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Most of the site will reflect the ongoing surgical activity of Prof. Munir Elias MD., PhD. with brief slides and weekly activity. For reference to the academic and theoretical part, you are welcome to visit  neurosurgery.tv

 
23-MAY-2006 YAHYA ABDEL-QADER MUHAMED 49 YEARS GIANT III VENTRICULAR CRANIOPHARYNGIOMA
The patient came to the clinic 13-May-2006 complaining of headache with visual disturbances. The patient is a Sudanese citizen was operated 05-March-2003 : Right VPS inserted for the hydrocephalus caused by the craniopharyngioma. Right pterional approach was performed 2004 with absent data about his surgery.

On examination he had weak left side of the body with constriction of the visual fields and he has constricture  due to previous Foley's application.

It was explained to the relatives and to doctors, that such radical surgery is very costly and they insisted to operate upon him with minimal cost. And here is the challenge, how to operate, radically remove such a giant tumor, knowing that he will progress postoperative diencephalic syndrome, without putting him in ventilator minimum for three days.

Using the old surgical incisions, a right frontal approach was performed  with placement of the bone flap anterior to the shunt , which was inserted previously. Transcortical route was used. The right foramen Monro was widely expanded and elevated upward by the cystic part of the tumor with the atrophied choroid plexus and the strio-thalamic veins running anteriorly. The cystic part contained golden-green fluid, which was aspirated, after what the widen foramen Monro collapsed down. Using the three small spatulas they were inserted directly to the third ventricle cavity and the solid part of the tumor was resected in piece-meal fashion. It contained soft parts of violet fleshy attenuation, which was friable and easily dissectible from the left wall of the III ventricle. Further cystic components were removed from the left side and it was possible to see the basilar artery under the arachnoid in the floor of dissection.

All the calcified part was present in the right side and it was removed, using Smith-Kerrison and pituitaries. After removing the entire intracapsular part of the tumor, the capsule was removed in toto and it had good cleavage with the anterior part of the third ventricle. The most difficult part was the separation of the capsule from the right wall of the third ventricle.

After the third ventricle got normal position and total removal of the craniopharyngioma, it was possible to see the running right A1 with Heubner over the flatted optic chiasm  in the right side. Attempt to see the previously seen basilar artery was denied intentionally to avoid possible vascular reactions.

Total resection of the craniopharyngioma was achieved and there was no bleeding in the bed of the tumor cavity, which is actually the third ventricle. For 20 min irrigation of the bed was performed and the water flowing back was crystal clear.

Routine closure of the wound and the patient was extubated immediately after the operation.  The operation took approximately 8 hours and the patient was lethargic with moderate signs of diencephalic syndrome, with acceptable breathing drive. The patient showed right sided weakness with total aphasia, for what he was immediately sent for check CT-scan.

CT-scan showed complete resection of the tumor with no evidence of hematoma or any problem in the left side of the brain, which actually was not touched. But for the great surprise, the previously inserted shunt from the right side, became clear that, it is inserted to the left lateral ventricle.

Strict observation in the ICU. the breathing drive still acceptable and the right sided paralysis start to resolve, but the patient showed surges of hyperthermia, which was treated accordingly. 

The patient continued in somnolence state and developed left sided paresis more the hand area , which resolved over 12-14 hours.  Hypernatreamia was corrected accordingly. The surges of hyperthermia resolved and the patient start to show some improvement. Daily CT-scan was performed and it was quite silent with gradual reabsorbtion of air

In the early morning around 7.00 in the 6th postoperative day, the patient showed massive MI with sudden cardiac arrest, which did not respond to resuscitation.

Comments:

1. For the theoretical part about craniopharyngiomas , click here!

2. The patient surgery was clean and straight-foreword and the patient  seem to be not in need for ventilator after the operation, and he was homeodynamically stable all the time without signs of diabetes insipidus. Despite that, the patient progressed massive MI the 6th postoperative day.

3. The hypothalamus got physiological irritation, which mostly was the cause of his MI and death. Do not be overconfident and consider your self ace in surgery. Some of the time, it is better to be satisfied with partial resection, leaving Ommaya reservoir  inside the cystic component. It is better to reoperate the patient many times, than leaving him to die.

4. In our practice, intraperative  monitoring of the hypothalamus is lacking to decide, when to stop and when to continue, because  delicate surgery, never mean that it succeed. It is the time to hold the importance of various intraoperative monitoring devices and with experience to predict  and refine the surgical strategies.

5. Most of these speculations could have no place, since an identical case the very huge multilobulated colloid cyst was operated before him and made a very smooth postoperative course. To see that case click here !. Both of them surgically were identical.


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[2006] [CNS CLINIC - NEUROSURGERY - JORDAN]. All rights reserved