Use of a minimally invasive tubular retraction system for deep-seated tumors in pediatric patients

Technical note

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Object

Microsurgical removal is the preferred treatment for most deep-seated, intraaxial tumors in the pediatric population. The feasibility of surgery as an option has improved with advances in surgical technology and technique. Tubular retractors disperse retraction forces over a greater surface area than do conventional retractors, which can lower the risk of ischemic complications. The authors describe their experience utilizing a new tubular retractor system specifically designed for cranial applications in conjunction with frameless neuronavigation.

Methods

The Vycor ViewSite retractor was used in 4 pediatric patients (ages 15 months and 9, 10, and 16 years) with deep-seated intraaxial tumors. The lesions included a papillary tumor of the pineal region, a low-grade astrocytoma in the occipital lobe, a dysembryoplastic neuroepithelial tumor arising from the basal ganglia, and an intraventricular low-grade glioma. The extent of white matter damage along the surgical trajectory (based on T2 or FLAIR and diffusion restriction/apparent diffusion coefficient signals) and the extent of resection were assessed on postoperative imaging.

Results

Satisfactory resection or biopsy was achieved in all patients. A comparison of pre- and postoperative MR imaging studies revealed evidence of white matter damage along the surgical trajectory in 1 patient. None of the patients demonstrated new neurological deficits postoperatively.

Conclusions

Obtaining surgical access to deep-seated, intraaxial tumors is challenging. In this small series of pediatric patients, the combination of the ViewSite tubular retractor and frameless neuronavigation facilitated the surgical approach. The combination of these technologies adds to the armamentarium to safely approach tumors in deep locations.

Abbreviations used in this paper: DNET = dysembryoplastic neuroepithelial tumor; DT = diffusion tensor; DW = diffusion-weighted; fMR = functional MR.

Article Information

Address correspondence to: Violette Renard Recinos, M.D., Pediatric Neurosurgical Oncology, Cleveland Clinic Foundation, 9500 Euclid Avenue, S-60, Cleveland, Ohio 44195. email: recinov@ccf.org.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    The ViewSite tubular retractor. It is notable that the retractor is composed of plastic, has a tapered end, and has an inner obturator that is slightly longer and more closed than the retractor itself. Reprinted with permission from Vycor Medical, Inc.

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    Preoperative T1-weighted MR imaging sequences (left) with contrast-enhancement (right) demonstrating an isointense tumor in the atrium of the left lateral ventricle with central contrast enhancement.

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    Preoperative fMR images used to map cortical function, and DT images used to map underlying white matter tracts. Functional MR images demonstrating the cortical map for motor function (A) and word production (B, orange areas) and the proposed surgical corridor (blue arrows). Diffusion tensor images (C) visualizing the corticospinal tracts (blue). The proposed surgical corridor (red arrow) avoids critical word production areas, motor cortex, and the corticospinal tract.

  • View in gallery

    The ViewSite tubular retractor initially introduced into the operative corridor. It is attached to a flexible arm and secured to a Leyla bar for stabilization. Alternatively, the Greenberg system can also be used for stabilization.

  • View in gallery

    Postoperative axial (A) and sagittal (B) T1-weighted MR images demonstrating gross-total resection of the left atrial tumor. Axial T2-weighted (C) or FLAIR (D) MR images demonstrating no changes.

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