This document outlines surgical approaches for intraventricular tumors (IVTs). It discusses the surgical anatomy, indications for surgery, considerations for choosing a surgical approach, specific approaches to the lateral and third ventricles, microscopic versus endoscopic resection, potential post-operative issues and complications, predictors of post-operative hydrocephalus, and outcome. The approaches described include anterior and posterior interhemispheric transcallosal, transfrontal, subfrontal, transparietal, occipital transtentorial, infratentorial supracerebellar, transtemporal, transsylvian, and telovelar approaches.

1. Surgical Approaches to
intra-ventricular tumors
(IVT)
BY Dr. Mestet Y. ( Neurosurgical Resident)
6/18/202
2
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2. Outline
• Surgical Anatomy
• Indications
• Considerations for choice of approaches
• Surgical Techniques
• Post op issues /complications/
• Outcome
• References
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3. Structures in the walls of the lateral ventricles
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4. Third ventricle anatomy
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5. Arterial & Venous Anatomy
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6. White matter fibers
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7. 4th Ventricle Anatomy
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8. Indications & Decision-Making Algorithm for
surgical management of IVT
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9. Considerations for Choice of Surgical
Approach
1. Minimal transgression and retraction of
normal/functional brain,
2. Expanded working angles to allow effective gross
total tumor resection,
3. Early exposure of vital structures and access to
the tumor’s blood supply, and
4. The technical difficulty of the operative route.
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10. Cont’d
• Localization of the tumor
• The expansion side of tumor,
• The size of the tumor,
• The origin of the vascular
feeding branches,
• The venous drainage, and
• The relationship of the
structures, and
• Histopathology
• +/_ Of hydrocephlus
• Clinical status (visual status…)
• Laterality of the lesion (
midline, Right or left)
• Imaging (involvement of
splenium…)
• Seizure risk
• Bridging veins
• Memory impairment
• Clinical significance of the
Disconnection syndrome
• Eloquence
• Experience of surgeon
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11. Approaches to the Lateral
and Third Ventricles
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12. Approaches
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13. Anterior Interhemispheric Transcallosal
Approach
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14. Maneuvers to expand the foramen
of Monro.
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15. Trans cortical (middle fronatl gyrus)
approach
• The transfrontal approach to the frontal horn, lateral
ventricular body, or third ventricle can be performed
using either a transcortical or transsulcal technique.
• The transfrontal approach is best utilized in patients
with hydrocephalus, which
presents a wide operative corridor for the surgeon
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16. Subfrontal Translamina Terminalis
Approach
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17. Transparietal Transcortical/Transsulcal
Approach (via intraparietal sulcus)
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18. Posterior inter-hemispheric transcallosal
(Dandy’s) approach
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19. Posterior Interhemispheric Transcingulate
& transprecuneus Approach
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20. Contralateral Interhemispheric Transfalcine
Transprecuneus Approach
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21. Occipital Transtentorial Corridor
(Jamieson & Poppen Approach)
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22. Infratentorial Supracerebellar (Krause )
approach
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23. Paramedian Supracerebellar Infratentorial
Approach
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24. Supracerebellar Transventricular (Van Wagenen’s
posterior transventricular) approach
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25. Occipital Trans-cortical approach
• Mainly considered for patients with irreversible
preoperative homonymous hemianopsia and
significantly dilated ventricular horns.
• Not favored.
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26. Transtemporal Approach
• Through posterior part of the middle temporal
gyrus or transsulcal route and white matter
dissection.
• Allows early identification and managing of the
anterior choroidal artery.
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27. Transsylvian Approach
• To resect paraventricular lesions arising from mesial
temporal lobe structures while sparing the lateral
cortical surface gyri and visual fibers of the Meyer
loop.
• Pterional craniotomy
• Superficial sylvian vein and vein of Labbé
must be preserved to avoid venous infarction.
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28. Occipitotemporal Sulcus
(subtemporl) Approach
• To access lesions in the posterior part of the
temporal horn.
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29. Anterior Temporal Neocortical Resection
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30. Telovelar Approach
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31. Microscopic vs Endoscopic Rx for
IVTs
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32. Post op issues/complications/
• EVD/ Lumbar drain?
 When to remove?
 How to wean EVD?
• Infection: risk factors?
• Redo vs staged surgery
• Extent of resection?
• HCP: Obstructive to
communicative???...Shun
ting, ETV,
• Hematoma :absolute
Hemostasis
• Memory impairment
• DI
• Posterior fossa
syndrome
• OUR SETUP?
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33. Predictors of hydrocephalus after
lateral ventricular tumor resection
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34. Modified Canadian preoperative
prediction rule for hydrocephalus in
pediatrics (CPPRH )
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35. Pathophysiology of PRH
• Multifactorial
 Post tumor resection conversion of obstructive to communicating HCP.
 abnormal in the basal cisterns
 70% decrease in the cross-sectional area of the venous sinuses (restored to normal 4
months after the surgery)
 high protein content and blood in CSF affect arachnoid granulations, inflammatory
process in subarachnoid space takes place due to subarachnoid blood and proteins
and affection of dural sinuses
 adaptation period
 it takes several days for the CSF bulk flow to reopen the peripheral subarachnoid
spaces and to restore CSF absorption at the arachnoid granulations
 increased ICP could be managed with 1–3 lumbar punctures with ICP monitoring,
and thus, permanent CSF diversion could be avoided.
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36. EVD Weaning Protocols
• 10cm H20 prior to weaning
• Initiation of weaning left to discretion of attending
neurosurgeon.
Neurocritical Care Society Guideline:
• EVD weaning should be accomplished as quickly as is
clinically feasible so as to minimize the total duration of
EVD monitoring and VRI risk.
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38. Outcome
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39. References
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40. Thank you
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