Lasica Nebojsa, Motiwala Mustafa, Golembeski Christopher P, Arnautovic Kenan I
Clinic of Neurosurgery, University Clinical Center of Vojvodina, Novi Sad, Serbia; University of Novi Sad, Faculty of Medicine, Novi Sad, Serbia.
Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA; Semmes Murphey Clinic, Memphis, Tennessee, USA.
World Neurosurg. 2025 Sep;201:124189. doi: 10.1016/j.wneu.2025.124189. Epub 2025 Jun 18.
Intracranial epidermoid cysts are rare, benign lesions accounting for 1% of intracranial tumors. They may arise from misplaced squamous epithelium during neural tube closure, and are found in the paramedian position, cerebellopontine angle, or parasellar region with other locations considered rare. The far lateral approach and its extensions enables access and visualization of ventral and ventrolateral lesions at the craniocervical junction without retraction. A 32-year-old female patient presented with gait instability, visual disturbances, and severe headaches. Magnetic resonance imaging (MRI) demonstrated a solid, non-contrast enhancing T1 hypointense and T2 hyperintense lesion in the right cerebellomedullary cistern with mass effect on cerebellum and brainstem, consistent with radiologic findings of epidermoid cysts. The patient underwent far lateral suboccipital craniotomy (performed by KIA) with partial posterior medial condylectomy and C-1 hemilaminectomy while prone, which enabled unobstructed ventral view. A 4-hand (i.e., 2-surgeon) microsurgical technique in tumor resection enabled dynamic, gentle tissue retraction and safe tumor resection (Video 1). Apart from transient swallowing problems that resolved 2 weeks postoperatively, the patient's postoperative course was uneventful. Follow-up MRI revealed gross total removal. This video demonstrates the steps, anatomy, and technical nuances for vascular and neural preservation during removal of epidermoid cysts in the cerebellomedullary cistern. To the best of our knowledge, this is the first operative video showing the resection of a pure cerebellomedullary cistern epidermoid cyst. The utility of fat graft dural closure enhancement decreased the risk of cerebrospinal fluid leak. The patient provided consent. Institutional review board approval was not required for individual cases and thus was not sought.
颅内表皮样囊肿是罕见的良性病变，占颅内肿瘤的1%。它们可能源于神经管闭合期间鳞状上皮错位，常见于正中旁位、桥小脑角或鞍旁区域，其他部位则较为罕见。远外侧入路及其扩展术式能够在不进行牵拉的情况下显露和观察颅颈交界区的腹侧和腹外侧病变。一名32岁女性患者出现步态不稳、视觉障碍和严重头痛。磁共振成像（MRI）显示右侧小脑延髓池有一个实性、无强化的T1低信号和T2高信号病变，对小脑和脑干有占位效应，符合表皮样囊肿的影像学表现。患者俯卧位接受了由KIA实施的远外侧枕下开颅手术，部分切除后内侧髁并进行C-1半椎板切除术，从而实现了无阻碍的腹侧视野。肿瘤切除采用四手（即两名外科医生）显微外科技术，能够进行动态、轻柔的组织牵拉并安全切除肿瘤（视频1）。除了术后2周内自行缓解的短暂吞咽问题外，患者术后恢复顺利。随访MRI显示肿瘤全切。本视频展示了在切除小脑延髓池表皮样囊肿过程中进行血管和神经保护的步骤、解剖结构及技术细节。据我们所知，这是首个展示纯小脑延髓池表皮样囊肿切除术的手术视频。脂肪移植增强硬脑膜闭合的方法降低了脑脊液漏的风险。患者已签署知情同意书。因个别病例无需机构审查委员会批准，故未寻求批准。
