Elsevier

World Neurosurgery

Volume 110, February 2018, Pages 391-396
World Neurosurgery

Case Report
A Novel Dissection Method Using a Flexible Neuroendoscope for Resection of Tumors Around the Aqueduct of Sylvius

https://doi.org/10.1016/j.wneu.2017.11.044Get rights and content

Background

Flexible endoscopes have both a wide range of movement and a wide field of view and are therefore widely used for endoscopic third ventriculostomy and biopsy. However, tumor resection around the aqueduct of Sylvius using flexible endoscopes has scarcely been reported.

Case Description

We report 2 cases of tumor resection around the aqueduct of Sylvius. The first case is a 38-year-old man presenting with progressive headache, nausea, and diplopia. Magnetic resonance imaging (MRI) revealed a 1.4 cm nonenhancing mass at the entry of the aqueduct of Sylvius and occlusive hydrocephalus. We performed tumor resection and endoscopic third ventriculostomy (ETV) simultaneously. His symptoms disappeared after the operation. Final pathologic diagnosis was ancient schwannoma. The second case is a 78-year-old woman presenting with progressive disturbance of consciousness (coma). MRI showed 0.7 cm nonenhancing mass at the entry of the aqueduct of Sylvius and occlusive hydrocephalus. We performed tumor resection and ETV similarly. Her consciousness improved after the operation. Final tumor diagnosis was cavernous malformation. In both cases there was no additional neurologic deficit after the surgery.

Conclusions

By using a flexible endoscope for tumor dissection, resection of a tumor without a neck, which cannot be removed through aspiration alone, becomes possible. To our knowledge, the presented cases are the first to describe the effectiveness of complete resection of a tumor in the third ventricle using flexible endoscopy.

Introduction

Tumors in the posterior third ventricle are rare and clinically challenging to resect because of their highly internalized position; the third ventricle is surrounded by the midbrain, thalamus, pineal gland, and great vein of Galen. Damaging these structures may lead to several neurologic impairments. Further, lesions in these sites can often result in hydrocephalus. The operation for this lesion is necessary to resect tumors and to perform third ventriculostomy for preventing hydrocephalus. Several techniques and tools have been proposed for tumor removal in this region. Recently, endoscopic surgery has developed significantly, and many authors have reported tumor biopsy or resection in this region while performing an endoscopic third ventriculostomy (ETV).1, 2 Endoscopic surgery may be less invasive than microsurgery in resecting deep intraventricular tumors. In many of these reports, a rigid endoscopy with a trans-Monro approach has been used. However, in this method, the foramen of Monro limits the trajectory both anteriorly and posteriorly.3 Flexible endoscopy has a large range of movement in the ventricles and can easily reach from the tuber cinereum to the aqueduct of Sylvius via a single 10-mm burr hole without burdening the foramen of Monro or other periventricular structures.3 However, until now, there have been few reports of tumor resection using a flexible endoscope. In the current report, we present a new method of tumor dissection by flexible neuroendoscopy through 2 illustrative cases.

Section snippets

Operative Procedure

We used a flexible endoscope (VEF-2 [Olympus, Tokyo, Japan]), which is 4 mm in diameter, with a 1.5-mm working channel and 6-mm sheath (NeuroPort MINI [Olympus]). First, we inserted the flexible scope into the frontal horn through a right frontal burr hole, which was located approximately 10–11 cm superior to the nasion (approximately 1–2 cm anterior to the coronal suture) and 2 cm from the midline (pupil line). This burr hole position is suitable for both third ventriculostomy and manipulation

Discussion

Tumor resection around the aqueduct of Sylvius is difficult because of its anatomic position. In microscopic surgery, the approaches typically used for the posterior half of the third ventricle and the pineal region are the occipital transtentorial approach, the infratentorial approach, and the transcallosal approach. However, these approaches have some risks, such as hemianopia, eye movement disturbances, and cognitive decline.4, 5 In addition to creating a lesion in the posterior half of the

Conclusions

By using a flexible endoscope for tumor dissection, resection of a tumor without a neck, which cannot be removed through aspiration alone, becomes possible. To our knowledge, the presented cases are the first to describe the effectiveness of complete resection of a tumor in the third ventricle using flexible endoscopy.

References (19)

  • E.T. Hidalgo et al.

    Resection of intraventricular tumors in children by purely endoscopic means

    World Neurosurg

    (2016)
  • H.W. Schroeder

    Intraventricular tumors

    World Neurosurg

    (2013)
  • A. Fiorindi et al.

    A restricted neuroendoscopic approach for pathological diagnosis of intraventricular and paraventricular tumours

    Acta Neurochir (Wien)

    (2008)
  • K. Oka et al.

    Neuroendoscopic approach to tectal tumors a consecutive series

    J Neurosurg

    (1999)
  • J. Roth et al.

    Combined rigid and flexible endoscopy for tumors in the posterior third ventricle

    J Neurosurg

    (2015)
  • J. Oliveira et al.

    The infratentorial supracerebellar approach in surgery of lesions of the pineal region

    Surg Neurol Int

    (2013)
  • S. Qi et al.

    Radical resection of nongerminomatous pineal region tumors via the occipital transtentorial approach based on arachnoidal consideration: experience on a series of 143 patients

    Acta Neurochir (Wien)

    (2014)
  • S. Chibbaro et al.

    Neuroendoscopic management of posterior third ventricle and pineal region tumors: technique, limitation, and possible complication avoidance

    Neurosurg Rev

    (2012)
  • M.M.M. Santos et al.

    Purely endoscopic resection of a choroid plexus papilloma of the third ventricle: case report

    J Neurosurg Pediatr

    (2015)
There are more references available in the full text version of this article.

Cited by (0)

Supplementary digital content available online.

Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

View full text