Preparation for Surgery for Supratentorial Pleomorphic Xanthoastrocytomas in Children

Indications for Procedure

• Presence of tumor: Surgery is indicated to obtain tissue for pathological analysis and diagnosis of the lesion. Surgery is the optimal treatment for this tumor, and gross total removal should be the goal. Removal of the lesion helps in the treatment of the seizures.

Preoperative Orders

• Routine: Typical preoperative orders (NPO for at least 6 hours, type and cross-match blood, preoperative cefazolin)

Anesthetic Considerations

• Routine: Anesthetic considerations are dictated by the age of the patient and are typical for craniotomy. Usually, there is no ICP increase, except in cases of very large tumors (in which case raised ICP should be taken into consideration during induction).

Surgical Planning

• Planned approach: The location of the tumor must be assessed carefully to choose the correct approach; this assessment can be done with the use of anatomical knowledge as well as fMRI in children who are old enough (motor and language for a left-sided tumor).
• Total resection: A total excision should be planned if a PXA is suspected, and frozen tissue can be sent to pathology during the surgery to confirm the diagnosis.

Devices to be Implanted

• EVD: If there is associated hydrocephalus with the tumor blocking the CSF pathways, an EVD can be inserted. However, it is typically not needed.

Ancillary/Specialized Equipment

• Operative microscope: The operative microscope is usually used for intraventricular tumors. It allows better lighting of the operative field, better angles for seeing the tumor, and better visualization of the vessels associated with the tumor in comparison to unaided vision.
• Ultrasonic aspirator: The ultrasonic aspirator is helpful for removal of the solid part of the tumor and when the tumor is slightly more fibrous and difficult to aspirate with suction alone.
• Neuronavigation: Image guidance with a computer-assisted frameless stereotactic system can help in planning the approach. The shortest route to the tumor is usually the best approach, and the use of neuronavigation might maximize the craniotomy placement and minimize the corticectomy.
• Intraoperative imaging: Intraoperative CT, MRI, or ultrasound may be useful, if available, to check the complete resection of the tumor.