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Transcallosal and Endoscopic Approach to Intraventricular Brain Tumors

Introduction Endoscopic surgery for intraventricular brain tumors is a logical application of endoscopic technology. Because of the central and deep location of intraventricular brain tumors, conventional neurosurgical approaches have a relative increase in potential morbidity. Traditional approaches involve a craniotomy and opening of the lateral ventricle through a transfrontal approach, opening of the third ventricle through a transfrontal transforaminal approach, or an interhemispheric, interforniceal approach and…

Surgical Approaches to Lateral and Third Ventricular Tumors

The majority of tumors of the lateral and third ventricles are benign or low-grade lesions. Because of their relatively slow growth rate, these lesions may reach several centimeters in size before patients present with neurologic dysfunction. The most common clinical manifestations of these tumors include headaches, memory loss, gait disorders, and cognitive changes. There are multiple surgical approaches to these tumors, all designed to minimally displace…

Minimally Invasive Surgeries for Deep-Seated Brain Lesions

Introduction Deep-seated brain lesions include a variety of pathologies, including benign and malignant brain tumors, vascular malformations, and intracranial hemorrhages (ICHs), among others. A deep-seated location is a nebulous term, but generally refers to any location below the deepest sulcal boundary ( Fig. 18.1A ). This therefore includes a variety of anatomical locations, including the centrum semiovale, basal ganglia, thalamus, and deep cerebellar nuclei, as well…

The Endoscopic Endonasal Approach for Craniopharyngiomas

Craniopharyngiomas are benign tumors originating from squamous epithelial remnants of Rathke pouch that can arise anywhere along the axis from the nasopharynx to the hypothalamus. , Their consistency can be cystic, solid, or a combination of both, and there is often intralesional calcifications occurring in 60% to 80% of cases. Craniopharyngiomas are relatively rare, accounting for only 1% to 5% of all intracranial tumors in the…

Transcranial Surgery for Pituitary Macroadenomas

Introduction and Epidemiology The most common tumors affecting the sellar, suprasellar, and parasellar regions include pituitary adenomas, Rathke cleft cysts, craniopharyngiomas, meningiomas, germ cell tumors, and gliomas involving the hypothalamus or optic chiasm. Management is dictated according to each specific diagnosis. Although medical therapies can be utilized in a subset of patients, many lesions require surgical management, which is most commonly carried out using a transsphenoidal…

Endoscopic Endonasal Pituitary and Skull Base Surgery

The use of the endonasal pathway for skull base surgery was initially reported in 1909 by Hirsch, who performed his first pituitary surgery in Vienna by approaching the sella through an endonasal route using multiple-staged operations with unenhanced visualization. Despite his first endonasal transsphenoidal surgery having reported success, Hirsch subsequently converted to a transseptal submucosal approach. The first reported use of the endoscope for transsphenoidal surgery…

Medical Management of Hormone-Secreting Pituitary Tumors

Introduction The majority of pituitary tumors are hormone-secreting. With the exception of prolactin (PRL)-secreting tumors (prolactinomas), surgery has historically been the mainstay of treatment for hormone-secreting as well as nonfunctioning pituitary tumors. In recent years, however, medical therapy has assumed an increasingly important role in the management of hormone-secreting pituitary adenomas. In addition to being the primary treatment for prolactinomas, medical therapy can serve an adjunctive…

Endoscopic Endonasal Approach to Lateral Cavernous Sinus Lesions

Acknowledgements We are indebted to Karam Asmaro, MD, and Nyall London, MD, PhD, for preparing the surgical video presented. Introduction The lateral cavernous sinus is bounded medially by the cavernous segment of the internal carotid artery (ICA), laterally by the lateral cavernous sinus dura and its intimately involved cranial nerves, superiorly by the distal dural ring of the ICA, and inferiorly by the maxillary strut and…

Endoscopic Endonasal Approach to Sellar, Parasellar, and Suprasellar Surgery

Introduction Endoscopic pituitary surgery highlights a confluence of anatomic insight, surgical technique, advancing technologies, and multidisciplinary collaboration. Starting with the ancient Egyptians, who used the nose as a route for embalming, the evolution of endonasal skull base surgery has extensively evolved. Pierre Marie (1886) set forth the pituitary as the master hormone driver and thus pushed pituitary surgery forward; however, first attempts at transcranial approaches were…

Surgical Management of Cerebral Metastases

Cerebral metastases are a leading cause of morbidity and mortality in individuals with cancer and are the most frequently encountered tumors in neuro-oncology. Approximately 50% of those affected by brain metastases will succumb to their central nervous system (CNS) disease or neurologic sequelae. The incidence of intracranial metastases continues to increase as advancements in neuroimaging lead to improved detection of symptomatic and asymptomatic lesions, and developments…

Cerebellar Tumors in Adults

The cerebellum serves as the principal site of disease in 2.6% of all primary central nervous system tumors, with a much higher prevalence in children than in adults. The clinical impact of a mass in the cerebellum belies its relatively low incidence, and involvement of contiguous brainstem structures significantly increases the morbidity and mortality of these tumors. A wide spectrum of pathologies is observed among cerebellar…

Management of Primary Central Nervous System Lymphoma

Management of Primary Central Nervous System Lymphoma in Immunocompetent Patients Presentation Primary central nervous system lymphoma (PCNSL) is a category of extranodal lymphoma restricted to the nervous system accounting for approximately 3% of all brain tumors. Histologically, the majority of these tumors are identified as large B-cell lymphomas; however, T-cell lymphoma cases have also been reported ( Fig. 9.1 ). PCNSL most commonly presents as a…

Low(er) Grade Gliomas: Surgical Treatment

Introduction Low-grade gliomas are a group of intrinsic brain tumors, mainly occurring with seizures in young patients, appearing on conventional magnetic resonance imaging (MRI) as highly infiltrative nonenhancing masses, well visible in fluid-attenuated inversion recovery (FLAIR) images, involving one to multiple lobes, occasionally presenting with small enhancing nodules inside the tumor mass. More than 90% of these tumors have IDH1 mutation and share a common biological…

Current Surgical Management of High-Grade Gliomas: New and Recurrent

Introduction Surgical treatment of high-grade gliomas has been a challenge for neurosurgeons since the early days of our specialty with Harvey Cushing and Walter Dandy. Dandy developed the hemispherectomy to treat patients with invasive high-grade gliomas and observed they still succumbed to their disease. Despite his failure to find a cure, one patient did live an astounding 3.5 years after surgery. Unfortunately, almost 90 years after…

Chemotherapy for Brain Tumors

Factors Influencing the Delivery of Chemotherapy to the Brain Blood-Brain Barrier Treatment of brain tumors with systemic chemotherapy poses unique challenges. Concentrations of chemotherapeutic agents within the central nervous system (CNS) depend on multiple factors, including ability of the agents to cross the blood-brain barrier (BBB), the volume of distribution of the drug in the brain parenchyma, and the extent to which the drug is actively…

Cortical and Subcortical Brain Mapping

Introduction The ultimate goal of brain surgery, especially in neuro-oncology, is to maximize the extent of resection (EoR) while preserving or even improving the patient’s quality of life (QoL)—that is, to optimize the oncofunctional balance. , Indeed, maximal safe resection of gliomas, when feasible, is currently the first treatment both in low-grade gliomas (LGGs) and high-grade gliomas. All the recent surgical series that have objectively calculated…

Intraoperative Neurophysiology: A Tool to Prevent and/or Document Intraoperative Injury to the Nervous System

Over the past 25 years, intraoperative neurophysiology (ION) has established itself as a clinical discipline that uses neurophysiologic methods—especially developed or modified from existing methods of clinical neurophysiology—to detect and prevent intraoperatively induced neurologic injuries. Recent developments have solidified its role in neurosurgery and other surgical disciplines. Ideally, ION not only predicts but also serves to prevent intraoperatively induced injury to the nervous system. Furthermore, ION…

Diffusion Tensor Imaging and Functional Tractography

Diffusion tensor imaging (DTI) is a noninvasive technique that makes it possible to assess the integrity and location of subcortical white matter tracts in vivo. Its importance is underscored by the developing understanding that neurologic outcomes are more dependent on the integrity of the subcortical white matter tracts than specific cortical areas. Indications for the clinical use of DTI are rapidly broadening. Although it is still confined…

Surgical Navigation With Intraoperative Imaging: Special Operating Room Concepts

Acknowledgments I thank all friends from Boston (The MRT crew and SPL) at Brigham and Women’s Hospital, Colleagues in Kiel from Anesthesiology, Tec and OR Team. Introduction One of the most challenging developments in neurosurgery encompasses the interdisciplinary effort to integrate microneurosurgery and technology, in particular imaging. Neurosurgical techniques have reached a high level of sophistication. Increasing understanding of neurophysiology as well as neuropathology, precise preoperative…

Ensuring Patient Safety in Surgery: First Do No Harm and Applying a Systems-Engineering Approach

Primum non nocere —first do no harm. The Hippocratic statement epitomizes the importance the medical community places on avoiding iatrogenic complications. In the process of providing care, patients, physicians, and the entire clinical team join to use all available medical options to combat disease to avert the natural history of pathologic processes. Iatrogenic injury or, simply, “treatment-related harm” occurs due to various reasons and sometimes gets…