Microscopic Resection of Intracranial Lesions with Tubular Retractor of Plastic Syringe: A Single-Center Experience of 157 Cases

Abstract

Objective

Deeply located intracranial lesions such as intraparenchymal and intraventricular lesions are surgically challenging and associated with unavoidable complications such as seizure, surgical bed hematoma, and brain contusion caused by traction. The objective of this study is to evaluate the safety and effectiveness of the microscopic tubular retractor of a plastic syringe for the resection of deeply located brain lesions.

Materials and Methods

We retrospectively studied 157 patients with deep-seated intracranial lesions who underwent microscopic resection with the help of a tubular retractor made of a plastic syringe and Teflon introducer between January 2018 and January 2024 in a tertiary hospital. All deep-seated lesions were such as neurocytoma, lymphoma, ependymoma, colloid cysts, metastatic brain tumors, astrocytoma, and meningiomas. We evaluated all patients postoperatively with computed tomography (CT) scan on the first/second day of surgery. The amount of blood loss, the complications, and the mortality rate were recorded.

Results

There were 104 males and 53 females with a mean age of 54.13 (range: 15–80) years. Gross total resection was obtained in 85.35% and subtotal in 14.65% of patients. Complications such as surgical bed hematoma in 5.73%, seizure in 3.18%, weakness in 2.54%, and contusion in 3.82% of patients were noted. The blood loss varied from 30 to 500 mL (average, 100 mL). The mortality rate was observed in 2.54% of all patients. Follow-up ranged from 1 to 25 months (average, 10 months).

Conclusion

Plastic syringe tubular retractor with Teflon introducer system is safe and effective for the treatment of deeply located intracranial lesions in terms of low morbidity and excellent rate of resection.

Keywords

deeply located - intracranial lesions - plastic syringe - tubular retractor - outcome

Introduction

Treatment for deeply located intracranial lesions is surgically challenging because of the presence of vital neurovascular structures close to the deep lesion, and a reduction in the degree of freedom and maneuverability by increasing the depth of the surgical corridor. The making and keeping a safe surgical corridor into deep lesions during resection is very important to visualize lesions and surrounding structures.[1] Therefore, retraction of healthy brain tissue is required to reach the target deep brain lesion resection, which can injure the normal brain tissues. Greenberg first introduced self-retaining retraction in 1981; however, the possible risk of brain injury and infarction was debatable due to excessive brain retraction pressure.[2] Similarly, other studies also described that resection of deep brain lesions with blade retractors is associated with ischemic brain injury, contusion, or neurological impairments by the focal pressure created by the blade.[3] [4] Presently, minimally invasive brain procedure has also been widely performed after advancement in neuroimaging, operative microscope or endoscope, and navigation system to improve the safety and efficacy of surgery for deep-seated brain lesion.[5] Tubular retractors are developed to create a cylindrical surgical corridor for resection of deeply located brain lesions, which splits normal brain tissue equally and reduces applied pressure on retracted tissue by distributing pressure over the entire surface of the tubular retractor, therefore decreasing the risk of traumatic complications.[6] [7] [8] [9] [10] [11] Various types of retractors are available commercially for neurosurgical use.[3] [6] [10] [11] [12] [13] [14] [15] We present our experience with an indigenously designed brain port system using a plastic syringe for microscopic removal of deep-seated intracranial lesions.

Materials and Methods

This is a retrospective study of 157 patients with deeply located intracranial lesions treated from January 2019 to January 2024 in our tertiary hospital. The study was approved by local Institutional Review Board. The informed consent was taken from all patients. Data regarding patient's age, sex, clinical presentation, radiographic imaging (computed tomography [CT] scan/magnetic resonance imaging/tractography), operation record, pathological findings, treatment-related complications, and outcome were obtained from patient's electronic medical record. All patients were operated under general anesthesia. Patient's age younger than 15 years, and basal ganglion and thalamic bleed cases were excluded from this study. Patients were evaluated postoperatively by CT scan on the first/second day of the surgery in all patients as per required.

Procedure Note

All patients' head was positioned in a MAYFILED Tripod Skull Clamp after general anesthesia. A straight 5 to 6 cm skin incision was made, and then a minicraniotomy was done. The dura was opened in a circular fashion after reflecting the bone flap. A small corticectomy or arachnoid over sulcus was opened with sharp dissection and minimally extended in depth by separating gyral lining with blunt dissection according to the size of the syringe. We performed the procedure with 5 and 10 mL having different lengths of 4 to 7 cm according to the size and depth of lesions from the cortex. The edges of the plastic syringe appear relatively sharp and rigid after cutting to the required size, which might pose a high risk of injury to normal tissue compared with other retractors. Therefore, the surface was smoothened by rubbing on a smooth metallic object, which might avoid potential brain injury. A trocar made of Teflon was applied for insertion of a sterilized syringe tubular retractor ([Fig. 1]). The tip of the Teflon trocar was specifically designed to gently dilate the path to the lesion. Syringe retractor was stitched with dura, which helps dislodge of retractor. This retractor can be moved in any direction as required to help in complete resection ([Fig. 2]). Neuronavigation and neurophysiological monitoring were applied for a few cases associated with the eloquent region. Aggressively adherent or extending lesion to the basal ganglia was not tried for gross total resection and kept the residual part intentionally. After excision of tumors, the surgical field was irrigated, and the syringe retractor was withdrawn slowly to visualize and secure any bleeding point along the path of the retractor. Dura was closed primarily, and bone flap was positioned with miniplates and screws, then kin was closed in two layers.

Fig. 1 (A) Teflon dilator; (B) 5 and 10 mL size of syringe; and (C) plastic syringe with introducer—Teflon trocar.

Fig. 2 Schematic diagram showing illustrations of procedure in use: The small corridor through the brain cortex was made by bipolar forceps (A). Teflon introducer being progressively inserted with syringe tube along the path to promote the required space to position the retractor (B). Teflon removed after reaching desired location and syringe tubular retractor sutured with dura to prevent the dislodgement of tube during surgery (C). Excision of the lesion started with special instruments such as bipolar along with a suction tube (D).

Results

A total of 157 patients operated on were included in this study. There were 66.24% male and 33.67% female, with a mean age of 54.13 years. At admission, clinical presentations revealed headache in 63.69%, nausea and vomiting in 44.58%, seizure in 21.65%, decreased power on limbs in 19.74%, urinary incontinence in 8.28%, reduced memory in 9.55%, altered sensorium in 12.73%, and unconsciousness in 5.09%. The most common pathologies of lesions were astrocytoma (50.39%) ([Figs. 3] and [4]), followed by meningioma (22.29%), colloid cyst (9.55%) ([Fig. 5]), ependymoma (6.36%), metastatic brain lesion (6.36%), neurocytoma (3.18%) ([Fig. 6]), and lymphoma (1.91%). The lesions were located in frontal (n = 57), parietal (n = 39), occipital (n = 16), cerebellar (n = 12), thalamic (n = 6), and intraventricular area (n = 25). Lesion from cortex varied from 2.2 to 6.2 cm ([Table 1]).

Fig. 3 A 16-year-old girl with MRI—sagittal section (A) and coronal section (B)—showing sellar/suprasellar lesion extending to third ventricle with hydrocephalus; syringe tubular retractor with lesion (C); postoperative follow-up MRI showing complete resection of lesion with no recurrence at 3 months (D) (histopathology report—pilocytic astrocytoma, WHO grade I). MRI, magnetic resonance imaging.

Fig. 4 A 58-year-old woman with imaging (postcontrast MRI) T2 sagittal section (A) and axial section (B) showing heterogeneous hyperintense large lesion in deep right frontal lobe extending to wall of lateral ventricle and peri-insular cortex with hydrocephalus; syringe retraction with tumor (C); postoperative CT scan showing near total resection of invasive lesion with cavity filled with air and hematoma (D) (histopathology report—high-grade glioma, WHO grade III). CT, computed tomography; MRI, magnetic resonance imaging.

Fig. 5 A 34-year-old woman with imaging (CT of the head), axial section (A) and MRI T1, axial section(B) showing small oval lesion with size of 1.6 × 1.4 × 1.3 cm in roof of third ventricle (in foramen of Monro) with hydrocephalus; excising cyst through syringe retractor (C) and postoperative image (CT of the head, axial section) showing complete resection of cyst with resolution in hydrocephalus and tiny pneumocephalus in left frontal horn of third ventricle (D) (histopathology report—colloid cyst). CT, computed tomography; MRI, magnetic resonance imaging.

Fig. 6 A 28-year-old woman with imaging (postcontrast MRI T1), sagittal section (A), axial section (B), and FLAIR (C) showing 15.3 × 15.5 × 17.5 mm lesion in anterosuperior aspect of third ventricle; syringe tubular retractor with lesion (D); postoperative CT of the head showing gross total resection of lesion with left frontal pneumocephalus and Ommya in situ (E); follow-up CT of the head at 6 months showing no hydrocephalus with Ommaya in situ (F) (histopathology report—central neurocytoma). CT, computed tomography; FLAIR, fluid-attenuated inversion recovery; MRI, magnetic resonance imaging.

Table 1 Characteristics of patients and intracranial lesions

Variables	N (%)
Age, y	15–80 (average 54.13 ± 16.68)
Sex
Male	104 (66.24%)
Female	53 (33.76%)
Clinical presentations at admission
Headache	100 (63.69%)
Nausea and vomiting	70 (44.58%)
Seizure	34 (21.65%)
Decreased power in limbs	31 (19.74%)
Urinary incontinence	13 (8.28%)
Reduced memory	15 (9.55%)
Altered sensorium	20 (12.73%)
Unconsciousness	8 (5.09%)
Pathology of lesions
Astrocytoma	79 (50.39%)
Meningioma	35 (22.29%)
Ependymoma	10 (6.36%)
Colloid cyst of the third ventricle	15 (9.55%)
Metastatic brain tumor	10 (6.36%)
Neurocytoma	5 (3.18%)
Lymphoma	3 (1.91%)
Location
Frontal	57 (36.30%)
Parietal	39 (24.84%)
Occipital	16 (10.19%)
Cerebellar	14 (8.91%)
Thalamic	6 (3.82%)
Intraventricular	25 (15.92%)
Depth of lesions, cm	2.2–6.2 (average 4.32)

Gross total resection was achieved in 85.35% patients, and subtotal resection was achieved in 14.65% patients. There was no local infection or infarction of all patients. Hematoma in tumor bed following surgery was noted in 5.73% of patients, contusion in 4.45% of patients, and postoperative seizure in 3.18% of patients and weakness of limbs in 2.54% of patients. Blood loss during surgery varied from 30 to 500 mL. One patient with large ventricular tumor died due to meningitis after 2 months of surgery. Second patient died after 5 months following surgery because of heart attack. He had a history of ischemic heart disease with hypertension and diabetes mellitus. Two patients died between 6 and 12 months of surgery due to recurrence of glioblastoma involving basal ganglia who were under radiotherapy. The follow-up period was varied from 1 month to 25 months ([Table 2]).

Table 2 Surgical outcome following resection of deep-seated brain lesion with syringe port tubular retraction system

Variables	N (%)
Resection of lesions
Gross total resection	134 (85.35%)
Subtotal resection	23 (14.65%)
Partial resection	0
Complications
Surgical bed hematoma	9 (5.73%)
Contusion	7 (4.45%)
Seizure	5 (3.18%)
Weakness	4 (2.54%)
Blood loss, mL	30–500 (average 100)
Mortality	4 (2.54%)
Follow-up, mo	1–25 (average 10.15 ± 5.80)

Discussion

Deeply located intracranial lesions are frequently encountered in neurosurgical practice. It is surgically and technically challenging because it requires brain retraction to reach the deep-seated brain lesion, which is often associated with vital neurovascular structures. Management of these lesions has evolved with the advancement of various surgical approaches and techniques, as well as tools such as self-retaining retractors.[2] [16] Although flat blade retraction induced brain edema, contusion has been described in the literature.[7] Tubular retractor was proposed by Kelly et al in 1988 to reduce or avoid these complications.[17] [18] Tubular retractors provide pressure equally on the surrounding brain and pressure not more than 10 mm Hg which lessens the brain tissue injury as compared with flat blade retractors, where they exert maximum focal pressure over brain tissue.[10] [12] [19] Furthermore, applying focal pressure continuous for 2 hours and more than 30 mm Hg can reduce blood flow in cerebral parenchyma, which may result in ischemic brain injury.[20] [21] Either a microscope or an endoscope and both can be used for tubular resection of deep-seated brain lesions. We used a microscopic plastic syringe tubular approach for all patients. Neuroendoscopic surgery has developed as a minimally invasive technique; however, hemorrhage, infection, cranial nerve deficits, and hormonal dysfunction, as well as a higher rate of recurrence have been reported for resection of deeply seated brain lesions such as ventricular and periventricular tumors.[22] [23] [24]

Numerous tubular retractors have been developed and used for resection of deep brain lesions such as astrocytoma, meningiomas, colloid cyst, vascular malformation, cavernomas, lymphoma, neurocytoma, and metastasis successfully with excellent results in terms of safety and surgical achievement.[6] [15] [25] [26] [27] [28] [29] [30] [31] [32] [33] However, studies for resection of deep brain lesions with a plastic syringe retractor are rarely reported. Ratre et al described that 100 patients with deep-seated lesions treated microendoscopic foldable silicone tubular retractor system where there were 74% astrocytomas; 12% meningiomas, 4% colloid cyst of third ventricle, 4% metastasis, 4% primitive neroectodermal tumor, 1% neurocytoma, and 1% ependymoma; and total resection was in 49%, subtotal resection was in 29%, and partial resection was in 22% of patients.[27] In our study, there were 157 patients with deep brain lesion treated with microscopic plastic syringe tubular retraction system where 50.39% had astrocytomas, 22.29% meningiomas, 6.36% ependymomas, 9.55% colloid cyst of third ventricle, 6.36% metastasis, 3.18% neurocytoma, and 1.91% lymphoma, and total resection was achieved in 85.35% and subtotal resection was achieved in 14.65% of patients. Our reports are almost similar to the report of a study where total resection was performed in 88.9% and subtotal resection in 11.1% of patients with deep-seated brain lesions (including glioblastoma, gliosarcoma, and toxoplasmosis), surgery by plastic syringe with Foley probe system.[34] Similarly, another meta-analysis study on deep-seated brain lesions with four different types of retractors explained that a lower rate of gross total resection was found to be 75% as compared with our result.[35] Furthermore, Vaish et al described that 100% gross total resection in colloid cyst with plastic syringe retraction system,[25] which is consistent with report of a study done by Moraes et al where gross total resection was also 100% in deep-seated lesion (including meningioma, metastasis, and astrocytoma) patients with plastic syringe with Foley probe system ([Table 3]).[26]

Table 3 Literature review of plastic syringe as a tubular retractor technique for resection of intracranial lesions

Author	Number of patients	Diameter of the syringe	Insertion technique	Pathology	Resection of the tumor	Complications
Vaish et al (2014)	20	5 mL (13 mm)	Syringe introduced with Teflon trocar	Colloid cyst	GTR (100%)	Short-term memory impairment (10%)
Almubarak et al (2018)	9	10 mL (17 mm)	Syringe introduced with Foley probe	Glioblastoma, gliosarcoma, toxoplasmosis	GTR (88.9%) STR (11.1%)	Transient aphasia (22.22%), weakness (33.3%), sixth nerve palsy (11.1%), memory impairment (11.1%)
Moraes et al (2024)	4	20 mL (20 mm)	Syringe introduced with Foley probe	Meningioma, metastasis, astrocytoma	GTR (100%)	No complications or postoperative morbidity
Karki et al (present study)	157	5 mL (13 mm) 10 mL(17 mm)	Syringe introduced with Teflon trocar	Astrocytoma, meningioma, ependymoma, colloid cyst, metastasis, lymphoma, neurocytoma	GTR (85.35%) STR (14.65%)	Contusion (4.45%), hematoma (5.73%), seizure (3.18%), weakness (2.54%)

Abbreviations: GTR, gross total resection; STR, subtotal resection.

Minimally invasive techniques with tubular retractor through small corticectomy need the aid of a stereotactic or neuronavigation system, which are expensive and not available in all hospitals[13] [36]; however, some of these tubular retractors have some limitations.[6] [11] [12] We used a plastic syringe tubular retractor system with Teflon trocar from small corticectomy to desired area, which is similar to technique explained by Vaish et al.[25] This plastic syringe is lightweight, transparent, and versatile which can be moved in any direction and avoids time for repositioning as well as it does distort the shape by pressure from surrounding brain, which in contrast to foldable silicone tubular retractor.[27] Furthermore, this plastic syringe retractor made it possible to view the retracted brain parenchyma due to its transparent surface, which protected the brain parenchyma throughout the surgery. It does not need any holder, or we can fix it with dura by suturing. It is a simple, easily reproducible technique, inexpensive and provides an equally safe system as the commercially available ViewSite tubular brain retractor (Vycor Medical Inc., Boca, Raton, Florida, United States) and BrainPath (NiCO Corporation, Indianapolis, Indiana, United States). However, transparent ViewSite retractors are expensive and not easily available as syringe tube, which need manual support or a fixator to hold in position during surgery.

We believe that it also helps reduce bleeding over surgical field by light pressure, which is similar to effect of silicone tube proposed by Yadav et al.[37] We performed surgery with 5 mL (13 mm) plastic syringe for colloid cyst and small brain lesions and 10 mL (17 mm) syringe for large brain lesions, which is consistent with other studies.[25] [34] Our low cost and easily available plastic syringe retraction system is safe and effective with other tubular retractors.[13] [28] [30] [31] [33] [38] [39]

Retraction-related brain injury leading to seizure, brain edema, and neurological deficits has also been reported in literature.[3] [40] Similarly, lower rates of complications were observed in our series such as surgical bed hematoma (5.73%), contusion (4.45%), seizure (3.18%), and transient hemiparesis (2.54%). No second surgery was required for hematoma and contusion, which resolved slowly. Seizure improved with antiepileptic therapy before discharge from the hospital. Weakness in limbs improved gradually in all patients till 1 to 3 months of follow-up period; 30 mL to 500 mL blood was lost in our surgery, and similar blood loss was noted in another study (20–500 mL).[27] A meta-analysis studied 309 patients with deep-seated brain lesion with different four types of retractors such as modified retractor, METRx, Brain Path, and ViewSite Brain Access System where complication rate was found to be 9% of all patients and none of the different retraction system was found to be superior regarding extent of resection or complication.[35] Similarly, there were some complications such as transient aphasia (22.22%), weakness (33.3%), sixth nerve palsy (11.1%), and memory impairment (11.1%) reported in patients with removal with syringe tubular retractor system for deeply located brain lesions.[34] There was 2.54% of death in our patients which was not related to direct surgical complications where one patient died due to a heart attack; there was a recurrence of one metastatic and two glioblastoma cases between 6 and 12 months following a surgical procedure. Similarly, Eliyas et al did a multicenter study on the Brain Path tubular retraction system for deep brain lesions where they found death in 4% of patients due to pulmonary illness at the third month of surgery as well as transient morbidity in 15% of patients, memory impairment in 10% of patients, and weakness in 5% of patients.[3]

We believe that the advantages of syringe tubular retraction system are low cost, effective, and easily available, as well as lighter in weight, which provides the radial distribution of force on brain parenchyma, causing less injury as compared to other traditional microscopic or endoscopic excision. These retractors having round corridor provide better visibility of deep-seated brain lesions because of wider intraoperative pathway for bimanual instrumentation as compared with endoscopic surgery. Due to this shortcoming in endoscopic surgery, better intraoperative hemostasis and total tumor resection are a bit difficult as compared with the microscopic syringe tubular system.[22] [23] [24] To our knowledge, this is the first study of larger number of cases with deep brain lesion treated with a simple syringe tubular retraction system with Teflon probe, and reported safe with low complication and acceptable resection rate because of transparent, better, wider visibility working channel providing for good bimanual instrumentation. However, there are some limitations such as this is a retrospective study and follow-up period is no longer enough to evaluate the recurrence rate in brain lesions. We also did not correlate the size and depth of lesions with resection rate using this technique. Therefore, multicenter large numbers of cases in deep-seated brain lesions treated by a simple syringe retraction system assisted by a Teflon probe with longer follow-up period are needed to study and compare with older retraction system to find out the effectiveness and efficacy of this low-cost tubular retractor system.

Conclusion

Our study reports that the plastic syringe with Teflon probe and tubular retraction technique is safe and effective with low complication rate and excellent resection rate for the treatment of deep-seated intracranial lesions. This is also cheap, easily available in every hospital, lightweight, and transparent, as well as it does require tubular holder. However, further studies with a larger number of patients and a longer follow-up period are required to validate this low-cost syringe tubular retraction technique.

Conflict of Interest

None declared.

Authors' Contribution

M.K. conceived and designed the study, collected data, and wrote and drafted the manuscript. M.V., Y.S.B., H.C., Y.B.R., D.N., and R.P. were responsible for editing and providing technical feedback on design and analyses.

Ethical Approval

This is a retrospective study, so informed consent was taken from the involved participants in this study. This study was approved by the Local Ethics Committee of the Max Super Specialty Hospital.

Data Availability Statement

Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study.

Patients' Consent

We declare that all patients gave informed consent prior to inclusion in this study.

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Publication History

Article published online:
16 May 2025