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Alberto Feletti and Pierluigi Longatti

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Konstantinos Margetis, Prajwal Rajappa, Apostolos John Tsiouris, Jeffrey P. Greenfield, and Theodore H. Schwartz


A critical goal in neurosurgical oncology is maximizing the extent of tumor resection while minimizing the risk to normal white matter tracts. Frameless stereotaxy and white matter mapping are indispensable tools in this effort, but deep tumor margins may not be accurately defined because of the “brain shift” at the end of the operation. The authors investigated the safety and efficacy of a technique for marking the deep margins of intraaxial tumors with stereotactic injection of Indigo Carmine dye.


Investigational New Drug study approval for a prospective study in adult patients with gliomas was obtained from the FDA (Investigational New Drug no. 112680). At surgery, 1–3 stereotactic injections of 0.01 ml of Indigo Carmine dye were performed through the initial bur holes into the deep tumor margins before elevation of the bone flap. White light microscopic resection was conducted in standard fashion by using frameless stereotactic navigation until the injected margins were identified. The resection of the injected tumor margins and the extent of resection of the whole tumor volume were determined by using postoperative volumetric MRI.


In total 17 injections were performed in 10 enrolled patients (6 male, 4 female), whose mean age was 49 years. For all patients, the injection points were identified intraoperatively and tumor was resected at these points. The staining pattern was reproducible; it was a sphere of stained tissue approximately 5 mm in diameter. A halo of stained tissue and a backflow of dye through the needle tract were also noted, but these were clearly distinct from the staining pattern of the injection point, which was vividly colored and demarcated. Postoperative MR images verified the resection of all injection points. The mean extent of resection of the tumor as a whole was 97.1%. For 1 patient, a brain abscess developed on postoperative Day 16 and needed additional surgical treatment.


Stereotactic injection of Indigo Carmine dye can be used to demarcate multiple deep tumor margins, which can be readily identified intraoperatively by using standard white light microscopy. This technique may enhance the accuracy of frameless stereotactic navigation and increase the extent of resection of intraaxial tumors.

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Prajwal Rajappa, Konstantinos Margetis, Dimitri Sigounas, Vijay Anand, Theodore H. Schwartz, and Jeffrey P. Greenfield

The authors report a case of a recurrent pediatric ventral pontine ependymoma that they resected through an endonasal endoscopic transclival approach. Regarding the options for a surgical approach to ventral pontine tumors, traditional far-lateral approaches are associated with considerable morbidity due to the required muscle mobilization, brain retraction, and in-line obstruction of cranial nerves before reaching the target. The endoscopic endonasal transclival approach was made appealing by eliminating all of these concerns. The patient's fully pneumatized sphenoid sinus, laterally displaced basilar artery, and the direct ventral location of the bulky disease all further supported this unconventional choice of surgical corridor to achieve a palliative brainstem decompression of an incurable recurrence.