Thalamic lesion for diagnostic biopsy:Dr Nitin's patient

Friends,
This is 35 year old lady with progressive Left third nerve and right hemiparesis over 2 months. She had obstructive hydrocephalus for which she underwent a shunt.
Her CSF did not reveal any malignant cells.
I would like your opinion regarding how to biopsy this lesion. I am strongly considering lymphoma as possibility. She is not immunocompromised and has no other features of systemic involvement.
Unfortunately, our Stereotactic system is not working and patient cannot afford to move out to some other place.
She has a shunt.
I was considering 3 probable options:
1. Block the shunt, repeat scan after 6 hours and if further dilatation of ventricles, do an endoscopic biopsy. Her right frontal horn is still dilated.
2. Subtemporal approach.
3. Posterior transcallosal approach.

Would like your opinions regarding options.

Nitin Garg

Responses

As you suggested , one could do open biopsy of this lesion through several approaches,including frontal transcortical , transcallosal, subtemporal, parietal transcortical, even with modified Poppen's, approach,
I would rather do an endoscopic biopsy through the frontal horn
of right lateral ventricle
I think right lateral ventricle is not adequately decompressed with the VP shunt , which may need to be followed up

I have a suggestion about the discussion here, I think we should avoid showing the identity of the patients here, esp since this is an open forum

Pramod

Dear Nitin,

A very interesting case indeed. It is rather difficult from the images you have uploaded to ascertain the nature of the lesion. is it T2 dark witha spectro pattern favouring a lymphoma. If so you should strongly consider only a minimally invasive biopsy.Stereotaxy is ideal. I am not sure if an endoscopic approach via the right frontal horn will get you to the lesion. You could consider an image guided (ultrasound) biopsy if you have the apparatus.

Having siad that , I have my reservations on the presumptive diagnosis of a lymphoma. The lesion almost looks extra-axial in some of the cuts. More images would be better to determine the exact location to plan the approach. I may be wrong...but its worth a second look...all the best. Keep us posted on the progress.

ali

Some points reg. nitins case.

1.From limited images sent, to me it is an intrinsic lesion though as ali pointed out the left side thalamic- subthalamic- midbrain component has become exophytic in inferior aspect.

2. Fact that it is present in opp. thalamic region makes extrinsic diagnosis fairly less likely.

3. though lymphoma is a good bet based on periventricular intrinsic location and multiplicity another strong contender would be multifocal high grade glial mass-GBM perhaps. The large size of the left sided lesion in my opinioin makes me think of nonlymphomatous possibility.

4.Reg. approach, this is an ideal case for a)Frame based stereotactic surgery or b)Navigation based frameless stereotaxy.

I would be loathe to pursue craniotomy for just a biopsy, however for circumstances u have mentioned u need to do open surgery, I think post. transcallosal would not be my choice.

for subtemporal too it would require too much retraction of dominant temporal lobe and would risk jeoparadising Labbe'.

If u r comfortable with endoscopy go ahead but 6 hours will not suffice to dilate the ventricles and u would not see the lesion if the foramen monroe is not well dilated to pass thru safely.

Best wishes and keep us updated.

Satish

PS:Maqsood, what happened to your case? Was it not a meningioma?

I agree with pramod that we should maintain anonymity of pt. identity.

Brain stem glioma: surgical approach?

14 year old girl with swallowing dysfunction, gaze paresis, facial nerve paresis, and mild quadriparesis.
[Please click the second last button on the you tube bottom bar to get full screen so that you can see in more detail]


Responses

Hi gk.

Good to see you become active again in this site after a hiatus

My thoughts.

1.It is a GBM medulla and pons extensively involved whatever the treatment options excercised, prognosis is grave with few weeks of survival, that being the case, would do everything to stabilise/improve quality of life.

2.would go with retro sigmoid app, need to work deep between cranial nerves, between lower cranial and 7,8th complex and then between 5th and 7th too. Realistically looks like a modest decompression is all that is possible without worsening neuro status.If you could hit the cyst at the summit would be good to reduce mass effect.

3.Temporal horns are getting big, is there significant hydro?

Another development in treating GBMS in general, Avastatin(anti angiogenic) has shown good promise adding few weeks to months for new/recurrent GBMs

Best wishes

Satish Sathya

Dear GK,
I think the retrosigmoid approach is the best to reach and do whatever decompresion that is possible. Probably decompressing the cyst and taking a biopsy is all I would attempt surgically , given the location and malignant nature of the lesion.
regards,
Maqsood

I agree with Dr Satish about its dismal prognosis regardless of the histopathology and extent of surgical resection.The tumor has significant ventrally exophytic component with areas showing some sort of margin from the brain stem.I would attempt to decompress this part of the tumor as well as the necrotic/cystic component through a retrosigmoid/far lateral approach

Pramod

Olfactory groove meningioma with sinus invasion: Dr Maqsood's patient

Dear all,

This is a 48 yr old lady presenting with long standing anosmia of 8 years and recent adult onset seizures. She has no deficits except bilateral anosmia. Attached is the contrast MRI.
Kindly advise regarding the approach to take out the tumour completely including that of the paranasal sinus part.
I am planning an extended subfrontal approach.
Will an endoscopic endonasal approach be required to mobilise the lower component?
Regards

Dr.Maqsood





Hi Maqsood

The sinus component looks very large and there also appears to be hypertelorism. Is it evident clinically?

Have you considered a transnasal biopsy of the tumor before definitive surgery? It might not be a meningioma at all and even if it is it might be atypical or malignant.

Approach wise -
Extended subfrontal should be able to remove the tumor completely, IMO. Needless to say, reconstruction of the ACF base will have to be meticulous.

All the best with this one. Do let us know how it goes.

Regards

Arvind

Dear Chief, i think the extended subfrontal approach should be enough for the lower part as well, in this case.

Dr. Anirban Deep Banerjee
Neurosurgeon( NIMHANS)

Dear Dr Maqsood,
Thank you for illustrating such a case. To me bi-frontal, or even unilateral sub-frontal approach may be enough for the intracranial part. It is a more or less olfactory groove meningioma invading the base. If you notice, there is no major edema around, denoting the presence of an arachnoid plain which will make your dissection a little easier. The endonasal part may be approached from above, being intra-tumoral all the time during dissection; or may be approached with a combined endo nasal approach. The absence of signal voids intratumorally is a good sign of safe dissection. The most important is the plan of reconstruction, to provide a good base reconstruct and to prevent fistula formation later on. Lastly, a good look at the hormonal profile of the patient is a mandatory pre- and post-operative task.

Looking forward to hear from you.
Thanks
Mohamed Mohi Eldin , MB-BCH , M.Sc., MD
Prof. of Neurosurgery, Faculty of Medicine, Cairo University, Egypt,


Dear maqsood,
Agree that extened transfrontal is ideal for excising tumor completely.
I disagree need for biopsy, regardless of path, and beingn or atypiacal or even nonmeningioma makes no difference for need for complete excision,
Would take a large pericranial graft going behind skin incision and keep duragen plus or eqvivlaent as standby.
you would be surprised at the extent of access from above once intraranial component is removed.
Bewre of retraction, use less or none as bothfrontal lobes are already edematous, give good amount of steroids perioperatively.
Best wishes
Le us know the outcome.
One of our members(not sure if he is in the group) will be salivating seeing this MRI as it is a good and challenging case to do entitely endoscopically by extended transnasal approach(he is our desi amin kassam!).
Satish

Dear Maqsood,

I would agree with Dr Satish that an extended subfrontal approach would suffice in this case. the approach is able to access lesions in the frontoethmoids and nasal cavities. it is only when the leson involves the maxillary sinuses (which is not the case here) that an additional nasal approach (median maxillectomy or an endoscopic approach ) may be needed. This looks like a meningioma (and hence a biopsy is really not required)and I feel the bifrontal approach also provides for an excellent (and a very important) repair of the base.
all the best

Ali