Completely endoscopic resection of intraparenchymal brain tumors

Clinical article

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Object

The authors introduce a novel technique of intraparenchymal brain tumor resection using a rod lens endoscope and parallel instrumentation via a transparent conduit.

Methods

Over a 4-year period, 21 patients underwent completely endoscopic removal of a subcortical brain lesion by means of a transparent conduit. Image guidance was used to direct the cannulation and resection of all lesions. Postoperative MR imaging or CT was performed to assess for residual tumor in all patients, and all patients were followed up postoperatively to assess for new neurological deficits or other surgical complications.

Results

The histopathological findings were as follows: 12 metastases, 5 glioblastomas, 3 cavernous malformations, and 1 hemangioblastoma. Total radiographically confirmed resection was achieved in 8 cases, near-total in 6 cases, and subtotal in 7 cases. There were no perioperative deaths. Complications included 1 infection and 1 pulmonary embolus. There were no postoperative hematomas, no postoperative seizures, and no worsened neurological deficits in the immediate postoperative period.

Conclusions

Fully endoscopic resection may be a technically feasible method of resection for selected subcortical masses. Further experience with this technique will help to determine its applicability and safety.

Abbreviations used in this paper: CM = cavernous malformation; GBM = glioblastoma multiforme.

Article Information

Address correspondence to: Johnathan A. Engh, M.D., Department of Neurological Surgery, UPMC Presbyterian, 200 Lothrop Street Suite B-400, Pittsburgh, Pennsylvania 15213. email: enghja@upmc.edu.

Please include this information when citing this paper: published online October 24, 2008; DOI: 10.3171/2008.7.JNS08226.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Intraoperative photographs showing the cannulation of a deep frontal lesion using the brain needle and the bulletshaped dilator. A: The brain needle is aligned along the 5-mm corticectomy prior to cannulation. A small craniotomy has been performed, and the dura mater is tacked apart in cruciate fashion. B: The bulleted dilator with overlying transparent conduit is passed over the brain needle, dilating the surrounding white matter. C: The conduit is shown within the tumor after the dilator has been removed. Fluid is seen exiting the port (this tumor was a cystic GBM). D: The 2-suction technique is demonstrated through the endoscopic view into the port. The first suction (S1) puts traction on the tumor while the second suction (S2) aspirates tissue. A thrombosed vein (TV) is visualized on the left, with a large amount of tumor superiorly in the port. In addition, the more superficial part of the tumor with some surrounding white matter is visible through the clear conduit (CC) of the port to the left.

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    Schematic diagram showing how an endoscopic port can be used to cannulate a deep tumor within the brain (in this case, a left transfrontal trajectory into a subcortical tumor). Left: The initial cannulation with the bullet-shaped dilator. Right: The conduit of the port within the tumor itself following dilator removal.

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    Preoperative (left) and postoperative (right) contrast-enhanced axial MR images obtained in a patient who had a left frontal GBM extending into the lateral ventricular ependymal wall. Radiographically confirmed near total tumor resection was achieved with completely endoscopic surgery.

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    Preoperative contrast-enhanced axial (left) and nonenhanced T1-weighted sagittal (right) MR images showing a left frontal GBM prior to endoscopic resection.

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    Postoperative nonenhanced (left) and contrast-enhanced (right) T1-weighted axial MR images obtained following completely endoscopic radiographically confirmed total resection of the left frontal GBM. The corpus callosum, ependymal wall of the lateral ventricle, and frontal gyri are better delineated following the resection than on the preoperative images.

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    Preoperative (left) and postoperative (right) contrast-enhanced T1-weighted axial MR images obtained in a patient who underwent total endoscopic resection of a cerebellar metastatic adenocarcinoma.

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    Endoscopic photograph showing hemostasis during a parafalcine metastasis resection. The bipolar cautery (BP) is being used to coagulate a tumor vessel adjacent to the falx (F). Suction (S) is used to keep the field dry. A clear delineation between the white matter (WM) and the tumor (T) above it is evident, and the channel through the brain into the tumor may be seen through the clear conduit (CC) of the port.

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