- Department of Neurosurgery, Osaka University Graduate School of Medicine, Suita, Japan.
Noriyuki Kijima, Department of Neurosurgery, Osaka University Graduate School of Medicine, Suita, Japan.
DOI:10.25259/SNI_53_2023Copyright: © 2023 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, transform, 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: Noriyuki Kijima, Manabu Kinoshita, Naoki Kagawa, Yoshiko Okita, Ryuichi Hirayama, Haruhiko Kishima. Surgical resection of glioblastoma in basal ganglia and utility of exoscope: Technical case reports. 23-Jun-2023;14:213
How to cite this URL: Noriyuki Kijima, Manabu Kinoshita, Naoki Kagawa, Yoshiko Okita, Ryuichi Hirayama, Haruhiko Kishima. Surgical resection of glioblastoma in basal ganglia and utility of exoscope: Technical case reports. 23-Jun-2023;14:213. Available from: https://surgicalneurologyint.com/surgicalint-articles/12379/
Background: Due to the presence of many perforating arteries and the deep location of basal ganglia tumors, dissection of the perforating arteries is critical during tumor resection. However, this is challenging as these arteries are deeply embedded in the cerebrum. Surgeons need to bend their heads for a long time using operative microscope and it is uncomfortable for the operating surgeon. A high-definition (4K-HD) 3D exoscope system can significantly improve the surgeon’s posture during resection and widen the operating view field considerably by adjusting the camera angle.
Methods: We report two cases of glioblastoma (GBM) involving basal ganglia. We used a 4K-HD 3D exoscope system for resecting the tumor and analyzed the intraoperative visualization of the operative fields.
Results: We could approach the deeply located feeding arteries before successfully resecting the tumor using a 4K-HD 3D exoscope system which would have been difficult with the sole use of an operative microscope. The postoperative recoveries were uneventful in both cases. However, postoperative magnetic resonance imaging showed infarction around the caudate head and corona radiata in one of the cases.
Conclusion: This study has highlighted using a 4K-HD 3D exoscope system in dissecting GBM involving basal ganglia. Although postoperative infarction is a risk, we could successfully visualize and dissect the tumors with minimal neurological deficits.
Keywords: Basal ganglia glioblastoma, Exoscope, Neurosurgery, Operating microscope, Tumor
Resections for basal ganglia tumors are challenging because the lesions are deeply located, and many perforating arteries traverse through this area. Thus, the prognosis of basal ganglia glioblastoma (GBM) is poor,[
In this report, we discuss two cases of GBM located in the basal ganglia, which was successfully resected by approaching the deeply located feeding arteries using a recently developed 4K-3D exoscope system, ORBEYE.
A 74-year-old previously independent woman presented to our neurosurgical department with difficulty walking, right-sided mild hemiparesis, and cognitive impairment. Her right side manual muscle test (MMT) was 4, and she was slightly disorientated, although she is almost independent. She did not show any other neurological deficits. Magnetic resonance imaging (MRI) showed both left-sided basal ganglia and parietal tumors. The basal ganglia tumor was heterogeneously enhanced using gadolinium (Gd) with peripheral edema by fluid-attenuated inversion recovery imaging. This tumor extended upward toward the left lateral ventricle and presented with hydrocephalus. Further, malignant glioma was suspected as it was surrounded by severe peritumoral edema. Moreover, the left parietal tumor suggested meningioma because it showed the dural tail sign. Thus, we planned resection of the basal ganglia tumor [
Two different approaches can be used for resecting this tumor, that is, the transsylvian approach and transcortical approach. Using the transsylvian approach, we can visualize and coagulate feeding arteries from the MCA and ACA before resecting the tumor. However, using the transcortical approach, we can visualize them during the later stage of the operation. Although the tumor extended toward the left lateral ventricle, we thought that we could visualize the intraventricular tumor using ORBEYE; therefore, we chose the transsylvian approach for resecting the tumor.
We performed left ventricular drainage into the left lateral ventricle, followed by left frontotemporal craniotomy [
Intraoperative images of the Case 1 patient. (a) shows the A1 perforator that supplied the tumor, (b) demonstrates coagulation of the recurrent artery of Heubner to manage the hemorrhagic tumor, (c) demonstrates the lateral ventricle visualized by adjusting the camera angle, and (d) represents the final view of the operative field. ICA: Internal carotid artery, Lt.ON: Left optive nerve, ACA: Anterior cerebral artery, Tm: Tumor, LV: Lateral ventricle, MCA: Middle cerebral artery.
The postoperative recovery was uneventful, and the patient was discharged home with a Karnofsky Performance Status (KPS) score of 90. Her postoperative MRI showed no enhanced lesions [
A 50-year-old previously independent man presented to our neurosurgical department with memory loss and headache. His right side MMT was 5, and he had slight memory loss, although he is independent. His Mini-Mental State Examination score was 28. MRI showed a left temporal lobe tumor extending into the basal ganglia. The tumor was heterogeneously enhanced using Gd with cyst formation. The tumor extended toward the external capsule. GBM was suspected as it was surrounded by severe peritumoral edema. We planned resection of the tumor with the lateral leticulostriate artery (LSA) compressed medial to the tumor [
We performed left frontotemporal craniotomy and corticotomy in the middle temporal gyrus. We aspirated the cyst and dissected the lateral part of the tumor in the temporal lobe. This was followed by the dissection of the medial part of the tumor and visualization in the basal ganglia. Although the margins between the tumor and cerebrum were unclear, the anteromedial margin of the tumor, which was located in the basal ganglia, was visualized and safely resected using ORBEYE and 5-ALA [
The postoperative recovery was uneventful, and the patient was discharged home with a KPS score of 90. His postoperative MRI showed that most of the enhanced tumor was removed without any infarction of LSA-perfused area, but a slight residual tumor was present [
Postoperative magnetic resonance imaging (MRI) scans of the Case 2 patient. (a and b) represent gadolinium-enhanced MRI, which shows that most of the enhanced tumor was removed. (c) represents the diffusion-weighted imaging image, which shows no infarction of leticulostriate artery -perfused area.
The outcomes of our case are consistent with the results of previous studies suggesting that the basal ganglia lesions are deep-seated and that the basal ganglia are not a common location of GBM; thus, resections of basal ganglia tumors are not extensively reported because their resections are challenging.[
Furthermore, the newly developed exoscope system, ORBEYE, also contributed to the resections of the basal ganglia tumors. In the first case, the tumor extended upward into the lateral ventricle, necessitating a combination of the transsylvian and transcortical transventricular approaches using an operative microscope. However, we could visualize the intraventricular tumor by adjusting the ORBEYE camera angle, which was otherwise difficult using the conventional microscope.[
The recently introduced 4K-HD 3D exoscope system, ORBEYE, can offer more favorable ergonomics, optics, and maneuverability than the operative microscope. The previous studies compared the utility of the ORBEYE exoscope system with that of the operative microscope.[
In addition, learning curve of using exoscope system is also reported. The previous studies reported that exoscopes have a shorter learning curve than the operative microscope.[
Thus, ORBEYE may enable neurosurgical procedures that were previously difficult for the surgeon, including procedures such as basal ganglia tumor resections, gravity-assisted brain retraction surgeries for midline brain tumors,[
Resecting deeply seated GBM involving basal ganglia using a 4K-HD 3D exoscope system are feasible and 4K-HD 3D exoscope system can provide improved visualization to the surgeon. Although deeply seated GBM have many perforating arteries and postoperative infarction is a risk, we could successfully visualize and dissect deeply seated GBM with minimal neurological deficits by 4K-HD 3D exoscope system.
This analysis was approved by the Institutional Review Board, and the patient gave informed consent before inclusion in this study.
The authors certify that they have obtained all appropriate patient consent.
There are no conflicts of interest.
The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Journal or its management. The information contained in this article should not be considered to be medical advice; patients should consult their own physicians for advice as to their specific medical needs.
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