Microscopic is better or endoscopic assisted microsurgery

In my opinion this depends on several factors, like size of the tumor, size of the ventricles, experience of the surgeon with endoscopic equipment etc. I prefer the endoscope for small intraventricular tumors in the frontal horn of the lateral ventricles or colloid cysts, expecially when hydrocephalus is present. Larger tumors in the third are possible better aproached by a transcallosal approach, larger tumors in temporal horn or atrium are possibly better approached by a transcortical approach either purely microscopic or endoscopically assisted. I would also recommend Al-Mefty's "Controversies in neurosurgery II" that covers the pro's en cons of colloid cyst approaches.

In my opinion there are multiple considerations, for example for removal of colloid cysts if the lateral ventricular size is big it would mean that the corresponding foramen of Monroe is blocked and an endoscopic approach would directly and easily show the tumour and allow puncture and then cyst wall removal. If the colloid cyst is posteriorly placed then the lateral ventricle may not be enlarged because in these cases the foramen of Monroe is not blocked and the cyst itself may remain away from the view of a zero angle endoscope. In this case a microscopic approach is feasible. The venous angle at which the thalamostriate vein and septal vein join with the internal cerebral vein is also important because if this is posteriorly placed then it is possible to open the choroid fissure for a posteriorly placed or a large colloid cyst or other third ventricular tumour for a microscopic approach via the transcallosal or transcortical route.

For small intraventricular tumours in the third ventricular roof not causing the ventricles to enlarge the transcallosal microscopic route has the advantage of bilateral approach, the ability to open the choroid fissue and also to use an endoscope as an assistive instrument to visualise tumour in otherwise inaccessible areas.

I recently used a combined approach for resection of a large third ventricular neurocytoma which was filling the entire third ventricle. I first approached it subfrontally via the translaminaterminalis route and could reach about a centimeter above the anterior communicating artery level. Then I used a 30 degree angled endoscope to look up and resected more tumour under vision. In a second stage I went transcallosal and resected more tumour. We found it difficult to get to the anterior part of the tumour just above the anterior communicating artery with both approaches although the transcallosal approach was better. Also by angling the approach posteriorly we could get to the back of the third ventricle and remove the tumour from the region of the aqueduct. However for this the callosotomy has to be slightly larger than 2 centimeters.

Large ventricular tumours may distort the anatomy so much that a neurinavigation system is essential and this is easier with the microscopic method in my opinion.

One important reason for a microscopic approach in colloid cysts may also be the consistency of the cyst content which will be apparent on a T2 MRI which will show different densities. Thick inspissated content may not be easily sucked out with an endoscopic approach and may need a microscopic approach.

Large tumours in the lateral ventricle going into the frontal horns or exophytic in the ventricles with enlarged ventricles may require a microscopic transcortical approach for optimal safe resection.

it depends on many factors like

#size of the ventricles

#extension of the tumor

#nature and vascularity of the tumor

My opinion colloid cysts and intravenricular arachnoid cysts can be managed well by endoscopic surgery , while other intravenricular tumors needs microscopic and endoscopic assisted surgery , also ultrasonic aspirator is very important during removal of the intrventricule tumors as well as

There is no simple answer as simple, small and benign makes endoscopy easier whereas complex, large, vascular, and malignant makes open craniotomy better.

I would prefer microsurgical procedure.

I. Sulla

I agree with what dr quadri says there are many factors that go into the surgical desicion process. Surgeon comfort is the most important. The morbidity associated with the surgery is more related to the approach ( trans collossal vs trans cortical) than whether you use an endoscope or a microscope

Large and invasive intra-ventricular tumor needs microscopical approach by craniectomy.

My opinion is that it depends on several things. size of tumor, extension, vascularity, invasiveness but also I prefer microscopic because I recommend to choose method that one is familiar with. Maybe endoscopically assisted is acceptable option for me.

Endoscopic surgery for ventricular tumors has its clear limitations in the 'red-out'-phenomenon caused by spoiling the CSF with blood oozing from the resection site. 'Clean' surgeries as resections of colloid cysts can be easily performed endoscopically.Therefore, one should be prepared to switch to microscopical resection if bleedings occur. This in turns requires advanced consideration how to approach the tumor,as I would prefer to approach ventricular tumor in the anterior third via a transcallosal inter hemispheric route, which is not suitable for endoscopy.