|Year : 2015 | Volume
| Issue : 3 | Page : 155-158
Combined microsurgical extra-axial and transcortical transventricular endoscopic excision of parasellar tumors with ventricular extension
Augustine A Adeolu1, UA Osazuwa2, AA Oremakinde2, TA Oyemolade2, MT Shokunbi1
1 Department of Neurological Surgery, UCH; Department of Surgery, College of Medicine, University of Ibadan, Ibadan, Nigeria
2 Department of Neurological Surgery, UCH, University of Ibadan, Ibadan, Nigeria
|Date of Web Publication||28-May-2015|
Augustine A Adeolu
Department of Neurological Surgery, UCH, Ibadan
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Sella/parasellar tumors with intraventricular extension present unique neurosurgical challenges in achieving gross total resection with minimal morbidity and mortality. Firm attachment of large tumors, especially craniopharyngiomas, in this location to critical structures, makes the goal of complete microsurgical resection more difficult to attain. Several traditional surgical approaches are available. We report two patients who had novel combination of the traditional extra-axial microsurgical and transcortical transventricular endoscopic approaches to resect sellar/suprasellar tumors with intraventricular extension as either staged or simultaneous procedures.
| Abstract in French|| |
Sella/parasellartumeurs avec extension intraventriculaire présentent des défis neurochirurgicales uniques dans la réalisation de la résection totale brute avec la mortalité et la morbidité minime. Ferme attachement de grosses tumeurs, surtout des craniopharyngiomes, dans cet endroit aux structures critiques, rend l'objectif de la résection complète de microchirurgie plus difficiles à atteindre. Il existe plusieurs approches chirurgicales traditionnelles. Nous rapportons deux patients qui avaient une combinaison inédite de la traditionnelle extra axial microchirurgicales transcorticale transventricular approches endoscopique pour résection de tumeurs sellar/suprasellaire avec extension intraventriculaire, les procédures de mise en scène ou simultanées et.
Mots-clés: Endoscopic, microchirurgie, parasellar tumeurs, extension ventriculaire
Keywords: Endoscopic, microsurgical, parasellar tumors, ventricular extension
|How to cite this article:|
Adeolu AA, Osazuwa U A, Oremakinde A A, Oyemolade T A, Shokunbi M T. Combined microsurgical extra-axial and transcortical transventricular endoscopic excision of parasellar tumors with ventricular extension. Ann Afr Med 2015;14:155-8
|How to cite this URL:|
Adeolu AA, Osazuwa U A, Oremakinde A A, Oyemolade T A, Shokunbi M T. Combined microsurgical extra-axial and transcortical transventricular endoscopic excision of parasellar tumors with ventricular extension. Ann Afr Med [serial online] 2015 [cited 2019 Dec 10];14:155-8. Available from: http://www.annalsafrmed.org/text.asp?2015/14/3/155/149891
| Introduction|| |
Gross total resection of sellar/parasellar tumors with significant intraventricular extension pose several challenges with any singular approach. Although pituitary tumors are the most common lesion in this location, accounting for over 90% of lesions, craniopharyngiomas which are benign tumors account for a greater percentage of sellar region pathology in children.  The latter lesions are particularly difficult to resect because they often adhere to adjacent delicate structures. , Roughly, 90% of the lesions have suprasellar extension.  This often elevates the floor of the third ventricle and the latter frequently gets completely obliterated.
In order to prevent significant postoperative complications, the degree of tumor removal must be guided by the degree of difficulty envisaged preoperatively and encountered intraoperatively. This can be achieved through several microsurgical approaches. Nakamizo et al. recognized that with significant intraventricular extensions these approaches pose several problems including difficulty in locating lateral landmarks, high risk of hypothalamic damage, poor visualization of the third ventricular wall, and the need to divide the frontal cortex. 
For craniopharyngiomas located in the intraventricular area, access via an endoscope is possible especially for the Yarsargil Types D, E, F. 
With the refinement of multipurpose multichannel endoscope in the late last century, endoscopy has increasingly been used for diagnostic and therapeutic purposes. Caemaert et al. reported in 1994 that endoscopic fenestration of para- and intraventricular cysts is a valuable method that in most cases replaces an open surgical intervention or extracranial shunting procedure.  The same authors reported in 1995 that endoscopic management of craniopharyngiomas can be applied in these modes: Total resection of small lesions, evacuation of the cyst with marsupialization into the subarachnoid space or ventricular system and aspiration of the cyst without removal of the cyst wall. 
In order to improve the extent of resection with minimal morbidity and mortality, we have combined the traditional extra-axial microsurgical and transcortical transventricular endoscopic approaches to resect sellar/suprasellar tumors with intraventricular extension. Two cases which were so managed are hereby presented.
| Case Reports|| |
A 5-year-old boy presented with generalized headache of 3 months duration. He also had vomiting, urinary incontinence, forgetfulness, frequent falls, and progressive difficulty with walking. He had been unable to sit without support for 3 weeks before presentation. He did not have seizure or visual disturbances. On examination, he was awake with Glasgow Coma Score (GCS) of 15. He had bilateral abducens nerve palsy and right supranuclear facioparesis. His cranial computerized tomographic (CT) scan showed hyperdense lesion with areas of calcification, arising from the sella and extending to the third ventricle with obstructive hydrocephalus [Figure 1]a. A diagnosis of sellar/suprasellar mass most likely craniopharyngioma was made. He had a staged endoscopic transcortical transventricular and microsurgical extra-axial near total excision of the tumor [Figure 1]b-d; the latter was performed 2 weeks after the endoscopic decompression.
|Figure 1: (a) Preoperative cranial computerized tomographic (CT) scan of the first patient showing the tumor in the third ventricle with a focus of hyperdensity and obstructive hydrocephalus. (b) Cranial CT scan of the first patient after transventricular endoscopic decompression of the tumor. The ventricles are less dilated. (c and d) Cranial CT scan of the first patient after the second surgery showing gross total excision and restored ventricular system. The hyperdense lesion in the tumor bed in 1c is a blood clot|
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The postoperative course was satisfactory, and there was no neurological deficit at follow-up 6 weeks after discharge.
A 33-year-old man presented with severe, generalized headache of a-year duration. His vision had been deteriorating progressively over the same period. There was no loss of consciousness, seizure, limb weakness, or endocrine dysfunction. On examination, he was awake with GCS of 15 and normal mental status. The pupils were 3 mm bilaterally and briskly reacting to light. Visual acuity was counting finger on the right and 6/24 on the left. He had bilateral abducens nerve palsy and grade 3 tendon reflexes. His cranial CT scan showed mixed density sellar mass, extending to the third ventricle, with solid contrast enhancing and cystic components and obstructive hydrocephalus [Figure 2]a and b. A diagnosis of sellar/suprasellar mass most likely craniopharyngioma was made. He had single stage endoscopic transcortical transventricular tumor cyst decompression and right pterional craniotomy with gross total tumor excision. Postoperative course was satisfactory. Postoperative CT scan showed complete tumor excision [Figure 2]c and d. Subsequent evaluation 6 weeks after discharge showed improved vision with visual acuity of 6/60 on the right and 6/12 on the left.
|Figure 2: (a and b) Preoperative cranial computerized tomographic (CT) scan of the second patient showing the suprasellar tumor extending into the third ventricle with obstructive hydrocephalus. (c and d) Postoperative cranial CT scan of the second patient showing gross total excision and restored ventricular system. Combined endoscopic-micriosurgical resection of intracranial tumors Combined endoscopic-micriosurgical resection of intracranial tumors|
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| Discussion|| |
There are several reports on combined approaches to the tumors of the sellar/parasellar region. They may be performed as simultaneous or staged procedures. These include combined endoscopic transsphenoidal and simultaneous transventricular approach,  combined transcranial microsurgical-endoscopic transphenoidal approach, combined simultaneous transcranial-transphenoidal approach,  and the staged transcranial-transphenoidal approach. 
Combined transcranial extra-axial microsurgical and transcortical transventricular endoscopic resection provides another option in the management of large suprasellar tumor with intraventricular extension. This is particular so for cystic tumors as in cystic craniopharyngioma. A staged or simultaneous combined procedure has obvious merits. The merits include the fact that the staged form of this approach in which the transventricular endoscopic procedure was performed in the first seating may be more suitable than the above mentioned previously reported combined approaches for patients who have acute neurological status from raised intracranial pressure due to hydrocephalus or the huge cystic component of the tumor. This initial minimally-invasive endoscopic decompression will optimize the patient's neurological condition and render the brain less tense for the more invasive microsurgical procedure. It may be more suitable for the elderly or debilitated patients who need an initial less invasive procedure to buy time for them to be medically fit for long anesthesia and more extensive microsurgical approach compared to the previously reported combined approaches. In the previously reported combined approaches mentioned earlier, the endoscopic components are more invasive and are mainly via the transphenoidal route which is far away from the third ventricular component that is difficult to be assessed from below. The first patient presented had an initial transventricular endoscopic tumor cyst decompression and a right pterional craniotomy with near total tumor excision 2 weeks later. The second patient, on the other hand, had a single stage simultaneous combined transcortical transventricular endoscopic tumor cyst decompression and right pterional craniotomy with gross total tumor excision. Intuitively, the indications for such an approach would include sellar/parasellar tumors with intraventricular extension, cystic or soft tumors and the presence of obstructive hydrocephalus. The advantages are obvious. It enables a more complete resection of the tumor; there is relief of the hydrocephalus, and it offers minimally-invasive tumor cyst decompression. In addition, there is a good visualization of the third ventricular anatomy; the relief of intracranial pressure following cyst decompression will enhance extra-axial dissection with minimal brain retraction and concomitant reduced risk of damage to adjoining structures. However, such an approach is not without its challenges; it presupposes the availability of instrumentation for nueroendoscopy and that the neurosurgeon is skilled in neuroendoscopic techniques. In the second patient, the bone flap was removed before the endoscopic cannulation of the frontal horn of the lateral ventricle transcortically. The expected changes in the brain compliance and ventricular size and orientation in the absence of the bone flap could make localization of the ventricle technically more difficult in a resource-limited setting like ours without the intraoperative neuronavigation. This could in part be mitigated by proper positioning of the patient to alleviate the effects of gravity on brain shift. Is the operation time prolonged in the combined approach? While the extra time required in setting up the neuroendoscopic apparatus may add a few minutes to the procedure the gains in carrying out a more complete tumor resection with decreased morbidity and mortality are adequate compensation.
| Conclusion|| |
Combined transcranial extra-axial microsurgical and transcortical transventricular endoscopic resection of suprasellar tumors with ventricular extension is feasible. The technique provides safe option for ensuring complete tumor resection with minimal morbidity.
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[Figure 1], [Figure 2]