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Open access

James K. Liu and Vincent N. Dodson

Cervicomedullary gangliogliomas are rare low-grade neoplasms of the brainstem. They can be challenging lesions to resect due to the eloquent location in the brainstem. In some instances, the absence of a clear surgical plane between the tumor and normal neural tissue can prohibit a complete resection. Therefore, it is important to leave a thin rim of residual tumor at the tumor-brainstem interface in order to avoid irreversible neurological injury. In this operative video, the authors demonstrate the technique to develop a surgical pseudoplane using sharp microdissection for a cervicomedullary brainstem ganglioglioma without a clear interface between the tumor and normal neural tissue. This strategy allowed for radical near-total resection of the tumor, thereby maximizing the extent of removal while preserving neurological function. Postoperatively, the patient had normal neurological function and returned to work without any disability. In summary, due to the lack of a clear surgical dissection plane, a pseudoplane near the surgical interface can be performed using sharp dissection to facilitate radical near-total resection.

The video can be found here: https://youtu.be/biD4G1Hh0yk.

Open access

James K. Liu and Vincent N. Dodson

Fourth ventricular tumors have traditionally been removed via transvermian approaches, which can result in potential dysequilibrium and mutism. The telovelar approach is an excellent alternative to widely expose fourth ventricular tumors without transgressing the cerebellar vermis. This is achieved by opening the cerebellomedullary fissure and incising the tela choroidea and inferior medullary velum, which form the lower half of the roof of the fourth ventricle. In this operative video manuscript, the authors demonstrate microsurgical resection of a fourth ventricular subependymoma arising from the rhomboid fossa via the telovelar approach. The key technical nuance in this video is to demonstrate a gentle and safe technique to identify a dissectable plane to peel the tumor off of the rhomboid fossa using a microspreading technique with fine micro-bayonetted forceps. A gross-total resection was achieved, and the patient was neurologically intact.

The video can be found here: https://youtu.be/ZEHHbUGb9zk.

Open access

James K. Liu and Vincent N. Dodson

Brainstem cavernous malformations are formidable lesions because of their eloquent location and propensity for bleeding resulting in neurological impairment. The surgical management can be challenging due to their deep location around critical neurovascular structures. In this operative video manuscript, the authors demonstrate resection of a large recurrent pontine cavernous malformation with an exophytic component in the cerebellopontine angle via a combined petrosal approach. Both anterior and posterior (retrolabyrinthine) petrosectomies were performed to allow multi-corridor access to the lesion. Due to excessive scar formation from prior surgeries, sharp dissection was paramount to create dissection planes around the lesion. This video atlas demonstrates the operative technique and surgical nuances of the skull base approach, safe resection of the malformation through the operative corridor, gentle handling of the neurovascular structures and a multi-layered reconstruction technique to prevent cerebrospinal fluid leakage. The use of endoscopic-assisted microsurgery of the brainstem is also demonstrated. A gross total resection was achieved, and the patient improved neurologically. In summary, the combined petrosal approach with endoscopic assistance is an important strategy in the armamentarium for the surgical management of brainstem cavernous malformations.

The video can be found here: https://youtu.be/oAETW6tVc_Y.