• 36 year-old lady with 1 year history of hypertension, headache, and nausea and vomiting. After loosing consciousness a couple of times, she was sent for radiographic study of her brain.
• On examination she exhibited upper tract signs and papilledema, and diplopia

• MRI scan of patient’s brain shows a tumor (outlined in red) arising from the midbrain segment of brain stem with extension to quadrigeminal plate and occluding the cerebral aqueduct

• Obstruction of cerebral aqueduct by the tumor had resulted in obstructive hydrocephalus, accounting for her headache, hypertension, nausea and vomiting,

• She underwent minimally invasive surgical approach of endoscopic resection of the tumor followed by third ventriculostomy using two small burr holes, utilizing computer simulation and mapping, and intra-operative neurophysiological monitoring.

Computer assisted simulation was utilized to plan two approaches: red dotted line is the trajectory to the tumor, and the yellow dotted line to the floor of the third ventricle for third ventriculostomy.

After induction of general anesthesia, patient’s brain and skull coordinates are co-registered to computer navigation system for the purpose of stereotaxy.

Dr. Limonadi and his team proceed with third ventriculostomy using a small opening (dime size) in the skull. This procedure treats hydrocephalus as opposed to placing a shunt system.

During this step the left monitor shows the actual surgical field through the small lens of the endoscope and the right monitor shows the computer navigation which functions as the radar system of the brain.

The monitor showing the endoscope (blue) resting on small opening of the skull and aimed at the target (floor of the third ventricle). The right lower image shows the target and the distance.

The monitor showing the endoscope (blue) entering the lateral ventricle and the surgical view through the small lens of the endoscope (right upper image) shows the anatomy of the lateral ventricle.

The monitor showing the endoscope (blue) entering the third ventricle through the forman of Monroe.

Third ventricle is entered and its anatomy is studied. The floor of the third ventricle is thinned out due to hydrocephalus and a stoma will be created here to complete third ventriculostomy

A micro-instrument is inserted through the working channel of the endoscope and used to create a stoma and third ventriculostomy has been performed without complication. This successful operation averts the need of surgical implantation of a permanent ventriculo-peritoneal shunt in this patient.

Subsequently, through another dime size burr hole the red trajectory is utilized to approach the tumor

Tumor is found arising from the tectal plate of midbrain and obstructing the aqueduct.

Tumor is removed through the small aperture of the neuro-endoscope and the aqueduct is opened

This single view through the endoscope demonstrates successful completion of both third ventriculostomy and resection of the tumor.

The pathology of the tumor confirmed diagnosis of anaplastic astrocytoma

Post op MRI shows complete resection of the tumor radiographically

Patient was discharged home with no neurological deficit. Here she shows her small incision.