Intraventricular metastatic brain cancer

Introduction

Metastatic brain cancer is the most common type of brain tumor in adults, in which 30% of cancer patients will develop brain tumors, with an estimated incidence of 200,000 new cases each year in the United States alone. ^, The majority of brain metastases occur at the gray-white junction, and as a result, most of these lesions are in close juxtaposition to the cortical surface. ^, An uncommon location is within the ventricular system, which accounts for 1% to 2% in most series. In this chapter, we present a case of a metastatic brain tumor within the lateral ventricles.

Example case

Chief complaint: confusion

History of present illness

A 59-year-old, right-handed man with a history of renal cell cancer (RCC) status post nephrectomy and hypertension who presented with confusion. He underwent right nephrectomy followed by radiation and chemotherapy 2 years prior for RCC. His last positron emission tomography scan was 4 months prior and was negative for systemic disease. More recently, he presented with increasing confusion in which he forgot how to get home from work while driving. He saw his oncologist who ordered a magnetic resonance imaging (MRI) scan ( Fig. 37.1 ).

Medications : Metoprolol.
Allergies : No known drug allergies.
Past medical and surgical history : RCC status post nephrectomy, radiation, and chemotherapy; hypertension.
Family history : No family of intracranial malignancies.
Social history: Sales executive, remote smoking and no alcohol.
Physical examination : Awake, alert, oriented to person, place, and time; Language: intact naming and repetition; Cranial nerves II to XII intact; Right drift, moves all extremities with full strength.
Computed tomography chest/abdomen/pelvis : Small lung lesions concerning for metastatic disease.

	Bernard R. Bendok, MD, Devi Prasad Patra, MD, Mayo Clinic, Scottsdale, AZ, United States	Shlomi Constantini, MD, Danil A. Kozyrev, MD, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel	Maryam Rahman, MD, University of Florida, Gainesville, FL, United States	Charles Teo, MBBS, University of New South Wales, Sydney, Australia
Preoperative
Additional tests requested	DTI fMRI Neurooncology evaluation Oncology evaluation Radiation oncology evaluation	Diffusion MRI DTI Spine MRI	None	None
Surgical approach selected	Left fronto-parietal craniotomy for tumor with EVD	Left parietal craniotomy interhemispheric approach	Left occipital-parietal craniotomy	Right frontal craniotomy
Anatomic corridor	Middle one-third interhemispheric transcallosal	Left parietal interhemispheric	Left occipital-parietal transventricular	Right interhemispheric, transcallosal
Goal of surgery	Maximal safe volume reduction	GTR	Near total resection, relief of hydrocephalus	Complete resection with preservation of fornices
Perioperative
Positioning	Right lateral	Left supine with 45-degree rotation	Left three-quarter prone	Left lateral
Surgical equipment	Surgical navigation IOM Surgical microscope Ultrasonic aspirator	Ultrasound IOM Surgical microscope Electrified ultrasonic aspirator	Surgical navigation Surgical microscope Brain retractors	Central line Surgical navigation 30-degree rigid endoscope
Medications	Mannitol Steroids Antiepileptics	Mannitol Steroids	Mannitol Steroids Antiepileptics	Steroids Antiepileptics
Anatomic considerations	Bridging veins, pericallosal and callosomarginal ACA branches, corpus callosum, fornix, thalamus, thalamostriate veins, internal cerebral veins, choroid plexus, motor cortex	Interhemispheric fissure, cingulate gyrus, corpus callosum, pericallosal arteries	Thalamus	Superior sagittal sinus and draining veins, ACA and branches, corpus callosum, both fornices, thalamus, choroid plexus, and arteries
Complications feared with approach chosen	Cortical injury, thalamic injury , ACA injury, injury to superior sagittal sinus and/or bridging veins, intraventricular hemorrhage	Cerebral edema, venous infarct, hydrocephalus	Avoid interhemispheric veins around motor cortex	Ipsilateral approach would lead to SMA syndrome and injury to primary motor cortex, brain retraction
Intraoperative
Anesthesia	General	General	General	General
Skin incision	Horseshoe	Linear bicoronal posterior to coronal suture	Linear	Right linear paramedian
Bone opening	Left fronto-parietal	Left parietal	Left occipital-parietal	Right frontal
Brain exposure	Left fronto-parietal	Left parietal	Left occipital-parietal	Right frontal up to SSS
Method of resection	Lumbar drain placement, horseshoe skin flap raised with preservation of pericranium, two pairs of burr holes on both sides of sagittal sinus anteriorly and posteriorly, sinus separated and craniotomy on left side, exposed sinus covered with gelfoam, U-shaped dural opening based on sagittal sinus with preservation of bridging veins, identify falx and interhemispheric fissure, drain from EVD to facilitate openings, retract with cotton balls, identify ACA branches, divide arachnoid between pericallosal arteries and identify corpus callosum, 1- to 2-cm corpus callosotomy based on navigation, coagulate and shrink tumor because of anticipated vascularity, debulk tumor and avoid tumor spillage, dissect along cleavage plane between tumor and brain parenchyma, if good plane not evident then maximal safe debulking with avoidance of injury deep drainage veins/thalamus/fornix, copious irrigation, placement of EVD, dural closure with pericranium	Burr holes on sagittal sinus, left parietal craniotomy, administer mannitol and hyperventilation, C-shaped dural opening based on sinus, interhemispheric approach, CSF drained from cistern and drainage of tumor cyst, tumor should be identified at area of corpus callosum, mapping of tumor with electrified ultrasonic aspirator to guide resection, leave EVD for 2–3 days for CSF drainage and ICP measurement	Craniotomy over occipital-parietal area guided by navigation, dural opening, stereotactic-guided corticectomy, placement of EVD under navigation into atrium, place fixed brain retractors around EVD, resect tumor, leave EVD	Perpendicular positioning guided by stereotaxis, burr holes on SSS, right fontal craniotomy exposing SSS, identify bilateral pericallosal arteries, blunt dissection through corpus callosum left of midline using navigation, visualize tumor as it bulges into the cingulate gyrus, minimize corticectomy if possible, remove tumor totally if edges are well defined, identify choroidal artery blood supply if possible, inspection of cavity with 30-degree endoscope for residual with possible need for angled sucker-bipolar instrument, especially superolateral portion, watertight dural closure
Complication avoidance	Lumbar drain placement, interhemispheric approach, drain CSF, extent of resection based on cleavage planes, placement of EVD	Interhemispheric approach, drain CSF, electrified ultrasonic aspirator for mapping, care taken at inferolateral wall of tumor, EVD for ICP measurement and CSF drainage	EVD to guide trajectory, avoid thalamus	Anterior contralateral approach, ideal positioning, operative side down, identification of choroidal arteries, inspection with endoscope
Postoperative
Admission	ICU	ICU	ICU	ICU
Postoperative complications feared	Cognitive dysfunction, disconnection syndrome, thalamic edema, intraventricular hemorrhage, seizures, venous infarct	Disconnection syndrome, cognitive deficit, hydrocephalus	Visual deficit, thalamic injury, hydrocephalus	Venous hypertension, short-term memory loss, delayed intraventricular hemorrhage, seizures
Follow-up testing	CT within 24 hours after surgery MRI within 72 hours after surgery	MRI within 48 hours after surgery MRI 1 month after surgery	MRI 4 weeks after surgery prior to radiation	MRI within 24 hours after surgery
Follow-up visits	14 days after surgery	14 days after surgery	4 weeks after surgery	6–8 weeks after surgery
Adjuvant therapies recommended	Radiation therapy 3–6 weeks after surgery	Oncology board discussion	SRS to brain lesion	Observation with GTR, SRS with residual