Video AtlasUncorrected of Proof NEUR SURGERY Contemporary Tumor and Skull Base Surgery Alfredo Quiñones-Hinojosa Contents SECTION 1 Intra-axial Tumors 1 Awake craniotomy and speech mapping for gliomas 000 Jordina Rincon-Torroella M.D., Ignacio Jusue-Torres M.D., Eibar Ernesto Cabrera-Aldana M.D. and Alfredo Quinones-Hinojosa M.D. 2 Cortical/subcortical motor mapping for gliomas 000 Norma Arechiga, MD; Karim Refaey, MD; Jordina Rincon-Torroella, MD; Kaisorn L. Chaichana, MD; Alfredo Quiñones-Hinojosa, MD 3 Trans-sulcal versus transcortical resection of subcortical metastases 000 Kaisorn Chaichana, M.D., Jordina Rincon-Torroella, M.D., Shami Yesha Acharya, M.B.B.S. and Alfredo Quinones-Hinojosa, M.D. 4 Deep intra-axial lesions 000 Jordina Rincon-Torroella, M.D., Kaisorn L. Chaichana, M.D., Salvador Manrique-Guzman S. M.D., Alfredo Quinones-Hinojosa, M.D. 5 Brainstem tumors 000 Jordina Rincon-Torroella, MD; Kaisorn L. Chaichana, MD; Alfredo Quinones-Hinojosa, MD 6 Cerebellar tumors 000 Kaisorn L. Chaichana MD, Jordina Rincon-Torroella MD, Salvador Manrique-Guzman MD, Quinones-Hinojosa A MD. 7 Cervicomedullary tumors 000 Jordina Rincon-Torroella, MD; KarimUncorrected Refaey, MD ; Kaisorn L. Chaichana, MD; Alfredo ProofQuiñones-Hinojosa, MD 8 Supracerebellar-infratentorial approach 000 Jordina Rincon-Torroella, Arnau Benet, Alfredo Quiñones-Hinojosa 9 Intra-operative extent of resection 000 Jordina Rincon-Torroella; Eibar Ernesto Cabrera-Aldana; Alfredo Quiñones-Hinojosa SECTION 2 Extra-axial Tumors 10 Convexity and parasagittal meningiomas 000 João Paulo Almeida,MD; Jordina Rincon-Torroella, MD; Kaisorn L. Chaichana, MD; Alfredo Quiñones Hinojosa, MD 11 Falcine and falcotentorial meningiomas 000 João Paulo Almeida,MD; Jordina Rincon-Torroella, MD; Kaisorn L. Chaichana, MD; Alfredo Quiñones-Hinojosa, MD 12 Posterior fossa meningiomas 000 João Paulo Almeida,MD; Jordina Rincon-Torroella, MD; Kaisorn L. Chaichana, MD; Ignacio Jusue-Torres, MD; Alfredo Quiñones-Hinojosa, MD 4 Contents SSSECTION 3 Intraventricular Tumors 13 Transcortical approach to the lateral ventricles 000 Alejandro Ruiz-Valls, MD; Jordina Rincon-Torroella, MD; Kaisorn L. Chaichana, MD; Alfredo Quinones-Hinojosa, MD. 14 Transcallosal approach to the third and lateral ventricles 000 Jordina Rincon-Torroella, MD; and Alfredo Quinones-Hinojosa M.D. 15 Telovelar approach 000 Jordina Rincon MD, Alfredo Quinones-Hinojosa MD 16 Endoscopic approach to the ventricles 000 Jordina Rincon-Torroella, MD; Kaisorn Chaichana, MD; Alfredo Quiñones-Hinojosa, MD SECTION 4 Skull Base Approaches 17 Pterional craniotomy 000 Jordina Rincon-Torroella, MD; Alfredo Quiñones-Hinojosa, MD 18 Orbitozygomatic craniotomy 000 Jordina Rincon-Torroella, MD; Alfredo Quiñones-Hinojosa, MD 19 Supraorbital osteotomy 000 Jordina Rincon-Torroella, MD; Elizabeth Ogando, MD; and Alfredo Quinones-Hinojosa M.D. 20 Subfrontal and extended bifrontal craniotomy/transbasal approach 000 Jordina Rincon-Torroella and Alfredo Quinones-Hinojosa M.D. 21 Retrosigmoid/extended retrosigmoid approach 000 Jordina Rincon-Torroella, MD; Karim Refaey, MD; and Alfredo Quinones-Hinojosa M.D. 22 The far lateral approach 000 Arnau Benet, MD; Jordina Rincon-Torroella, MD; Tito Vivas-Buitrago, MD; Alfredo Quiñones-Hinojosa, MD SECTION 5 Endoscopic Approaches to Skull Base Tumors 23 Principles and anatomy in endoscopic endonasal surgery 000 Arnau Benet, MD; Jordina Rincon-Torroella, MD, Alfredo Quiñones-Hinojosa, MD 24 Pituitary adenomas 000 Joao Paulo Almeida, MD; Alexandra Larsen, BS; Jordina Rincon-Torroella, MD; Kaisorn L. Chaichana, MD; Alfredo Quinones-Hinojosa, MD 25 Surgical treatment of craniopharyngiomas 000 João Paulo Almeida, MD; Roberto Andrés Medina, MD; Jordina Rincon-Torroella, MD; Kaisorn L. Chaichana, MD; Alfredo Quiñones Hinojosa, MD 26 Clival chordomas 000 Jordina Rincon-Torroella, MD; OmarUncorrected Antonio Perez morales, MD; Joao Paulo Almeida, MD;Proof Alfredo Quinones-Hinojosa M.D. 27 Techniques for skull base reconstruction 000 Jordina Rincon-Torroella, MD; João Paulo Almeida, MD; Arnau Benet MD; and Alfredo Quinones-Hinojosa M.D. SECTION 6 Combined Approaches to the Skull Base 28 Combined subfrontal and endonasal approach 000 Karim Refaey, MD; Jordina Rincon-Torroella, MD and Alfredo Quinones-Hinojosa M.D. 29 Combined transconjunctival and endoscopic endonasal approach 000 Brian Hwang, Danilo Tueme, Jordina Rincon-Torroella, Alfredo Quiñones-Hinojosa M.D. 30 Combined transmaxillary and subfrontal approach 000 Eva F. Pamias-Portalatín, MD; Tito Vivas-Buitrago, MD; Jordina Rincon-Torroella, MD; Arnau Benet Cabero, MD; Alfredo Quiñones-Hinojosa, MD Contents 5 SECTION 7 Skull Base Tumors 31 Anterior midline meningiomas 000 Jordina Rincon-Torroella, João Paulo Almeida,MD and Alfredo Quinones-Hinojosa M.D. 32 Medial sphenoid wing meningiomas 000 Jordina Rincon-Torroella, MD; Kaisorn Chaichana, MD; Alfredo Quiñones-Hinojosa, MD 33 Parasellar tumors 000 Christina Jackson, MD; Jordina Rincon-Torroella, MD; and Alfredo Quinones-Hinojosa M.D. 34 Invasive pituitary adenomas 000 João Paulo Almeida,MD; Martín A. Chacón Portillo, MD; Jordina Rincon-Torroella, MD; Kaisorn L. Chaichana, MD; Alfredo Quiñones Hinojosa, MD 35 Approaches to the temporal bone: basic principles 000 Eva Pamias-Portalatín, MD; Arnau Benet, MD; Tito Vivas-Buitrago, MD; Jordina Rincon-Torroella, MD and Alfredo Quinones-Hinojosa M.D. 36 Approaches to the orbit 000 Elizabeth Ogando-Rivas, MD; Jordina Rincon-Torroella, MD; Alfredo Quiñones-Hinojosa, MD 37 Vestibular schwannomas 000 Eva F. Pamias-Portalatín, MD; Tito Vivas-Buitrago, MD; Jordina Rincon-Torroella, MD; Alfredo Quiñones-Hinojosa, MD 38 Foramen magnum meningiomas 000 Eva F. Pamias-Portalatín, MD; Tito Vivas-Buitrago, MD; Jordina Rincon-Torroella, MD; Alfredo Quiñones-Hinojosa, MD. Uncorrected Proof 1 Awake Craniotomy and Speech Mapping for Gliomas Jordina Rincon-Torroella M.D., Ignacio Jusue-Torres MD, Eibar Ernesto Cabrera-Aldana MD and Alfredo Quinones-Hinojosa MD Indications tion through the craniotomy window (e.g. antic- ipated intracranial hypertension) • Intra-axial lesions invading, or located in elo- quent areas related to language cortex, especial- ly in the dominant hemisphere. The infiltrative Pre-operative Considerations rather displacing nature of gliomas makes this • Neuropsychological and language evaluation approach very suitable for low-grade gliomas may be helpful to detect complex neurolog- (astrocytoma, oligoastrocytoma or oligodendro- ic symptoms and to determine the behavioral gliomas) and high-grade gliomas. tasks (paradigms) that will be used for the func- • The goal of intraoperative speech mapping are: tional MRI (fMRI) and intra-operative mapping. • To determine the limits of the resection and the • Neuro-imaging considerations (Figure 1a-f): best surgical corridor to approach the lesion Positron emission tomography (PET) and fMRI • To allow maximal resection while limiting func- can be used for surgical planning and to localize tional impairment of eloquent areas. the eloquent areas pre-operatively. If those tests • Increasing body of evidence supports longer indicate that the lesion is involving functional survival and better quality of life in low-grade language cortex or is adjacent to it, an awake gliomas (LGG) after gross total resection or craniotomy with intra-operative speech map- smaller residual tumor Uncorrectedvolumes. ping is usually Proof required. • Intra-operative mapping and functional imag- • fMRI is preferred because it allows a non-in- ing have transformed into resectable some brain vasive cortical mapping avoiding the use of tumors previously considered inoperable and radioisotopes. fMRI measures relative changes has considerably decreased the post-operative in oxygenated and deoxygenated hemoglobin. functional deficits. Especially in language mapping, fMRI or PET cannot distinguish in between essential and Contraindications complementary but nonessential areas. fMRI • Non-cooperative patient because of disease or can guide the surgical planning but cannot be psychosocial issues. the solely object to locate the eloquent areas and • Inability to follow commands or to reproduce to establish the resection margins. the speech tests in the pre-operative training. • With the combination of different speech para- • Anticipation of airway compromise during the digms fMRI can give an estimate of the localiza- awake portion (e.g. morbid obesity, medically tion of eloquent areas related to language cor- intractable seizures, or sleep apnea). tex and hemispheric language lateralization or • Comorbidities that could promote brain hernia- co-dominance. 8 Chapter 1 • Awake Craniotomy and Speech Mapping for Gliomas • Despite its limitations, DTI can be also useful to • Behavioral tasks (Paradigms): spontaneous assess the white matter tracks. The most import- speech, fluency, counting, object naming, spell- ant tracks related to speech are the superior lon- ing, reading, writing, comprehension, silent gitudinalis fasciculus (SLF), the arcuate fasciculus word generation, rhyme detection, semantic-de- and the inferior fronto-occipital fasciculus (IFOF). cision, repetition, word stem completion, and Those fascicles conform a dorsal pathway (phono- switching from one language to another in bi- logical processing) and a ventral pathway (seman- lingualPhiladelphia patients. Art (Figure Dept./Elsevier 2a-f) tic processing). • The functionalElsevier Author mapsISBN can # be fused Author'swith review the mor- Quinones 978-0-323-26149-4 (if needed) • Regions of interest: