2026 Poster Presentations
P063: MINIMALLY INVASIVE RESECTION OF PEDIATRIC CLIVAL CHORDOMA USING ULTRASOUND GUIDANCE
Aman A Singh; Daniel A Donoho, MD; James A Leonard, MD; Children's National Hospital
Objective/Background: Clival chordomas are rare, slow-growing malignant tumors arising from notochordal remnants at the skull base. In pediatric patients, these tumors present unique surgical challenges due to their anatomical location and proximity to critical neurovascular structures. The clivus is bounded superiorly by the dorsum sellae, laterally by the cavernous and paraclival segments of the internal carotid arteries, inferiorly by the foramen magnum, and posteriorly by the brainstem. These boundaries make complete resection difficult, as the tumor often abuts or encases the carotid arteries and lower cranial nerves. Achieving gross total resection is crucial for long-term disease control but carries significant risk. Intraoperative ultrasound has emerged as a valuable adjunct for real-time identification of vascular structures, particularly the carotid arteries, during endoscopic skull base surgery.
Case Presentation: An 18-year-old male presented with recurrent epistaxis and was found to have a right vascular, nasal cavity mass. MRI incidentally revealed an enhancing lesion involving the lower third of the clivus, extending anteriorly to the cranio-cervical junction and filling the space between the clivus and the odontoid process. The lesion was closely associated with the paraclival carotid arteries and adjacent to the brainstem.
Procedure: The patient initially underwent resection of the vascular nasal tumor. Subsequently, a minimally invasive endoscopic endonasal approach was used to address the clival lesion. Intraoperative biopsy confirmed the diagnosis of chordoma. Intraoperative ultrasound was employed to provide real-time visualization of the carotid arteries, allowing for precise dissection and minimizing the risk of vascular injury. Notably, the resection was accomplished without division of the palate or posterior septectomy, preserving normal anatomy and reducing morbidity. Gross total resection of the chordoma was achieved, as confirmed by postoperative MRI. The patient received adjuvant radiation therapy and remains clinically stable.
Conclusion: This case illustrates the complexity of pediatric clival chordoma resection, given the tumor’s challenging anatomical boundaries and proximity to vital neurovascular structures. The use of intraoperative ultrasound enabled dynamic, real-time identification of the carotid arteries, enhancing the safety of the minimally invasive endoscopic approach. Importantly, the procedure was completed without the need for division of the palate or posterior septectomy. Incorporating ultrasound guidance may improve outcomes and reduce complications in the surgical management of skull base chordomas in pediatric patients.