5 Case Examples

5 Case Examples



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Case 5.1


• Diagnosis: Pineal cyst (related anatomy: pp. 10, 11, 3847)


• Preoperative examination: Neurologically intact


• Approach: Right paramedian keyhole endoscopic-assisted supracerebellar infratentorial (related approach: pp. 238246)


• Positioning: Sitting


• Monitoring: Somatosensory evoked potentials


• Outcome: Complete removal of the cyst; patient is neurologically intact, with resolution of headaches.


See Video 5.1


Figure 5.1. A 33-year-old woman presented with a long history of migraines.












Case 5.2


• Diagnosis: Pineal cyst (related anatomy: pp. 10, 11, 3847)


• Preoperative examination: Neurologically intact


• Approach: Right paramedian keyhole supracerebellar infratentorial (related approach: pp. 238246)


• Positioning: Left-sided park bench position


• Monitoring: Somatosensory evoked potentials


• Outcome: Complete removal of the cyst; patient has resolution of symptoms and is neurologically intact.


See Video 5.2


Figure 5.2. A 42-year-old woman presented with headaches, visual disturbance, and diplopia.













Case 5.3


• Diagnosis: Pineal parenchymal tumor (related anatomy: pp. 10, 11, 3847)


• Preoperative examination: Neurologically intact


• Approach: Left lateral keyhole endoscopic-assisted supracerebellar infratentorial (related approach: pp. 238246)


• Positioning: Sitting


• Monitoring: Somatosensory evoked potentials


• Outcome: Complete resection of tumor; patient is neurologically intact but later required shunting.


See Video 5.3


Figure 5.3. A 24-year-old woman presented with headaches.











Case 5.4


• Diagnosis: Pineal cavernous malformation (related anatomy: pp. 10, 11, 3847)


• Preoperative examination: Neurologically intact


• Approach: Right paramedian endoscopic-assisted supracerebellar infratentorial (related approach: pp. 238246)


• Positioning: Sitting


• Monitoring: Somatosensory evoked potentials


• Outcome: Complete removal of the lesion; patient is at neurologic baseline, with persistent diplopia that gradually resolved.


See Video 5.4 and Animation 5.1


Figure 5.4. A 31-year-old man presented with a history of headaches and difficulty with eye movement.














Case 5.5


• Diagnosis: Right posterior thalamic cavernous malformation (related anatomy: pp. 912, 1416)


• Preoperative examination: Neurologically intact


• Approach: Right lateral supracerebellar transtentorial (related approach: p. 247)


• Positioning: Prone


• Monitoring: Somatosensory evoked potentials


• Outcome: Complete removal of the lesion; patient is neurologically intact.


See Video 5.5


Figure 5.5. A 10-year-old girl with a family history of cavernous malformations presented with a recent history of headaches and diplopia.












Case 5.6


• Diagnosis: Thalamic cavernous malformation (related anatomy: pp. 912, 1416)


• Preoperative examination: Left oculomotor nerve palsy, upward gaze paresis, and mild right arm weakness


• Approach: Left lateral supracerebellar transtentorial (related approach: p. 247)


• Positioning: Modified park bench


• Monitoring: Somatosensory evoked potentials


• Outcome: Complete removal of the lesion; patient is at neurologic baseline.


See Video 5.6


Figure 5.6. A 15-year-old girl, who had undergone a previous craniotomy and shunting, presented with left oculomotor nerve (CN III) palsy, upward gaze paresis, and mild right arm weakness.



















Case 5.7


• Diagnosis: Posterior thalamic cavernous malformation (related anatomy: pp. 912, 1416)


• Preoperative examination: 4–/5 in left arm and leg


• Approach: Right parieto-occipital transcortical transventricular approach (related approach: p. 185)


• Positioning: Supine


• Monitoring: Somatosensory evoked potentials


• Outcome: Complete removal of the lesion; patient is at neurologic baseline.


See Video 5.7


Figure 5.7. A 25-year-old woman presented with sudden-onset left-sided weakness.












Case 5.8


• Diagnosis: Thalamic cavernous malformation (related anatomy: pp. 912, 1416)


• Preoperative examination: Sudden-onset, progressive, right hemiparesis in arm and leg


• Approach: Anterior interhemispheric transcallosal transchoroidal fissure (related approach: pp. 186194)


• Positioning: Supine, with head turned to place lesion up


• Monitoring: Somatosensory evoked potentials


• Outcome: Complete removal of the lesion; patient is at neurologic baseline.


See Video 5.8


Figure 5.8. A 26-year-old man presented with sudden-onset right-sided weakness.

















Case 5.9


• Diagnosis: Third ventricular/thalamic cavernous malformation (related anatomy: pp. 912, 1416)


• Preoperative examination: Left hemiparesis in arm and leg


• Approach: Anterior interhemispheric transcallosal transchoroidal fissure (related approach: pp. 186194)


• Positioning: Supine, with head turned to place lesion up


• Monitoring: Somatosensory evoked potentials


• Outcome: Complete removal of the lesion; patient is at neurologic baseline.


See Video 5.9


Figure 5.9. A 35-year-old man presented with sudden-onset left-sided weakness.















Case 5.10


• Diagnosis: Thalamic cavernous malformation (related anatomy: pp. 912, 1416)


• Preoperative examination: Right hemiparesis in arm and leg


• Approach: Anterior interhemispheric (related approach: pp. 186194)


• Positioning: Supine, with head turned to place lesion down; craniotomy on side of lesion


• Monitoring: Somatosensory evoked potentials


• Outcome: Complete removal of lesion; patient is at neurologic baseline.


See Video 5.10


Figure 5.10. A preteen girl presented with sudden-onset right-sided weakness.













Case 5.11


• Diagnosis: Thalamic cavernous malformation (related anatomy: pp. 912, 1416)


• Preoperative examination: Left hemiparesis in hand and diminished left upper-extremity sensation


• Approach: Right supracerebellar transtentorial (related approach: p. 247)


• Positioning: Prone


• Monitoring: Somatosensory evoked potentials


• Outcome: Complete removal of the lesion; patient is at neurologic baseline.


See Video 5.11


Figure 5.11. A 5-year-old girl presented with a history of sudden-onset left hemiparesis that had improved significantly by 4 months after the ictus.














Case 5.12


• Diagnosis: Ruptured grade V thalamic arteriovenous malformation (related anatomy: pp. 912, 1416)


• Preoperative examination: Left hemiparesis; 2/5 in strength


• Approach: Right transcortical


• Positioning: Prone


• Monitoring: Somatosensory evoked potentials and motor evoked potentials


• Outcome: Obliteration of arteriovenous malformation; patient is at neurologic baseline.


See Video 5.12


Figure 5.12. A 13-year-old boy presented with severe headache and progressive left weakness due to a ruptured grade V thalamic arteriovenous malformation. His history was significant for a prior hemorrhage at age 8 that required a decompressive hemicraniectomy and a ventriculoperitoneal shunt. With rehabilitation after the first operation, he had improved neurologic examination results (4+/5 on the left side), but the family did not follow up with a recommendation for gamma knife radiosurgery.




















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Case 5.13


• Diagnosis: Midbrain cavernous malformation (related anatomy: pp. 5, 6, 17, 18, 26, 27, 39, 42)


• Preoperative examination: Intubated, right side flickering, and left side withdrawing


• Approach: Right orbitozygomatic (related approach: pp. 144160)


• Positioning: Supine


• Monitoring: Somatosensory evoked potentials and motor evoked potentials


• Outcome: Complete removal of lesion; the patient requires a tracheotomy but is able to follow commands on the left side and to flex the right side.


See Video 5.13 and Animations 5.2 and 5.3


Figure 5.13. A 59-year-old man presented with sudden-onset slurring of speech and right-sided hemiplegia.













Case 5.14


• Diagnosis: Midbrain cavernous malformation (related anatomy: pp. 13, 38, 43)


• Preoperative examination: Left arm 4/5; bilateral dysmetria


• Approach: Left supracerebellar infratentorial (related approach: pp. 238246)


• Positioning: Prone


• Monitoring: Somatosensory evoked potentials and motor evoked potentials


• Outcome: Complete removal of lesion; bilateral intranuclear ophthalmoplegia, Parinaud syndrome, right facial droop, proprioceptive deficit, and right hemiparesis (arm 2/5; leg 4–/5)


See Video 5.14 and Animations 5.2 and 5.4


Figure 5.14. A 56-year-old man presented with diplopia on right gaze.













Case 5.15


• Diagnosis: Thalamic/midbrain cavernous malformation (related anatomy: pp. 18, 38, 43)


• Preoperative examination: Gait instability, bilateral abducens nerve (CN VI) palsy, and partial bilateral oculomotor nerve (CN III) palsy


• Approach: Left lateral supracerebellar infratentorial and transtentorial (related approach: pp. 238246)


• Positioning: Prone


• Monitoring: Somatosensory evoked potentials and motor evoked potentials


• Outcome: Complete removal of lesion; postoperatively, the patient is unable to mobilize but by 4.5-month follow-up, he is able to ambulate without assistance; preoperative cranial nerve deficits persist but are stable.


See Video 5.15 and Animations 5.2 and 5.4


Figure 5.15. A 67-year-old man with a midbrain cavernous malformation presented after a prior unsuccessful resection attempt via a subtemporal approach at an outside institution.














Case 5.16


• Diagnosis: Pontine cavernous malformation (related anatomy: pp. 5, 6, 17, 18, 26, 27, 39, 42)


• Preoperative examination: Difficulty with tandem walk and right arm pronator drift


• Approach: Left orbitozygomatic craniotomy (related approach: pp. 144160)


• Positioning: Supine


• Monitoring: Somatosensory evoked potentials and motor evoked potentials


• Outcome: Complete removal of lesion; transient worsening of right arm weakness; otherwise, neurologic status is unchanged.


See Video 5.16 and Animations 5.2 and 5.3


Figure 5.16. A 26-year-old woman presented with difficulty with tandem gait and right arm pronator drift.












Case 5.17


• Diagnosis: Midbrain cavernous malformation (related anatomy: pp. 312, 1416)


• Preoperative examination: Neurologically intact


• Approach: Right posterior interhemispheric transcallosal interforniceal


• Positioning: Semi-sitting


• Monitoring: Somatosensory evoked potentials and motor evoked potentials


• Outcome: Complete removal of lesion; no new deficit; memory is stable.


See Video 5.17 and Animation 5.2


Figure 5.17. An 18-year-old man presented with progressive memory loss.













Case 5.18


• Diagnosis: Midbrain cavernous malformation (related anatomy: pp. 18, 38, 43)


• Preoperative examination: Neurologically intact


• Approach: Left lateral supracerebellar infratentorial (related approach: pp. 238246)


• Positioning: Supine


• Monitoring: Somatosensory evoked potentials and motor evoked potentials


• Outcome: Complete removal of lesion; diminished sensation on right side of body; otherwise, the patient is neurologically intact.


See Video 5.18 and Animations 5.2 and 5.4

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Apr 23, 2018 | Posted by in NEUROSURGERY | Comments Off on 5 Case Examples
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