0:01
SNI Digital, Innovations and Learning, a new video journal, interactive with discussion, with James Osfun as its editor-in-chief, in association with SNI, Surgical Neurology International and
0:18
the Internet Journal with Nancy Epstein as its editor-in-chief. Are pleased to present a series of programs from the University of California Irvine Department of Neurosurgery, Interdisciplinary
0:32
Scobase Surgery Team. On these topics, there are a number of faculty and departments involved in the Scobase Surgery Team. I'll introduce you to them in a few minutes, but not only includes
0:32
members of the Department of Neurosurgery, Odolaryngology, but it's also radiation, proton therapy, and multiple other specialties.
1:01
Dr. Frank Sue is the professor of neurologic surgery and he's also a professor of biomedical engineering and otolaryngology and is chair of the department of neurologic surgery at the University of
1:14
California in Irvine, in Irvine, California.
1:20
Edward Kwan is a professor of otolaryngology in the division chief of rhinology and scobe surgery and co-director of the comprehensive scobe's program at the University of California in Irvine. And
1:39
Dr. Dennis Malkasian, who is a professor emeritus in the department of neurologic surgery, the director of neuroanatomy and scobe-based laboratory at the University of California in Irvine. And
1:53
finally, Alexander Himmstead, who is a resident physician in neurologic surgery. at the University of California in Irvine. And was a Vincent P. Carroll research award winner and the Christopher
2:07
and Megarts award senior student with the most honors and promise in 2022. Alpha Omega Alpha and his junior and senior years. And was graduated, someone come louder from Chapman University and has
2:23
worked internationally on the global health in Ghana and Panama. It looks okay to me Okay, great. So, we'll get into it. This is just some skull-glazed cases that I put together from Dr. Sue and
2:40
Dr. Kwan and that we've done over the past couple of years. I put together a number of cases. We'll see how many we get through the first two are more in-depth than the rest of them. So we'll
2:49
start there
2:54
So the first case, I was a 53-year-old female who presented with sinusitis, congestion, and intermittent headaches. She initially didn't have any neurological symptoms, but kind of when we
3:09
discussed how she's been doing more with her in clinic, she endorsed some issues with gait instability, balance, like feeling like she was gonna fall over. She was, however, neurologically
3:19
intact without hyperreflexia on exam, full strength.
3:25
So we can go ahead and look at our MRI here.
3:30
So the MRI pre-op, these are just a bunch of sort of pictures of what we have. Starting on the bottom left is the T1 post-contrast, where you can see this hypo-intense sort of hydrologer to the
3:45
enhancing lesion centered on the clavis. And then looking at the T2 flare, you can really see really see this right. hyper-intense lesion occupying the clavis, and anteriorly and inferiorly just
3:57
posterior to the back edge of the palate, and then extending through the dura to the, to sit in front of the brainstem, kind of at the pontimigillary junction and inferior and laterally, adjacent
3:60
to C1. Terrificates, okay And so our plan was to proceed with a multidisciplinary endoscopic and nasal transclival approach with Dr. Sue and Dr. Kwan. Here are some of the
4:34
specifics of the approach. Of course, Mayfield pins for nerve navigation, a lumbar drain to mitigate the post-op CSF leak, prep for facial autograph, just in case it's needed. Dr. Kwan can
4:48
potentially talk on this more what the approach included a posterior septectomy with a reversed flap. to create additional space for dissection in the lower clavis to make sure we got that good
4:59
exposure. And then we, of course, began by debulking the extroderal disease and then sort of took that back to the point where it actually entered into the dura, identified that point. And that's
5:10
where we made the dura opening, which we'll see in a few slides. And then there's a layered closure that Dr. Quand performed highlighted here with two different vascularized flaps, including the,
5:26
of course, tried and drew an ASMR flap. Well, let me stop you there for a minute, Ashley. And had you ever done this before? You guys saw this case. Yes. So we get a couple of cordomas every
5:41
year and they're all a little bit different because it kind of depends on what component of the clivis that it involves And these are pretty low. and cranial cervical junction cordoma. So it poses a
5:53
unique challenge because it's a nasal pharynx. Gets a little bit closer to an area which is pretty hard to bolster with packing. And so the challenge with posterior cranial fossa case is always
6:05
getting enough access, working around very critical anatomy. And also the skull-based recon, it becomes very important, this is a very high-risk area. And that's why we always plan in advance And
6:19
in this case, we chose
6:22
this reconstructive strategy and hopefully to be able to show you some of it in the video as well.
6:27
So really, the experience here is not - we only have one every week, it's limited. And this, obviously, is a variation in what you'd seen before.
6:38
So
6:40
this takes a lot of thinking and a lot of discussion as to how we're going to get there.
6:48
avoiding, avoiding some very sensitive structures. And in order to reach your point and take out the tumor, could you take it all out? So the extra-dural component was completely just filling the
7:02
nasal pharyngeal submucosal tissues and that was fully accessible from our approach. The intra-dural component, the video will showcase that a little better, but there are limitations when it comes
7:02
to inferior and lateral, which I believe Alex will also talk about. So, would you sub-totally remove the tumor or would you say was it a gross total resection or total resection or is it a 10 left
7:03
or do you, who didn't know? Yeah, so this one, I think we anticipated the likelihood of a near total
7:37
resection because there was a component that was actually much lower. But in the nasal cavity, the extra-dural side, gross total. and then the, I still felt that this was the best approach
7:50
because of the mass effect on the brainstem and the direct angle of attack from anterior to posterior.
7:60
Ed, Frank, do you have any thoughts about this case? Yeah, so I was gonna go back to the MRI. So again, you know, we have to put things in context, right? Cordoma is a benign but locally
8:16
aggressive disease that eats away at the skull base,
8:23
attacks the cranial nerve, displays them, inmates them, and causing progressive disability. You know, if we look at the pathology under the microscope, it looks clearly benign. You have these
8:37
visyphilis cells and they don't look like GBM I mean, they look like they would divide slowly, but they're so locally invasive, and you have to try to get everything out. And if you don't, they
8:54
recur, then it's a salvage situation. It's a very, very difficult situation. So the first shot is the best shot, and then followed by aggressive radiation such as proton.
9:10
I was blessed and fortunate to be at Loma Linda for nine years, and you know, they have the first proton on the west coast. And there I saw so many Cordomas that you can't even imagine. And so I
9:23
learned a lot about these tumors while I was at Loma Linda, got a lot of exposure. So here we want to get everything out, but that doesn't mean we have to get everything out at one setting. You
9:36
can always stage it, you can go back, you don't have to
9:41
kind of stretch your ability or take high risk. to get everything out at one time. I think it's okay to do one or two or sometimes three surgeries to keep the person whole. And that's why we kind
9:57
of will demonstrate a little bit later with this case. And the first approach, obviously, extra duodly in the nasal sinuses and that's the most direct approach. And also, Cordoma, once they
10:10
invade the intra-dural space, it's a different animal It's a lot more serious, in this case, it did. So we have to try to get that portion out.
10:22
A very complicated tumor. Now, let's say I put you
10:34
in Africa. We have a monthly grain rounds with Africa, Sub-Saharan Africa, there are a billion people in Sub-Saharan Africa, one billion.
10:40
And let's say a case like this comes in.
10:48
I mean, I've been surprised by how some surgeons in other countries that we think are a little bit behind us, they are actually pretty good, depending on how they are trained, and I have seen some
11:04
other efforts to train local surgeons elsewhere And I think if they have the training, the equipment, the know-how, and also very importantly in the infrastructure, you know, like once you take
11:20
this out, that's not it, like the nursing have to know you can't put an NG tube down, you can't have them blow there. I mean, there are a lot of post-operative
11:32
care that cannot be ignored, you know, if you do a beautiful surgery and somebody else doesn't understand this can totally mess up and we've seen that before. So I think, you know, surgeons may
11:44
be able to do this Thank you. And I don't totally know the exact infrastructure they have there, but I think if they have the resources they know how, they should be able to handle this. If not,
11:58
they send it somewhere else, yeah. You're absolutely right. We had a fellow from Iraq, Baghdad, who was their atomer surgeon, and they centralized them. And he had a very comfortable case that
12:11
was in the Clavis. And they hadn't done it They even hadn't done a transoral approach before.
12:19
And so he got his anti-colleague, and they looked at it, and they went through a lot of preparation, a lot of thought,
12:27
and they didn't have all the equipment and so forth. So he staged it, just like what you said. He did a little bit, and then he came back, and made sure the patient was okay after surgery, then
12:38
came back, and after they assembled the next part and got everything organized, did the next part and then the third part. And he did very well. And so I think your comment is extremely,
12:49
extremely appropriate because
12:54
it's not the technology. It's the brains behind the technology that really counts. Isn't that what we're talking about?
13:02
And it's also when Danny or probably the most difficult lesson to learn is when to say no, it's enough, right? Absolutely, you don't wanna be peak and shriek, but you don't wanna cross the
13:17
ribicon and that red line and
13:23
point of no return. That's just not worth it. And that takes experience of the surgeon, a lot of elements, which at the bottom, the common denominator is prima nono seria. It's still the main
13:41
effort. You cannot have a nice looking post-op image
13:46
and the patient has serious neurological injury. It's just you, the patient has paid too great of a price for that. I think that's right. A terrific case, Frank. I know a lot of teaching value
14:00
here and it's, and
14:03
I could see ultimately Alex, or you'll be working on her writing a paper on the genetic, the unique genetic composition of a Cordoma and I could see Stereotactically injecting a localized
14:17
chemotherapeutic or some agent in there, which may not even be a chemotherapeutic agent, which breaks up the molecular change or the stem cell, where this essentially kills the stem cells and you
14:30
kill it. Well, this is a good example. We use what we call a brachyuria as a marker
14:40
and it acts as an antigen for a monol.
14:43
clonal antibody, and it stains it. And this tells us that the brachioria, which is named on lower vertebrates, that brachioria is a transcription factor that develops the nodocord in the length of
14:50
a tail.
14:60
And it's what we call a T-box transcription factor. And it's inhibited and modulated in lower animals by what we call twist and other transcription factor Orendrosophila, an invertebrate, is
15:14
modulated by macho. And it's very interesting that there are elements in nature that control, stimulate, and inhibit brachioria. Well, if brachioria is
15:31
mutated and placed in a constitutively active state by its mutation, it will drive it So a tumor like this, I can imagine that if these kind of factors we really learn more about in the gateways
15:47
they use and what other things affect its activity. That you look at a tumor like this, you'd debulc it. And maybe with one surgery, you'd be able to implant those mediators that
16:04
either stop the tumor from growth or mature it into a benign hammer-toam-a-like motor cord that just sits there and doesn't do any harm to the patient. So I see where there's a lot of work that's
16:21
will be very exciting to do that's on the molecular level. And it is reasonable to think these things can be done, but there are so many pathways in that I think that's where AI could really be a
16:37
pivotal help Absolutely brilliant, terrific, and I can understand Frank way. you enjoy having Denny on his staff. And it's
16:48
just, are you in her search in Dennis? My mother at the beauty shop, she told everybody I was and I think that gave board certification. Oh, is that your mother was the residency director? Oh,
16:60
okay. Okay, terrific case. We've got a lot out of that, Frank. What's the next one? Well, we're not done with this case, actually. Oh, okay, I'm sorry, I'm sorry. I'm interested in the
17:08
story. You know, I just want to make a quick comment Maybe 10, 15 years ago, we would have done a big, big open surgery, like a trans patrol cell, or, you know, and it's a gigantic, high,
17:24
more, highly morbid approach. But with the endoscopic approach, even before that, we'll do a trans oral that's still very morbid with all these retracting. But with the endoscopic approach, This
17:41
becomes very elegant. beautiful way to take out these tumor. And Alex has a video to show. Outstanding, okay. Yeah, so first time coming in Alex? Yeah, I will. First, well, I guess we can
17:58
see what order makes sense. Dr. Mokazian and I kind of went through and he made it some schematic drawings of the anatomy that I can go through quickly before the surgical video.
18:09
So this is sort of the first picture of the corridor showing that the pallet
18:16
is basically at the left below the frame and the magnum and sort of the corridor that we're trying to take is that inferior corridor.
18:24
This is a schematic view of the tumor section where we sort of show the anterior approach followed by the theoretical staged approach to get this lateral and inferior possible residual. This is sort
18:38
of our preoperative thought process, right?
18:43
potentially that this part might be the hardest to resect
18:50
and then here is sort of the anterior view as you go in for the approach and you can see the superior pharyngeal constrictor here one of the swallowing muscles you can see the terminus on the side
19:03
which are mobilized and or sometimes resected. There's the opening of the tympanic canal with these little stars and then the oral pharynx inferiorly as well as the sphenoid buttress superiorly which
19:17
is where you go for a pituitary and a traditional endoscopic anenasal approach.
19:24
This is the picture that Dr. Mukheysian made where you're basically sitting with your back to the clevis looking anteriorly so you're looking kind of out the nose of the patient and so this is the
19:37
sphenoid sinus These are the nasal passages, the turbinates.
19:43
the Palatine bone is horizontal here and vertical. And then this is some of the anatomy or the neurovascular chair. And he made the point that when you're doing these approaches, if you're, you
19:55
always have to be careful when you're inferior and lateral. If you're working too far over here, you can kind of
20:04
pull on this nerve, which can cause a neuropraxia leading to problems with lacrimation. And then you can also get into bleeding from getting into this branch of the internal maxillary. Is AI
20:15
advanced to the point where you can determine that
20:20
or do you just have to know this from being there that I'm getting close to that structure? Or is AI tell you where it is?
20:29
What we usually do is go based off of either fixed landmarks. We always, for these complex cases, we have image guidance so we do use MRI and CT both merge. And so we're able to identify the
20:42
structures and understand how close we are. A lot of it still does not supplant our knowledge of just being able to look at where the boundaries of our dissection are. But the image guidance, I
20:54
would say, is still the standard of care for a lot of these complex tumors. And AI hasn't gone too much into this space just yet, but I'm sure it will very soon. If you have seven tests, am I,
21:05
wouldn't that show this better?
21:09
It would. Now, most of the time we are able to just use enough thin cuts and that gives us enough resolution to merge with the CT in order to identify all the boundaries. Because CT and MR only
21:24
show you blood vessels that are a millimeter or two. We're not into microns, right?
21:32
The endoscope does blow up a lot of the structures though, so it becomes a lot easier to take a peek around corners or get really magnified. So, it's been really helpful in being able to see some
21:44
of these structures. I've seen seven tesla and germs and they're incredible. Do you guys have a seven tesla MR there? They're not common. Only in research, not in clinical use. Yeah, I've seen
21:59
a number of people have it in research, but you've seen the images. Images are incredible, right? For vessels and nerves, they may be better. You kind of pay a price, the higher the power, you
22:14
may lose resolution of other structures. Okay, good point. Good point. All right, terrific, terrific job. So this is, Alex, you got yourself through this part of the anatomy. What's next?
22:26
So next, Dr. Makazian,
22:29
he kind of made a special point of thinking about the use station tube I think that's not something that we commonly think about during these procedures, but since we're low and the opening is there.
22:41
there is a potential for injury.
22:44
And so this is kind of the path of the U-Station tube as it goes from the middle air down into the nasal pharynx and there's two parts, the ausia's part and the membrane is cartilaginous part, which
22:57
the transition point, which
23:03
is at this isthmus marked by the spine of the temporal bone, of the spinous process of the temporal bone is an area where there can be injury from the endoscope if it's not considered. And then that
23:16
can lead to all kinds of middle-air problems, like can't pop your ears feel full, muffled hearing, that sort of thing, which, you know, it's not the end of the world, but it certainly would
23:27
interfere with the quality of life as we've been kind of discussing. I'll make a footnote here. Alex has done a super job on a very difficult subject This is based on my experience. not necessarily
23:41
surgeries that I did, but people came back for a second opinion for some reason, not an error of the surgeon or anything, but they were having trouble, or should they go through another surgery or
23:55
not. And I found that in an ordered number of people that complained about their ear, and sometimes when I looked in, they had, I think, a spontaneous tympanoplasty, you know, where there was a
24:08
tear, and those symptoms went away with most of them. I never wrote it up because I didn't have a good follow-up on these people to make something accurate or it's just just by
24:25
a coincidence. But at fixed points between Osteos
24:33
and membranous, that's where you would expect the fracture. And there was a time that people put long nasal specula Thank you.
24:41
in there and I think some had noticed a problem with that. But it's not heavy duty, but it's making people think about what they're doing and what the structures are around their corridor.
24:55
Absolutely right, patient goes home, has some problems for the rest of his life. Doesn't really know what they are, but this is what it is and it's a nuisance.
25:06
It's a nuisance and I've had that So you're absolutely right, terrific. Okay, you're gonna, oh, that's the next one. Okay, great. And these are just a couple more kind of diagrams, looking at
25:16
the system of the collateral anatomy. But we can get to the surgical video, I think. Yeah, I think you have to proceed with that. It is here. Oh, I just wanted to go back on one image that
25:30
says
25:32
DBM, is that DBM, that's Frank Natter, Oh, that's what it was. Yeah, I can understand it. No. Sure, sure.
25:40
Frank better. Okay. All right. Good.
25:44
All right. So this is kind of the start of the surgical video, which has Dr. Kwan debulking some of the tumor
25:51
in the,
25:53
in the,
25:57
now you're in the center of the tumor here, Frank.
26:01
Yes. Dr. Kwan is actually working right now. Okay Paul King, the sign and you want to comment on these things? Yeah, this is the extra-dural component within the nasal pharynx. So we've raised
26:13
the inferiorly based phrenal pharyngeal flop, actually we're in that right now. And then that was the middle clevis component that we were taking out. And so this is an inferiorly based and allows
26:26
us to access the nasal pharynx with the tumor posterior to it. And then we do this in a special way, just like Dr. McKuzz, like I was saying, to protect your station tubes by being
26:39
medial to the boundaries of the acoustation tubes. And you can see it actually gives you a lot of lateral access once you're behind them. And then we're just gently removing all the corners of tumor
26:50
around there. And this is the inferior extent of the
26:55
corridor at this point. This is the sphenoid floor. So we're removing that and creating enough access so Dr. Sue can later come in and work in this area. Of course, Cordoma tracks everywhere So
27:08
that's exactly why we're still trying to create all these angles of attack. And then
27:17
now we have the dura exposed in the back. The extra dural tumor has been removed. And then Dr. Sue, this is your part here with the intra-dural dissection. Yeah, so now we're just, you know,
27:30
the tumor tracks into the intra-dural space. So now we're opening the clival dura You can see the brain stem and the cranial nerve 12. kind of going to the left side. And unfortunately, the tumor
27:43
was not very hearing to the brainstem and you can see this gelatinous, I call it crap meat. Cordomas look like crap meat. And we just gently try to tease it out without disrupting the vertebral
27:59
artery to your left and the 12 cranial nerve and the brainstem in the depth. And once we do that, you can stick the scope in there. And this is the part that the quan is repairing the defect.
28:20
So this is collagen matrix. We usually place it as a subdural inlay. This is porcelain small intestine submucosa, which is watertight. And the first layer is there to obliterate the defect. You
28:32
can see it's already having this watertight appearance Support the bottom and here's my left-sided nasal septal flap. that we harvested that were positioning very carefully for full coverage. And
28:43
then that's the nasal, the rhinopharyngeal flap, which adds an additional bolstering effect, which tends to help this area heal very well. There's a lot of nuances on how to position this flap,
28:54
but overall, they're the very fortunate that this patient healed very well.
28:59
So very important concept here is we made a big hole and it's the SF continuous with the sinuses. It's not a good situation And earlier on, when they were developing the endoscopic approach, the
29:14
CSF leak rate was so high, like 40, and they almost abandoned it until they discovered these mucosal septal flap that that's a natural life flap that can actually seal things off. The other thing
29:28
Ed was doing was, you know, you saw the endoscope, which only gives you a two dimensional image. And like the microscope, we have your binocular vision. You see the depth. But here, we only
29:42
see 2D. And the only way we can appreciate the 3D is by that quan moving the scope dynamically around. By going in, going out, that gives us a sense of the three-dimensional - it's like going into
29:56
the cave. You've got to put your head in the cave with the headlight on, and you can go to the end of the cave, and you can look around. And that really gives us a sense of 3D, even though the
30:05
image is 2D Action score teamwork at underscores teamwork. That's real teamwork. That's excellent, excellent points. That's a terrific job, you guys.
30:19
And so then this is the post-op outcome. As we sort of alluded to, there's a very small residual down here adjacent to the vertebral artery lateral to the brainstem, and the patient did very well.
30:34
No focal deficits afterwards. We kept them bed rest with the lumbar drain for three days. We kept her NPO with an NG tube for three days as well, just due to the location of the surgery. And then
30:47
she went home, I think it was on post-op day five. And so then we sort of discussed this already, early re-operation versus proton beam for the residual. And we of course decided to go back after
31:01
the mass. And we did a far lateral approach, which I don't have figures for, but you can see the pre and post of MRI and the patient did well after the surgery as well. Alex, can you go back to
31:12
those last two drawings?
31:16
This one? Yeah, yeah. Go to the one just before. This one. Okay, now go back to the last one that you showed. Just, okay. The reason why I showed this, depending on the age of the patient,
31:31
if you take the middle drawing on the left.
31:39
That's a misaginal cut. And you have a membrane that's there at just above the anterior margin of the foramen magnum. You have the anterior longitudinal ligament that attaches the thins out. That's
31:50
generally not in the way. But it has a deeper layer, especially on younger patients, that it's called the anterior alanto occipital
32:00
membrane And as we get older, that thins out. And when you go through the bone and you're this low, you have the insertion of the posterior longitudinal ligament. When somebody's young is thicker,
32:21
older people, it thins out. They call that the tectorial membrane. So it would not surprise me, especially if those ligaments are there. that it would give some resistance to the tumor and keep
32:37
it in the more anterior position, which is where the nodocord generally runs. It runs really through the apical ligament, which is at the tip end of the adorn to it up. Older people, those
32:51
membranes really thin out and they disappear. Now, when you look at the lower, when you look at the lower central picture, you see that they were not that low. They were not below the frame of
33:05
magnum and you really have to consider the oral pharynx, not the nasal pharynx route as well in that. Maybe with technology, that won't be a problem. But I've showed where the tectorial membrane
33:19
attaches and there's just below that, on the right and left side, I put an asterisk and that asterisk is showing the attachment of the a-lar ligaments If they are involved in taking You go too far
33:34
lateral on your anterior margin of your foramen magnum. You run too wrist.
33:41
This joint doesn't show it. My did something later on. If you see that little box and you go over to the anterior edge of the foramen magnum, you see a dark spot just above the alar ligament. That
33:56
is where the hypoglossal artery and hypoglossal nerve transition. So when you go out lateral, you gotta be really thoughtful that you're very close to that structure. If you weaken the alar
34:14
ligaments laterally, you run a potential unstable cranial cervical junction. That's a lot of talk for things that generally don't have, but this is what I call collateral anatomy I don't think it
34:27
occurs very often, but I've seen it as a problem. Excellent.
34:35
Okay. All right. Terrific job, Frank and Ting.
34:41
Do you have another case you wanna do or? Yeah, let's go to finish this case up. And then don't forget, you know, taking it out first time is the most important thing, even though you can do a
34:52
couple surgeries, but gotta follow up with Proton. I think that really reduces the recurrence rate. Otherwise, if you leave it, it's gonna come back and it will become very aggressive When it
35:03
does come back, it's very sticky and scars up really badly. And it's very difficult to dissect. So it becomes a very salvage situation. Frank, did you do this before the Proton therapy or did you
35:19
do this before you did the Proton therapy? Yes, so do the surgery first, follow up Proton therapy, yeah. And now I'm sure they're not 100 cases of this treated with Proton therapy.
35:31
I think - No, there are more. There are lots of data - There are lots of data experienced with proton on chordoma. So the experience with this, and that's very focused radiation therapy is what
35:42
you're talking about.
35:44
Because it's a very deep part of the skull base, and you really wanted to dose it very high. So proton allows you to penetrate without releasing the energy until it hits the target. And that's why
35:58
proton is good for it. Yeah, good So in the experience that the people have had with this have been, has been good because what I was worried about is you're gonna go give them some radiation
36:08
therapy, you go back and it's all scarred down and it makes it more difficult. But this is a more precise delivery of radiation therapy, is that correct? Yes. Okay, excellent. Excellent
36:23
teaching points. Did we miss anything Danny?
36:29
of that from me, but there's a lot more they could talk about. Okay, I think Alex has more cases. I don't know, I mean, Alex is very well prepared. He came with a slew of cases. So we can,
36:42
you can decide how far you want to go. But Alex, you want to do another case? I think it's another. No, we're about, we started at about five. So we're about six 30. So you have another case
36:53
you could do in a half hour. Oh yeah, absolutely, yeah And then what we could do is we can think about it, but my guess is people are gonna say, we want you to come back for some more in the
37:03
future because this is very instructive, okay? Yeah, all right. Let's see in the next one. Okay, so the next case. Number one, skull-based surgery, present and future, and principles of
37:18
treatment. 50 minutes. My second program is how we manage Cordoma of the clevis for 35 minutes. And the third topic is giant anterior and middle faucum and angioma for 21 minutes. Ace is a spin
37:36
around. Alex, you're gonna have to get better prepared for all these in the future. I mean, this is a,
37:43
did a terrific job of putting this together. Thank you. Thank you. So this is a 67 year old female who presented with progressively worsening headaches. She was worked up by her primary care
37:56
provider who got a CT scan that showed a large, right-sided, dural-based mass. And then she was referred to UCI, our school-based center for neurosurgical evaluation. When we saw her in clinic
38:09
preoperatively, she had no focal neurological deficits, as is sometimes the case. And we have this MRI before surgery, which shows a T1 enhancing lesion involving the
38:27
that should say rights to the United Wing, extending superiorly with mass effect on the lateral ventricle and then on the T2 you can see that there's not a ton of edema, but there is some flow voids
38:41
within the tumor that are like the MCA
38:44
branches.
38:48
But there does appear to be a fairly reasonable margin between the tumor and the brain
38:56
So what was your preoperative diagnosis?
39:02
Likely, likely meningioma. Is it
39:08
in both cavernous sinuses there?
39:12
Or is that just the contrast? It's not in this, I think that's the contrast on this side and then for this one, I don't actually know if it was inside the cavernous sinus. I don't think we opened
39:24
the cavernous sinus in the operating room to look.
39:29
But maybe Dr. Xu or Dr. Huang or Dr. Xu as a thought.
39:34
Yeah, sometimes it's hard to tell whether it involves the cavernous sinus or not. I think there are some telltale signs, you know, with the border, if it's filling the cavernous sinus, it will
39:49
displace the outer wall and will bulge it out This looks more kind of based on the clinoid area and wrap around, maybe it's invading the cavernous sinus, it's hard to tell from these images. You
40:06
won't know until kind of when you get in there. Okay. Do you think we missed something on the neurologic exam, what our neurologists have picked some things up that we didn't see with the tumor of
40:19
the size, or does it tell us this has been there for a long, long time.
40:25
I think it was the latter, Adeza's slow growing and the brain kind of just gave in and has a certain tolerance until it hits the threshold and they come in.
40:39
Did she have a compromise or a
40:43
vision in her eye there next to the tumor? That's what you could tell, right? No. Okay. Which is amazing, right? I mean, look at the size of this thing. Yeah, but looking at the size, you'd
40:54
take everything And she won't have anything. And she won't have anything. Like nothing, so, yeah. Okay. Okay, terrific.
41:04
So we did do an angiogram before surgery to look at the vasculature better and to attend to the do an embolization. The blood supply came from the middle meningial frontal division, the artery of
41:16
the frame of the retundum, and then the recurrent meningial branch of the right ophthalmic artery.
41:23
We, the, the, the neural IR team did embolized, the right MMA, which is,
41:29
you know, they were in there so they can do it. It's, it's a structure that you encounter on the, on the extra portion of the approach. So we would have gone to it with our extra drill dissection.
41:40
And then our surgical plan was for a right. Modify it. It was a craniotomy for tumor a section.
41:50
And then there's just some slides going over some basic anatomy for an OZ, you have your temporalis dissection where you can either do a subfacial or interfacial dissection to preserve the temporalis
42:03
branch of the facel nerve shown here. We have sort of the way that we do an OZ where you
42:11
make a burhol at the keyhole, another burhol at the root of the zygoma and then curve it around towards the orbit, just lab roll to the superior, to the super orbital notch with the super orbital
42:22
nerve. And then the zygoma cut here is shown to finish the osteotomy,
42:32
it's just some bony anatomy of the cenoid that you take into consideration during this approach, especially for a lesser spinoid wing in orbital minigiomas. And then
42:44
here's just some of the middle slash anterior school-based anatomy that you. encounter when you're looking from lateral to medial. And
42:56
we don't have to get into this in too great of detail, but these are pictures from the Rotong collection. And you just pointed out a couple of the structures in there 'cause the audience may not be
43:06
oriented to this. Yeah, so we have the trigeminal nerve coming here, the trigeminal ganglion, and then V1, V2, V3 through frame and the superior riddle fissure O-valley and Rotundum. There's
43:24
the greater superficial patrosal nerve running here adjacent to the
43:29
internal carotid in the petriest temporal bone. You have the oculomotor nerve as it comes through and then the optic chiasm with the ICA kind of coming out kind of coming out
43:44
This is, I believe, the trochlear nerve as it comes around from the back of the brain stem and all kind of enters through the superior rheumatoid fissure. And this is just sort of the same view
43:54
with more of the gerostructoid.
43:58
You can see the tintorial edge, the cerebellum. Perfect. Thank you very much. I think the strategy here is this - imagine that tumor would just saw sitting on top of all this, right? And the
44:10
bottom is where the epicenter of the origin is. And if you started a tumor, most of the surgeon would probably do that. Just open the dura, come in, and attack the tumor from the top. If the
44:25
blood supply has not been taken out, it's just going to bleed and bleed, bleed. And it would be a kind of an ugly operation. Absolutely. So the way we kind of do it is come from underneath, do
44:38
an extended mineral fossa, drill it out of the spomb,
44:44
two layers of dura on the bottom, you know, this is known as a dolinx approach to kind of define the bottom and take out the clinoid, basically finish off the blood supply first, and then the
44:58
tumor debugging becomes a lot less bloody, and then you know the boundary, the border, you're not going to get into the cavernous sinus because you already know where it is. Excellent, and
45:12
excellent, and I think he and I'm an NGO always to see if you can get to the origin of the blood supply. It makes a big difference, right? Right.
45:22
I think it is there any thoughts from your perspective as to any particular caution that really would be taken in this area, particularly around where the or is the origin come right through to the
45:36
bone there on the sereneur bridge, or where's the origin? Yeah, this is actually a case that. I wouldn't be able to even tackle from an endoscopic approach. So I wouldn't be able to comment too
45:47
much on it. But as you can see, even that cavernous sinus component is always a perilous area because of all the cranial nerves that are crossing through there. So typically what Dr. Sue and I do
45:59
is, if there is any cavernous sinus extension of any pathology, we always look at the preoperative cranial nerve function before deciding whether or not it makes sense to chase into there Did you
46:09
embolize it, Frank, or did you surgically essentially divide the vascular supply? We try to embolize, but sometimes you can get a vessel that's
46:26
really robust and then deep to those are good target, but most of the time these are supplied by superficial meningio arteries which we can't get to from the surgical approach. But
46:40
embolization can be key and that's - Also part of that team theme we talk about, neural intervention is a big part of the skull-based team as well. Okay.
46:52
So Alex, you wanna go on? I think there's more, yeah. Yeah, so we can show the surgical video here, starting with sort of the extra-dural work after the bone plasma been removed.
47:07
You can see the navigation here, we're trying to develop
47:12
the dual dual dual plane between the cavernous sinus and then you can actually peel that off
47:26
So, once you did all the extra-dural work, then you can come into a durali
47:36
Again, just be aware of the surrounding structures, the nerve, the vessels and you debug with the
47:45
ultrasonic aspirator.
47:49
The other key about these is because the tumor is so big and it's been there for a long time. All the MCA branches are very adherent. So you got to take extra caution. That's the MCA branch And you
48:05
can see all the almost like feeding little collaterals from the internal circulation. And the trick here is not to be a hero and go right on the vessel. I think it's okay to stay like a millimeter
48:23
to await and leave a little rim on it instead of giving the patient a stroke. That's called judgment and experience.
48:34
Keep debulking the tumor. I think a lot of the young surgeon try to, try to get the tumor out in one piece, which is very dangerous. And you've just got to be patient. Keep debulking. And at the
48:47
end, it was just kind of roll out. But that's the last 10 seconds. Excellent job.
49:01
So postoperatively, she tolerated the surgery very well. She did note some numbness in the right maxillary region after surgery,
49:11
but was otherwise intact. And I think that's a pretty tolerable issue. And I don't know if we followed her long enough to know if that got better or not.
49:21
But the final pathology was who grade one meningioma. You can see
49:26
the postoperative MRI here She was a very good resectioned. And
49:32
she has not had or needed radiation yet postoperatively. We're just monitoring with surveillance MRIs to see if there's any residual starts to grow over time.
49:46
What was she neurologically like after surgery?
49:51
She was okay. She had this full on eye from the OZ approach that always happens. I'm returning to clinic did she come back and say my or the family see my personality is different or I can think
50:06
more clearly or did you you know the things we can't even measure. Yes. Yes. What she said she said the family notice she was more interactive. She she's better in terms of her cognition and her
50:21
movement and just overall they they really they were really appreciative of what we did And because we made we made her better
50:32
and and left her intact really I mean and then the question is was that due to compression longstanding compression was it due to compression and ischemia
50:44
because she was losing some blood supply to her frontal lobe and it was going into the tumor and out We don't know and we haven't, we really never got to that level in our examination to know, have
50:56
we? It's very subtle, but just imagine the temple draining veins were going in that direction, but there's no where to go. So it has to develop collaterals and there's congestion. And if you look
51:10
at the T2 images, probably there is some edema developing around that. Yeah, that's true. Well, I think that's just an outstanding job. Any more you wanna come in about this one? Well, I just
51:22
had one question, to your point
51:25
I think that cognitive function, higher cognitive function is really important. Obviously for all of us, if we had a brain tumor, we would want to maintain all of our cognitive faculties if it was
51:38
removed. Do you know if people are studying that in school-based tumors to any robust degree where they have people see a neuropsychologist before and after surgery and do some of those more
51:53
extensive testings?
51:56
You already thought about that, Frank.
51:59
Oh, that's a great, great point. I think
52:03
we pay a lot more attention to the cognitive function for some other patients, like the functional Parkinson's disease patients, normal pressure hydrocephalus patients, because the presenting
52:19
symptoms are mostly cognitive. For skull-based patients, unless the tumor is like this big, they come in with some cranial nerve deficit, headache, and vision problems. So
52:32
cognition is not like the highest function to be effective first. So maybe we need to pay attention more, because obviously this case, and many of our cases, patients have impaired cognition.
52:46
Now, Denny, you already thought about this. Are we paying, I couldn't, we had some very famous neurologists who came and we had them as visiting professors. and I can tell it was embarrassing.
52:59
They just did a phenomenal job and they preceded the MR and what they could detect neurologically because they were so careful and so in their examination. Denny, we got into imaging which allowed
53:14
us to be sloppier and so forth. Wouldn't you think that there would be some interruption of cognitive function with a mask like this? Yeah, absolutely It's hard to imagine there wouldn't be some
53:28
deficiencies there. I think it would take special testing.
53:34
The mirrored contralateral side may pick it up but I suspect that there is some, you know, a lot of times people don't exactly know what their own cognitive dysfunction is until they recover. how,
53:56
you know, it's not scientific, but they'll tell you, you know, I feel much better. I can do things better. I don't get confused. I didn't realize that I really was with the deficiency. I've
54:09
had patients say that, but that's not science. I think you're right. I think as I study into the metabolic basis of neurologic disease, if you think about it and you have some cerebral dysfunction
54:26
or some neural cell, it'd be better to say dysfunction. How does that manifest itself? Is it the fact that these confused or it forgets a word or two or it just doesn't feel exactly where they are?
54:41
If somebody comes in with a broken bone, you take an x-ray and know it's a broken bone, you feel it, it's a broken bone, we just don't have that sophistication in evaluating damage to neurologic
54:54
function particularly. if it's subtle, you agree with that? Yes, I do, and if you take a look at this and you speak about the neuroanatomy of it, this is pushing over the
55:10
gyrus rectus and the sulky rectus. And so this
55:15
is frontal basal frontal lobe, isn't it? It's orbital This is also catching, and you probably get a better view on the coronal cut, but I suspect that there's disruption or displacement of the
55:35
unsanade fascicle from the amygdala. So
55:39
it's hard to believe that
55:44
there wouldn't be some changes to executive behavior. Do you think it would be important to be valuable to do fiber tracked imaging, I know it would be. if you're going around and want to sell it
55:55
to everybody, and they say, What are you crazy? But it would be obvious that the fiber tracks and their fiber tracks image would have to be distorted. Well, the problem there, yes and no,
56:08
because distortion doesn't mean malfunction. So what needs to be done in the last 35 years, they've been doing the tractographies, but they haven't been talking about, is there a change in the
56:22
behavior? Well, maybe DWI gives that flare, it kind of gives that information, at least to be suspicious. But we really need to know what the axoplasmic flow is. And so you need a biomarker for
56:35
those things. Right, right. Good point. We don't know the function. No. No, I think you're right. So there, Alex, is a challenge
56:46
And it's obviously there's something wrong. Something has to be disturbed here. And we're just not smart enough to figure it out.
56:57
and it's very subtle and it's below any kind of testing we do, what we're doing testing is gross. We don't have a threshold that's accurate. Yeah. We just, so that would be a terrific challenge.
57:10
Okay, we get everything out of this, we can get out of it.
57:15
I think so. I think so. Frank
57:20
and Alex, thanks for preparation. Ed, thank you for all your contributions here and making this meaningful. Denny, there's not enough time to
57:30
thank you for all the wisdom that you always give when I sit and talk to you and I'm sure the others feel the same way. But I think I can, I can probably, you're gonna hate me if I tell you this,
57:40
but this is terrific, a terrific job. You should save those and I hope I can persuade you maybe to come back and maybe you can make a regular feature sometime. I know it takes a lot of work, The
57:53
amount of the teaching value is just incredible. And I appreciate that for all the people who are watching.
58:02
Well, we wanna thank you for the opportunity and let us be part of this important mission. All right, great, thank you. Okay, Ed, thank you, Frank, thank you. Alex, thank you for your
58:14
preparation. Dennis, I'll call you, take care of it. Everything, okay? Thank you for the invite I'm glad at all. Personally, thank you very much. All right, terrific. Thank you, Dr. Asman.
58:27
Bye-bye, guys.
58:29
These are the references for these programs. Be prepared to take screenshots for your records.
58:39
This is the first set of references. Please take a screenshot of these five references so you can keep them for your records. And these are basically on the current status of skull-based surgery.
58:51
multidisciplinary, technological, neuroanatomical-driven approach with investigators pushing the boundaries of minimally invasive and endoscopic approach.
59:05
Set of references too for your screenshot. Looking at the future, advances in imaging, Raman spectroscopy for real-time determination of histopathology advances in robotics, artificial
59:13
intelligence, and advancements in training and skull-based surgery. And there are set of references here. For novel scoring systems for the extent of resection, predicting tumor occurrence, and
59:35
changes in guidelines for post-operative treatments, and surveillance based on these updated systems, there is reference one at the bottom of this page
59:47
References 3. Deal with advances in molecular classification of skull-based tumors. And these are a series of three references on those subjects. Please take a screenshot.
1:00:01
References four, deal with neuro-anatomical references. And there are three major references here, which we think you'll find helpful. Please take a screenshot of these references
1:00:18
We hope you enjoyed this presentation. Views and opinions expressed in this program are those of the author or interviewees, and do not necessarily reflect the official policy or position of SNI
1:00:31
digital or its management. This information and the program should not be considered to be medical advice. People should consult their own physicians as to their specific medical needs.
1:00:43
For your evaluation and questions, please fill out your evaluation of this video. or these videos at the bottom of the home page. There's a rating scale you'll see which has five stars. Five is
1:00:54
the top or the most or the best or the excellent. And that helps us improve the programs and information we bring to you in the future. If you wanna ask some questions, can have comments, ever
1:01:06
request for your CMA credit or suggestions for us at the bottom of the home page on the right hand corner, look for the blue icon and just consent an email directly to us.
1:01:19
The foundation supporting these programs believes there are many ways to learn. SI, Surgical Neurology International, is an internet journal. Its web address is siglobal.
1:01:42
And if you have seen as its editor-in-chief, it's been published for 15 years. And SI Digital, Innovations and Learning, is a new internet video journal. All video, interactive with discussion,
1:01:44
its web address is sidigitalorg. Both are free on the internet
1:01:50
247,
1:01:53
365. SI surgical neurology international is read in 239 countries and territories. In the last 15 years, it's the third largest journal of neurosurgery and readership as 240, 000 readers a year.
1:02:05
And
1:02:09
SI innovations and learning is published for 20 months and it's seen in 155 countries It's the first video journal of neurosurgery and video journal as far as we know. Has 20, 000 viewers or more
1:02:24
and listeners a year. The goal of the foundation is to help people throughout the world.
1:02:32
SI offers this program and all of its program on podcasts on Apple, Amazon, or Spotify. Look for SI digital on those commercial programs and you will find the podcasts.
1:02:46
The Foundation also supports the Medical News Network, bringing truthful medical and science news to the world.
1:02:53
This program and all the programs are copyrighted by the James IOSman and Carolyn ROSman Educational Foundation, all rights are reserved. If you have questions, write to Dr. OOSman at
1:03:04
JamesOSmanMaccom. Thank you for watching
1:03:08
the program. We hope you found it valuable.
