Combined endoscopic endonasal transtubercular and transclival approaches for large neurenteric cyst in posterior cranial fossa: A case report and literature review
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan.
- Department of Otolaryngology, The University of Tokyo Hospital, Tokyo, Japan.
Masahiro Shin, Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan.
DOI:10.25259/SNI_648_2021Copyright: © 2021 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Daisuke Sato1, Hirotaka Hasegawa1, Masahiro Shin1, Kenji Kondo2, Nobuhito Saito1. Combined endoscopic endonasal transtubercular and transclival approaches for large neurenteric cyst in posterior cranial fossa: A case report and literature review. 08-Nov-2021;12:554
How to cite this URL: Daisuke Sato1, Hirotaka Hasegawa1, Masahiro Shin1, Kenji Kondo2, Nobuhito Saito1. Combined endoscopic endonasal transtubercular and transclival approaches for large neurenteric cyst in posterior cranial fossa: A case report and literature review. 08-Nov-2021;12:554. Available from: https://surgicalneurologyint.com/surgicalint-articles/11220/
Background: Intracranial neurenteric cysts (NCs) are extremely rare tumors that more commonly involve the posterior fossa than any other cranial part. While transcranial skull base surgery has been the mainstay of treatment, the utility of endoscopic transnasal surgery (ETS) remains to be established.
Case Description: We report a case of a large posterior fossa NC extensively involving the suprasellar region, cerebellopontine angle, and prepontine cistern, which we successfully resected with ETS through a combination of transtubercular and transclival routes. Before surgery, the patient presented with abducens nerve and pseudobulbar palsies, which resolved within 2 weeks postoperatively. The patient remained free from recurrence for 3 years postoperatively.
Conclusion: Extended ETS may offer a minimally invasive option for the posterior fossa NC, extensively occupying the ventral space of the brainstem.
Keywords: Endoscopic transnasal surgery, Extended endoscopic transnasal surgery, Neurenteric cyst, Posterior fossa, Skull base tumor
Neurenteric cysts (NCs) are rare benign congenital lesions that most commonly arise in the spinal canal, especially at the cervical and upper thoracic levels.[
Pathologically, the cyst is lined with nonciliated gastrointestinal-type epithelium and ciliated respiratory-type epithelium, which is poor in mucin-producing cells, or a mixture of both.[
A 46-year-old male patient who suffered from progressive diplopia, dysphagia, and hoarseness was referred for the management of a 35 × 32 × 51 mm lobulated cystic lesion located ventral to the brainstem, extending from the suprasellar region to the pontomedullary junction, involving the oculomotor, trochlear, trigeminal, abducens, facial, and acoustic nerves [
Under standard general anesthesia, the patient was secured in the supine position. After a 3-point pin head holder was applied, the head was slightly rotated to the right and tilted to the left so that the nostrils were directed toward the surgeon. A surgical navigation system (StealthStation S7; Medtronic, Minneapolis, MN, USA) and electrophysiological monitoring of the extraocular muscles, cranial nerves (facial nerves and lower cranial nerves), auditory brainstem response, motor-evoked potential, and sensory evoked potential for all the extremities were established. During the surgery, a 4 mm diameter, 0° and 30° rigid neuroendoscope (Karl Storz Endoscopy Japan, Tokyo, Japan) and a robotic arm holder (Point Setter; Mitaka Kohki, Tokyo, Japan) were used.
After lateralizing the bilateral middle turbinates, vertical mucosal incisions were made on both sides of the nasal septum, and the submucosal dissection was advanced until the anterior bony wall of the sphenoid sinus was exposed. Next, a nasal speculum designed for ETS (Fujita Medical Instruments, Tokyo, Japan) was deployed in the submucosal space to obtain a wide surgical corridor without being disturbed by redundant nasal anatomical structures. The posterior edge of the bony septum was temporarily displaced during the surgery, and the sphenoid sinus was opened wide. The purpose of this approach was to ensure the smooth delivery of the surgical instruments and endoscopes without performing middle turbinectomy and posterior septostomy.[
Suprasellar part of the mass is removed through the transtubercular route, and the lesion in the posterior cranial fossa is resected through the transclival route (a). The cyst is composed of soft grayish capsule, and yellow mucinous and caseous components are observed (b). During the procedure, we identified the stalk, pituitary gland (c), basilar artery, facial nerve, vestibulocochlear nerve (d), and oculomotor nerve (e). Surgical resection was enabled under direct vision (f). The skull base defects are reconstructed using gelfoam, in-lay and over-lay fascial grafts with abdominal fat pieces in a multilayer fashion (g-i).
The cyst comprised a soft, grayish capsule filled with yellow mucinous and caseous components [
The postoperative course was uneventful, and diplopia, dysphagia, and hoarseness resolved completely within 2 weeks. Histological examination revealed colloidal material and fragments of ciliated columnar epithelium, consistent with the diagnosis of NC [
Histological examination demonstrates colloidal material and fragments of ciliated columnar epithelium, which indicates the diagnosis of neurenteric cyst (a, hematoxylin-eosin stain, ×40). Follow-up magnetic resonance imaging demonstrates gross total resection (b-d), with no sign of recurrence at 3 years after surgery.
Herein, we report a case of a large posterior fossa NC extending from the suprasellar region to the pontomedullary junction. Localized NCs can be successfully treated using transcranial surgery. Lateral suboccipital approaches have been most frequently used to tackle posterior fossa NCs.[
In the past decade, the application of eETS has been further expanded to intradural lesions in the posterior cranial fossa, such as posterior fossa meningiomas, ventrally located brainstem cavernous malformations, schwannomas, chordomas, chondrosarcomas, and even vertebrobasilar aneurysms.[
Although extensive skull base defects may increase the risk of postoperative CSF leak, our multilayered reconstruction method seems applicable to any size of the dural defect and can successfully prevent CSF leakage.[
For the posterior fossa NC located ventral to the brainstem, eETS can offer a useful option, especially when a wide range of skull base regions and associated cranial nerves is involved. The surgical field can be easily extended with a combination of transtubercular and transclival approaches. A larger case series is needed to determine the efficacy of eETS for extensive posterior fossa NCs.
The authors certify that they have obtained all appropriate patient consent.
This study was supported by a grant from JSPS KAKENHI (grant number JP19K09500) to Masahiro Shin.
There are no conflicts of interest.
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