2026 Poster Presentations
P329: MULTICOMPARTMENT INTRACRANIAL EPIDERMOIDS - SURGICAL APPROACHES AND ROLE OF ENDOSCOPE
David Baker, MD1; Asad Lak, MD2; Taimur Khan3; Christopher Carr, MD1; Fernando Vale, MD1; M. Salman Ali, MD1; 1Medical College of Georgia at Augusta University; 2University of Iowa Hospitals and Clinics; 3University of California, San Diego
Introduction: Intracranial epidermoid cysts (IEC) are rare benign tumors. Surgery remains the primary treatment modality but maximizing resection while maintaining function can be challenging due to their intimate relationship with neurovascular structures. Multicompartment nature of some IECs adds another layer of complexity to extent of resection. Endoscopes have revolutionized neurosurgical management of complex tumors both with endoscopic endonasal and endoscopic assisted transcranial approaches. Here, we review complex multicompartment IECs and discuss surgical management strategies.
Methods: Cases performed in last 18 months since completion of fellowship of the senior author were reviewed. Total of 5 cases of IEC were identified and three were found in multicompartmental.
Results:
Case 1 (Fig A and B) involved a large IEC in cerebellopontine angle (CPA) which extension to middle cranial fossa (MCF) through the tentorial incisura in a 55-year-old male. A retrosigmoid approach (RSA) was performed to remove the cerebellopontine angle (CPA) component. Further, the tentorium was cut to perform a trans-tentorial approach (TTA). Using 0 and 45-degree endoscopes, supratentorial MCF portion of the tumor was removed. A small adherent tumor was left at the origin of lower cranial nerves. Patient was discharged home POD3 without any neurological deficits.
Case 2 (Fig C and D) presented with hydrocephalus and involved a large suprasellar IEC with extension into interpeduncular and prepontine cisterns in a 24yr old male. Pre-operative external ventricular drain (EVD) was placed. An endoscopic endonasal approach (EEA) was adopted to remove the suprasellar portion of the tumor. Further, a pituitary transposition was performed along with removal of posterior clinoids, dorsum sella and upper clivus to remove the retroclival portion of the tumor. A small residual adherent to the thalamus was left in place. A ventriculoperitoneal shunt (VPS) was required to address the hydrocephalus. Patient had blurry vision in the right eye which improved by 3 months post-op.
Case 3 (Fig E and F) involved a large quadrigeminal IEC with extension rostral and caudal to the tentorium and lateral ventricles in a 32yr old male. Patient presented with hydrocephalus and seizures. An EVD was placed. A supracerebellar transtentorial approach was performed to remove the infratentorial posterior fossa portion of the tumor, followed by use of 0 and 45-degree endoscopes to resection the supratentorial component via a transtentorial approach. Initially patient was weaned off the EVD but required a VPS in a delayed fashion. Gross total resection was achieved, and no neurological complications were noted.
Conclusions: We have demonstrated that complex multicompartment IECs can be successfully removed using a single surgical corridor, either through endonasal or endoscope assisted transcranial approaches. Endoscope is a vital tool in accessing these deep-seated tumors which allows for smaller surgical corridors and faster recovery. Familiarity with surgical anatomy and comfort using angled endoscopes is critical.
