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Case of the Month - July 2017

63 female patient  years. Sleepy and with convulsions. Known history of lung cancer. Scheduled for resection of a right frontal lesion with lobectomy. In the simple and contrasted brain resonance images, a single mixed hyperintense ring lesion with defined edges is observed with a hypointense cystic center in postgadolinium T1 and hypertensive in T2, with nodular walls and a cystic center that generates a mass effect in the right frontal region. , moving the midline to the left side. Compatible with possible metastasis of already known primary cancer. 

Intraoperative Imaging with Craniotomy Approach  front right  with resection of the lesion. Fibrillar surgicel hemostatic material is observed in the resection bed. 

Postoperative MRI showing resection surgical site with frontal lobectomy. 

Right frontal approach with lobectomy

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  1. Approach: incision is made in the right "L"  approximately 7 cm with a 20 scalpel blade. Dissection is done by planes. Raney hooks are placed. Haemostasis is done with bipolar. Temporal muscle fascia is incised with Metzembaum and monopolar scissors. Deiostization is done with rugin and freer dissector. Trepanning is performed with a high-speed motor burr and a craniotomy is completed with a high-speed motor blade. Front right.

  2. Resection: bulging dura is evidenced. An arcuate durotomy with a caudal base is made with a scalpel blade 15 and is completed with metzembaum scissors, protecting the brain with cotonoids. Suction and bipolar resection is continued. Sample is sent for pathology. Resection with previously proposed margins is verified. (frontal lobectomy: posterior margin prefrontal gyrus, lower limit and posterior opercular gyrus, inner knee of the internal capsule, medial: falx cerebri) hemostasis was performed with hydrogen peroxide and then a standard surgicel layer was left. Haemostasis is completed with bipolar and cotonoid.  

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References

 

  1. Wen HT1,  Da Róz LM2,  Rhoton AL Jr, et al.  Frontal Lobe Decortication (Frontal Lobectomy with Ventricular Preservation) in Epilepsy-Part 1: Anatomic Landmarks and Surgical Technique.   World Neurosurg.  2017 Feb; 98: 347-364. doi: 10.1016 / j.wneu.2016.10.090. Epub 2016 Oct 2

  2. https://www.neurosurgicalatlas.com/storage/pdfs/volumes/2320.pdf

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