Brain stem glioma surgery via a telovelar approach using sodium fluorescein in a 6-year-old pediatric patient

Brain stem glioma surgery via a telovelar approach using sodium fluorescein in a 6-year-old pediatric patient | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Brain stem glioma surgery via a telovelar approach using sodium fluorescein in a 6-year-old pediatric patient Sergio Cavalheiro, José Antonio Rangel Quiróz, Patricia Alessandra Dastoli, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5921159/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Tectal gliomas are a subset of brainstem gliomas that typically present symptoms related to hydrocephalus due to obstruction of cerebrospinal fluid pathways. These tumors are generally low grade and have a favorable prognosis. Management often focuses on resolving hydrocephalus, with surgical intervention considered when symptoms worsen. Sodium fluorescein is a fluorescent dye used in brain tumor surgeries to enhance visualization, allowing surgeons to distinguish between tumor tissue and normal brain tissue more effectively. This technique improves the precision and safety of tumor resection. We present the case of a 6-year-old patient in whom we performed the telovelar approach to resect the exophytic portion at the level of the Sylvian aqueduct via sodium fluorescein (2.5 mg/kg) for adequate resection, with excellent postoperative results. Ethics committee approval was not required to perform the surgical procedure on the patient. The patient's parents provided informed consent for the surgery and gave verbal consent for the publication of their video surgery. Neurosurgery Oncology Pediatrics midbrain children fluorescent tumor Figures Figure 1 Figure 2 Introduction Brain stem gliomas account for approximately 10% of all pediatric primary CNS malignancies. ​ Approximately 85% of these tumors are high grade and spread through local infiltration of the pons, medulla, and midbrain[ 1 ]. Tectal gliomas are generally low-grade tumors and often present with symptoms related to hydrocephalus due to obstruction of cerebrospinal fluid pathways[ 1 ], [ 2 ]. Management focuses on resolving hydrocephalus by shunting or endoscopic third ventriculostomy. ​ Patients are observed, and biopsy and adjuvant therapy are reserved for those with radiographic and clinical progression[ 2 ], [ 3 ], [ 4 ]. ​ Tectal gliomas that are exophytic toward the aqueduct and fourth ventricles, the subvermian approach can be used, especially in cases where the fourth ventricle is dilated[ 5 ]. Sodium fluorescein is used in brain tumor surgeries to enhance the visualization of the tumor, making it easier for surgeons to distinguish between tumor tissue and normal brain tissue.[ 6 ], [ 7 ] Historical Background The historical background of brainstem glioma treatment and management has evolved significantly. Brainstem gliomas are recognized as a distinct group of tumors affecting the brainstem, a critical area controlling many vital functions. Early attempts at surgical intervention were limited due to the high risk of damaging essential neural structures. The development of advanced imaging techniques, such as magnetic resonance imaging (MRI) and cerebral tomography (CT) scans, has allowed for better visualization and understanding of brainstem gliomas. This improved the ability to diagnose and plan treatment strategies. Over the past two decades, the introduction of neuronavigation systems and intraoperative imaging (such as intraoperative MRI) has revolutionized brainstem glioma surgery. These technologies provide real-time guidance and help avoid critical structures, making surgeries safer and more precise. The use of intraoperative neurophysiological monitoring (iOM), including techniques such as brainstem mapping and motor-evoked potentials, has significantly improved the safety of brainstem surgeries. These methods allow surgeons to monitor neural function during surgery, reducing the risk of permanent damage. Various surgical approaches have been developed and refined for different types of brainstem gliomas. [ 5 ]The development of surgical microscopes equipped with filters, such as the YELLOW 560 nm filter, has significantly improved the visualization of fluorescein-stained tumors. This advancement has allowed lower doses of fluorescein to be used effectively for the treatment of brain tumors[ 6 ]. Classification of Brainstem Glioma Brainstem gliomas are classified on the basis of their location, growth pattern, and histological characteristics. One commonly used classification system, proposed by Choux et al ., divides brainstem gliomas into four types: -Type I: Diffuse brainstem gliomas are the most common type, representing up to 80% of brainstem tumors. Multiple nuclei and pathways are affected, often causing bilateral cranial nerve paralysis and progressing to hemiparesis and tetraparesis. Most are malignant astrocytomas (WHO grade III or IV). They have a rapid clinical evolution and poor prognosis, with most patients dying within two years of diagnosis. -Type II: Focal intrinsic tumors: These tumors are slow-growing and have well-delimited borders. They can be solid or cystic and are usually low-grade gliomas. Surgery is advised if the tumor is superficial; otherwise, conservative treatment is preferred. -Type III: Exophytic Tumors: These tumors have a significant portion that grow out of the brainstem, making them more accessible surgically. They often have a cystic component and are mostly low-grade astrocytomas. -Type IV: Cervicomedullary junction tumors: These tumors grow at the junction of the cervical spinal cord and medulla. These tumors often present as exophytic growths, allowing direct surgical access without incising the brainstem. They may cause hydrocephalus or syringomyelia due to changes in cerebrospinal fluid dynamics.[ 8 ] Clinical presentation Tectal gliomas, which are focal intrinsic tumors (type II) located in the tectal plate of the midbrain, typically present with symptoms related to hydrocephalus due to obstruction of cerebrospinal fluid flow.​ Common clinical presentations include the following: Headache : Often, this is due to increased intracranial pressure.​ Nausea and vomiting are also related to increased intracranial pressure.​ Eye Movement Disturbances : These disturbances include difficulty in upward gaze (Parinaud's syndrome) due to pressure on the tectal plate. Hydrocephalus : Symptoms of hydrocephalus, including balance issues and lethargy, are common.[ 9 ] Diffuse intrinsic pontine glioma (DIPG) typically involves rapid onset of symptoms, with a median duration of 1 month from presentation. The classical presentation involves a triad of neurological signs: Long-tract involvement: This includes extremity weakness and hyperreflexia.​ Multiple cranial nerve deficits usually affect the sixth or seventh cranial nerves.​ Cerebellar involvement: Manifesting as ataxia and/or incoordination[ 10 ] Cervicomedullary gliomas, which are tumors located at the junction of the cervical spinal cord and the medulla, typically present with the following clinical symptoms: Neck Pain: This pain is due to the tumor's location and pressure on surrounding structures. Weakness: Often in the arms and legs, due to involvement of the corticospinal tracts.​ Ataxia: Coordination problems, particularly those affecting gait and balance.​ Swallowing Difficulties (Dysphagia): This is due to the involvement of the lower cranial nerves. [ 11 ] Respiratory Issues: In severe cases, the respiratory centers in the medulla are involved. Headache and vomiting: If there is associated hydrocephalus.[ 9 ] Diagnosis The diagnosis of brainstem gliomas in children involves the following: Clinical Presentation : Symptoms can include cranial nerve deficits (dysphagia, dysarthria, abnormal breathing), long tract signs (hemiparesis, spasticity, hyperreflexia, Babinski's sign), and hydrocephalus-related symptoms (headaches, nausea, vomiting, lethargy).​ Neuroimaging : MRI is the primary diagnostic tool. Brainstem gliomas typically appear hypointense on T1-weighted images and hyperintense on T2-weighted images. Postgadolinium sequences may show varying degrees of enhancement.​ Surgical Biopsy : A biopsy is generally recommended to confirm the diagnosis and verify the tumor histology. ​ However, owing to the critical location of brainstem gliomas, biopsies are pursued cautiously to avoid complications and preserve neurological function.[ 2 ] Sodium fluorescein is a fluorescent dye that can pass through a damaged blood‒brain barrier and accumulate in tumor tissue. ​ When exposed to specific lighting conditions, such as those provided by a surgical microscope equipped with a YELLOW 560 nm filter, fluorescein-stained tumor tissue fluoresces, typically appearing yellowish-green, whereas normal brain tissue retains its natural color. This contrast helps surgeons demarcate the tumor margins from the surrounding normal brain tissue and avoids the risk of complications related to the procedure.[ 6 ], [ 12 ], [ 13 ] Management The management of brainstem glioma involves a multidisciplinary approach and varies depending on the type, location, and grade of the tumor. - Surgical intervention : Focal Brainstem Gliomas: Surgery is often considered for focal gliomas, especially if they are exophytic or cervicomedullary. The goal is to achieve as much tumor resection as safely possible while preserving neurological function. Advanced techniques such as neuronavigation, intraoperative magnetic resonance imaging (MRI), intraoperative neurophysiological monitoring, and sodium fluorescein are used to increase the safety and precision of surgery. [ 5 ], [ 10 ] Diffuse Brainstem Gliomas: These gliomas are generally considered inoperable because of their infiltrative nature and high risk of damaging critical brainstem structures. A biopsy may be performed in select cases to confirm the diagnosis and guide treatment. [ 10 ], [ 14 ] - Radiation Therapy : Conventional Radiation: This is a standard treatment for diffuse brainstem gliomas, particularly in children. It can help control tumor growth and alleviate symptoms. Stereotactic radiosurgery: This technique delivers high doses of radiation precisely to the tumor, minimizing damage to surrounding tissues. It may be used for smaller, well-defined tumors.[ 10 ] - Chemotherapy is often used in conjunction with radiation therapy, especially for high-grade gliomas. Agents such as temozolomide are commonly used. The effectiveness of chemotherapy can vary, and ongoing research aims to identify more effective regimens.[ 10 ] - Targeted Therapy and Immunotherapy : Advances in molecular biology have led to the development of targeted therapies that focus on specific genetic mutations and pathways involved in tumor growth. Immunotherapy, which harnesses the body's immune system to fight cancer, is also being explored in clinical trials.[ 15 ], [ 16 ] Surgical Approach for Brainstem Glioma The surgical approach for brainstem glioma depends on the location, type, and extent of the tumor. Midbrain Gliomas : 1. Anterior Midbrain: Transventricular Transforaminal Endoscopic Approach: Used for tumors growing toward the third ventricle. Transsylvian Approach (Pterional or Fronto-Orbito-Zygomatic): For tumors growing toward the interpeduncular cistern, the perioculomotor entry zone is used.[ 8 ] 2. Central midbrain: Infratentorial supracerebellar approach: For tumors growing toward the pineal region or fourth ventricle. Combined Infratentorial Supracerebellar and Suboccipital Telovelar Approach: For tumors extending into both the third and fourth ventricles. [ 8 ] Subvermian approach: This approach is suitable for exophytic tumors located toward the aqueduct and fourth ventricle, especially when the fourth ventricle is dilated.[ 5 ] 3. Posterior Midbrain (Quadrigeminal Plate): Infratentorial supracerebellar approach: For tumors growing toward the third ventricle. Transtentorial occipital approach: For tumors growing toward the fourth ventricle.[ 8 ] Pontine Gliomas : 1. Anterior Pons: Fronto-Orbito-Zygomatic Approach: For superior ventral lesions, the supratrigeminal entry zone is used. Presigmoid approach: For ventrolateral lesions, the peri-trigeminal entry zone was used. 2. Posterior Pons: Suboccipital Craniotomy with the Telovelar Approach: For superior and posterior lesions, the suprafacial or interfacial entry zones were used. Infrafacial approach: For inferior and posterior lesions, the infrafacial entry zone is used. [ 5 ], [ 8 ] Medulla and Cervicomedullary Junction Gliomas : 1. Anterior Medulla: Far-lateral approach: For anterior lesions, the transolivary entry zone is used. 2. Posterior Medulla: Suboccipital Craniotomy with the Telovelar Approach: For cervicomedullary junction tumors, the midline entry zone was used.[ 5 ], [ 8 ] Intraoperative Techniques: Intraoperative techniques for brainstem glioma surgery have significantly advanced, enhancing the safety and precision of these complex procedures. Neuronavigation is a critical tool that helps neurosurgeons accurately locate lesions and avoid important functional and vascular structures. Intraoperative MRI (iMRI) provides real-time imaging, allowing surgeons to verify the extent of tumor resection and make necessary adjustments during the operation. Additionally, intraoperative neurophysiologic monitoring (iOM) is employed to monitor the integrity of neural pathways and cranial nerve nuclei continuously, reducing the risk of neurological damage. Currently, the use of intraoperative sodium fluorescein at doses ranging from 2–5 mg/kg between 20 and 30 minutes before dural opening allows adequate differentiation of tumor tissue from healthy parenchyma. These techniques, when used in combination, enable more precise and safer resections, ultimately improving surgical outcomes for patients with brainstem gliomas.[ 5 ], [ 6 ], [ 7 ], [ 12 ] Prognosis and Outcomes Pediatric low-grade gliomas of the brainstem generally have a favorable prognosis, particularly for dorsally exophytic and cervicomedullary gliomas. These tumors tend to grow slowly, and most patients remain progression-free after near-total resection. Five-year progression-free survival rates for cervicomedullary gliomas exceed 60%, and long-term survival is common for both types of gliomas. Tectal gliomas, which are typically indolent, have a slow progression rate, with only 15–25% of tumors showing progression. Management primarily focuses on resolving hydrocephalus, and long-term survival is common with minimal functional impairment. The extent of resection is a significant prognostic factor, with gross total resection associated with better outcomes. However, even with favorable survival rates, long-term follow-up is essential to monitor tumor progression or recurrence and manage potential neurocognitive and behavioral impairments, particularly in younger patients. Overall, the prognosis for pediatric patients with low-grade brainstem gliomas is positive, but careful management and follow-up are crucial to ensure the best possible quality of life for survivors. The prognosis and outcomes for pediatric high-grade brain stem gliomas, including diffuse intrinsic pontine gliomas (DIPGs), are very poor. [ 17 ] The 1-year overall survival (OS) was 41% (95% CI 38–44%), the 2-year OS was 15.3% (95% CI 12–20%), and the 3-year OS was 7.3% (95% CI 5.2–10%).[ 2 ], [ 17 ] Exemplary case description A 6-year-old female patient who had a history of progressive difficulty looking up, associated with headaches and vomiting that increased in intensity, underwent surgery for placement of a ventriculoperitoneal valve because previously performed brain tomography demonstrated obstructive hydrocephalus with an isodense lesion at the mesencephalic level. She was provided with outpatient support, but the patient began to notice worsening of her vision accompanied by a slight increase in the size of the lesion on a brain resonance image (Fig. 1 , Fig. 2), which is why it was decided to undergo surgery (“Online Resource 1”), where she was treated. performed a medial suboccipital craniotomy with a telovelar approach because most of the tumor had an exophytic portion at the level of the Sylvian aqueduct, sodium fluorescein was used, and intraoperative neuromonitoring in conjunction with neuronavigation was used to differentiate the injury from healthy tissue and avoid complications related to the surgical process. During her postoperative period, there was no worsening of the previously known symptoms, and histopathological examination revealed a low-grade glioma, which is why she was accompanied in the outpatient clinic with follow-up imaging studies every 6 months. Conclusion It can be concluded that tectal gliomas generally have a favorable prognosis. Management in most cases is the control of hydrocephalus, which is indicated to address the tumor lesion when symptoms worsen to confirm the histopathology of the tumor and be able to resect. as much of the tumor as possible so as not to cause greater morbidity to the patient For these brain stem tumors, the use of fluorescein sodium at a dose of 2.5 mg/kg does not cause major complications in the pediatric population and is very useful for the surgeon to differentiate tumor tissue from normal tissue. The type of approach chosen depends on the skill of the surgeon as well as the location of the tumor. Declarations Funding source: No funding was obtained for this study. Financial Disclosure: The authors have no financial disclosure to declare. Submission Statement: The contents of this video have not been copyrighted or published previously. Disclosure: The authors do not have any conflicts of interest to declare. References Donahue B, Allen J, Siffert J, Rosovsky M, Pinto R, PATTERNS OF RECURRENCE IN BRAIN STEM GLIOMAS (1998) : EVIDENCE FOR CRANIOSPINAL DISSEMINATION Sievert AJ, Fisher MJ (2009) Pediatric low-grade gliomas. J Child Neurol 1397–1408. 10.1177/0883073809342005 Lorincz KN et al (2024) Role of surgery in the treatment of pediatric low-grade glioma with various degrees of brain stem involvement, Child’s Nervous System , Oct. 10.1007/s00381-024-06561-y A. Fonseca and E. Bouffet, Brainstem gliomas … The devil is in the details, Jun.01, 2021, Oxford University Press . doi: 10.1093/neuonc/noab064 Sabbagh AJ, Alaqeel AM (2015) Focal brainstem gliomas: Advances in intraoperative management. Saudi Arab Armed Forces Hosp. 10.17712/nsj.2015.2.20140621 Xue Z, Kong L, Pan CC, Wu Z, Zhang JT, Zhang LW (Jun. 2018) Fluorescein-Guided Surgery for Pediatric Brainstem Gliomas: Preliminary Study and Technical Notes. J Neurol Surg B Skull Base 79(4):S340–S346. 10.1055/s-0038-1660847 Molina ES, Stummer W (Sep. 2018) Where and when to cut? Fluorescein guidance for brain stem and spinal cord tumor surgery-technical note. Operative Neurosurg 15(3):325–331. 10.1093/ons/opx269 Cavalheiro S et al (2015) Surgical approaches for brainstem tumors in pediatric patients, Child’s Nervous System , vol. 31, no. 10, pp. 1815–1840, Oct. 10.1007/s00381-015-2799-y Walker DA, Punt JAG, Sokal M Clinical management of brain stem glioma. Khatua S, Zaky W (2014) Diffuse intrinsic pontine glioma: time for therapeutic optimism. 10.2217/cns.14.37 Mahony MJ, Kennedy JD, Leaf A, Matthew DJ, Milla PJ Brain stem glioma presenting as gastro-esophageal reflux. Chen B et al (2012) Gross total resection of glioma with the intraoperative fluorescence- Guidance of fluorescein sodium, Int J Med Sci , vol. 9, no. 8, pp. 708–714, Oct. 10.7150/ijms.4843 Falco J et al (Aug. 2022) Fluorescein-guided surgery for the resection of pilocytic astrocytomas: A multicentric retrospective study. Front Oncol 12. 10.3389/fonc.2022.943085 Dellaretti M, Faraj de Lima FB, de Melo MT, Figueiredo HPG, Acherman ND, Faria BCD (2024) Fluorescein-guided frameless stereotactic brain biopsy, World Neurosurg X , vol. 22, Apr. 10.1016/j.wnsx.2024.100322 Bernstock JD et al (2022) Immunotherapy approaches for the treatment of diffuse midline gliomas. Taylor Francis Ltd. 10.1080/2162402X.2022.2124058 Nonnenbroich LF, Bouchal SM, Millesi E, Rechberger JS, Khatua S, Daniels DJ H3K27-Altered Diffuse Midline Glioma of the Brainstem: From Molecular Mechanisms to Targeted Interventions. Jul 01 2024 Multidisciplinary Digit Publishing Inst (MDPI). 10.3390/cells13131122 Hassan H, Pinches A, Picton SV, Phillips RS (2017) Survival rates and prognostic predictors of high grade brain stem gliomas in childhood: a systematic review and meta-analysis, Oct. 01, Springer New York LLC . 10.1007/s11060-017-2546-1 Additional Declarations The authors declare no competing interests. Supplementary Files Bsgstasfpp.mp4 Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5921159","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":408382390,"identity":"8382ceaa-3661-4c17-93ae-f8ee6549000c","order_by":0,"name":"Sergio Cavalheiro","email":"","orcid":"","institution":"University Federal of São Paulo, Brazil","correspondingAuthor":false,"prefix":"","firstName":"Sergio","middleName":"","lastName":"Cavalheiro","suffix":""},{"id":408382391,"identity":"9f1d2653-0a3f-4c3d-9983-6506754d21c4","order_by":1,"name":"José Antonio Rangel 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patient\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eBrain stem gliomas account for approximately 10% of all pediatric primary CNS malignancies. ​ Approximately 85% of these tumors are high grade and spread through local infiltration of the pons, medulla, and midbrain[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Tectal gliomas are generally low-grade tumors and often present with symptoms related to hydrocephalus due to obstruction of cerebrospinal fluid pathways[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Management focuses on resolving hydrocephalus by shunting or endoscopic third ventriculostomy. ​ Patients are observed, and biopsy and adjuvant therapy are reserved for those with radiographic and clinical progression[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. ​ Tectal gliomas that are exophytic toward the aqueduct and fourth ventricles, the subvermian approach can be used, especially in cases where the fourth ventricle is dilated[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSodium fluorescein is used in brain tumor surgeries to enhance the visualization of the tumor, making it easier for surgeons to distinguish between tumor tissue and normal brain tissue.[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/p\u003e"},{"header":"Historical Background","content":"\u003cp\u003eThe historical background of brainstem glioma treatment and management has evolved significantly. Brainstem gliomas are recognized as a distinct group of tumors affecting the brainstem, a critical area controlling many vital functions. Early attempts at surgical intervention were limited due to the high risk of damaging essential neural structures. The development of advanced imaging techniques, such as magnetic resonance imaging (MRI) and cerebral tomography (CT) scans, has allowed for better visualization and understanding of brainstem gliomas. This improved the ability to diagnose and plan treatment strategies. Over the past two decades, the introduction of neuronavigation systems and intraoperative imaging (such as intraoperative MRI) has revolutionized brainstem glioma surgery. These technologies provide real-time guidance and help avoid critical structures, making surgeries safer and more precise. The use of intraoperative neurophysiological monitoring (iOM), including techniques such as brainstem mapping and motor-evoked potentials, has significantly improved the safety of brainstem surgeries. These methods allow surgeons to monitor neural function during surgery, reducing the risk of permanent damage. Various surgical approaches have been developed and refined for different types of brainstem gliomas. [\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e]The development of surgical microscopes equipped with filters, such as the YELLOW 560 nm filter, has significantly improved the visualization of fluorescein-stained tumors. This advancement has allowed lower doses of fluorescein to be used effectively for the treatment of brain tumors[\u003cspan class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\n\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n\u003ch2\u003eClassification of Brainstem Glioma\u003c/h2\u003e\n\u003cp\u003eBrainstem gliomas are classified on the basis of their location, growth pattern, and histological characteristics. One commonly used classification system, proposed by Choux \u003cem\u003eet al\u003c/em\u003e., divides brainstem gliomas into four types:\u003c/p\u003e\n\u003cem\u003e-Type I: Diffuse\u003c/em\u003e brainstem gliomas are the most common type, representing up to 80% of brainstem tumors. Multiple nuclei and pathways are affected, often causing bilateral cranial nerve paralysis and progressing to hemiparesis and tetraparesis. Most are malignant astrocytomas (WHO grade III or IV). They have a rapid clinical evolution and poor prognosis, with most patients dying within two years of diagnosis.\n\u003cp\u003e\u003cem\u003e-Type II: Focal\u003c/em\u003e intrinsic tumors: These tumors are slow-growing and have well-delimited borders. They can be solid or cystic and are usually low-grade gliomas. Surgery is advised if the tumor is superficial; otherwise, conservative treatment is preferred.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e-Type III: Exophytic\u003c/em\u003e Tumors: These tumors have a significant portion that grow out of the brainstem, making them more accessible surgically. They often have a cystic component and are mostly low-grade astrocytomas.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e-Type IV: Cervicomedullary\u003c/em\u003e junction tumors: These tumors grow at the junction of the cervical spinal cord and medulla. These tumors often present as exophytic growths, allowing direct surgical access without incising the brainstem. They may cause hydrocephalus or syringomyelia due to changes in cerebrospinal fluid dynamics.[\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Clinical presentation","content":"\u003cp\u003eTectal gliomas, which are focal intrinsic tumors (type II) located in the tectal plate of the midbrain, typically present with symptoms related to hydrocephalus due to obstruction of cerebrospinal fluid flow.​\u003c/p\u003e \u003cp\u003eCommon clinical presentations include the following:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eHeadache\u003c/em\u003e: Often, this is due to increased intracranial pressure.​\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eNausea and\u003c/em\u003e vomiting are also related to increased intracranial pressure.​\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eEye Movement Disturbances\u003c/em\u003e: These disturbances include difficulty in upward gaze (Parinaud's syndrome) due to pressure on the tectal plate.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eHydrocephalus\u003c/em\u003e: Symptoms of hydrocephalus, including balance issues and lethargy, are common.[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eDiffuse intrinsic pontine glioma (DIPG) typically involves rapid onset of symptoms, with a median duration of 1 month from presentation. The classical presentation involves a triad of neurological signs:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eLong-tract involvement: This includes extremity weakness and hyperreflexia.​\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eMultiple cranial nerve deficits usually affect the sixth or seventh cranial nerves.​\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eCerebellar involvement: Manifesting as ataxia and/or incoordination[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eCervicomedullary gliomas, which are tumors located at the junction of the cervical spinal cord and the medulla, typically present with the following clinical symptoms:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eNeck Pain: This pain is due to the tumor's location and pressure on surrounding structures.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eWeakness: Often in the arms and legs, due to involvement of the corticospinal tracts.​\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eAtaxia: Coordination problems, particularly those affecting gait and balance.​\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eSwallowing Difficulties (Dysphagia): This is due to the involvement of the lower cranial nerves. [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eRespiratory Issues: In severe cases, the respiratory centers in the medulla are involved.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eHeadache and vomiting: If there is associated hydrocephalus.[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e"},{"header":"Diagnosis","content":"\u003cp\u003eThe diagnosis of brainstem gliomas in children involves the following:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eClinical Presentation\u003c/em\u003e: Symptoms can include cranial nerve deficits (dysphagia, dysarthria, abnormal breathing), long tract signs (hemiparesis, spasticity, hyperreflexia, Babinski's sign), and hydrocephalus-related symptoms (headaches, nausea, vomiting, lethargy).​\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eNeuroimaging\u003c/em\u003e: MRI is the primary diagnostic tool. Brainstem gliomas typically appear hypointense on T1-weighted images and hyperintense on T2-weighted images. Postgadolinium sequences may show varying degrees of enhancement.​\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eSurgical Biopsy\u003c/em\u003e: A biopsy is generally recommended to confirm the diagnosis and verify the tumor histology. ​ However, owing to the critical location of brainstem gliomas, biopsies are pursued cautiously to avoid complications and preserve neurological function.[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] Sodium fluorescein is a fluorescent dye that can pass through a damaged blood‒brain barrier and accumulate in tumor tissue. ​ When exposed to specific lighting conditions, such as those provided by a surgical microscope equipped with a YELLOW 560 nm filter, fluorescein-stained tumor tissue fluoresces, typically appearing yellowish-green, whereas normal brain tissue retains its natural color. This contrast helps surgeons demarcate the tumor margins from the surrounding normal brain tissue and avoids the risk of complications related to the procedure.[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e"},{"header":"Management","content":"\u003cp\u003eThe management of brainstem glioma involves a multidisciplinary approach and varies depending on the type, location, and grade of the tumor.\u003c/p\u003e\n\u003cp\u003e-\u003cem\u003eSurgical intervention\u003c/em\u003e:\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003e\n\u003cp\u003eFocal Brainstem Gliomas: Surgery is often considered for focal gliomas, especially if they are exophytic or cervicomedullary. The goal is to achieve as much tumor resection as safely possible while preserving neurological function. Advanced techniques such as neuronavigation, intraoperative magnetic resonance imaging (MRI), intraoperative neurophysiological monitoring, and sodium fluorescein are used to increase the safety and precision of surgery. [\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e], [\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eDiffuse Brainstem Gliomas: These gliomas are generally considered inoperable because of their infiltrative nature and high risk of damaging critical brainstem structures. A biopsy may be performed in select cases to confirm the diagnosis and guide treatment. [\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e], [\u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/p\u003e\n\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e-\u003cem\u003eRadiation Therapy\u003c/em\u003e:\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003e\n\u003cp\u003eConventional Radiation: This is a standard treatment for diffuse brainstem gliomas, particularly in children. It can help control tumor growth and alleviate symptoms.\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eStereotactic radiosurgery: This technique delivers high doses of radiation precisely to the tumor, minimizing damage to surrounding tissues. It may be used for smaller, well-defined tumors.[\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/p\u003e\n\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e-\u003cem\u003eChemotherapy\u003c/em\u003e is often used in conjunction with radiation therapy, especially for high-grade gliomas. Agents such as temozolomide are commonly used. The effectiveness of chemotherapy can vary, and ongoing research aims to identify more effective regimens.[\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/p\u003e\n\u003cp\u003e-\u003cem\u003eTargeted Therapy and Immunotherapy\u003c/em\u003e: Advances in molecular biology have led to the development of targeted therapies that focus on specific genetic mutations and pathways involved in tumor growth. Immunotherapy, which harnesses the body's immune system to fight cancer, is also being explored in clinical trials.[\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e], [\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/p\u003e\n\u003ch3\u003eSurgical Approach for Brainstem Glioma\u003c/h3\u003e\n\u003cp\u003eThe surgical approach for brainstem glioma depends on the location, type, and extent of the tumor.\u003c/p\u003e\n\u003cp\u003e\u003cspan class=\"ItalicUnderline\"\u003eMidbrain Gliomas\u003c/span\u003e:\u003c/p\u003e\n\u003cp\u003e1. Anterior Midbrain:\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003e\n\u003cp\u003eTransventricular Transforaminal Endoscopic Approach: Used for tumors growing toward the third ventricle.\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eTranssylvian Approach (Pterional or Fronto-Orbito-Zygomatic): For tumors growing toward the interpeduncular cistern, the perioculomotor entry zone is used.[\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/p\u003e\n\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n\u003cp\u003e2. Central midbrain:\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003e\n\u003cp\u003eInfratentorial supracerebellar approach: For tumors growing toward the pineal region or fourth ventricle.\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eCombined Infratentorial Supracerebellar and Suboccipital Telovelar Approach: For tumors extending into both the third and fourth ventricles. [\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eSubvermian approach: This approach is suitable for exophytic tumors located toward the aqueduct and fourth ventricle, especially when the fourth ventricle is dilated.[\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/p\u003e\n\u003c/li\u003e\n\u003c/ul\u003e\n3. Posterior Midbrain (Quadrigeminal Plate):\u003cbr\u003e\n\u003cul\u003e\n\u003cli\u003e\n\u003cp\u003eInfratentorial supracerebellar approach: For tumors growing toward the third ventricle.\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eTranstentorial occipital approach: For tumors growing toward the fourth ventricle.[\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/p\u003e\n\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cspan style=\"text-decoration: underline;\"\u003e\u003cem\u003e\u003cspan class=\"ItalicUnderline\"\u003ePontine Gliomas\u003c/span\u003e:\u003c/em\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e1. Anterior Pons:\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003e\n\u003cp\u003eFronto-Orbito-Zygomatic Approach: For superior ventral lesions, the supratrigeminal entry zone is used.\u003c/p\u003e\n\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003ePresigmoid approach: For ventrolateral lesions, the peri-trigeminal entry zone was used.\u003c/p\u003e\n\u003cp\u003e2. Posterior Pons:\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003e\n\u003cp\u003eSuboccipital Craniotomy with the Telovelar Approach: For superior and posterior lesions, the suprafacial or interfacial entry zones were used.\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eInfrafacial approach: For inferior and posterior lesions, the infrafacial entry zone is used. [\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e], [\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/p\u003e\n\u003c/li\u003e\n\u003c/ul\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cspan class=\"ItalicUnderline\"\u003eMedulla and Cervicomedullary Junction Gliomas\u003c/span\u003e:\u003c/p\u003e\n\u003cp\u003e1. Anterior Medulla:\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003e\n\u003cp\u003eFar-lateral approach: For anterior lesions, the transolivary entry zone is used.\u003c/p\u003e\n\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e2. Posterior Medulla:\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003e\n\u003cp\u003eSuboccipital Craniotomy with the Telovelar Approach: For cervicomedullary junction tumors, the midline entry zone was used.[\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e], [\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/p\u003e\n\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cspan style=\"text-decoration: underline;\"\u003e\u003cem\u003eIntraoperative Techniques:\u003c/em\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003eIntraoperative techniques for brainstem glioma surgery have significantly advanced, enhancing the safety and precision of these complex procedures. Neuronavigation is a critical tool that helps neurosurgeons accurately locate lesions and avoid important functional and vascular structures. Intraoperative MRI (iMRI) provides real-time imaging, allowing surgeons to verify the extent of tumor resection and make necessary adjustments during the operation. Additionally, intraoperative neurophysiologic monitoring (iOM) is employed to monitor the integrity of neural pathways and cranial nerve nuclei continuously, reducing the risk of neurological damage. Currently, the use of intraoperative sodium fluorescein at doses ranging from 2–5 mg/kg between 20 and 30 minutes before dural opening allows adequate differentiation of tumor tissue from healthy parenchyma. These techniques, when used in combination, enable more precise and safer resections, ultimately improving surgical outcomes for patients with brainstem gliomas.[\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e], [\u003cspan class=\"CitationRef\"\u003e6\u003c/span\u003e], [\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e], [\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/p\u003e\n\n"},{"header":"Prognosis and Outcomes","content":"\u003cp\u003ePediatric low-grade gliomas of the brainstem generally have a favorable prognosis, particularly for dorsally exophytic and cervicomedullary gliomas. These tumors tend to grow slowly, and most patients remain progression-free after near-total resection. Five-year progression-free survival rates for cervicomedullary gliomas exceed 60%, and long-term survival is common for both types of gliomas. Tectal gliomas, which are typically indolent, have a slow progression rate, with only 15–25% of tumors showing progression. Management primarily focuses on resolving hydrocephalus, and long-term survival is common with minimal functional impairment. The extent of resection is a significant prognostic factor, with gross total resection associated with better outcomes. However, even with favorable survival rates, long-term follow-up is essential to monitor tumor progression or recurrence and manage potential neurocognitive and behavioral impairments, particularly in younger patients. Overall, the prognosis for pediatric patients with low-grade brainstem gliomas is positive, but careful management and follow-up are crucial to ensure the best possible quality of life for survivors. The prognosis and outcomes for pediatric high-grade brain stem gliomas, including diffuse intrinsic pontine gliomas (DIPGs), are very poor. [\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e] The 1-year overall survival (OS) was 41% (95% CI 38–44%), the 2-year OS was 15.3% (95% CI 12–20%), and the 3-year OS was 7.3% (95% CI 5.2–10%).[\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e], [\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/p\u003e"},{"header":"Exemplary case description","content":"\u003cp\u003eA 6-year-old female patient who had a history of progressive difficulty looking up, associated with headaches and vomiting that increased in intensity, underwent surgery for placement of a ventriculoperitoneal valve because previously performed brain tomography demonstrated obstructive hydrocephalus with an isodense lesion at the mesencephalic level.\u003c/p\u003e\u003cp\u003eShe was provided with outpatient support, but the patient began to notice worsening of her vision accompanied by a slight increase in the size of the lesion on a brain resonance image (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e, Fig.\u0026nbsp;2), which is why it was decided to undergo surgery (“Online Resource 1”), where she was treated. performed a medial suboccipital craniotomy with a telovelar approach because most of the tumor had an exophytic portion at the level of the Sylvian aqueduct, sodium fluorescein was used, and intraoperative neuromonitoring in conjunction with neuronavigation was used to differentiate the injury from healthy tissue and avoid complications related to the surgical process.\u003c/p\u003e\u003cp\u003eDuring her postoperative period, there was no worsening of the previously known symptoms, and histopathological examination revealed a low-grade glioma, which is why she was accompanied in the outpatient clinic with follow-up imaging studies every 6 months.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIt can be concluded that tectal gliomas generally have a favorable prognosis. Management in most cases is the control of hydrocephalus, which is indicated to address the tumor lesion when symptoms worsen to confirm the histopathology of the tumor and be able to resect. as much of the tumor as possible so as not to cause greater morbidity to the patient\u003c/p\u003e \u003cp\u003eFor these brain stem tumors, the use of fluorescein sodium at a dose of 2.5 mg/kg does not cause major complications in the pediatric population and is very useful for the surgeon to differentiate tumor tissue from normal tissue.\u003c/p\u003e \u003cp\u003eThe type of approach chosen depends on the skill of the surgeon as well as the location of the tumor.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eFunding source: No funding was obtained for this study.\u003c/p\u003e\n\u003cp\u003eFinancial Disclosure: The authors have no financial disclosure to declare.\u003c/p\u003e\n\u003cp\u003eSubmission Statement: The contents of this video have not been copyrighted or published previously.\u003c/p\u003e\n\u003cp\u003eDisclosure: The authors do not have any conflicts of interest to declare.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eDonahue B, Allen J, Siffert J, Rosovsky M, Pinto R, PATTERNS OF RECURRENCE IN BRAIN STEM GLIOMAS (1998) : EVIDENCE FOR CRANIOSPINAL DISSEMINATION\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSievert AJ, Fisher MJ (2009) Pediatric low-grade gliomas. J Child Neurol 1397\u0026ndash;1408. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/0883073809342005\u003c/span\u003e\u003cspan address=\"10.1177/0883073809342005\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLorincz KN et al (2024) Role of surgery in the treatment of pediatric low-grade glioma with various degrees of brain stem involvement, \u003cem\u003eChild\u0026rsquo;s Nervous System\u003c/em\u003e, Oct. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00381-024-06561-y\u003c/span\u003e\u003cspan address=\"10.1007/s00381-024-06561-y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eA. Fonseca and E. Bouffet, Brainstem gliomas \u0026hellip; The devil is in the details, Jun.01, 2021, \u003cem\u003eOxford University Press\u003c/em\u003e. doi: 10.1093/neuonc/noab064\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSabbagh AJ, Alaqeel AM (2015) Focal brainstem gliomas: Advances in intraoperative management. Saudi Arab Armed Forces Hosp. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.17712/nsj.2015.2.20140621\u003c/span\u003e\u003cspan address=\"10.17712/nsj.2015.2.20140621\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eXue Z, Kong L, Pan CC, Wu Z, Zhang JT, Zhang LW (Jun. 2018) Fluorescein-Guided Surgery for Pediatric Brainstem Gliomas: Preliminary Study and Technical Notes. J Neurol Surg B Skull Base 79(4):S340\u0026ndash;S346. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1055/s-0038-1660847\u003c/span\u003e\u003cspan address=\"10.1055/s-0038-1660847\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMolina ES, Stummer W (Sep. 2018) Where and when to cut? Fluorescein guidance for brain stem and spinal cord tumor surgery-technical note. Operative Neurosurg 15(3):325\u0026ndash;331. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/ons/opx269\u003c/span\u003e\u003cspan address=\"10.1093/ons/opx269\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCavalheiro S et al (2015) Surgical approaches for brainstem tumors in pediatric patients, \u003cem\u003eChild\u0026rsquo;s Nervous System\u003c/em\u003e, vol. 31, no. 10, pp. 1815\u0026ndash;1840, Oct. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00381-015-2799-y\u003c/span\u003e\u003cspan address=\"10.1007/s00381-015-2799-y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWalker DA, Punt JAG, Sokal M Clinical management of brain stem glioma.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKhatua S, Zaky W (2014) Diffuse intrinsic pontine glioma: time for therapeutic optimism. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.2217/cns.14.37\u003c/span\u003e\u003cspan address=\"10.2217/cns.14.37\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMahony MJ, Kennedy JD, Leaf A, Matthew DJ, Milla PJ Brain stem glioma presenting as gastro-esophageal reflux.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen B et al (2012) Gross total resection of glioma with the intraoperative fluorescence- Guidance of fluorescein sodium, \u003cem\u003eInt J Med Sci\u003c/em\u003e, vol. 9, no. 8, pp. 708\u0026ndash;714, Oct. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.7150/ijms.4843\u003c/span\u003e\u003cspan address=\"10.7150/ijms.4843\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFalco J et al (Aug. 2022) Fluorescein-guided surgery for the resection of pilocytic astrocytomas: A multicentric retrospective study. Front Oncol 12. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/fonc.2022.943085\u003c/span\u003e\u003cspan address=\"10.3389/fonc.2022.943085\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDellaretti M, Faraj de Lima FB, de Melo MT, Figueiredo HPG, Acherman ND, Faria BCD (2024) Fluorescein-guided frameless stereotactic brain biopsy, \u003cem\u003eWorld Neurosurg X\u003c/em\u003e, vol. 22, Apr. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.wnsx.2024.100322\u003c/span\u003e\u003cspan address=\"10.1016/j.wnsx.2024.100322\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBernstock JD et al (2022) Immunotherapy approaches for the treatment of diffuse midline gliomas. Taylor Francis Ltd. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1080/2162402X.2022.2124058\u003c/span\u003e\u003cspan address=\"10.1080/2162402X.2022.2124058\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNonnenbroich LF, Bouchal SM, Millesi E, Rechberger JS, Khatua S, Daniels DJ H3K27-Altered Diffuse Midline Glioma of the Brainstem: From Molecular Mechanisms to Targeted Interventions. Jul 01 2024 Multidisciplinary Digit Publishing Inst (MDPI). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/cells13131122\u003c/span\u003e\u003cspan address=\"10.3390/cells13131122\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHassan H, Pinches A, Picton SV, Phillips RS (2017) Survival rates and prognostic predictors of high grade brain stem gliomas in childhood: a systematic review and meta-analysis, Oct. 01, \u003cem\u003eSpringer New York LLC\u003c/em\u003e. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s11060-017-2546-1\u003c/span\u003e\u003cspan address=\"10.1007/s11060-017-2546-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"University Federal of Sao Paulo, Brazil","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"midbrain, children, fluorescent, tumor","lastPublishedDoi":"10.21203/rs.3.rs-5921159/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5921159/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eTectal gliomas are a subset of brainstem gliomas that typically present symptoms related to hydrocephalus due to obstruction of cerebrospinal fluid pathways. These tumors are generally low grade and have a favorable prognosis.\u003cbr\u003e\nManagement often focuses on resolving hydrocephalus, with surgical intervention considered when symptoms worsen.\u003cbr\u003e\nSodium fluorescein is a fluorescent dye used in brain tumor surgeries to enhance visualization, allowing surgeons to distinguish between tumor tissue and normal brain tissue more effectively. This technique improves the precision and safety of tumor resection.\u003c/p\u003e\n\u003cp\u003eWe present the case of a 6-year-old patient in whom we performed the telovelar approach to resect the exophytic portion at the level of the Sylvian aqueduct via sodium fluorescein (2.5 mg/kg) for adequate resection, with excellent postoperative results.\u003c/p\u003e\n\u003cp\u003eEthics committee approval was not required to perform the surgical procedure on the patient. The patient's parents provided informed consent for the surgery and gave verbal consent for the publication of their video surgery.\u003c/p\u003e","manuscriptTitle":"Brain stem glioma surgery via a telovelar approach using sodium fluorescein in a 6-year-old pediatric patient","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-01-30 10:23:01","doi":"10.21203/rs.3.rs-5921159/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6ea54b33-4b18-44e8-81d7-dc2b47e54a3d","owner":[],"postedDate":"January 30th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":43544236,"name":"Neurosurgery"},{"id":43544237,"name":"Oncology"},{"id":43544238,"name":"Pediatrics"}],"tags":[],"updatedAt":"2025-01-30T10:23:01+00:00","versionOfRecord":[],"versionCreatedAt":"2025-01-30 10:23:01","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5921159","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5921159","identity":"rs-5921159","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}