- 6 hafta önce
Brain tumor and awake brain surgery Resection of metastatic melanoma
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00:00This is a case of a 70-plus-year-old gentleman with history of aortic valve insufficiency,
00:28thrombocytopenia together with stage IV metastatic melanoma, and history of resection of melanoma
00:35from scalp with multiple areas of skin graft and also radiation to several regions of the
00:40scalp, who developed a solitary brain tumor, which was initially treated with immunotherapy.
00:46However, he presented with progressive growth of this tumor despite immunotherapy, which
00:52resulted in dense right-sided hemiparesis and weakness, as well as expressive dysphagia
00:58speech problems.
01:00MRI scan of his brain revealed a large brain tumor in the left frontoparietal region, accounting
01:07for his right-sided weakness and speech deficit.
01:10An anatomical review using MRI before the operation.
01:14On patient's right side, which is the left side of the screen, where anatomy is not distorted,
01:19we can readily identify PARS bracket, anterior to which is central sulcus, sigmoidal hook
01:26sign, and motor strip.
01:40Now let's review the MRI slice by slice.
01:43Tumor has a lobular morphology, with significant local mass effect and edema.
01:50Here is PARS bracket sign and motor strip.
01:53Tumor has completely distorted the anatomy on the left side of the brain.
01:57Computer navigation is further used to study the anatomy and plan the approach to the tumor.
02:16Superior sagittal sinus and a large draining vein overlying the tumor is identified.
02:21Given the location of the tumor adjacent to motor strip and overlying large draining vein,
02:29we plan for awake craniotomy with cortical mapping.
02:38Patient's tolerance of an awake craniotomy relies on effective analgesia of the surgical area,
02:45which we will review here.
02:47Skip ahead if this does not interest you.
02:50So after prepping his scalp with chlorhexidine, his scalp was blocked, essentially made numb,
02:57by infiltrating local anesthetic agent, consisted of Marcane and Lidocane mixture,
03:02along the course of seven involved nerves.
03:05These nerves are consisted of supraorbital, supratrochlear, zygomaticotemporal,
03:12auriculotemporal, greater and lesser occipital, and finally, great auriculonerve.
03:18Local anesthetic is injected along the dotted line marked on patient scalp,
03:24the skull clamp pin sites, as well as incision sites.
03:31Let's have a quick review of anatomy of the blocked scalp nerves, which is quite important,
03:36but if this doesn't interest you, please skip ahead.
03:41Supraorbital notch can easily be palpated, and this is where the supraorbital nerve can be found.
03:49Supratrochlear nerve is just medial to the supraorbital nerve, above the brow line.
03:54Supratrochlear nerve
03:59Blocking zygomaticotemporal nerve involves infiltration at the lateral edge of the supraorbital margin
04:06to the distal aspect of the zygomatic arch.
04:11A recalled temporal nerve crosses over the root of the zygomatic process of the temporal bone
04:17and lies deep to the superficial temporal artery.
04:20Avoid intra-arterial injection.
04:23To block great auricular nerve, inject the local anesthetic about 2 cm posterior
04:29to the auricle, or ear, at the level of the tragus.
04:32To block the lesser occipital nerve, infiltrate local anesthetic subcutaneously behind the ear,
04:41starting from the top down to the auricular lobule, and then continue to infiltrate along the superior
04:47nuchal line. Greater occipital nerve is found about 3 to 4 cm lateral to the external occipital
04:56protuberance along the superior nuchal line.
05:12While patient is completely sedated, a bone flap is raised over left frontoparietal region,
05:27overlying the tumor.
05:33Patient is then awakened gently and maintained calm and comfortable prior to dura opening.
05:42So, we have done the craniotomy, overlying the tumor precisely.
06:01And we are gently waking the patient up. Do us a little bit tight, but we want to make sure
06:05patient wakes up nicely. And this is the front, back, superior, superior.
06:12Once patient is awakened and made comfortable, dura is opened gently and mindful of the large
06:21underlying draining vein.
06:22So, are you in any pain at all? No? Good. Now, can you open and close your right hand so I can see it? Open and close your right hand.
06:46Make a fist. And open. There you go. That's good. And can you wiggle your toes as well? Wiggle your toes?
06:55Yeah. Okay, good. You're in no pain. Can you say hello?
07:00Hello. Good. Everything's good.
07:02Under a wake condition, we started cortical stimulation at 2 mA and increased it in 1 to 2 mA intervals
07:11using biphasic square wave at 60 Hz for 2 to 3 seconds stimulation with minimum of 4 seconds
07:19pause between each run, thus establishing safety of the surgical corridor.
07:24Next, the arachnoid overlying the large draining vein is carefully opened for temporary occlusion of the
07:31vein and examining whether its occlusion results in any neurological deficit.
07:54of the F
08:17you're doing really good. You're doing awesome and poor.
08:21Awesome, and for, do you have the micro clip?
08:28Yes, I do.
08:30You're doing awesome.
08:31Okay, good.
08:32Now let's get the micro clip.
08:34Micro clip is used to temporarily occlude the large draining vein and the adjacent vein,
08:40while patient is neurologically evaluated for a relatively long time with no side effects.
08:46Okay, keep that for a while.
08:48Can I see another one?
08:49Keep moving.
08:50Yeah, keep moving.
08:51Yeah.
08:52Actually, if that one is going to be okay, the other one is going to be fine.
08:57I can't quite move.
08:58Open and close your hand.
08:59You're doing great.
09:00Uh-huh.
09:01You got it.
09:03There you go.
09:04Do you have the other one?
09:05What is it?
09:06No.
09:07I can hear that.
09:10I can see the operating room.
09:12The operating room is wide awake.
09:14Now, can you open and close your hand?
09:16You're doing so well.
09:17Yep.
09:18One or both.
09:19One or both.
09:20Just the right hand would be good.
09:21This one, but you can do both.
09:22Yep.
09:23There you go.
09:24And how about whittling your toes?
09:25That's fine too?
09:26Oh, man.
09:27Good job.
09:28Good job.
09:29Good job.
09:30That looks awesome.
09:31Great.
09:32Are you in any pain at all?
09:33No.
09:34Good.
09:35Are you comfortable?
09:36Yeah.
09:37Okay.
09:38You're doing awesome.
09:39I think you're moving it pretty good.
09:40Okay.
09:41Okay.
09:44I'm trying to lift a push up against me here.
09:45I'm trying to lift a push up against me here.
09:46I'm trying to lift a push up against me here.
09:47I'm still going to keep it alive.
09:48I'm still going to keep it alive.
09:49Oh, no.
09:50Can I see the applicator again?
09:51Are you talking to me?
09:52You're doing awesome.
09:53I'm not right now, but...
09:54I can't quite use the layer as much as I have.
09:59It looks like you're moving it pretty good.
10:00Okay.
10:02I'm trying to lift a push up against me here.
10:04Push up against me here.
10:05Push up against me.
10:06Yeah.
10:07There you go.
10:08You're doing everything.
10:09Everything good?
10:10Mm-hmm.
10:11Pulling arms and legs.
10:12Yeah.
10:13Beautiful.
10:14Yeah.
10:15One more.
10:16One more.
10:17One more.
10:18One more.
10:19One more.
10:20One more.
10:21One more.
10:22One more.
10:23One more.
10:24One more.
10:25One more.
10:26One more.
10:27One more.
10:28One more.
10:29One more.
10:30All right.
10:31Let me sing a song.
10:32Please.
10:33What are you going to say?
10:34You don't remember it.
10:35I can only do you hold on the ring.
10:38See you.
10:39That trick you played with me again.
10:41That's okay.
10:42That's Dr. Illuminati's favorite song, huh?
10:45The deer in the antelope play.
10:47There you go.
10:48The birds of the lizard and the spirits of the spirits in the world.
10:53And the skies are not proud to be on there.
10:56All right, that's the only one I can remember.
10:59Hey, that was pretty good.
11:00That was awesome.
11:08The silcus between the two veins is used to approach the superficial pole of the tumor.
11:26Low-current bipolar cautery and gentle suction is used to minimize trauma to the tissue.
11:56.
12:26Computer navigation confirms that we are on lateral edge of tumor and specimen is sent
12:53for pathological study.
12:56Then the capsule of the tumor is hardened using glucuron bipolar and the tumor is elevated
13:17carefully with vascular supplies ligated prior to complete removal.
13:26Can you move your arm?
13:27I can't move the best boy in this.
13:31What about opening close your hand?
13:33There you go.
13:35What about opening close your hand?
13:36There you go.
13:42Yes, no problem.
13:43Okay.
13:44That's your bipolar?
13:45What?
13:46Open and close your hand.
13:47You're doing great.
13:48Good job.
13:49Yeah, no problem.
13:50Uh-huh.
13:51Okay.
13:52Yeah, can you open and close your hand?
13:53You're doing awesome.
13:54You see a big grass closer?
13:55I'm ready.
13:56I'm ready.
13:57Okay.
13:58Okay.
14:11Great.
14:12Great.
14:13Good job.
14:14Yeah, no problem.
14:15I'm ready.
14:16I'm ready.
14:17Are you talking to me?
14:18Yeah.
14:19Can you open and close your hand?
14:20You're doing awesome.
14:21You see a big grass closer?
14:22Okay.
14:33Big.
14:34Okay.
14:35Good.
14:36Take it in.
14:37Can I have all the variations in here, please?
14:40I'm going to do it, boy.
14:42Can you open and close your hand?
14:44Very good.
14:45Moving?
14:46Yes.
14:47Good.
14:48Good.
14:49Good.
14:50All right.
14:51Now, you're going to need to go around and make sure everything is out.
14:54You took the bulk of the tumor.
14:56You did awesome.
14:57Resection cavity is carefully inspected to ensure there is no residual tumor.
15:15Sodium fluorescein microscopy is used as an adjunct to evaluate the resection cavity.
15:21Subcortical stimulation is used prior to any additional resection, especially in the anterior border of the resection cavity adjacent to the motor strip.
15:44Patient surprisingly opted to stay awake during closure and had immediate post-surgical
16:07improvement.
16:08You have a choice of staying awake or go to bed or sleep.
16:18You want to stay awake?
16:19You're kidding me.
16:20You're the champion.
16:21Nobody's ever wanted to stay awake.
16:23Are you serious?
16:24I want to do 15 pounds.
16:26Good man.
16:27You're going to do awesome.
16:29If you get uncomfortable at all, you let me know and we'll have you sleep.
16:38Hydrogen peroxide solution is used for hemostasis as well as for therapeutic reason.
16:57The surgical cavity was covered with absorbable hemostatic film.
17:07Duro was closed.
17:10Bone flap was re-approximated.
17:24Post-operative MRI scan showed complete resection of the tumor.
17:43To reduce resection of the tumor.
18:14Patient did well postoperatively with resolution of his preoperative deficits.
18:20He subsequently underwent conformal radiotherapy and immunotherapy.
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