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The patient came to the clinic 13-May-2006 complaining of
headache with visual disturbances. The patient is a Sudanese citizen
was operated 05-March-2003 : Right VPS inserted for the
hydrocephalus caused by the craniopharyngioma. Right pterional
approach was performed 2004 with absent data about his surgery. On
examination he had weak left side of the body with constriction of
the visual fields and he has constricture due to previous
Foley's application.
It was explained to the relatives and to doctors, that such
radical surgery is very costly and they insisted to operate upon him
with minimal cost. And here is the challenge, how to operate,
radically remove such a giant tumor, knowing that he will progress
postoperative diencephalic syndrome, without putting him in
ventilator minimum for three days.
Using the old surgical incisions, a right frontal approach was
performed with placement of the bone flap anterior to the
shunt , which was inserted previously. Transcortical route was used.
The right foramen Monro was widely expanded and elevated upward by
the cystic part of the tumor with the atrophied choroid plexus and
the strio-thalamic veins running anteriorly. The cystic part
contained golden-green fluid, which was aspirated, after what the
widen foramen Monro collapsed down. Using the three small spatulas
they were inserted directly to the third ventricle cavity and the
solid part of the tumor was resected in piece-meal fashion. It
contained soft parts of violet fleshy attenuation, which was friable
and easily dissectible from the left wall of the III ventricle.
Further cystic components were removed from the left side and it was
possible to see the basilar artery under the arachnoid in the floor
of dissection.
All the calcified part was present in the right side and it was
removed, using Smith-Kerrison and pituitaries. After removing the
entire intracapsular part of the tumor, the capsule was removed in
toto and it had good cleavage with the anterior part of the third
ventricle. The most difficult part was the separation of the capsule
from the right wall of the third ventricle.
After the third ventricle got normal position and total removal
of the craniopharyngioma, it was possible to see the running right
A1 with Heubner over the flatted optic chiasm in the right
side. Attempt to see the previously seen basilar artery was denied
intentionally to avoid possible vascular reactions.
Total resection of the craniopharyngioma was achieved and there
was no bleeding in the bed of the tumor cavity, which is actually
the third ventricle. For 20 min irrigation of the bed was performed
and the water flowing back was crystal clear.
Routine closure of the wound and the patient was extubated
immediately after the operation. The operation took
approximately 8 hours and the patient was lethargic with moderate
signs of diencephalic syndrome, with acceptable breathing drive. The
patient showed right sided weakness with total aphasia, for what he
was immediately sent for check CT-scan.
CT-scan showed complete resection of the tumor with no evidence
of hematoma or any problem in the left side of the brain, which
actually was not touched. But for the great surprise, the previously
inserted shunt from the right side, became clear that, it is
inserted to the left lateral ventricle.
Strict observation in the ICU. the breathing drive still
acceptable and the right sided paralysis start to resolve, but the
patient showed surges of hyperthermia, which was treated
accordingly.
The patient continued in somnolence state and developed left
sided paresis more the hand area , which resolved over 12-14 hours.
Hypernatreamia was corrected accordingly. The surges of
hyperthermia resolved and the patient start to show some
improvement. Daily CT-scan was performed and it was quite silent
with gradual reabsorbtion of air
In the early morning around 7.00 in the 6th postoperative day,
the patient showed massive MI with sudden cardiac arrest, which did
not respond to resuscitation.
Comments:
1. For the theoretical part about craniopharyngiomas ,
click here!
2. The patient surgery was clean and straight-foreword and the
patient seem to be not in need for ventilator after the
operation, and he was homeodynamically stable all the time without
signs of diabetes insipidus. Despite that, the patient progressed
massive MI the 6th postoperative day.
3. The hypothalamus got physiological irritation, which mostly
was the cause of his MI and death. Do not be overconfident and
consider your self ace in surgery. Some of the time, it is better to
be satisfied with partial resection, leaving Ommaya reservoir
inside the cystic component. It is better to reoperate the patient
many times, than leaving him to die.
4. In our practice, intraperative monitoring of the
hypothalamus is lacking to decide, when to stop and when to
continue, because delicate surgery, never mean that it
succeed. It is the time to hold the importance of various
intraoperative monitoring devices and with experience to predict
and refine the surgical strategies.
5. Most of these speculations could have no place, since an
identical case the very huge multilobulated colloid cyst was
operated before him and made a very smooth postoperative course. To
see that case click
here !. Both of them surgically were identical. |
