Preparation for Surgery for Supratentorial Tumors of the Lateral and Third Ventricles in Children

Indications for Surgery

• Acute relief of symptoms of elevated ICP: The removal of all or a portion of the intraventricular tumor will result in a decrease in any intracranial hypertension that may be present. This is accomplished by the removal of tumor mass and by the removal of obstructions in the CFS pathway.
• Tissue for pathological examination: Removed tissue can be identified, thereby aiding in treatment planning.

Preoperative Orders

Standard preoperative orders for a craniotomy

• In case of EVD: CSF drainage is monitored and ICP is kept in normal range according to the age of the patient prior to surgery. The height of drainage may be adjusted, whenever required (2).

Anesthetic Considerations

• Standard prophylactic antibiotics
• Standard IV access and monitoring
• Consider excessive blood lost and need of transfusion
• ICP precautions: Drugs that increase the ICP should be avoided, and mild hyperventilation can be used to maintain a relaxed brain during surgery.

Devices to Be Implanted

• EVD: An EVD kit may be necessary.
• ICP monitor: An intraventricular ICP monitoring kit may be needed.

Ancillary/Specialized Equipment

• Operative microscope: Microscope allows proper lighting and gentle manipulation of tumors through deep corridors with less retraction and damage of the surrounding tissues.
• Intraoperative ultrasonography: Provides real-time information on the location of the lesion without the disadvantages of techniques such as frameless stereotactic guidance in which brain movements or shifting limit the accuracy after the initial steps in removing the tumor.
• Ultrasonic aspirator:  An ultrasonic aspirator is extremely useful in cases where fragmenting, emulsification, and aspiration of tissue are indicated. It helps to prevent undue traction on the nervous system and makes easier the debulking of most of the tumors.
• Neuronavigation: Allows a decrease in the surgical trauma while approaching the lesion. Secures the neurosurgeon in the choice and execution of his or her pathway to the target. Neuronavigation can become less accurate after the ventricle is opened because the brain shift induced by the loss of CSF can cause important changes in the system’s accuracy.
• Neuroendoscope: Is an important tool not only for ETV but also for biopsy and even removal of selected supratentorial intraventricular tumors (39).