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In this illustrative video, the authors demonstrate an endoscopic-assisted combined transcrusal anterior petrosal approach for resection of a large petroclival meningioma with significant brainstem compression involving Meckel’s cave. This unique petrosal variant provides increased petroclival exposure that can potentially preserve hearing by combining a transcrusal labyrinthectomy with anterior petrosectomy (Kawase’s approach). The advantages include multidirectional angles of attack to the brainstem and petroclival region without cerebellar retraction. Endoscopic assistance allows expanded visualization into deep surgical corridors. The surgery was performed in a two-stage fashion, and a near-total resection was achieved with cranial nerve and hearing preservation. The operative nuances are demonstrated.

The video can be found here: https://stream.cadmore.media/r10.3171/2022.1.FOCVID21257

In this illustrative video, the authors demonstrate retrosigmoid resection of a giant cystic vestibular schwannoma using the subperineural dissection technique to preserve facial nerve function. This thin layer of perineurium arising from the vestibular nerves is used as a protective buffer to shield the facial and cochlear nerves from direct microdissection trauma. A near-total resection was achieved, and the patient had an immediate postoperative House-Brackmann grade I facial nerve function. The operative nuances and pearls of technique for safe cranial nerve and brainstem dissection, as well as the intraoperative decision and technique to leave the least amount of residual adherent tumor, are demonstrated.

The video can be found here: https://stream.cadmore.media/r10.3171/2021.7.FOCVID21128

In this illustrative video, the authors demonstrate microsurgical resection of a papillary tumor of the pineal region using a retractorless interforniceal approach via the anterior interhemispheric transcallosal route. The tumor presented to the posterior third ventricle occluding the cerebral aqueduct, resulting in obstructive hydrocephalus. The retractorless interforniceal approach is performed in the lateral position with BICOL collagen spacers to keep the corridor open. Gross-total resection was achieved, and the patient was neurologically intact without needing a permanent shunt. The operative nuances and pearls of technique for safe microdissection and gentle handling of the retractorless interforniceal approach are demonstrated.

The video can be found here: https://stream.cadmore.media/r10.3171/2021.4.FOCVID2139.

In this illustrative video, the authors demonstrate resection of a superior vermian arteriovenous malformation (AVM) using the endoscopic-assisted parieto-occipital interhemispheric precuneal transtentorial approach. Lateral positioning allows for gravity-assisted access to the interhemispheric fissure without retractors. The parieto-occipital trajectory is useful in patients who have a steep tentorial angle and avoids manipulation of the occipital lobe and visual cortex. In addition, the authors utilize an angled endoscope, which allows full inspection of the resection bed after AVM removal to visualize areas hidden from the microsurgical view to minimize the chance of residual disease in a deep corridor with multiple visual obstructions.

The video can be found here: https://youtu.be/hk9nIIdtqbI

In this illustrative operative video, the authors demonstrate a Teflon bridge technique to achieve safe transposition of a large, tortuous ectatic basilar artery (BA) and anterior inferior cerebellar artery (AICA) complex to decompress the root entry zone (REZ) of the trigeminal nerve in a 61-year-old woman with refractory trigeminal neuralgia via an endoscopic-assisted retractorless microvascular decompression. Postoperatively, the patient experienced immediate facial pain relief without requiring further medications. The Teflon bridge technique can be a safe alternative to sling techniques when working in narrow surgical corridors between delicate nerves and vessels. The operative technique and surgical nuances are demonstrated.

The video can be found here: https://youtu.be/hIHX7EvZc1c

Tumors of the infratemporal fossa (ITF) are surgically formidable lesions due to their deep location and proximity to critical neurovascular structures. Selecting the optimal surgical corridor for a giant ITF lesion with extensive medial and lateral extension can be challenging due to the limited surgical freedom offered by each individual approach. In this operative video, we demonstrate a case of a 44-year-old female with a giant ITF schwannoma with intracranial extension and erosion of the central skull base. Although we considered several surgical approaches, including a standard binostril endoscopic endonasal approach and an endoscopic Denker’s approach, we eventually chose a combined endoscopic endonasal and sublabial (Caldwell-Luc) transmaxillary approach. This combined approach provides significantly greater surgical freedom than a pure endonasal route to the lateral ITF. The sublabial Caldwell-Luc corridor provides a more direct “head-on” trajectory to the target of the lateral ITF than the pure endonasal route. This combined approach provides a multiportal, multicorridor access, allowing for more surgical freedom and preservation of the piriform aperture and nasolacrimal duct. This case illustrates the versatility of the combined endoscopic endonasal and sublabial transmaxillary approach for giant ITF tumors with significant lateral extension. The technical nuances and surgical concepts are demonstrated in this operative video manuscript.

The video can be found here: https://youtu.be/gy-pkjLdDgE.

Craniopharyngioma is a rare and benign intracranial tumor of the sellar and suprasellar region. Historically, these tumors were mostly accessed through transcranial corridors and resected with microsurgical techniques. Endoscopic endonasal surgery has recently gained popularity in the treatment of these tumors and has shown at least comparable results to transcranial approaches. The endoscopic endonasal approach provides direct midline access through a transplanum transtuberculum corridor and gives excellent visualization of the undersurface of the optic chiasm to allow safe bimanual sharp dissection of the tumor from the hypothalamus. In this operative video, we demonstrate the case of a 56-year-old female who had a complex craniopharyngioma with solid and cystic components extending superolaterally into the right frontal lobe. This lesion was invasive and partially encased the right optic nerve, optic chiasm, and anterior communicating artery complex. Although a traditional transcranial approach could have been utilized, we elected for an endoscopic endonasal approach for a maximal safe near-total resection, preserving the neurovascular structures. The patient underwent radiation therapy with favorable regression of the residual tumor on subsequent imaging studies. This case illustrates the feasibility of a combined strategy of maximal safe endoscopic endonasal resection followed by early radiation therapy for a complex, invasive cystic and solid craniopharyngioma. The technical nuances of safe bimanual microsurgical dissection of tumor adhesions off of critical neurovascular structures are demonstrated.

The video can be found here: https://youtu.be/z0AINLpRZGs.