SURGICAL VIDEO Radical, Staged Approach to Extensive Posterior Fossa Pediatric Ependymoma: 3-Dimensional Operative Video ∗ ∗ Karol P. Budohoski, MD, PhD , Mathew R. Guilfoyle, MD , ∗‡§ ∗ Damiano G. Barone, MD , Ramez W. Kirollos, MD, FRCS(SN) , Rikin A. Trivedi, MD, PhD, FRCS(SN) , Thomas Santarius, MD, PhD, FRCS(SN) Watch now at https://academic.oup.com/ons/article-lookup/doi/10.1093/ons/ Department of Neurosurgery, Addenbrooke’s Hospital, University of Cambridge, opx206 Cambridge, United Kingdom; Department of Neurosurgery, The Walton Centre, Liverpool, United Kingdom; Brain Repair Centre, University of Cambridge, Cambridge, United Kingdom COMMENT Pediatric ependymoma is the third most common brain tumor his exquisite 3-dimensional operative video of resection of an found in children. Up to 66% are found in the fourth ventricle. T infratentorial ependymoma presents a commonly encountered In localized disease, surgery constitutes the mainstay of treatment. pediatric posterior fossa tumor with extensive disease beyond the fourth Posterior fossa ependymomas originate from the obex (medial- ventricle. Though molecular subtyping of ependymoma promises to type) or the lateral recess of the fourth ventricle (lateral-type), help tailor treatment approaches in the near future, gross-total resection still remains the mainstay of neurosurgical treatment for these tumors frequently extending outside the ventricles, encasing cranial if possible. Because of the invasion of this tumor beyond the fourth nerves and posterior circulation vessels. We present a case of ventricle into the cervical spine as well as the ventral brainstem, the a 2.5-yr-old child with an extensive lateral-type posterior fossa authors developed a staged approach to achieve optimal and complete ependymoma extending from C4 to interpeduncular cistern, resection with the primary goal of preserving neurologic function. encasing the brainstem, cranial nerves IV to XII, and the verte- This video provides both standard midline posterior fossa and lateral brobasilar junction with a solitary lumbar drop metastasis seen retrosigmoid approaches to the fourth ventricle, cranial nerves, and on magnetic resonance imaging. We describe a preplanned staged even offers a view of a corridor to the ventral brainstem that is not approach. Informed consent was obtained. Surgeries included: often seen through posterior approaches. Operative footage demon- (1) midline suboccipital approach with retrosigmoid extension; strates meticulous dissection of the tumor off the brainstem, spinal (2) contralateral retrosigmoid approach; and (3) lumbar lamino- cord, and surrounding nerve roots and essential blood vessels, and plasty to access the solitary metastasis. After the first operation, commentary by the author clearly describes both relevant technique and anatomic concerns throughout the operation. Mastering approaches the patient was allowed time to recover and underwent a to the posterior fossa and comfort with addressing complex tumors series of neurological assessment including audiology given the in this region are especially relevant in today’s pediatric neurosurgery preplanned contralateral approach. Given good recovery from practice and this operative video is very instructive for developing a thefirst stage, thesecondand thirdstage operations were general approach to tumors in this location. We look forward to more performed and gross-total resection was achieved without any such high-resolution educational videos from this group and others new neurological deficits. He was then treated with ‘baby brain’ as we now are able to capture these videos from our 3-dimensional chemotherapy and at the age of 3 yr was given craniospinal microscopes. radiotherapy with a boost to the posterior fossa and location of the previous focal spinal disease. There was no recurrence at 18-mo follow-up. The video focuses on displaying relevant surgical anatomy and discussing aspects of operative technique. We highlight the benefits of a preplanned staged approach for large posterior fossa lesions to achieve the best possible outcome. Allen Ho Gerald Grant Disclosure Stanford, California The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article. OPERATIVE NEUROSURGERY VOLUME 14 | NUMBER 6 | JUNE 2018 | 705 Downloaded from https://academic.oup.com/ons/article-abstract/14/6/705/4345715 by Ed 'DeepDyve' Gillespie user on 17 June 2018
Operative Neurosurgery – Oxford University Press
Published: Sep 29, 2017
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