Left Intraventricular Tumour resected via Superior Frontal Transulcal Transcortical Approach

Bolivian male, 40 years, tailor, a history of evolutive headache of 6 months of evolution, last weeks with nausea and vomiting, admitted and waiting for surgical treatment of another surgical team, evolves with sensory impairment and generalized seizures.

Presurgical brain TC shows an iso-hyperdense left intranvetricular tumour with obstructive hidrocephalus and trans ependymal edema. Presurgical MRI shows a hypointense on T1-weighted image, not enhancement with the administration of paramagnetic contrast.


I apologize about the case, but have no more preoperative MRI sequences. Operated in a public hospital, with limited equipment resources.

A transcortical transulcal approach by the left superior frontal sulcus with a complete microscopic resection was performed.

The histopathological result was a low-grade glioma (WHO I). Patient did well with no neurological deficit and was discharged from hospital at 6th postsurgical day.

A brain TC at the day 21st postsurgical  day is shown at the end of this presentation

Comments:

Edgar M. Carrasco

carrascoem@aol.com

00591-73679331

Santa Cruz - Bolivia

Comments (5)Add Comment

surgical approach
written by sharmakchand, August 14, 2011
Good job done. I would have done a midline frontal craniotomy more on the side of tumour and gone along the falx cerebrii and split the corpus callosum just of midline towards left side. This avoids cortical incision. Midline craniotomy affords you a chance to have good retraction of falx and control of superior sagittal sinus. If you find large draining vein joining superior sagittal sinus, you can go to corpus callosum from other side.
Fornix?
written by Thomas S, August 14, 2011
Nice job and thank you for interesting case report! No problem with tumor attachment to fornix?
RE: surgical approach
written by carrascoem, August 14, 2011
Thanks for the comment. This case have been very discussed in the preoperative time. Some proposals were a transcallosal approach to avoid the cortical incision, a biopsy by neuroendoscopy at the first time and a transcallosal approach in a second time according the histopathology result.
Considering in this case the risks and benefits of a transcallosal approach versus a transcortical approach I personally believe that the transcallosal approach for a tumor located in the left lateral ventricle, with approx 40 x 30 x 35 mm size was insufficient, knowing I have a just a save margin of 2.5 cm incision over the corpus callosum and knowing that we don't have an image guided navigation system. A microscopic transcortical approach, through a frontal sulcus, in a dilated lateral ventricle, for a left intraventricular tumour located in the frontal horn, allowed a better visualization of this tumour, its base of implantation and the intraventricular anatomical structures.
Warm regards
RE: fornix
written by carrascoem, August 14, 2011
Thanks for the comment. Fortunately, as we can see in the presurgical MRI, the tumor had little vascularization and most of the implantation base was medial and anterior to the foramen of Monro. Careful microscopic dissection allowed a satisfactory resection.
Warm regards
About approach
written by neurosurgeon80, December 08, 2012
Good work done.This surgical approach is an ideal for such type of tumor location.Thank you for the interesting case report

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