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Dr. Schupak,

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we have a 30-year-old woman with a known suprasellar tumor

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or mass. And I'm here with an experienced neurosurgeon,

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the big Kahuna. Let's talk about the Big Kahuna briefly,

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which is macroadenoma. We're not in the pituitary gland.

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We're suprasellar.

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So we can get rid of that one and talk about

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the other components of the Big Five.

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We're hunting in Africa together: leopard, lion, elephant, cape,

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buffalo, and rhino. We've got macroadenoma.

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It's not meningioma. It's not sacular aneurysm wrong signal,

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no pulsation mismapping. It's not pilocytic astrocytoma.

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That's a possibility.

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Could it be coming from the Hypothalamic region?

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Although there is a plane of separation right here and

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this solid mass in the suprasellar region cranio.

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The fifth one of the Big Five is likely.

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And if it is a cranio,

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it's going to be the solid papillary variety of cranio

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and you've seen in a younger individual.

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Accompanying vignette, the adamantinomatous form of cranio,

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which is more cystic. So this one is solid.

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If it is a cranio, it's likely to be papillary.

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What is it? Right, well,

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we've been focusing earlier on the initial diagnosis,

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but if you're going to do cela,

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I think one of your most common indications for ordering

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a cellar study is not the initial diagnosis,

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but they've been treated and they want to know how they did.

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Sure. How's this patient doing?

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And this one is kind of a treasure trove of treatment.

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How's she doing? Well, let's look at a couple of things here.

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So we got a shunt apparatus here, and in fact,

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you got two shunt tubes.

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So why are there two shunt tubes?

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Well, they're working. Two is better than one.

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Well, no, if it was working, there'd only be one.

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Okay, that's not a good sign.

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You got one that's kind of over in the thalamus,

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and so the tip is there.

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Now, there might still be some holes out here,

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but probably was not working quite as well as it needed to.

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Mind if I put a little dot on the tip right over here,

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just so everybody can see it?

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Right there.

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There's the tip of one of the shunts in the wrong place.

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Hang on. Let me just close that out for you.

2:03

Go ahead. Okay. So we got another shunt tube.

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Now, this is heading for the frontal horn.

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So that's in a little better position,

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although it's kind of

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so that's probably got holes exposed.

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So that may be working.

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But could you point to that shunt in the axial right there?

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Okay. Cross-reference it.

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And so here it's the tube coming right up here.

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Got you. Okay.

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But there is an asymmetry here,

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so it may very well be that this is getting drained more

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than this. So I'd have to keep an eye on this one,

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make sure this ventricle is not getting trapped.

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Okay. So that's one thing to talk about,

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is how is our shunt working?

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Sure. Now, another issue is so this was treated,

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and we've already talked about some approaches,

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but what's this action up here?

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Okay. Was this a shunt tube that was put in?

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And I think the answer to that is no.

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I think what happened here is there's a craniotomy over here,

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and then there's an area of encephalomalacia. Leading to where? To the ventricle.

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So there was a transfrontal approach to the ventricle taken

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to try to remove as much of this lesion as possible.

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Looks like they hollowed out a little bit right in the middle.

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Maybe they did put your arrow right over there,

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but it's kind of in the third ventricle.

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It's going to be very hard to reach by this approach,

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so I don't know how successful it was.

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Now,

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there's actually two approaches you could take to the ventricle.

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One is this transfrontal, okay?

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Which is what happened here.

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The other would be transcollosal,

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which actually might have given you a little better shot

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at this tumor. So you can see they didn't get it out.

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Now, I don't know, maybe there was some here before.

3:37

So this is another approach to add.

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We talked about the pterional approach.

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You talked about the transphenoidal approach.

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Pterional from the side, transphenoidal from underneath.

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So this is an option transventricular.

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Now, you need dilated ventricles to do this approach.

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So they probably were dilated at some point okay.

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To give you some room.

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That's why they shunted them.

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Right?

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But at any rate, there's a bit of tumor left,

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but they got some kind of decompression hydrocephalus.

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Although, once again,

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I think the fact that there is differential drainage

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is something we might want to keep an eye on.

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Make sure this is not bigger next time we look at it and suggest

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that it should be looked at to make

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sure that this lateral ventricle,

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which is not getting trapped and they say there's a

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transfrontal. So they're going to want to know, how did they do?

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Well, we got to know what it looked like beforehand,

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but they probably removed some.

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But they do have decompression,

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at least of the ventricular system,

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and there's no transappendimal spread.

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Okay,

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so there's been some treatment here that's at least been

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effective. Sure. Getting the old scan, as usual, is critical.

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The optic apparatus is spared.

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I'm going to ask you one silly question

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and then make two points,

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and I know it might be silly.

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When you go transcallosal, do you actually have to cut the corpus callosum?

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Absolutely. You do? Yeah.

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And you can do that in the anterior portion.

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You can make about a 1 CM

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it's. Very similar sort of right at the coronal suture,

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a craniotomy and the midline.

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Now,

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the thing about the midline is

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it's actually a great approach, gives you a great exposure,

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but the problem is the anterior cerebrals.

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Okay? So if you're thinking about something like this,

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where they might be thinking about a transcallosal approach,

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really be conscious of where are the anterior cerebrals,

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because that's the biggest complication of of it.

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Because if you have an azygos anterior cerebral,

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a single anterior cerebral, they can damage cerebral artery.

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Okay. Because they can't mobilize it.

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Sure. So if they're looking for two of them,

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they're going to try to spread them or move them

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over out of the way so they don't damage that.

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So if you think that it's something

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that for a transcallosal approach,

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really looking for the configuration and location of the

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anterior cerebrals is going to be really

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essential to the surgeon. Sure.

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And it might be prudent to do an MRA to help

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you out with the vascular anatomy.

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Two quick points in the coronal projection.

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It's rather surprising. It's actually not that surprising.

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Mildly surprising that this papillary craniopharyngioma has very

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scant little enhancement on contrast-enhanced coronal MRI.

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You see the nice tapering, by the way, of the pituitary stalk,

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little chubbier at the top, thin at the bottom.

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And then in the axial projection,

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you can see the lesion is pretty solid,

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as most papillary craniopharyngiomas are,

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in contrast to the adamantinomatous variant.

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And then finally, when you look at the diffusion image,

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there's no diffusion restriction,

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and you wouldn't expect there to be in a lesion like this.

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So that concludes our discussion of this post-surgical papillary

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craniopharyngioma. Ready to move on to the next case.

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All right, let's go.