• 35 year old lady who presented with sever headache and photophobia.
• On examination she had no focal neurological deficit.
• MRI scan of her brain was obtained which showed a well circumscribed contrast enhancing tumor in the fourth ventricle.

MRI of the brain showed a well circumscribed contrast enhancing tumor in the fourth ventrcile. 
This tumor is outline in the dotted red circle.

• She underwent suboccipital craniectomy and Telovelar approach to the fourth ventricle with gross total resection of the tumor
• This operation was performed using
  1-Stereotactic image guidance
  
  2- Intraoperative neurophysiological monitoring of lower cranial nerves
  (9, 0, 11, and 12) and BAER (Brain Stem Auditory Evoked Response)
  
  3- Neuroendoscopy

Stereotactic Neuroendoscopy is used to see and resect tumor from hard to see corners in the 4th ventricle

Patient is placed in prone position and using surgical microscope suboccipital craniectomy following exposure of cerebellar tonsills are performed.


A special tracheal tube with electrical circuit is utilized for monitoring of cranial nerves 9 and 10.



Cranial nerves 9, 10, 11 and 12 are monitored carelfully during dissecting the tumor off the brainstem.


Stereotactic Image guidance was used to identify and resect the tumor. 
The tumor is being resected off the brainstem and is shown in a dotted green circle.

• The tumor was resected in gross total fashion.

The slide above shows the tumor which was removed in one piece.


The slide above the H&E stain of the tumor.  The cauliflower papillary shape with cuboidal and columnar cells is typical features of choroid plexus papilloma.

• Patient did well post operatively with mild double vision which improved shortly thereafter.
• MRI of patient's brain post operatively revealed complete resection of the tumor
• These MRIs are shown below:

Axial MRI of the brain before and after shows complete resection of tumor.


Sagittal MRI of the brain before and after shows complete resection of tumor.