- Site dependent: Patient positioning is determined by the site of the tumor.
- Head fixation optional: Head fixation devices are avoided by the author. They are often difficult to use in small children, and they do not allow manipulation of position during intraventricular procedures, should it be necessary.
- Scalp incision: For most tumors located in a lateral ventricle, a frontal or frontotemporal flap is designed.
- Approach through brain to tumor: Tumors with predominantly third ventricular extensions can be approached in a transcallosal manner, whereas those that expand the lateral ventricle can be approached transfrontally. Tumors that extend laterally in the nondominant hemisphere may be approached through the insula after the sylvian fissure has been opened. Approaches to the ventricular system require an appreciation of the cortical and white matter anatomy to maximize surgical resection and minimize clinical morbidity (26, 27).
- Endoscopic approach: More recently, endoscopic resection of central neurocytomas has been proposed (28, 29). Although the presence of hydrocephalus is helpful for this approach, it is by no means a necessary requirement (30, 31).
- Total resection: In all cases, the aim of surgery is safe gross total resection. Use of ultrasonic suction devices often helps in tumor removal. Use of the operating microscope is mandatory.
- Endoscopic cases: The use of tissue glue to close the surgical track at the bur hole has been recommended to prevent CSF leak. Dural closure is recommended for all intraventricular tumors.
- Craniotomy: Routine
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