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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5801_Библиотеки_им_академика_М_И_Перельмана.pdf
84 Chapter 3 Clinical Application
3
Fig. 3.90. The frontal MR shows a tumor in the sella, which
broke through the sella floor (≠) into the sphenoid sinus,
where the sono-probe (+) is placed
Fig. 3.91. The sono-probe (1) is in the sphenoid sinus (3),
touching the dura of the sellar floor and showing the pituitary gland (2), with the tumor (≠) protruding into the
sphenoid sinus. The bony wall of the anterior sella (Ø) and
a septum (¨) of the sphenoid sinus are visible
Fig. 3.92. The sono-probe (1) is now pushed into the tumor
(2). The protruding part of the tumor (Ø) is clearly visible.
Lateral to the sella, both carotid arteries (3) are scanned
Fig. 3.93. This is the typical appearance of an enlarged sel-
la (1/Ø), seen laterally. The ENS catheter (2) is introduced
transnasally (Æ). To get beneath the sella, the subsellar
bone of the clivus (3/≠) had to be drilled to create enough
space for the catheter. This can be planned according to
individual neuroradiological findings
Transnasal Approach to Sellar Region
Fig. 3.94. Sagittal MR shows a sellar
tumor (*) with a suprasellar part (Æ)
85
Fig. 3.95. Coronal MR shows a sellar tumor (*) with a suprasellar part (Ø) compressing the optic chiasm
86 Chapter 3 Clinical Application
3
Fig. 3.96. The coronal MR shows an inhomogeneous tumor
(*) with enhancement in different parts (ÆO¨) and a
suprasellar part (Ø) compressing the optic chiasm and in
contact with the ICA bifurcation (fi‹) on both sides
Fig. 3.98. The sono-probe (1) is placed in the sphenoid si-
nus (2) with a strong bony wall (3) and is in contact with the
sellar dura (ØØ). Inside the sella (4) there are a tumor (*)
and several inhomogeneous enhancements (≠). Histology
allowed diagnosis of a metastasis of a carcinoma
Fig. 3.97. A 3D planning system shows the position of the
ENS catheter (red arrow). Such non-real-time images may
help to make interpretation of ENS images easier and give
the main orientation
Posterior Fossa
Posterior Fossa
Case 16
Clinical History
This 49-year-old patient had experienced left anacousis 2 years before her operation in our clinic.
After rheological therapy her hearing was restored.
One year later she had a second anacousis attack
followed by urgent diagnostic MR.An intracisternal
acoustic neurinoma was found; her hearing was
minimal, and acoustically evoked potentials (AEPS)
were diminished.
Intraoperative viewing (Fig.3.99) showed a
spherical tumor,reaching from tentorium to jugular
foramen.ENS imaging (Fig. 3.100–3.102) presented
a clear delineation of the tumor borders and of
most surrounding structures. However, it was not
possible to see the facial nerve attached to the tumor. Petrosal structures and sinuses were visible,
and the meatus was filled completely by the tumor.
Intraoperative real-time imaging showed details
invisible to conventional ultrasound probes in the
deep tissue.
Treatment and Outcome
Tumor resection was achieved by microsurgery
with endoscopic resection control, especially in the
meatus. Facial function was intact postoperatively,
and the patient’s hearing had recovered somewhat.
87
Fig. 3.99. This large CPA tumor (1) completely fills the
meatus of the petrosal bone (2) and almost reaches the tentorium (4), where it touches a small vein (≠) close to the
ambient cistern. The caudal margin reaches the lateral
cerebellomedullary cistern (5). Two spatulas (3) are protecting the cerebellum (6), and the dura (7) is reflected laterally. The ENS catheter is placed in three different positions (+)
Fig. 3.100. The sono-probe (5) is placed between the supe-
rior border of the tumor (1) and a small petrosal vein (≠),
in which blood flow is visible on the screen or video. The
pons and a spatula artifact (4) are visible, as is a small
artery, in an axial scan (Ø). The border of the tumor (*)
gives a round signal, attached to the petrosal bone (3) with
pneumatic areas (2)
88 Chapter 3 Clinical Application
Case 17
Clinical History
This 46-year-old man had had two operations for
cerebellar hemangioblastoma at the age of 15 and
3
3
Fig. 3.101. The sono-probe (1) is placed in the CPA (5) at
the tumor equator (*).The tumor (2) has enlarged (arrowheads) the meatus (arrow). The roof of the jugular bulb (3)
and the clivus (4) are visible
18 years.Now, 31years after the first operation and
28 years after the second,he was experiencing progressive impairment of walking.
MR showed a cystic relapse of the tumor
(Fig.3.103–3.105) in the cerebellum and in the dorsal medulla oblongata.
Treatment and Outcome
Intraoperative localization was not easy,as the cyst
walls did not allow observation of the tumor. ENS
was used for easy real-time imaging and targeting
of the tumors (Fig.3.106–3.108). ENS was used to
help check that resection was complete.
Postoperatively, the patient’s symptoms started
to diminish,but 1 month later he developed hydrocephalus.An ETV was planned, but the surgeon did
not use ENS and was not able to perform an adequate stomy, as there was not enough space. However, a shunt was finally inserted. Up to October
2000 several revision operations had been necessary because of tumor recurrences, spinal tumors,
and shunt problems.
Fig. 3.102. The sono-probe (1) is placed in the lateral cere-
bellomedullary cistern (8) at the inferior border (*) of the
tumor (2). The wide opening (thick arrow) of the meatus
(Æ) is visible, as is the jugular bulb (3). On the brain side
Bochdalek’s bodies are present (5), and caudally the subarachnoid way into foramen magnum (7) is within the scan
Posterior Fossa
Fig. 3.103. Sagittal MR shows a recurrence of a Lindau tumor (Ø) and an old resection cavity (+)
89
Fig. 3.104. This axial MR shows an old
resection cavity (+) with a Lindau
tumor (*). The tumor nodule (≠)
is seen within the cyst
90 Chapter 3 Clinical Application
3
3
Fig. 3.105. The coronal MR
represents a resection
cavity (+) plus the Lindau
tumor (*) with a highsignal nodule (≠) within
the cyst, plus a second
one on the medulla (Ø)
Fig. 3.106. The sono-probe (1), which is positioned in the
fourth ventricle (+), as shown in Fig. 107, imaging a coronal
plane (≈). The tumor nodule (2) and tumor cyst (*) are
within the scan
Fig. 3.107. The sono-probe (1) is inside the fourth ventricle
(2), which like the tumor cyst (5) or the old resection cavity (4),was a cystic cavity. On entry into the fourth ventricle
it was not at all clear which cystic space was present and
where the tumor nodule (3) was to be found.ENS produced
a precise real-time topography (see Fig.3.106) for navigation to the Lindau tumor (3)
Posterior Fossa
Fig. 3.108. The sono-probe (1) is in the fourth ventricle (2)
and can navigate instruments or the endoscope to the
Lindau tumor (3) with its cyst (5) or make a communication to the cavity (4)
91
Case 18
In this case, the approaches were planned in 3D,
and the use of ENS was demonstrated virtually
(Figs. 3.109–3.112).
Clinical History
This 66-year-old man had been suffering from
trigeminal neuralgia for 10 years. Carbamazepine
was used for primary pain control, but the dose had
to be increased more and more and eventually the
side effects became unacceptable.Neuroradiological examinations showed typical contact of the anterior inferior cerebellar artery (AICA) with the
trigeminal nerve entry zone.
Operative planning with 3D reconstruction and
computer assistance gave the impression of a
method of approach design and anatomical relationships. The geometry of ENS imaging was
demonstrated (Figs.3.109–3.112).
Treatment and Outcome
At operation, ENS imaging of the lateral-suboccipital approach was demonstrable (Figs. 3.113–3.116)
plus the compression point of the trigeminal nerve,
which was not visible on endoscopy (Fig.3.117).
Postoperatively, the patient did well and the
trigeminal neuralgia disappeared.
92 Chapter 3 Clinical Application
3
3
Fig. 3.110. This is a 3D representation of an operation plan-
ning-system, representing a right suboccipital approach
through which the ENS catheter (10/≠) is inserted into the
CPA cisterns. The computer reconstruction shows the right
ear (1), transverse sinus (2), sinus knee (3) and sigmoid sinus (4). In the deep tissues the Vth (5) and VIIth/VIIIth (7)
cranial nerves and the jugular nerve bundle (8) are visible.
Close to the trigeminal nerve (5) there is an AICA loop (6),
Fig. 3.109. The ENS catheter (1) was introduced by a right
lateral suboccipital approach into the CPA. Under the
transverse sinus (5) the trigeminal nerve (3) compressed
(2) by an AICA loop (4) was approached and examined
and close to the jugular nerve bundle the posterior inferior
cerebellar artery (PICA) (9) is visible
Fig. 3.111. The virtual view into the right CPA shows the
position of the ENS catheter (11) producing soundwaves
(()). At the laterosuperior border we see the transverse sinus (1), the sinus knee (2), and the sigmoid sinus (3). The
Vth (4) and VIIth/VIIIth (6) cranial nerves and the jugular
nerve bundle (7) running between brain stem (9) and petrosus bone (8) are visible. An AICA loop (5) and the PICA
(10) are close to neighboring nerves
Fig. 3.112. This virtual endoscopy in the right CPA shows
the position of the ENS catheter (9) with ultrasound waves
(()), and CPA between brain stem (8) and petrosus bone
(7). Transverse sinus (1) and sigmoid sinus are just coming
into view. The trigeminal nerve (2) is close (Æ) to an AICA
loop (3) and the 7/8 bundle (4). The jugular nerve bundle
(5) is in contact with the PICA (5)
Posterior Fossa
93
Fig. 3.113. The endoscopic view presents the right superior
cerebellar artery (SUCA). The sono-probe (1) is placed superior to the trigeminal nerve (2), which together with
Dandy’s vein (3) runs toward the petrosal bone (8) and the
tentorium (7). Between these, the facial nerve (4), the
acoustic nerve (5), and the AICA loop (6) run cranially below the trigeminal nerve (≠), causing neuralgia (Ø)
Fig. 3.114. The sono-probe (1) is inserted into the right CPA
cisterns (5) close to the 7/8 bundle (4), running into the
meatus (Æ) of the petrosal bone (3). The signal of the pons
(6) is overlaid by a spatula artifact (*). The tentorium (2)
marks the cranial border of the scan
Fig. 3.115. The sono-probe (1) is placed in the CPA cisterns
(2), where the tentorium (5) meets the transverse sinus (6),
bending into the sigmoid sinus (8).Medially the brain stem
is visible with Bochdalek’s body (plexus) (4) and the pons
(3) where the trigeminal nerve emerges (7)
Fig. 3.116. The sono-probe (1) is placed in the cerebello-
pontine cistern (7) between the trigeminal nerve (2 ≠≠ØØ)
and the 7/8 bundle (4) and close to the petrosus bone (5)
and the surface of the pons (3).The tentorium (6) forms the
superior border of the scan