SUMMARY; Dr Frank Hsu and his Skull base surgery team present a case on the management of Giant vertebral Artery Aneurysms. Drs. Eric Nussbaum and James Ausman are discussants. See the step by step description of the logic behind the surgery and the options along the way. How would you manage this case? Excellent discussion of the molecular biology and anatomy associated with this approach to the CPAngle by Dr. Dennis Malkasian. Excellent presentation and discussion Good for Video; needs image for podcast.

This educational video presents a detailed surgical case of subependymoma 15 x 19 x 17 mm located in the right ventricle, utilizing the NICO brain suction device. The author has no conflict of interests.

The procedure highlights the step-by-step approach to intraventricular tumor resection, emphasizing the importance of precise anatomical navigation and the use of advanced neurosurgical tools - an automated continuous aspiration device (no clogging). Headaches, ipsilateral enlarged ventricular size, close proximity to foramen of Monro and proposed avascular tumor (subependimoma) indicated the surgery and type of minimal invasive surgery (endoscopic). The mini trephination (22-25mm) instead of burr hole at Kocher's point has been chosen as it enables immediate switch to endoscopic transtubular procedure (eg. bleeding that can't be controlled by full endoscopy, large clot...). The insertion of the subependimoma was on the laterobasal aspect of the wall of the ventricle (between caudate nucleus and thalamus) just anterior to the venous point (separation of thalamostriatal vein from internal cerebral vein). The thalamostriate vein goes just posterior of the subependimoma origin.

The video aims to enhance the understanding of the surgical techniques involved in ventricle-based tumors, with an emphasis on minimizing damage to surrounding neural structures. By the end of this presentation, viewers will be equipped with knowledge regarding effective surgical practices and patient outcomes in cases of subependymoma.

Additional reading:

BOŠNJAK, Roman. Advanced neuroendoscopy : [automated & continuous aspiration of tumors and intracerebral hematomas in open microsurgery or endoscopy : our first experience with Nico Myriad]. [San Bruno]: YouTube [distributer], 2022. 1 spletni vir (1 videodatoteka (28 min 11 sek)), barve, zvok. https://www.youtube.com/watch?v=oJ3-KwrUjcE&rco=1. [COBISS.SI-ID 218398723]

For pure endoscopic transtubular (via endoport or PVC roll) removal of subependymoma see other video in my collection.

The endoport is a cylindrical device introduced stereotactically through brain tissue to access and remove deep‑seated tumors within the brain and ventricular system under endoscopic visualization.
It provides a stable surgical corridor and minimizes trauma to the surrounding brain tissue.

Although many commercial endoports exist today, this 2012 video demonstrates my original expandable PVC roll concept (no-cost improvisation).
A vinyl sheet, measuring 4 x 7 cm, is wrapped 3-4x around the tip of a navigation pointer or endoscope, and secured with a 7 cm long plastic straw cut longitudinally to function as a cuff. You can cut out the transparent vynil plate from the sterilisation bag.

In this case, a 3 cm subependymoma was removed through the tube under endoscopic vision from the left lateral ventricle, 6 cm deep.
A mini‑trephination, 20 x 25 cm, was performed in the left forehead.
Navigation was used to position the mini-trephination so that a symptomatic chronic subdural hematoma could also be evacuated during the same procedure.
The subependymoma itself was an incidental finding in this 64‑year‑old male patient.

A 5 mm transparent vinyl roll was first inserted, wrapped around the endoscope tip and guided stereotactically.
The cuff was then removed with forceps, and the endoscope withdrawn, leaving the empty roll in place.
The vinyl roll was subsequently unrolled and expanded using gradual Fogarty balloon inflation to a diameter of 10-12 mm.

A 4mm, 0‑degree endoscope was introduced into the expanded tube at the 12 o’clock position, accompanied by two instruments at 8 and 4 o’clock — an aspirator and a grasping forceps.
The tumor was removed completely using a piece‑meal technique, fragment by fragment and with suction.
The septum pellucidum was perforated to establish communication between the lateral ventricles.
At the end of tumor removal, the foramen of Monro, as well as the septal and thalamostriatal veins, were clearly visible.

The skin incision was placed within a natural forehead wrinkle, rendering it completely invisible and providing an excellent cosmetic result.
The procedure was uneventful.

Additional reading:

BOŠNJAK, Roman, ANTOLIN, Alenka, JEGLIČ, Arne, FELBABIĆ, Tomislav, VELNAR, Tomaž. Navigated endoport in the purely endoscopic microsurgery of intraventricular and other deep-seated brain lesions : a case report. V: Symposium Neuro-oncological aspects in modern neurosurgery of 21st century, 31 January 2020, Sarajevo. Sarajevo: Academy of Sciences and Arts of Bosnia and Herzegovina, 2020. Vol. 49, suppl. 1, str. 70-77, ilustr. Acta Medica Academica, vol. 49, suppl. 1 (2020). ISSN 1840-1848. http://www.ama.ba/index.php/ama/article/view/427/pdf, DOI: 10.5644/ama2006-124.309. [COBISS.SI-ID 51061251]

BOŠNJAK, Roman. Endoport-guided endoscopic transchoroidal fissure approach to the posterior third ventricle : WFNS Neuroendoscopy Committee, Webinar Series Session 14 - WFNS Neurosurgical Anatomy, 17th November 2021. [COBISS.SI-ID 85813251]

SUMMARY: Dr. Marcelo Bartuluchi, from the Pediatric Service of FLENI in Buenos Aires, Argentina reviews the history of Hemispherectomy for patients with intractable seizures and the operative procedures. No one procedure is superior to others. He describes his technical approach in detail in this surgery in 115 patients. Excellent review of a large series experience from a internationally recognized center. Good discussion of details and challenges. Good for Video and also OK for Podcast; 48 minutes.

SUMMARY : Creativity is forcing Functional Neurosurgery into disruptive technologies such as Neuromodulation with Pacemakers, Radiosurgery, Focused Ultrasound, & Optogenetics. Genetic surgery will be used to change  the human genome. DBS  for Movement Disorders and, now, cranial nerve stimulation is being tested for treatment of Depression, OCD, & Addictions, in the 21st century. These technologies promise therapies for more CNS untreatable diseases, avoiding conventional surgery complications. Ambulatory procedures and new treatments will decrease costs and improve quality of life by 2100. (2-20 min Lectures; 20 min Discussion; 5/5 ranking) Drs. A. DeSalles & AA Gorgulho