Please watch the video and post your comments.
Histopath: Transititional meningioma [WHO grade 1]
There was no perception of light in right eye and she was able to count fingers at one feet in left eye . A small residual temporal field of vision exists in left.Papilledema in left fundus has resolved after first surgery. There is optic atrophy in both eyes, severe in right.
Discussion on this case till now [copied from Yahoo group site activity]
Chief,
Great excision of intracranial portion.
What is the histopathology report?
Its difficult to say how to remove the extracranial part. I feel there could be two ways to excise the extracranial part :
1. endonasal endoscopic excision (navigation assisted)
2. Le-Fort osteotomy and excision.
Let us know further.
Nitin
Hey CHief
Great removal of the intracranial component. Well the extracranial appears to involve the posterior ethmoids more on the left and extending into the sphnoid sinus and uper clivus. I would consider the following options:
1.Transethmoid approach with an ENT collegue, the posterior most may be difficult to reach..
2. ENdoscopic transnasal/transeth moid would also be a good option, best with navigation..
3.If you want an open approach then, extended subfrontal route, you will be able to remove the entire lesion. GOod ACF base repair is a must
4. Options for involved bone would be to wait for HPE and if grade 1 then wait and follow up oterwise to irradiate, stereotactic radiotherapy. ..
Regards,
MAqsood
2 comments:
what we know: right hemiparesis,
right amaurosis,lef proptosis (6 mo,
transcranial surgery
what we need: visual acuity left eye, fundus oculi, WHO grading and MIB-1
what we see after transcranial surgery: the lesion seems quite fibrous and strong hyperostosis at level of the left orbital apex is both lateral and medial.
which approach:in my opinion, a subfrontal approach would be dangerous, due to adhesions from previous surgery. an endoscopic endonasal approach would follow a virgin route. the case should be evaluated by a multidisciplinary team (neurosurgeon and ENT surgeon). history of right ischemia is a controindication to hypotensive anesthesia.the reconstruction strategy should be planned: -pedicled nasoseptal flap better than fascia lata-.remove both turbinates and 1 cm of the posterior nasal septum, bilateral total ethmoidectomy (on the left u will already find tumor) and wide anterior sphenoidotomy. on the left side remove lamina papyracea and follow the orbital floor toward the apex. diamond burr to thin the bone. a blunt dissector to remove the last layer of bone. now the nerve is free at level of the apex.debulking of the tumor in the sphenoid sinus. critical points:bone at level of the carotid artery and at level of the clivus is very thin.avoid pushing and traction.in the lateral recess of the sphenoid sinus bone covering V2 will be very thin.identify the tuberculum sellae and thin it. blunt dissector to remove the last thin layer of bone.avoid tearing the sellar and suprasellar dura -no lesion, chiasm free and partial empty sellae-. decompress the optic canal. I would not open its sheat.reconstruction.I m young and I have never performed such procedure however I can ensure you that it is mandatory previous experience in standard endoscopic approach, csf leak reconstruction etc. and this is a bad case also in experienced hands. a dedicated drill (longer) and cavitron ultrassonic aspirator are mandatory. if u are still not skilled in endoscopy you may use the microsurgical transbasal approach and use the endoscope as assistance to check the blind corners(remove the whole cribriform plate an maybe drill also the crista galli since you should enter flush avoiding stretching of the optic apparatus) however i have no experience in this strategy. plz leave other comments :)
http://www.abovetopsecret.com/forum/thread557987/pg1
forget neurosurgery, stargate of lord shiva
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