Suboccipital approach for fourth ventricle choroid plexus papilloma: 3-dimensional operative video

Background: Choroid plexus papilloma (CPP) is a rare tumor of the central nervous system. The most common CPP surgery complication is intraoperative bleeding, mainly in cases of posterior inferior cerebellar artery (PICA) branch encasement. In these cases, early identification of the PICA and tumor feeding vessels is necessary, with their proximal control, and progressive coagulation of the choroid plexus, aiming to reduce the blood supply to the tumor. This video explains step-by-step the surgical technique CPP with intraoperative PICA breach bleeding. Case Description: We present a 48-year-old female with a year of progressive occipital headache and 2 weeks of ataxia and dizziness. In neurological examination, she presented with gait ataxia. The imaging investigation with magnetic resonance showed a fourth ventricle mass of 2,8 centimeter, with cerebellar compression and left PICA encasement. The treatment was a surgical resection by a suboccipital approach. There was a rupture of a PICA branch during tumor resection, which was controlled with compression and bipolar coagulation. A near-total resection was performed with a small tumor remnant remaining in the PICA. The patient evolved with improvement of pre-operative symptoms. Tumor biopsy confirms the CPP diagnosis. Conclusion: CPP of the fourth ventricle is a rare benign tumor, which should be included in the differential diagnosis of intraventricular tumors. The IV ventricle location presents additional surgical challenges, such as arterial encasement and brainstem adhesions. This surgical video highlights the main techniques to perform an IV ventricle CPP resection.