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 »  Abstract
 » Case Illustration
 » Surgical Approach
 » Pearls and Pitfalls
 » Discussion
 » Conclusion
 »  References
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Table of Contents    
NI SPECIAL FEATURE: OPERATIVE NUANCES: STEP BY STEP (VIDEO SECTION)
Year : 2020  |  Volume : 68  |  Issue : 6  |  Page : 1307-1309

Supracerebellar Infratentorial Endoscopy for Quadrigeminal Cistern Epidermoid


Department of Neurosurgery, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India

Date of Web Publication19-Dec-2020

Correspondence Address:
Dr. Sivashanmugam Dhandapani
Department of Neurosurgery, Post Graduate Institute of Medical Education and Research (PGIMER), Sector 12, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.304077

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 » Abstract 


Background: The standard microscopic supracerebellar infratentorial approach for the pineal region is limited by tunnel vision. Herein, we describe endoscopic supracerebellar infratentorial surgery in a patient with quadrigeminal cistern epidermoid presenting with hydrocephalus.
Description: In the sitting position, following a 6 cm longitudinal incision and small suboccipital craniotomy, the dura was cut in V shape and kept reflected. The bridging veins were coagulated and cut, taking the 0° endoscope inside. A sharp incision is given over the thickened arachnoid over the inferior paramedian area. The precentral cerebellar vein is exposed at the lower part, coagulated and divided. Gentle bimanual intracapsular removal of the epidermoid flakes is performed with intermittent saline irrigation and suction. Assisted by rotating the angled endoscope, curved coaxial instruments help remove the cerebello-mesencephalic and lateral extensions of the epidermoid.
Conclusion: Endoscopic supracerebellar infratentorial approach provides a panoramic and angled view of the pineal region, through a narrow corridor, avoiding cerebellar retraction.


Keywords: Endoscopy, epidermoid, quadrigeminal, supracerebellar infratentorial
Key Messages: Endoscopy in supracerebellar infratentorial approach bestows panoramic and angled view of pineal region, averting cerebellar retraction.


How to cite this article:
Dhandapani S. Supracerebellar Infratentorial Endoscopy for Quadrigeminal Cistern Epidermoid. Neurol India 2020;68:1307-9

How to cite this URL:
Dhandapani S. Supracerebellar Infratentorial Endoscopy for Quadrigeminal Cistern Epidermoid. Neurol India [serial online] 2020 [cited 2021 Jun 13];68:1307-9. Available from: https://www.neurologyindia.com/text.asp?2020/68/6/1307/304077




The traditional microscopic supracerebellar infratentorial approach has been a standard to access pineal region masses.[1],[2] However, this has a limited angle of illumination and visualization along the sides and corners, resulting in a tunnel vision. Hence, the required craniotomy is often more extensive, with some degree of cerebellar retraction. In comparison to the microscope, a standard endoscope offers a panoramic view with an additional option of using angled endoscopes[Figure 1].[3],[4]
Figure 1: Comparison of Microscopy & Endoscopy

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Moreover, by rotating the angled endoscopes, an even greater field of view is possible. When an endoscope is used with coaxial surgical instruments, cerebellar retraction can be averted, as a narrow corridor is sufficient. Herein, we illustrate the technique of endoscopic supracerebellar infratentorial excision in a patient having quadrigeminal cistern epidermoid.


 » Case Illustration Top


A 21-year-old male presented with progressive headache. On examination, there was papilledema. Magnetic resonance imaging (MRI) showed obstructive hydrocephalus due to an extra-axial mass in the quadrigeminal cistern, hypointense in T1WI, and hyperintense in T2WI, with no enhancement. Diffusion-weighted (DW) and apparent diffusion coefficient (ADC) imaging demonstrated restricted diffusion in the mass suggestive of epidermoid.


 » Surgical Approach Top


Supracerebellar infratentorial approach was chosen as the epidermoid was predominantly midline and inferior to the central veins. Endoscopy was chosen as a standalone tool for panoramic and angled illumination-visualization, avoiding cerebellar retraction.

Video Link: https://youtu.be/UPym1HhIMdE.

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Video timeline with audio transcript:

28.14 s: Sitting position is preferred, as irrigation fluid and blood tend to drain away from the endoscope. Head-holder fixation in maximal neck flexion and use of head-end of OT table for elbow support are key ergonomic tips.

41.48 s: 6 cm longitudinal incision and a 5 cm suboccipital craniotomy were made. Dura was cut in V shape and kept reflected.

50.44 s: The bridging veins were coagulated and cut, taking the 0° endoscope inside.

56.38 s: Using no retraction, the supracerebellar corridor is gently sailed through, without avulsing any vein.

1 min 4.03 s: A sharp incision is given over the thickened arachnoid over the inferior paramedian area.

1 min 13.11 s: The precentral cerebellar vein is exposed at the lower section, coagulated and cut.

1 min 25.37 s: The cavity of the epidermoid is entered, gentle bimanual intracapsular removal of the epidermoid flakes is performed using pituitary curettes with intermittent saline irrigation.

1 min 41.08 s: The endoscope can be fixed onto a holder with periodic adjustments, to enable bimanual dissection.

1 min 51.03 s: The superficial portion of epidermoid is most conveniently removed using 0° endoscope.

1 min 59.04 s: Profuse saline irrigation and soft suctioning are essential.

2 min 05.13 s: The internal cerebral veins and pineal body are appreciable now[Figure 2].
Figure 2: View after 0° endoscopic removal

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1 min 11.12 s: 30° endoscope is introduced now pointing inferiorly to remove the flakes from the cerebello-mesencephalic fissure exposing the corpora quadrigemina[Figure 3] and [Figure 4].
Figure 3: Additional removal with 30° inferior angled view

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Figure 4: 30° Inferior angled view at the end of surgery

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2 min 25.29 s: The angled endoscope can be rotated to view the lateral epidermoid extensions, and removeWd using angled instruments.

2 min 35.05 s: By turning the endoscope superiorly, we can appreciate the junction of Internal Cerebral Vein (ICV) with the vein of Galen.

2 min 41.43 s: Once the removal is complete, layered closure is done for good cosmesis.

2 min 47.28 s: Post-op MRI shows total resection with the resumption of aqueductal flow and resolution of hydrocephalus.

Outcome

The patient remained asymptomatic without the need for any intervention for at least 4 years.


 » Pearls and Pitfalls Top


  • The sitting position is preferred, as the prone position causes pooling of fluid and fogging of the endoscope
  • Incision of thickened arachnoid should start over the inferior paramedian area to avoid injury to venous channels
  • Gentle bimanual intracapsular removal of the epidermoid flakes is needed with intermittent saline irrigation and suction
  • Angled endoscopes and curved coaxial instruments aid in removing lateral and inferior extensions
  • More extensive craniotomy and cerebellar retraction may be avoided by using an endoscope.



 » Discussion Top


The standard microscopic supracerebellar infratentorial approach is often limited by tunnel vision, necessitating more extensive craniotomy and some cerebellar retraction.[1],[2] This is significantly more relevant in pathologies such as epidermoid, which tend to have extensions along with the subarachnoid spaces.[3],[4] Endoscopy is progressively replacing microsurgery in various disease conditions due to the panoramic illumination-visualization and increasing resolution of endoscope cameras.[4],[5] As a result, the size of exposure needed can decrease to become more minimally invasive.

Similar pathologies in quadrigeminal cistern are usually tackled both in sitting or prone positions. Prone position, though technically more straightforward, has many disadvantages, especially with the endoscope. The pooling of fluid and fogging of scopes can impede the visualization with a prone position, mandating continuous fluid irrigation.[6] In a sitting position, the endoscope is positioned superiorly and away from dissecting instruments so that the procedure becomes convenient.

We prefer to fix the head using the Sugita head holder in maximal neck flexion, as shown in the video. The head end of the table serves as elbow support. The endoscope can either be fixed or held by an assistant for bimanual dissection of flakes. Coaxial or single shaft instruments do not crowd the operative field and are more suitable for handling along the side of the scope.

The critical advantage of the endoscopic supracerebellar approach is in the utility of angled scopes. Angled optics have been shown not just to enhance the field of view but also to increase resection in some lesions.[7] By rotating the angled scope, we can visualize every nook and corner of the operative area, which are otherwise inaccessible, so that cerebellar retraction can be avoided totally.

One of the limitations of this approach may be vascular lesions, wherein blood spillage is likely to interfere with the endoscopic view, making it difficult to achieve hemostasis.


 » Conclusion Top


The endoscopic supracerebellar infratentorial approach provides a panoramic and angled view of the quadrigeminal region. Most pathologies except vascular lesions can be tackled through the narrow corridor, without any cerebellar retraction.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 » References Top

1.
Bruce J, Stein B. Supracerebellar approaches in the pineal region. In: Apuzzo M, editor. Brain Surgery: Complication Avoidance and Management. New York: Churchill-Livingstone; 1993. p. 511-36.  Back to cited text no. 1
    
2.
Sonabend AM, Bowden S, Bruce JN. Microsurgical resection of pineal region tumors. J Neurooncol 2016;130:351-66.  Back to cited text no. 2
    
3.
Chaussemy D, Cebulla H, Coca A, Chibarro S, Proust F, Kehrli P. Interest and limits of endoscopic approaches for pineal region tumours. Neurochirurgie 2015;61:160-3.  Back to cited text no. 3
    
4.
Uschold T, Abla AA, Fusco D, Bristol RE, Nakaji P. Supracerebellar infratentorial endoscopically controlled resection of pineal lesions: Case series and operative technique. J Neurosurg Pediatr 2011;8:554-64.  Back to cited text no. 4
    
5.
Dhandapani S, Karthigeyan M. “Microendoscopic” versus “pure endoscopic” surgery for spinal intradural mass lesions: A comparative study and review. Spine J 2018;18:1592-602.  Back to cited text no. 5
    
6.
Dhandapani S, Sahoo SK. Developmental Retrocerebellar Cysts: A New Classification for Neuroendoscopic Management and Systematic Review. World Neurosurgery 2019;132:e654-64.  Back to cited text no. 6
    
7.
Patil NR, Dhandapani S, Sahoo SK, Chhabra R, Singh A, Dutta P, et al. Differential independent impact of the intraoperative use of navigation and angled endoscopes on the surgical outcome of endonasal endoscopy for pituitary tumors: A prospective study. Neurosurg Rev 2020. doi: 10.1007/s10143-020-01416-x.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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