Intraventricular Tumor Resection
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Table of Contents
This is a case of a 49-year-old patient who presented with persistent headaches with no focal neurologic deficit. An MRI was performed which revealed an intraventricular tumor. The lesion was seen entering the third ventricle and potentially compressing both foramina of Monro. This was further confirmed through coronal reconstruction. The proposed method for tumor removal is an interhemispheric, transcallosal approach.
Central nervous system (CNS) tumors, such as this, are uncommon neoplasms that often present with symptoms like headache, nausea, vomiting, ataxia, vertigo, and papilledema. There is also the possibility of hydrocephalus, as the tumor can obstruct cerebrospinal fluid (CSF) outflow, and the development of seizures. These tumors often grow slowly and can be managed with surgical resection, chemotherapy, and/or stereotactic radiosurgery. For intraventricular tumor resection, the surgical approach can vary based on the tumor location, experience, and preference of the surgeon. Further details of the procedure and patient outcomes will be discussed in the subsequent sections of this article.
Ventricle tumor; cerebral neoplasm; cerebroventricular ventricular neoplasm; brain.
Intraventricular tumors of the central nervous system (CNS) can either arise in the anterior fossa or the posterior fossa, with the former being more common in adults. Of these tumors in the anterior fossa, the oncotypes are most commonly subependymomas, central neurocytomas, intraventricular meningiomas, and metastases.1 Brain tumors originating from the posterior fossa are commonly ependymomas, subependymal giant cell astrocytomas, and choroid plexus papillomas.1 Brain tumors of any type accounted for 1.4% of all new cases of cancer and 2.4% of all cancer deaths in 2014.2 Due to their precarious location, intraventricular tumors have been an operative challenge, historically. Fortunately, advancements in neurosurgery have circumvented much of the inherent risk of a transcortical approach, with microsurgery among the most important developments for patients with intraventricular tumors. Ionizing radiation is a well-known risk factor for CNS tumors. The common risk factors of cancers, tobacco, alcohol, and/or diet, have not yet been explicitly implicated in the pathogenesis of CNS tumors.3 In this case, an interhemispheric transcallosal approach was utilized to resect a tumor in the lateral ventricle of a 49-year-old patient with symptoms of persistent headaches.
In this case, the patient presented with persistent headaches. This symptom is one of the most common in patients with intracranial tumors, which can vary based on the size and location of the tumor. While the patient did not exhibit other common symptoms such as seizures, it’s important to note that these symptoms can occur in other cases.2
Intracranial tumors, depending on their location, can obstruct the cerebrospinal fluid (CSF) tracts, potentially leading to the development of hydrocephalus and causing papilledema, which would be observable on a fundoscopic exam. However, this patient did not present with these symptoms.
It’s also worth noting that intraventricular tumors are often asymptomatic and found incidentally.4 Despite the absence of these symptoms in our patient, the diagnosis was confirmed through imaging, which is the most reliable method for detecting such masses. This highlights the importance of thorough examination and diagnostic testing in the management of intracranial tumors. Further investigation and management of this case will be discussed in the subsequent sections of this report.
The most specific imaging modality, gadolinium-enhanced MRI, was used in this case.2 There is no specific radiological feature to delineate between tumors of metastatic or primary origin. There is a role for chest and abdomen computed tomography if metastasis is suspected; however, in the absence of clinical features pointing to a specific origin, determining the primary location of an extracranial tumor can be difficult.
Intraventricular and intracranial tumors that are left untreated not only lead to a worsening of symptoms but may also cause complications such as cerebral edema and volumetric growth of the tumor. While intracranial tumors are typically slow-growing, there is a possibility for acute intracranial or intratumoral hemorrhage or acute obstructive hydrocephalus, which would indicate a surgical emergency.5
Management of intracranial tumors is largely surgical. In certain circumstances, chemotherapy or radiotherapy can be utilized to optimize surgical candidates for total surgical resection. The surgical approach varies on the ventricle that the tumor is in.3
The chemotherapy regimen of choice is ifosfamide, carboplatin, etoposide (ICE).6 Chemotherapy can be used to stall the progression of the disease for patients’ first surgery or a second-look surgery, and pretreatment with chemotherapy has been shown to have high rates of near-total resection. Of note, the use of chemotherapy is associated with significant neurocognitive impairment.6
Stereotactic radiosurgery (SRS) and whole-brain radiotherapy (WBRT) are also options that can be used in conjunction with surgery or as a substitute for surgery. Outcomes of SRS and surgical resection are similar, with SRS being reserved for patients with more advanced disease with multiple locations.7
The goal of treatment was to remove the tumor in order to relieve symptoms, determine the oncotype of the tumor and other complications that may impact the patient’s quality of life.
Patients should always be counseled on the possible side effects of each treatment option. With advancements in microsurgery, the inherent risk of intracranial operations has been notably reduced and remains the best option for therapy.
In this case, a successful transcallosal approach was used to remove an intraventricular tumor lying in the lateral ventricles of a 49-year-old patient who presented with symptoms of an intracranial mass.
The surgical procedure began with a craniotomy, which was performed 2/3 ahead and 1/3 behind the coronal suture. However, it’s worth noting that some authors suggest that for the best avascular approach, the midpoint of the craniotomy could be aimed at 2.5 cm ahead of the coronal suture.9
Following the craniotomy, the dura was opened and the interhemispheric space was prepared. Both pericallosal arteries and the corpus callosum were then prepared. The next step involved opening the corpus callosum, removing the CSF, and identifying the intraventricular tumor.
The final stage of the procedure was the removal of the tumor. In this case, due to the small size of the callosotomy, the tumor was removed in a piecemeal fashion. However, it should be emphasized that en bloc removal is generally the preferred option when conditions permit. This comprehensive approach ensured the successful execution of the procedure, with further details to be discussed in the subsequent sections of this report.
Surgical management is the most effective treatment for intraventricular tumors if there are clinical manifestations and can be performed via three different approaches: open ventriculostomy, neuroendoscopical, and transcallosal.3,8 Choice of the surgical technique depends on several factors such as the size and location of tumor. Neuroendoscopy and transcallosal approaches are associated with positive outcomes such as shorter operative time, decreased blood loss, shorter hospitalization, reduced postoperative pain, and earlier return to normal activity. Alternatively, neuroendoscopy is becoming a more popular technique and is also associated with positive outcomes similar to traditional approaches.8 However, these approaches are not indicated when patients present with larger tumors, due to their increased risk of complications. Neuroendoscopic removal of the tumor can be especially challenging, causing excessive bleeding and thus prolonged operative time.8
SRS is an alternative procedure that has several indications: multiple intracranial tumors, very large intracranial tumors, restricted operability, microscopic disease remaining after primary resection.7 SRS remains a good option for metastatic disease in the brain. However, the risk-to-benefit ratio for radiation therapy for benign tumors has not been established. WBRT has a broad toxicity profile and has fallen out of favor as a result of SRS therapy becoming more accessible.7
In some circumstances, the ICE chemotherapy regimen is used in patients in addition to surgical intervention. ICE therapy is often used for lymphoma; however, it is also indicated in the treatment of choroid plexus carcinoma. In a study published by Lafay-Cousin et al., ICE therapy has been shown to lead to a cessation in tumor growth; however, this chemotherapy also comes with a plethora of side effects including nephrotoxicity, neurotoxicity, and neutropenia.6 Despite the evidence that pretreating with ICE improves the possibility of total or near-total resection, the risk of neurotoxicity is not to be understated. A plurality of patients treated with ICE chemotherapy displayed significant neurocognitive or sensory derangement after therapy. The risk-to-benefit ratio of nonoperative management of intraventricular tumors is low. At this time, further research is needed to determine the role, and in which combination with surgery, that these therapies play in the treatment of intraventricular tumors.6
Standard neurosurgical equipment.
Nothing to disclose.
The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.
Citations
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Scalia G, Silven MP, Costanzo R, et al. Intraventricular cerebral metastases: a comprehensive systematic review. Anticancer Res. 2024 Feb;44(2):453-462. doi:10.21873/anticanres.16833.
- Perkins A, Liu G. Primary brain tumors in adults: diagnosis and treatment. Am Fam Physician. 2016;93(3):211-217.
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Dang DD, Rechberger JS, Leonel LCPC, et al. Anatomical step-by-step dissection of common approaches to the third ventricle for trainees: surgical anatomy of the anterior transcortical and interhemispheric transcallosal approaches, surgical principles, and illustrative pediatric cases. Acta Neurochir (Wien). 2023 Sep;165(9):2421-2434. doi:10.1007/s00701-023-05697-1.
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Cohen-Gadol A. Principles of Intraventricular Surgery. The Neurosurgical Atlas: by Aaron Cohen-Gadol, M.D. Available at: https://www.neurosurgicalatlas.com/volumes/brain-tumors/intraventricular-tumors/principles-of-intraventricular-surgery. Published March 12, 2020. Accessed April 4, 2021.
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Oya S, Kim SH, Sade B, Lee JH. The natural history of intracranial meningiomas. J Neurosurg. 2011;114(5):1250-1256. doi:10.3171/2010.12.JNS101623.
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Lau G, Drummond J, Zhukova N, Wood P, Janson L. Triple intraventricular chemotherapy for treatment of relapsed choroid plexus carcinoma. Pediatr Blood Cancer. 2021 Sep;68(9):e29094. doi:10.1002/pbc.29094.
- Crompton D, Koffler D, Fekrmandi F, Lehrer EJ, Sheehan JP, Trifiletti DM. Preoperative stereotactic radiosurgery as neoadjuvant therapy for resectable brain tumors. J Neurooncol. 2023 Oct;165(1):21-28. doi:10.1007/s11060-023-04466-5.
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Xie S, Xu L, Wang K, Sun FJ, Xie MX, Wang P, Xiao SW. Endoport-assisted neuroendoscopic techniques used in the resection of intraventricular lesions. Turk Neurosurg. 2023;33(6):929-935. doi:10.5137/1019-5149.JTN.32824-20.5.
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Aldea S, Apra C, Chauvet D, Le Guérinel C, Bourdillon P. Interhemispheric transcallosal approach: going further based on the vascular anatomy. Neurosurg Rev. 2021 Oct;44(5):2831-2835. doi:10.1007/s10143-021-01480-x.
Cite this article
John Doe, PD Dr. med. Marcus Czabanka. Intraventricular tumor resection. J Med Insight. 2024;2024(141). https://doi.org/10.24296/jomi/141Procedure Outline
Table of Contents
- Prep and Drape
- Incision
- Drill Burr Holes
- Use Craniotome and Remove Bone Flap
- Hemostasis
- Open Dura
- Suture Dura to Bone
- Preparing Interhemespheric Fissure
- Resolve Cingulate Gyrus Adhesions
- Identifying Anterior Pericallosal Arteries
- Gauge Location with Navigation
- Open Ventricle and Drain CSF
- Obtain Entry into Ventricle
- Identify Tumor
- Identify and Prepare Tumor Boundaries
- Remove Tumor
- Check for Tumor Remnants
- Ensure All Important Structures are Intact
- Hemostasis
- Close Callosotomy
- Close Dura
- Refix Bone Flap
- Wound Closure
Transcription
CHAPTER 1
My name is Marcus Czabanka. Hello. Today we're going to resect an intraventricular tumor - that's a 49-year-old patient. And you can here see the tumor in the T1 image over here in this area and in the T2 image over there, and you can see the lesion here entering the third ventricle and potentially compressing both foramina of Monro. The same thing you can see here in the corona reconstruction. This patient presented with persistent headaches, no focal neurologic deficit, and, because of this persisting pain, he finally received an MRI showing this intraventricular lesion. So our idea to remove the tumor is basically via an interhemispheric, transcallosal approach for this purpose. So, the first step obviously will be a craniotomy over the coronary suture to really enable an interhemispheric approach. The second step will be opening of the dura and then preparing the interhemispheric space. Third step then will be to really prepare both pericallosal arteries and to prepare the corpus callosum. Fourth step will be opening the corpus callosum and removing CSF and identifying the intraventricular tumor, and the fifth step obviously will be removal of the tumor. The first strategy for this step would be to really circumvent the tumor and to really identify any tumor supplying vascular structures and to really cut these structures, and after this, we'll try to remove the tumor en bloc, or we might have to remove the tumor in parts.
CHAPTER 2
Okay, the positioning of the patient is very simple. The head's positioned straight in the Mayfield clamp, and it's basically inclined as much as possible to actually allow the surgeon to operate towards the floor and not to operate towards the front. And it's a very small skin incision on the level of the coronary suture. The craniotomy will be divided into two parts. Two-thirds will be in front of the coronary suture, and one-third will be posterior to the coronary suture. That's our surgical approach for this one. So we start with a straight skin incision. So, we do intensive hemostasis straight from the– straight from the skin incision. Then we have the retractors. So, we need to create some more space, so–but all the things that we need to see we can already see, okay? So, here you have the sagittal suture. Here you have the coronary suture, so the craniotomy will be in this area over here. We're going to increase the skin incision a little. Okay, now it's–I think, it now it's very clear. Here you have the sutures. So, I'll use a pen now to show you where we're going to do the craniotomy, so that it's easier for you to understand– for you to see where we want to do our cuts. So, one burr hole will be here, and another one will be here, and then the craniotomy will be like this. Okay. Okay, now we mobilize the dura from the bone to get a good entry for the craniotome. Okay, come here to me. And then - and then we do the cuts. The cuts–we always cut away from the sinus so we have no risk, or we have a reduced risk of injuring the sinus. And in this case, we– we increase the craniotomy to the contralateral side. And then we lift the flap, and remove it from the dura. Okay, here you can see the sinus. We're going to do just superficial hemostasis. And some compression. So, the reason to go over the sinus is to be able to retract the dura a little bit more into the contralateral side, so that we have an easier access to the– to the interhemispheric structures. Okay, good– yeah, that's okay.
CHAPTER 3
So, we open the dura. For this purpose, we just put a stitch on it, and then we lift and incise it. You know? And that's it. Okay, once that's done - I just open the dura with the regular scissors. When we approach the sinus, we need to get as close to the sinus as possible without really opening it. That's why I do these small incisions, and I use the retractors to retract the dura further. Okay. There's too much epidural oozing. That's why I'm going to do– I'm going to use stitches to suture the dura to the bone. Okay, do a whole half. Okay, now we make it– now, we generate the access to the interhemispheric fissure. Okay, that's it. Okay, now we can start to prepare the interhemispheric fissure. So, I'm– I've prepared this, just in case. And now, we need to go down. And the first important structure will be the cingulate gyrus where we usually find many adhesions. We need to resolve these adhesions. Here, we're just about to start already. Okay, there we go. Okay. We do it also here on the posterior part, just to resolve the adhesions– arachnoid adhesions. Okay. And we go one step further.
CHAPTER 4
And here's what we already need to see. Do you see the corpus callosum? And here we have– see one of the anterior arteries? The other one should be on the other side. In this case, we decide to go in between them. For retraction purposes, I usually cover this with– with cotton. Okay, here's the anterior– artery– pericallosal artery. That's the right one. So, I just cover it for the manipulation. Okay, here we have the pointer. We are just above the entry to the lateral ventricle. Can you see it? So, in the depth– if we follow the navigation to the depth, we'll see the tumor. See? Now we've opened the ventricle. There's CSF running. Okay. Now we have the entry into the ventricle. So here we're on the contralateral side. We are approaching the contralateral foramen of Monro. Okay. So, it's mostly on this on this side, okay?
CHAPTER 5
That's the tumor. So, I'm looking for the– for the boundaries over here. There's some bleeding. So, I try to first go around the tumor to see if maybe I– I can just cut blood supply and then resect the tumor. Yeah, so it's very hard– first of all, I see that I can get a very good plane towards the regular brain. So here, I have a good plane between the tumor and the regular brain. At the moment, still my strategy is the same. I try to go around the tumor to see if I can really dissect it from the regular brain without injuring too much physiological structures. What I think it is, I have no clue. To be honest. No clue. Maybe it's a– maybe it's a plexus tumor, but I don't see the plexus relationship at the moment. So, still difficulties to really say what it could be. The other problem that I currently have or– it's not a problem, but it's a surgical idea– I'm unsure of, for example– I'll tell you soon. See these are arteries. These, I don't want to– these I don't want to sacrifice or injure. See these small arteries down here? So, I have these little venous bleeding, but these arteries I'm sure I don't want to– I don't want to do any harm to them, because I might risk getting any form of ischemia. So that's very clear, so that's one of my anatomical landmarks where I say no. I'm not going to go further than this. I'm coagulating on the tumor because I know the tumor should not be– the tumor should not be my problem, right? If I coagulate on the tumor, I'm not going to see. Here, I have a good plane towards the brain again. You see regular brain underneath. So, the current question that I have is what I'm going to do with these big vessels over here. So I saved them so far. See right here? But, I still need to find out if they are just primarily for the tumor– then we have to resect them– or if these large vessels will have any effect on the brain. But, see, it becomes clear when you look here. If you have to– if you want to resect the tumor completely, you'll have to sacrifice them. So, I could coagulate them, and then I cut to have no hemorrhage. And then we continue resecting the tumor from the brain. Okay. So I have the front. Now, we have to change to the posterior part. I cover the foramen of Monro with a cottonoid, hoping that there will not be too much blood going to the– going to the remaining ventricles. Here, you see the– here you see the plexus– choroid plexus. Remnants of the thalamostriate vein. So it might very well be a plexus papilloma, for example. So, good border over here, see? Some little adhesions. We'll just remove them. So, I'll take the cottonoid to move it around the tumor. Ah, there we go. So here we need to go through the arachnoid. Okay. Perfect, regular brain. Vessels of the regular brain. Okay. Looks good. Okay, so I think we are almost set. See here– there's another one. Okay, so it's almost loose. I just need to make sure that I don't– I don't injure any vascular neuronal structures here on the posterior part where I don't have the complete... But here it looks good. Perfect.
CHAPTER 6
So now I have it loose, and I will try to remove it as it is. See the hole where I– the approach, the– the callosotomy is too small to resect it completely, so I just take it piece by piece. That's it. So we have removed the tumor now. We had to reduce it in size to remove it via the callosotomy because the approach is– again, the callosotomy is very small, so I can show you in a– in a smaller magnification. So that's the approach that we use to resect the tumor, so give me the tumor. That's just the part that we moved– that we removed after reducing it in size, so... Now I'm just going to check for tumor remnants and to check where the bleeding is coming from. Okay, so what did you can see very well now is– we look– now we look to the contralateral thalamus. Here we have the choroid plexus. Here we have the thalamostriate vein that we have somewhat distorted here. So if you go here, we have the– we have the left side foramen of Monro. There's a blood clot inside, so we need to get rid of this one. Okay, so that's the left side. I have to check what's going on back there. Let's do this one, over here. These are big veins. So now I'd like to see the important structures on the other side, on the– on the right side. For this purpose, I'm going to remove this. Okay that's the third ventricle down here. That's the right side foramen of Monro. Here you have the right side thalamostriate vein, so that's good. So we have that structure. Okay. Okay. Plexis– so I'm– this I'm just going to leave. This is plexus. This is also plexus. I think it was a plexus papilloma. I think that's it. We are all safe. So all the important structures are still present. So a lot of– a lot of hemostasis with water. Now we, in order to control a little oozing and bleeding, we just cover the tissue with this. See there's air coming out of the ventricles. See this? That's what's happens if you reposition the patient, put the head up, so that the air really gets out as much as possible– gets out of the ventricular system. Now I'm going to remove the cottonoids. I think now– now the hemostasis is okay.
CHAPTER 7
This is the contralateral pericallosa over here. The ipsilateral pericallosa– I think I've shown you before, which is right here up front. So, what we're going to do now is– we're going to close the callosotomy in order to hopefully reduce the incidence of a CSF fistula by using foam and glue. So I put it up here. Like this. So I seal it with fibrin glue. Okay. Now hemostasis of the superficial brain areas. But there's not much to do. So, now we going to start to close the dura. Okay, so we use these... how do you call it? That's what it's called. We use it to really seal the dura, if there's– if there's some small remnants where it remains open. So we put in the bone flap with foam sponge. So to just provide the second layer of potential dura, and to seal– to seal the defect on the dura. Nice. Okay. So we fill– we use the remaining bone to fill the gaps of the craniotomy.
CHAPTER 8
Okay, now we have finished the surgery. The surgery overall went quite well. The tumor was easy to prepare, and there was a clear-cut border between the tumor and the regular brain. In the beginning, I had some troubles really to make sure that I can ligate the rather big venous vascular structures that were overlying the tumor, but after some time, it became clear that these are really tumor-supplying vessels, so there was no problem for that. And I think after this, preparation of the tumor itself was quite straightforward without any real complications or problems. I think after surgery, I could really identify all important structures, which were the big thalamostriate vein on both sides and the foramina of Monro, which was compressed on the right side, but otherwise all the important vascular structures, also the pericallosal arteries, were patent and were unharmed, so there was no problem in this regard.