Transcortical approaches to large intraventricular tumors: a prospective case series of 20 patients

Abstract

Background Large intraventricular tumors (IVTs) impose technical and surgical challenges, due to their enormous sizes, mass effect, vast extensions, and vascularity. Objective The authors aim at presenting their results, clinical outcomes, and the surgical strategies in the management of large IVTs through transcortical approaches. Methods A prospective trial was conducted at the Main Hospital of Alexandria University, Egypt, between August 2018 and October 2020 on 20 patients harboring IVTs larger than 5 cm or bilaterally represented. The variables evaluated included the extent of resection, postoperative neurological deficits, blood loss, surgical approaches, intraoperative challenges, complications, adjuvant therapies, Glasgow Outcome Scale, hydrocephalus, and cerebrospinal fluid (CSF) diversion. Results The study included 20 cases (9 males and 11 females). Mean age at diagnosis was 16.1 years (range 1–45). Mean follow-up was 12 months (range 9–26). Primary tumor locations were ventricular body, atrium, temporal horn, and frontal horn in 11, 5, 3, and 1 cases, respectively. Main pathologies were central neurocytomas (7 patients/35%), ependymomas (3 patients/15%), and subependymal giant cell astrocytoma (SEGA) (3 patients/15%). Excision was gross total (n = 19) and near-total (n = 1). Significant intraoperative bleeding (n = 6). Postoperative minor intraventricular hemorrhage (n = 6), subdural collections (n = 8), hydrocephalus (n = 9), memory affection (n = 4), and motor deficits (n = 4). Postoperative Glasgow Outcome Scale of 5/5 (n = 20), no mortalities were recorded. preoperative seizures (n = 7), new onset postoperative seizures (n = 2). Conclusion Surgical approaches to large tumors of the lateral ventricles should be tailored to the variability of tumor locations, dimensions, extensions, and the individual morbid anatomy, in addition to the surgeon’s experience and preferences. Trans-cortical approaches can provide safe surgical corridors to tackle these challenging subtypes of IVTs with good clinical outcomes, tumor resectability rates, and seizure control.

Incidence and Surgical Outcome of Intraventricular Tumors at a Tertiary Care Hospital in Lahore, Pakistan

“…The ventricles in the brain are a complex system and surgeons face different hurdles due to anatomy while operating on these tumors. 5 Despite major improvements in microsurgical instruments and technical advancements, surgical resection of intraventricular tumors presents certain obstacles. This can be because of the tumor location within the ventricles or possible damage to important normal structures such as arterial and venous structures, internal capsule, corpus callosum, cerebral cortex, thalamus, etc.…”

“…This can be because of the tumor location within the ventricles or possible damage to important normal structures such as arterial and venous structures, internal capsule, corpus callosum, cerebral cortex, thalamus, etc. 5 That's why over the period different approaches have been developed to completely resect these tumors with minimum damage to the normal structure. A variety of approaches have been illustrated to enter the lateral ventricles, some of which include the anterior or posterior transcortical and interhemispheric transcallosal (anterior or posterior) approaches.…”

“…Similarly, the posterior transcortical approach was useful to resect tumors of the atrium, body, and occipital horns. 5 GTR was achieved in more than 78% of the procedure, while only one procedure had to be abandoned due to intraoperative cardiac arrest and hemodynamic instability, which later could not survive. EVD insertion as a form of temporary CSF diversion was practiced in almost all procedures despite adequacy of hemostasis at the end of the procedure to monitor the intracranial pressure and intraventricular bleed in the post-operative period and to assess the need for permanent CSF diversion/shunting.…”

“…This can be because of the tumor location within the ventricles or possible damage to important normal structures such as arterial and venous structures, internal capsule, corpus callosum, cerebral cortex, thalamus, etc. 5 Different microsurgical procedures to resect intraventricular tumors use transcortical, transcallosal, and supra-cerebellar infratentorial approaches. 5 Due to these presenting challenges and wide diversity, the objective of this study is to share our experience with intraventricular tumors micro-surgically treated at a tertiary level institute through technically appropriate and standard approaches to the ventricle system.…”

“…5 Different microsurgical procedures to resect intraventricular tumors use transcortical, transcallosal, and supra-cerebellar infratentorial approaches. 5 Due to these presenting challenges and wide diversity, the objective of this study is to share our experience with intraventricular tumors micro-surgically treated at a tertiary level institute through technically appropriate and standard approaches to the ventricle system. This study also explores the incidence, histopathological diagnosis, complications, and outcome of these patients undergoing microsurgical resection.…”