I have one. This is from 2005. It's been about 20 years for me now. This report does not include the two additional shunt surgeries. I got hit hard, being in the hospital about five weeks.
Here it is...
OPERATIVE REPORT.
PREOPERATIVE DIAGNOSIS: Large left acoustic neuroma (5cm).
POSTOPERATIVE DIAGNOSIS: Large left acoustic neuroma (5cm).
PROCEDURE: Left suboccipital microsurgical craniotomy for radical subtotal resection of acoustic neuroma, abdominal fat graft harvest, cranioplasty.
SURGEONS: Frederick Barker, M.D. and Michael McKenna, M.D.
ASSISTANT: Ziv Williams, M.D.
INDICATIONS: This man presented with a history of a large left cerebellopontine angle lesion, 5 cm in diameter. with moderate-to-severe hydrocephalus. A ventriculoperitoneal CSF shunt had been placed several weeks prior to operation to allow normalization of gait and to prepare for the tumor resection., which was undertaken today.
DESCRIPTION OF PROCEDURE: After the induction of satisfactory general endotracheal anesthesia, the patient was positioned supine with a blanket under the left shoulder and the head facing straight lateral toward the right in the Mayfield headrest. The left suboccipital area was widely clipped, prepped, and draped as was the left lower abdomen. We took care not to penetrate the CSF shunt with the Mayfield headrest.
An S-shaped extended suboccipital craniotomy incision was opened., pericranial graft harvested, suboccipital musculature stripped. A burr hole was placed and the subocciptal craniotomy was turned. The craniotomy was enlarged with Leksell and Kerrison ronguers to give a very generous exposure in the posterior fossa including the posterior edge of the lateral sinus, nearly down to the jugular bulb, and the inferior edge of the transverse sinus for several centimeters. The dura was opened in a stellate fashion. We accessed the basal cisterns easily because of the inferior extent of the craniotomy and drained CSF.
The operating microscope was used for the entire intradural operation. We defined the exposed tumor capsule, electrocoagulated it and incised it under the frozen section diagnosis., which was schwannoma. Of note, the tumor was extremely hypervascular and the entire operation was hindered by copious hemorrhage from the tumor at every step.. We did a radical intracapsular debulking of the tumor and began to separate it from the lateral cerebellum and lateral penduncle. The tumor could be separated from the lower nerves, which were markedly distorted and displaced by the tumor. The tumor was not not adherent to the hypoglossal nerve, but was in contact with the vertebral artery. Rostrally, the tumor was separated from the IVth nerve, which was displaced in a remarkable fashion over the tentorium.
The trigeminal nerve was not yet seen, although a region of the brainstem in the normal region of the trigeminal nerve was encountered.
Dr. McKenna entered the operation and removed additional tumor from the petrous face, then electrocoagulated and reflected the dura of the of the petrous face and drilled the temporal bone to reveal the internal auditory canal.
I reentered the operation and continued a prolong process of debulking and tumor removal. In all, the microsurgical portion of this case lasted for approximately 9 hours. At the conclusion of the dissection, a clean plane could no longer be maintained either laterally, or medially, where indeed we did not locate the origin of the facial nerve on the lateral surface of the pontomedullary junction because of dense adherence to the medulla. However, the remaining tumor fragment was quite thinned and the brainstem was pulsatile throughout the exposure. The origin of the VIth nerve was well seen and the VIth nerve was intact as was the IVth nerve. The trigeminal nerve was freed from compression over a significant portion of its course. It had been displaced quite far inferiorly from its normal position. The remaining tumor fragment appeared quite thin, as we could stimulate the nerve through it with 0.3 mA in more than one place. The brainstem was pulsatile, although it had not come entirely back to its normal position.- it was displaced across the midline at the beginning of the operation.
We placed a piece of Surgicel in the exposed portion of the residual tumor, harvested a fat graft in the left lower abdomen. This incision was closed with deep Vicryl sutures and an undyed Vicryl subcuticular stitch. The fat graft was placed into the internal auditory canal, which had been carefully waxed under microscopic control. The fat graft was held in place with a pledget of Surgicel. After thorough irrigation of the posterior fossa free of blood products, and instillation of 5mg of intrathecal vancomycin and 5mg intrathecal gentamycin because of the presence of the shunt, we closed the dura in a watertight fashion using the previously harvested pericranial graft. The bone plate was replaced into position and the 4.5 residual cranial defect was occluded with a titanium mesh cranioplasty. After further irrigation and hemostasis, the incision was closed in layers using Vicryl for the deep layers and a nylon running skin stitch. A sterile dressing was applied. The patient was released from the headrest and taken to the Blake 12 ICU, intubated, for further monitoring. The anesthesia service felt that because of facial and airway edema, extubation was not prudent. However, the patient demonstrated the ability to move all four extremities before resedation.
ATTESTATION: I was present or immediately available throughout the operation and performed its key neurosurgical portions personally. All material implanted during this operation is MRI compatible.
