Purely Endoscopic Transcortical Transforaminal Approach for Excision of a Chiasmatic-Hypothalamic Glioma: 2-Dimensional Operative Video

Optic pathway gliomas account for 4% to 6% of pediatric brain tumors.1,2 They may be associated with neurofibromatosis type 1 or may be sporadic.3 They are anatomically classified using the Dodge classification4 or other modified classifications.5 Chiasmal gliomas present with slow bilateral visual loss, bitemporal field defects, optic disc changes, and strabismus.6,7 Chiasmatic-hypothalamic gliomas may cause precocious puberty and hydrocephalus.1 Pediatric optic pathway gliomas are most frequently pilocytic or pilomyxoid astrocytomas.8 Treatment is only initiated after disease progression.9 Chemotherapy is widely used as the first-line treatment.2 The role of surgery is to preserve visual acuity, relieve intracranial pressure, reduce tumor burden, and control intractable progression.2 In this operative video, the patient is an 18-month-old girl who presented to the emergency department with a 2-day history of repeated vomiting and increasing sleepiness. She also had a recent loss of the ability to walk, irritability, frequent head tilting, and intermittent abnormal eye movements. Neurological examination revealed a disturbed conscious level, bilateral papilledema, exaggerated deep tendon reflexes, and neck stiffness. Neuroimaging was consistent with a chiasmatic-hypothalamic glioma. A purely endoscopic transcortical transforaminal approach was offered for excision of the lesion. The patient's father consented to the procedure. The use of the 4K rigid endoscope (Karl Storz) provided panoramic highly illuminated and extremely detailed views of the tumor and the juxtaposed anatomic structures within the lateral and the third ventricles, greatly adding to the ease, safety, and efficacy of tumor excision through a small cortical incision.The patient's father consented to the procedure and to use clinical data, imaging studies, and operative video for publication.