Minimally invasive port stent surgery: Re-purposing a balloon-expandable covered vascular stent for minimally invasive resection of deep cerebral masses: Report of 4 first-in-human stent port cases

Abstract

Background: Minimally invasive port surgery (MIPS) permits access to deep-seated intracranial lesions while minimizing cortical and subcortical disruption. Commercially available port systems may be unavailable or cost-prohibitive in certain practice environments. Case Description: Case #1 involved a 69-year-old man who presented with mild cognitive changes and gait disturbance and was found to have a left parietal enhancing mass consistent with a high-grade glioma. Case #2 involved a 63-year-old man who presented 5 months following prior resection with right-sided focal motor seizures and a recurrent left frontal lobe, premotor cortex glioblastoma multiforme. Case #3 involved a 49-year-old right-handed man who presented to the emergency department with a Glasgow Coma Scale of 8. Head computed tomography demonstrated a 65 cc intracerebral hematoma with surrounding edema involving the right thalamus and basal ganglia, bilateral lateral ventricle intraventricular hemorrhage, and 5 mm right-to-left midline shift. Case #4 involved a 77-year-old man with a 3.5 cm left frontal mass consistent with metastatic tumor, significant associated vasogenic edema, left-to-right midline shift, and herniation. In the absence of a dedicated MIPS port system, a balloon-expandable covered vascular stent was repurposed as a temporary intracranial access port using image guidance. Tumor resections in Cases 1, 2, and 4 were performed through the repurposed balloon-expandable covered stent port. GammaTile post-resection brachytherapy placement was accomplished through the stent port in Cases 1 and 4. In Case #3, intentional hematoma debulking was performed using stent port access. Gross total resection/complete resection was achieved in all three neoplasm cases. Post-operative imaging confirmed complete resections of both Grade IV glial neoplasms and complete resection of the Case #4 left frontal metastatic mass. In the hematoma case, intentional subtotal 30 cc evacuation was achieved. Conclusion: Balloon-expandable covered stents may represent a feasible alternative access port for MIPS procedures in select clinical circumstances.