid, amputate the third nerve. And then drill the poster orbit here, well in front of where the infection goes. And then cut across the orbit completely. Now we'll come laterally and we're gonna make a cut lateral to the cavernous sinus, this cut B and come down through the petrous bone. And here we're drilling across where the carotid is and the petrous bone, you don't have to worry about that now 'cause it's been trapped. So we're drilling across where the carotid runs in his canal there. And then drilling across the petrous apex. And then we're opening up the tentorium and cutting the fifth nerve now, at its root, there. Now we come medially and we're going to come medially and dissect the tumor out from the region of this sphenoid sinus and pituitary area and then we've removed the specimen. We're into this sphenoid sinus, we'll remove the mucosa and then we'll do an orbital exoneration here, it's a simple thing to do. You wanna do this because you can get... I don't know what happened there. You can get immunologically mediated, visual loss in the contralateral eye. And so we'll do an oval exoneration, take out the globe and then close. What we did here is you gotta be careful if you graph, you're gonna pack fat graft in. We did a nasal septal flap from below and sewed it over this venous sinus from below as well endoscopicly and then close the head. And this is what it looks like. We'll use an EVD just to help with CSF diversion and avoid CSF leak and this is what it looks like. And this is what his scan looks like, post-op. And if you see here, you'll see the carotid. Here's the graph coming up underneath the mandible into M2 there and the region of the cavernous sinus has been removed, there's fat graft there. So this operation has a significant morbidity and it's about over 10% mortality in our series and it's because they have a lot of medical problems after surgery, because you're using... he's doing it in such, inform people with a lot of medical problems. So it's not without its complications. So thank you very much.

- [Dr. Juan] So our next speaker is gonna be Dr. Paul Gardner, who is the director of the skull-based center at the University of Pittsburgh. Our session is gonna run a little bit late, so if you guys wanna stick with us for a few minutes, up to 3:30, we'll run at 3, 3 45 or so.

- [Dr. Paul] Thank you Juan, before, I just wanna ask one quick question, when you bring the bypass up, rather than coming over the temporal bone, you make a small opening through the middle fossa, is that just for a less torturous route for the graft or?

- [Dr. Bill] It shortens the graft comes straight up, and the idea is that you bring it up underneath the jaw, underneath the mandible. So it shortens the graft by about half instead of having come around the zygoma or over the zygoma, or even under... so if you go straight through the base of the skull, that's the reason.

- [Audience] I'd like to two questions. First of all, I enjoy your presentation. And I came here and I think I learned something here today, to press the shampoo foam... but you don't have any problem here. How will you do that?

- [Dr. Bill] So you take the tonsil clamp and you bring it from the middle fossa, and then yeah, you drill the hole like I showed you and then you put your finger under the en angle of the mandible and you pass it through the muscle and you can feel it. And it's really a short distance. And then you just guide it down above the 12th nerve.

- [Audience] Great idea, because I was using that to do my bypass, not behind the ear, but below the zygoma.

- [Dr. Bill] Right.

- [Audience] But below the zygoma, but past the zygoma sometimes you touch the facial nerve. So we have a problem, but here is much better. But my second question is, did you have ever some, hypoperfusion problem syndrome after this high flow with venous bypass?

- [Dr. Bill] I have not. I have not but I only use it when I take the carotid and replace it. I don't use it ever to augment blood flow, I use an STMCA for that, but I only use it when I'm gonna plan acute sacrifice of the carotid, okay, with either an aneurysm or a tumor, yeah.

- [Audience] I'm asking that because, I had the case with hypoperfusion and they change sphenous graph to--

- [Dr. Bill] Heart radial artery.

- [Audience] Radial artery, yeah.

- [Dr. Bill] So the radial artery is smaller than the venous graft as is narrower, there's no question about it. It's more, more, but to take the radiograph, we'll do it and we've done it many times, but the only reason that I liked the saphenous vein is it's so simple, there's no morbidity and you can take it either upper part of the leg or lower part of the leg to match the size of the carotid.

- [Audience] Do you measure the flow?

- [Dr. Bill] So we don't measure the flow acutely, no, we just do an ICG like you showed, yeah.

- [Dr. Paul] Thank you, Bill fantastic. All right, so had couple of cases here, when then one, that's a sorta more of two dimensional. This first case is a tumor, we didn't know what this was at first, but it was a 48 year old woman who initially had significant vertigo and some mild dysphagia along with headache. She has this sort of minimally enhancing tumor, because of her age, we weren't, I thought maybe this could be a schwannoma. And so we thought given its location was probably best for our far lateral approach gets a little better access to the jugular frame and drill off some of the juggler tubercles. So this a typical incision behind the right ear. I use a C shaped incision extending down towards C2, and here's the suboccipital triangle, I've preserved the occipital artery, just in case we have any issue with the PICA, which fortunately we did not. And here's just retracting that exceptional artery and then dissecting out the suboccipital triangle. Transecting the lateral attachments of the suboccipital triangle muscles and then retracting them posteriorly. And here, then I can doppler the vertebral, open the periosteum to expose the venous plexus, pack off the venous plexus and here I'm just passing a penfield4 into the transverse foramen at C1. I can complete opening of that periosteum, and now I can pass easily around the vertebral artery, as it runs in this groove over the top of C1, just placing a loop around that and the occipital artery. And then this allows me to drill out the rest of the foramen magnum just a minimal amount of the condyle. And then probably more importantly is to drill out a little bit of this juggler tubercle, which I'm doing right here, you can see it's above that emissary vein in the condyle, because that allows us really to flip all of the dura over laterally gets us a more lateral to medial trajectory to try to see as immediately as possible. She was a OB, so I just made a small opening and then opened the foramen magnum to let off some CSF. And then we can see the tumor pretty quickly down at the foramen magnum here. You can see, yeah she's again, very overweight, we're sort of struggling with the cerebellum a bit. And then I see PICA is immediately overlying the tumor, but a pretty, relatively straightforward to dissect out the PICA off the tumor. Still wasn't sure exactly what kind of tumor this was, at this point, maybe could have still been a schwannoma, but it really seems to have an epicenter here around a foramen luschka. We can see the seven, eight complex here, superiorly. And then I'm just dissecting with this CAR 2 stimulating dissector, to localize the ninth and 10th nerves, which turn out, are running deep to the tumor fortunately. So now I'm just, again, dissecting the PICA and then I started doing internal debulking and then dissecting out the capsule of the tumor. To here I'm localizing again, a branch of nine, 10, as it runs kind of through the tumor and then peeling the tumor up from below, I start to see some of the medela inferiorly, and then we can see the nine, 10 complex, which fortunately was pretty separable from the tumor. Here is again, PICA, which you just see sort of interdigitating with this tumor. To here, I'm doing the final dissection of the top part of this PICA loop. Again, debulking the tumor sort of breaking into smaller and smaller parts. And then finally moving back towards foramen of luschka and here we can see the floor of the fourth ventricle I'm peeling the tumor now off of the roof of a right word, enters into foramen of luschka. We can see the floor is pretty clear of tumor, I have a pretty nice view from lateral to medial towards the floor of the fourth, cutting some of the last adhesions of the tumor. And I really think I've done a pretty nice job, I can see PICA pretty well, here's the last attachment. So my pike is preserved, I can stimulate the flow of the fourth, and I think I pretty much have gotten most of the tumor out if not all of it, but I wanted to take a look with an endoscope to be sure. And here we're looking laterally out towards the juggler foramen, I can see the 10th nerve fibers, the ninth nerve running up, we can see 11 coming up here. There's a nice view of 11 as it comes up. Those are the 12th nerve fibers and then nine, 10. And now looking up from nine, 10 up towards the cochlear nerve. And now this is looking back at the brainstem and the junction of the roof of the foramen of luschka and sure enough, I've left some tumor behind. So here's that PICA loop, I have the same orientation as we had before looking back medial and here is some tumor extending deep to that PICA loop onto the roof of of foramen of luschka, peeling the last bit out, we can see it get some flash of venous bleeding. And she actually did remarkably well after this one, home after two days with fortunately no dysphagia problems, you can see a little bit of a DEMA in the cerebellum, but no residual tumor and this turned out to be an ependymoma, so which maybe not surprising it's localization. This next case is a little bit of a unique approach for a medial sphenoid wing menningioma. It's a 59 year old woman who had a left APD, very mild vision loss, but basically has a bit of compression of the posterior orbit that you see right here from this cavernous and medial sphenoid wing meningioma. So the goal here was just to decompress the orbit, remove the osseous involvement of the bone to decrease her orbital compression. And we thought we could do this all through just a lateral orbitotomy incision, which here is medial to the frontalis branch and really different, we take advantage of the entire eyelid as part of our incision through this lateral orbitotomy incision. So here's a view from the left. Again, the orbit is retracted here, the globe, and we just do this lateral Orbitotomy incision. And you can see the osteotomies that are performed in the lateral orbit nor to give us access to the sphenoid wing. So this is after those osteotomies, we can immediately see the, basically the posterior lateral orbit, which is really the sphenoid wing in this case, you can see the protective contact on the globe. We can then retract the globe to get access to the greater wing of the sphenoid. Here we are above the superior orbital fissure, right above the frontal orbital frontal meningeal fold and just resecting some more. And then transecting that orbital meningeal fold, the same way as you would do through a super orbital craniotomy with our frontotemporal craniotomy and this allows me to peel now the temporal dura from the cavernous sinus. I can further resect the remainder of the involved greater wing of the sphenoid, the inferior part of the orbit and peel the tumor dura of the temporal lobe off of the cavernous sinus and then coagulate the surface of the tumor. So I've left the tumor obviously in cavernous sinus and then I can open the dura immediately onto the temporal lobe. I don't have to ever even see the temporal lobe 'cause I'm able to access directly on the tumor, a little closer view. And then of course, internally debulk the tumor and then dissect around the capsule of it. Again, all of this has done just through this little lateral orbitotomy approach. Working next to the orbit with gentle retraction of the globe. You do have to retract release the globe attraction every 10 to 15 minutes, just to make sure there's not too much, there's no ischemia. And here's the final resection of the portion that's attached to the cavernous sinus. The dural attachment there, you can see there's if you resect this all the way up to the cavernous sinus, there's no way to suture this close, 'cause you've sort of destroyed any dural attachment there. And then here's the lateral part, the remainder of the lateral part of the tumor out towards the temporal lobe, which you'll see in a moment once the tumors resected. So here's our temporal lobe, here's the cavernous sinus, here's the Sylvian fissure back here. Obviously we can't get a watertight closure. We did suture in some pericardium, the nice thing about this, we put a little fat over it, but the temporalis muscle fascia here can be carefully sutured toperiorbita to get a pseudo fascial closure here. She fortunate did very well and she resolved her APD very nicely. And here's the kind of result we get, we're able to resect the temporal portion, completely decompress the posterior orbit and she had a extremely nice cosmetic result with this. So here's the side of surgery and I think it's very difficult to tell the incision that we used. So for her, it's very unique that you can access this area, but I think it turned out well. So I'd like to introduce our final speaker for the evening, which is my partner as well. Dr. Fernandez Miranda. And again, if you guys don't mind sticking around, we have, I think until at least till four.

- [Dr. Juan] So this is a case of a low grade glioma just to relax you a little bit after that aneurysm clipping. So this patient is 35 year old had previous tumor resection of this low grade glioma, which is around Broca's area, extend to the middle frontal gyrus. And he had initial summit speech deficits that resolve, we do functional mapping, but the most important thing I wanna show you today is how we use high-definition fiber tracking to do the plan of this operation. In particular, we can see here corticospinal tract behind the tumor. And this is the arcuate tract at the posterior border of the tumor. And we can use this to plan or resection to assess how much tumor we're gonna remove and to compliment or interrupt mapping. And you can see the flow signal, these are fibers from Borca's area, going to the arcuate tract, this is SLF, superior longitudinal fascicle. And now this is the frontal aslant tract. This is a tract that has been recently described, grows from Broca's area to supplementary model area. And it's the one that concerns me the most here, because he seems to be infiltrated by tumor, this and that you can nicely see with fiber tracking. So this is the area where I'm gonna be more careful with the tumor resection and with the internal mapping. We can also see the inferior fronto-occipital, which is the anterior and inferior aspect of the tumor. And also some of the deeper portion of the tumor, but outside the flow signal. We can map other fibers around the tumor, these are thalamic fibers and they are in the anterior and inferior portion of the tumor. All of this is on pre-op and here we see all the fiber tracts together. The one in red in particular is the frontal asland tract, the one that concerns me the most. You see how this involve with portion of the deep part of the tumor. In the first signal, you can see how there's probably infiltration right here of this tracts. So you're gonna leave tumor, this is your area where you're gonna do so. So a lot of the work is done before surgery to prepare your operation. This is just simply taking the abnormal to the clearly abnormal tissue. We did cortical mapping before and now we are confirming again our speech rescue in bronchus area, where number one is. In this area where number two is, this the white matter of going deep from Broca's area towards the SME area is eliciting slowness of his speech. Patient has struggled to make words, we are stimulating in this area and similarly in this deep area of the white matter. And now we're gonna continue with careful resection while the patient is doing some speech tasks to complete as much of tumor resection as we can do safely. And this is the area where we probably left a little bit of tumor where a stimulation was positive, right under this patty. So this is the post-op MRI, the patient had some transgender speech disorder, but it lasts for a few weeks and you can see the frontal aslant tract post-op period, this is a month after surgery that is still intact, or mostly intact and the same with the arcuate tract, intact posteriorly posterior to the tumor. So that's the case to highlight the use of, high-definition fiber tracking. So now we're gonna move into, can you stop at the MRI here, go next. So we're gonna talk about, endonasal versus transcranial approaches for the petroclival region. And we'll start, keep going into, please, we'll start with an endonasal approach to, a petroclival meningioma, which is something that we've been working on for the last two years. And this is a 62 year old patient asymptomatic, but this tumor had been followed for two years and there's size increase and your options are, an anterior petrosectomy versus an endonasal approach. We did fiber tracking on this particular patient also, you can see the cranial nerves, these are three and this one here is six post down, three post up and medial and you can see here in green three and in red, you have trochlear nerve and in blue you have, trigeminal nerve and in yellow you have the six nerve post down, so this also serves for planning. And then we're gonna do a posterior clinoidectomy, going through the carvenous sinus. So we use the layers of the carvenous sinus, we open the anterior wall, we moved the middle wall up, identify the inferior hypophyseal. We'll take the posterior clinoid out. So we can now open the dura in this direction and access the lateral recess of the interpeduncular system. Then we'll do a transclival, working from six to three and we have full access to the interpeduncular system, where you see the vascular bifurcation. So this is in surgery and now here am opening the anterior wall of the cavernous sinus. You will see that it's venous bleeding that is easily controlled with, sorry, foam. And then here is the inferior hypophyseal artery that I'm gonna dissect and carefully coagulate and then transact. And then as I do this, I can I start mobilizing the middle wall of the carvenous sinus. I cut these fibers, the survivors of the so-called collateral clinoid ligament, attached to the carotid. So I can keep moving this middle wall pituitary of the carvenous sinus and pituitary expose the roof of the carvenous sinus. And here you will see the interior clinoid ligament and I can dissect the posterior clinoid down and get this access. This is like a reverse doling approach. We go into the carvenous sinus to get the posterior clinoid out. Here, the carotid is completely skeletonised, so I coagulate the periosteum a little bit to get more space with the petrous apex and the beauty of the approach is now, I just need to open the dura, right where the tumor is attached. I can devascularize the tumor, I go first lateral towards the Petrotentorial region, where I can, I know the vascular supply is coming from there. Then I can go medial, After debulking tumor, I can move the tumor away from the vascular, there is a party protecting there, so I can have easy access to the vascular area and dissect that from the tumor and then can work above and below the pituitary gland. Here we can see six nerve, this is ICA and I keep working towards this petrous angle. That's the trigeminal nerve right here, the vascular supply is coming from here. He was gonna see five and then this is third nerve, oculomotor nerve. triming continuum away from oculomotor nerve, supossed median, an app, as the high-fiber tracking, told us before. And now this is the end of the resection, you see the vascular already 600 puts down. This is superior cerebellar and this is the tentorial edge with a tumor attached, that's four that's, five, three is up here, the pituitary in the middle and then we put, or elay duragent. This is a fossa ladder graft, then we'll put up a fat graft. And then the most important piece, of the reconstruction devascularized Sipple flap, which is the key for a successful repair. And you see a good resection of the tumor regrowth of the resection because it had no pituitary dysfunction at all, had a three and a six that were partial and recover completely three months after surgery. You can see nice correlation between, the prior fiber tracking and the interrupt findings. Now, this other case is clival chordoma, that is recurrent. And I did endonasal surgery for this patient first, but the tumor recurred laterally. So in this case, endonasal is not an option. We need to do a middle fossa approach and anterior petrosectomy. And this is briefly the anatomy we need to understand to perform this approach. You can see the petrous coratid have V3, DSBN, petrous apex bone. And this is the surgical beer with a middle menengeal. And the petrosal artery, greater petrosal nerve, lesser petrosal nerve. All this anatomy we'll see in our operation. And this is where the cochlea is located and do you wanna see the dura of the internal acoustic canal. So I like to do a larger incision for this because I wanna be able to access the whole middle fossa. Here we are cutting meningeal dural fold, dissecting the dural temporal lobe away from the cavernous sinus wall. This is V2 foramen rotundum and this is V3, and this is the middle meningeal. And you see there, we are using no retractors because I have a good mobilization of the dura and I will drill around for amino spinosum, so I can get better access to the middle meningeal. And now I'm going to drill completely around V3 to a lock V3, so I can move V3 away and work under V3. So that's the petro solarity being coagulated. Now middle meningeal being coagulated. After you coagulate middle meningeal, now you can start peeling the middle fossa dura away from V3 down to snecklescave. And now we work from posterior to anterior and we find GSPN and some tumor right under the GSPN and petrous apex here. The petrous is busy being dissected all the way to the medial reach this day. Our quit eminence does the location of the internal acoustic canal. Now we are dissecting the GSPN and I'm gonna transect the GSPN because I wanna expose the carotid, the petrous carotid, drill the bone, this is the lesser petrosal nerve being transected also to tumor under V3. You see how you can move V3 up. Now we start drilling away, all the abnormal bone that is around the tumor, because for chordoma, you're gonna remove as much bone as possible. And here we're using a diamond drill here on drilling, around the carotid artery in the petrous carotid and below the petrous carotid. And now taking the medial wall of the petrous carotid canal. That's where the GSPN was, is the petrous carotid. This is the location of internal acoustic canal and your output eminence. And here you see is the dura, the posterior fossa and dura of the internal acoustic canal. The outer layer of dura has been removed because it had tumor on it. And this is the post-op MRI with complete resection of the tumor and the abnormal bone in the worst surrounding the tumor. So we're gonna talk briefly this five minutes about optic canal region. We wanna talk about the area of the tuberculum sella, anterior clinoid, et cetera. So first, again, we'll do endonasal approach. This is a very large tuberculum sella meningioma, that is involvement of the optic canal as you see right here, there is some vascular involvement too. So this is the anatomy we need to understand. Pre cosmetics silk has been removed, plan on this Vinny dial dilate been removed. And now we need to understand, key, is to understand how to extend your approach laterally to expose the carotid and the optic canal. We do early decompression when we approach these tumors and the optic nerves are decompressed right at the beginning, before we take any tumor, nicely compression of this optic canal, then this day, super infra cosmetic anatomy. The super cosmetic anatomy, we to understand always remember this frontal orbital artery as well as the heubner artery. So this is inserted now very wide approach. The carotid is exposed, the optic nerve is completely are open here, the canal is exposed. The tumor is again, the first thing you encounter, so you open the dura widely, enter the tumor, debulk it and after you have done good debulking of the tumor, you can go extra capsular, this is liliequist membrane here. And now we are separating here the tumor from the arachnoid around the carotid on the right side, the super hypophyseal artery is running this arachnoid. This is the pituitary stock, from the pituitary stock we can go to the optic chiasm right here. And now from here, we wanna find the ipsilateral or the right side at A1, you can see it right there. Careful dissection from the A1 and you see there is a frontal orbital artery up here that we need to be careful about, that it's been dissected. Right here, this is the A2 on the right side. And now this is the AECOM. It happen to be a furnace at AECOM, as you see here and now careful dissection of arachnoid vents. And peeling off the tumor from the vascular structures. But now I have difficulties finding this left side at A1, so I decided not to go from lateral again, because I have a significant amount of tumor is still here. In order to get access to these tumor, we are gonna... I'm going to open the optic canal all the way lateral, almost to the orbital apex. So I can now mobilize the tumor from inferior. So this is the uncus right here, this is the P cam, the carotid, the A1, arachnoid bifurcation. So now I can see my A1. I can do a safer dissection of the tumor away from the vascular structures, peeling off tumor from vessel. This is probably heubner in this left side, direct branch from the AECOM to the tumor, that you can select decoagulated and transect. Another tumor has been safely separated from the vascular structures, like a mobilise the tumor away. And you can see the tumor invading the optic canal, there is the optic nerve right here. There is significant invasion of this optic canal, the nerve is very flatten and now just trimming off tumor from this area, this the ophthalmic artery and this is where the ophthalmic artery goes into the dura. And there is tumor between the ophthalmic artery and the optic nerve. And you see how nicely we can identify tumor in this area without manipulating the nerve. And this is the final result with a complete resection of these tuberculum sella meningioma. And the patient had a very good visual outcome with significant recovery of vision on that eye. We used a septal flap as we saw before and no leak. And now to finish, this is another case completely different. This is now an anterior clinoid meningioma. This tumor sits on the anterior clinoid. This of course is not an option for an endonasal approach, you need to do an open approach. You see the anterior, the posterior is modularity. You need to understand the anatomy of the anterior clinoid, the clinoidal region, the distal rings, the optic strut, which forms the attachment of the clinoid. How to peel the dura from the wall of the carvenous sinus and proximal ring, distal ring, clinoid carotid. This is your surgical view. So we'll start by going extra dural, take the clinoid, decompress the optic nerve and finally going through dura to see the anatomy integrally. So this is the exposure, we're gonna do an interfacial flap. This is the orbital-pterional craniotomy. One piece orbital-pterional craniotomy. I know we are gonna do first dissection extradural to identify the vascular supply to the tumor. And now the same thing on the temporal side to peel off the temporal love dura, from the carvenous sinus wall, because the tumor is in the dura and not in the carvenous sinus wall and we can get the vascular supply that way. This is the anterior clinoid, easy to remove in one piece, because the optical strut was probably involved with tumor. Dissecting of the dura, does the clinoid and then the next step is to decompress the optic nerve completely extradural before we even touch the tumor and this is what is known to cause an impact, on visual recovery. So now we do what we call a transoral resection. We open the dura, right where the tumor is without seeing brain yet. I know where the carotid and optic nerves have located in the clinoid angle space. So we can start doing aggressive debulking of the tumor. And then after the second, identify the carotid in the supraclavicular space. And then from here, try to identify the relation of the tumor with a psyllium fissure and the MCA branches. I found in this case that the psyllium fissure was actually collapsed by the tumor, so there is only one branch, which is this one, that was attached to the tumor, this temporal branch. The rest of the brain is actually impacting, the surface of the frontal lobe itself. And this is the carotid bifurcation right here, A1 and M1. And now I'm opening the dura, just a little bit more to see better brain tumor interface, carefully separate in both. And I will coagulate as usual the tumor capsule and bring the tumor down, separated from the brain surface and keeps shrinking the tumor, do more intracapsular bulking, to finally do a complete extracapsular dissection remove all the tumor out. And this is the carotid bifurcation here, this is the optic nerve after the tumor resection, but don't forget about the tumor attachment, this is the temporal lobe dura, that still has probably tumor on it, so you can dissect and transect. These are all the way to the oculomotor triangle, anterior petroclinoid ligament. This is a dura of the optic canal, that has some tumor on it. And it still some of the dura of the oculomotor triangle here, that we're going to transact. This is oculomotor nerve and this a foramen dura that you want to transect to complete your tumor resection. This is your dura reconstruction and this is the pos-top with very good visual recovery. Thank you.

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