Microsurgical techniques for achieving gross total resection of ependymomas of the fourth ventricle

Abstract

Ependymomas arising from the ventricular surface present a major challenge to achieving a complete operative extirpation when located in the fourth ventricle given the presence of significant adherence to the floor of the same. Overzealous dissection and removal of a tumor from this zone may precipitate potentially catastrophic neurological deficits attributable to cranial nucleopathies and cranial neuropathies. Consequently, the classic neurosurgical teaching has advised attempted gross total resection, leaving adherent residual in the floor of the fourth ventricle, in order to prevent the development of major cranial nucleopathies and cranial neuropathies. Following surgical tumoral extirpation, residual tumor is adjuvantly stereotactically irradiated. Authors have consequently developed novel neurophysiologically guided microsurgical techniques designed to remove adherent tumor from the fourth ventricular floor. These strategies have successfully and consistently facilitated gross total resection and improved clinical outcomes in patients harboring ependymomas of the fourth ventricle. We discuss and evaluate the innovation in microsurgical strategies developed to achieve complete operative extirpation of tumoral adherence to the floor of the fourth ventricle.

Keywords:

• Ependymoma
• ventricle
• microsurgical
• technique
• operative
• resection

Ethical approval

Compliance with ethical standards. All procedures performed in the studies involving human participants were in accordance with the ethical standards committee and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.

Author contributions

M. G. Z. Ghali is responsible for conception and design, acquisition of data, analysis and interpretation of data, drafting article and revising critically for intellectual content; approval of final version of manuscript.

Acknowledgments

The work is dedicated to my beloved father Emeritus Professor Dr. George Zaki Ghali and my beloved mentors Emeritus Professor Dr. M. Gazi Yaşargil and Emeritus Professor Dr. Erol Veznedaroglu.

Disclosure statement

The author has no conflicts of interest to disclose. No funding was received for this study.