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Endoscopic far-lateral supracerebellar infratentorial approach for resection of dumbbell-shaped trigeminal schwannoma: surgical techniques and preliminary results

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Abstract

Background

Trigeminal schwannomas (TSs) are mostly benign tumors. However, dumbbell-shaped TSs are most challenging for surgeons and pose a high surgical risk.

Objective

We describe the technique of the purely endoscopic far-lateral supracerebellar infratentorial approach (EFL-SCITA) for removing dumbbell-shaped TSs and further discuss the feasibility of this approach and our experience.

Methods

EFL-SCITA was performed for resection of 5 TSs between January 2020 and March 2023. The entire procedure was performed endoscopically with the goal of total tumor resection. During the operation, the tumor was exposed in close proximity and multiple angles under the endoscope, and the peri-tumor nerves were carefully identified and protected, especially the normal trigeminal fiber bundles around the tumor.

Results

All the tumors of 5 patients involved the middle and posterior cranial fossa, of which total removal was achieved in 2 patients and near-total removal in 3 patients. The most common preoperative symptoms were relieved after surgery. Two patients had postoperative mild facial paralysis (House-Brackmann grade II), and 1 patient had abducens palsy; both recovered during the follow-up period. Two patients experienced new postoperative facial hypesthesia, and 1 experienced mastication weakness, which did not recover. There was no tumor recurrence or residual tumor growth during the follow-up period in any of the patients.

Conclusion

EFL-SCITA is a new and effective alternative for the surgical treatment of TSs. For dumbbell-shaped TSs, this approach provides sufficient surgical field exposure and freedom of operation.

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Data Availability

The datasets used or analysed during the current study are available from the corresponding author.

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Acknowledgements

The authors thank the staff from the Department of Neurosurgery, Zhongshan Hospital, Fudan University, for their support and for clinical data collection.

Funding

This study was funded by the Foundation of Science and Technology Commission of Shanghai Municipality (19ZR1409800).

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Author notes

  1. Pin Chen and Chaolong Yan contributed equally to this study.

Authors and Affiliations

  1. Department of Neurosurgery, Zhongshan Hospital, Fudan University, Shanghai, China

    Pin Chen, Chaolong Yan, Tao Xie, Chen Li, Tengfei Liu, Qiaoqiao Yang, Shuang Liu, Silin Wu, Yuyang Yeh & Xiaobiao Zhang

  2. Cancer Center, Shanghai Zhongshan Hospital, Fudan University, Shanghai, China

    Tao Xie & Xiaobiao Zhang

  3. Digital Medical Research Center, Fudan University, Shanghai, China

    Xiaobiao Zhang

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Supplementary file1 Video legends: P1: This video displays “Endoscopic far lateral-supracerebellar infratentorial approach for resection of dumbbell-shaped trigeminal schwannoma”; P2-4: This case is a 25-year-old woman with a large right TS. The main preoperative symptoms are diplopia, vision loss, visual field defects, hearing loss, headache. Preoperative MRI showed a heterogeneously enhancing lesion involving both the middle and posterior fossa. The preoperative planning was to completely resect the tumor based on adequate neurovascular protection. We used the fully EFL-SCITA approach to expose, identify and carefully protect the trigeminal nerve throughout the operation. P5: This is layout of our operating room and the surgical position of EFL-SCITA. Schematic illustration showing the locations and characteristics of the incision and bone window in this approach. P6: We first opened the infratentorial supracerebellar corridor endoscopically and cut a small drainage vein between the cerebellum and the tentorium, exposed the superior lateral part of the tumor and the SPV. After intratumoral decompressive resection of the posterior cranial fossa tumor, the SPV was displaced and protected with brain cotton. We exposed and separated the normal trigeminal nerve fibers under direct endoscopic view, and then carefully separated and removed the tumor along the tumor-nerve interface. Then, we proceeded to resect the tumor part in MC under endoscopic, and normal trigeminal fibers of CN IV and CN VI were well exposed and protected. At last, the endoscopic view of the operative area showed complete removal of the tumor and satisfactory preservation of the SPV, CNV-VIII, and cerebellum. P6: Postoperative MRI scans indicated complete resection of the tumor, and sufficient decompression was achieved. The preoperative symptoms improved after surgery. The patient developed new postoperative mild facial palsy, which recovered during follow-up. However, the new postoperative facial hypesthesia and masticatory muscle weakness did not recover during the follow-up period. Thanks for attention. (MP4 72676 KB)

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Chen, P., Yan, C., Xie, T. et al. Endoscopic far-lateral supracerebellar infratentorial approach for resection of dumbbell-shaped trigeminal schwannoma: surgical techniques and preliminary results. Acta Neurochir 165, 2913–2921 (2023). https://doi.org/10.1007/s00701-023-05725-0

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