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INTRODUCTION
Thalamopeduncular tumors are a group of
pediatric low-grade gliomas that arise at the junction of the thalamus and
cerebral peduncle. They occur within the first 2 decades of life, presenting
with a thalamopeduncular syndrome characterized by progressive spastic
hemiparesis. Given their location and their pilocytic histology, obtaining a
curative resection without injury to the corticospinal tracts (CST), oculomotor
nerve or the optic tract can be challenging. Trans-cortical trans-choroidal
resection of thalamo-peduncular tumors through the middle temporal gyrus allows
for a high rate of gross total resection (GTR) and disease control with
acceptable surgical morbidity [1-3]. A 3 year old boy’s thalamopeduncular mass
was diagnosed after a typical presentation of progressive spastic hemiparesis.
Tumor was partially resected and pathological diagnosis was pilocytic
astrocytoma (PA). He progressed on chemotherapy and an Ommaya reservoir was
placed into a tumor cyst, but the patient developed progressive hydrocephalus,
bilateral trigeminal neuralgia and right hemiplegia. He was then referred us
for tumor resection. The patient consented to publication of his images.
Preoperative diffusion tensor
imaging (DTI) demonstrated anterolateral displacement of the CSTs. This video
demonstrates the surgical technique used for the one-stage
transcortical-transchoroidal and retrosigmoid approach to the extensive
thalamo-peduncular PA.
The
following are the main surgical pearls:
·
Minimize the use of fixed retractors to
avoid temporal cortical ischemic changes
·
Protect the hippocampus when opening the
choroidal fissure
·
Protect the branches of the posterior
communicating artery and anterior choroidal artery within the cistern
·
Identify the optic tract and protect it
as well.
DISCLOSURE
The authors have no personal, financial or
institutional interest in any of the drugs, materials or devices described in
this article.
DISCLOSURE OF
FUNDING
None.
1. Broadway SJ, Ogg RJ,
Scoggins MA, Sanford R, Patay Z, Boop FA (2011) Surgical management of tumors
producing the thalamopeduncular syndrome of childhood. J Neurosurg Pediatr 7:
589-595.
2. Foley R, Boop F (2017)
Tractography guides the approach for resection of thalamopeduncular tumors.
Acta Neurochir (Wien) 159: 1597-1601.
3. Lee
RP, Foster KA, Lillard JC, Klimo P Jr, Ellison DW, et al. (2017) Surgical and
molecular considerations in the treatment of pediatric thalamopeduncular
tumors. J Neurosurg Pediatr 20: 247-255.
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