Case Prep: Clival Chordoma Resection

Case / Approach Snapshot

• Anatomy at risk: tumor compartment, arterial supply, venous drainage/sinuses, cranial nerves, white-matter tracts, pituitary/CSF pathways when relevant, and functional cortex.
• Operative steps: review imaging and goals, choose exposure, obtain brain relaxation, devascularize when possible, debulk internally, dissect capsule from critical structures, verify extent/safety, and reconstruct watertight closure; use the detailed operative sequence and approach notes below as the step-by-step source.
• Rescue plans: venous or arterial injury, swelling, seizure, cranial nerve or endocrine change, CSF leak, residual tumor left for safety, staged surgery, radiation, or adjuvant therapy.
• Figures: review Figures, Imaging & Video and the Curated Image Set; embedded local figures should remain open-access, public-domain, or otherwise reusable with attribution.
• Papers: review High-Yield Literature for seminal sources, modern reviews, and outcome data specific to this page.

One-Liner

[Age]yo [M/F] with a clival chordoma presenting with [diplopia (CN VI) / headache / lower cranial neuropathy] planned for endoscopic endonasal [transclival] resection [± staged/combined approach].

Figures, Imaging & Video

🎥 Operative video — search operative video on YouTube ▸ · The Neurosurgical Atlas ▸

CNS Video Library

🧭 Operative approach: Endoscopic endonasal approach — detailed corridor setup, step-by-step technique & figures

Neurosurgical Atlas · Radiopaedia · PubMed Central — operative figures © linked; see media-sources.md

High-Yield Literature

• Clival Chordoma: Case Report and Review of Recent Developments in Surgical and Adjuvant Treatments — Khawaja AM. Polish journal of radiology 2017. PubMed
• Proton beam therapy for clival chordoma: Optimising rare cancer treatments in Australia — Mathew A. Journal of medical radiation sciences 2024. PubMed
• Clival Chordoma: Endoscopic Bilateral Transmaxillary Approach — Youssef AS. Journal of neurological surgery. Part B, Skull base 2019. PubMed
• Cytodiagnosis of Clival Chordoma — Giri R. Journal of cytology 2023. PubMed
• Clival chordoma — Tarshis LM. The Journal of otolaryngology 1976. PubMed
• Clival chordoma: a single-centre outcome analysis — Jägersberg M. Acta neurochirurgica 2017. PubMed
• Clival chordoma with drop metastases — Nor FEM. Journal of radiology case reports 2018. PubMed
• Surgical Outcomes of Clival Chordoma Through Endoscopic Endonasal Approach: A Single-Center Experience — Chen G. Frontiers in endocrinology 2022. PubMed
• Fractionated Radiotherapy After Gross Total Resection of Clival Chordoma: A Systematic Review of Survival Outcomes — Gendreau JL. Neurosurgery 2023. PubMed
• An unusual presentation of clival chordoma: a case report and review of the literature — Andijani M. British journal of neurosurgery 2020. PubMed

Curated Image Set

Open-access figures are embedded from PubMed Central articles and kept unique to this guide.

Figure 1. Comparison of ADC values between stable and aggressive chordoma (10–6 mm2/s). There were significant differences between groups in (a) maximum ADC (P = 0.012), (b) mean ADC (P < 0.001),… Source: Apparent diffusion coefficient as a prognostic factor in clival chordoma — Scientific Reports 2021; CC BY.

Figure 2. ROC curves for ADC values differentiating aggressive chordoma from stable chordoma. Source: Apparent diffusion coefficient as a prognostic factor in clival chordoma — Scientific Reports 2021; CC BY.

Figure 4. A 37-year-old man was diagnosed with classic chordoma and placed in the aggressive group. (a) Preoperative contrast enhanced T1-weighted imaging showed a tumor compressing the brainstem…. Source: Apparent diffusion coefficient as a prognostic factor in clival chordoma — Scientific Reports 2021; CC BY.

Figure 5. A 36-year-old man diagnosed with classic chordoma and placed in the stable group. (a) Preoperative T2-weighted imaging showed a T2 high signal mass arising from the clivus. (b) The ROI… Source: Apparent diffusion coefficient as a prognostic factor in clival chordoma — Scientific Reports 2021; CC BY.

Fig. 1. A. T2-weighted MRI, axial view. The arrow shows hyperintense Clival lesion located 3 mm from the anterior end of the clivus, the mass can be seen compressing the left internal carotid… Source: Clival chordoma presenting with isolated unilateral cranial nerve XII palsy: A case report — International Journal of Surgery Case Reports 2024; CC BY.

Fig. 2. T2-weighted MRI, axial view. Signs of surgical intervention on the clivus are noted. The arrow shows residual tumor. (post-operative MRI). Source: Clival chordoma presenting with isolated unilateral cranial nerve XII palsy: A case report — International Journal of Surgery Case Reports 2024; CC BY.

Fig. 3. A. Chordoma (H&E 100×). Prominent myxoid background containing small columns or clusters of bubbly physalipharous cells. B. Chordoma (H&E 400×). Occasional cells with irregular or… Source: Clival chordoma presenting with isolated unilateral cranial nerve XII palsy: A case report — International Journal of Surgery Case Reports 2024; CC BY.

Fig. 4. A. Chordoma, Immunohistochemical staining. Arrows show positivity for cytokeratin (CK). B. Chordoma, Immunohistochemical staining. The arrow shows positivity for epithelial membrane… Source: Clival chordoma presenting with isolated unilateral cranial nerve XII palsy: A case report — International Journal of Surgery Case Reports 2024; CC BY.

Figure 1. The pre- and post- MRIs of all the patients. Source: Surgical Outcomes of Clival Chordoma Through Endoscopic Endonasal Approach: A Single-Center Experience — Frontiers in Endocrinology 2022; CC BY.

History of Present Illness

• Chief complaint: Diplopia (CN VI palsy — abducens along clivus, classic), headache, lower CN dysfunction, brainstem compression
• Locally aggressive, midline, bone-destructive; arises from notochordal remnants
• Prior treatment/surgery/radiation (often recurrent/multiply-operated)

Imaging Review

MRI (T1±Gad, T2)

• Midline clival mass, T2 hyperintense, heterogeneous enhancement
• Brainstem compression, extent (upper/mid/lower clivus), lateral extension (petrous, cavernous, jugular foramen)
• ICA (paraclival/cavernous) and basilar artery relationship/encasement
• Dural breach, intradural extension

CT / CTA

• Bony destruction, calcification, sequestered bone; ICA bony canal; craniocervical junction stability (lower clival/C1-2 → may need fusion)

Labs

• CBC, BMP, Coags, Type and crossmatch

Neurological Examination

• Full CN (VI especially, lower CNs), brainstem/long tracts, swallowing

Surgical Planning

Case Logistics, OR Needs & Orders

• OR setup: navigation, endoscope/microscope as approach requires, ENT co-surgeon for endonasal cases, Doppler, lumbar drain only when indicated, reconstruction materials, and visual/endocrine baseline available.
• Special needs: steroid strategy individualized (Cushing workup may require avoiding preop steroids), DI/sodium protocol, AM cortisol/endocrine labs, visual-check plan, arterial line for large/vascular cases, and CSF-leak/nasal precautions.
• Immediate postop orders: neuro and visual checks, strict I/O with sodium/urine specific gravity schedule when pituitary stalk risk exists, cortisol/endocrine replacement plan, nasal precautions, MRI/CT timing, steroid taper, and DVT prophylaxis timing.

Diagnosis & Indication

• Indication: Maximal safe resection (extent of resection is the strongest prognostic factor) followed by high-dose proton/photon radiation
• Endoscopic endonasal transclival is workhorse for midline; lateral extension may need combined/transcranial or far-lateral
• Goals: Gross total/maximal resection while preserving neurovascular structures; en bloc when feasible (usually piecemeal due to location)

Position

• Supine, slight extension, navigation (CT/MR + CTA fusion), possible lumbar drain
• ENT co-surgeon (endonasal)

Key Surgical Steps (Endoscopic Endonasal Transclival)

1. Nasal phase, nasoseptal flap(s) harvested (reconstruction — may need bilateral/extended)
2. Wide sphenoidotomy, posterior septectomy
3. Identify and skeletonize both paraclival/cavernous ICAs (navigation + micro-Doppler) — define safe lateral corridor between carotids
4. Drill clival bone, remove tumor + involved bone (chordoma invades bone — must remove affected bone)
5. Work between the carotids; for intradural extension, open dura, debulk off brainstem/basilar
6. Preserve CN VI (Dorello canal), basilar perforators, brainstem
7. Maximal resection; accept residual on encased ICA/basilar/brainstem
8. Robust multilayer skull base reconstruction (fascia lata, fat, nasoseptal flap, sealant ± lumbar drain) — high CSF leak risk (clival/posterior fossa)

Critical Anatomy & Structures at Risk

1. Internal carotid arteries (paraclival/cavernous) — define lateral limits; injury catastrophic
2. Basilar artery and perforators, brainstem (pons/medulla)
3. CN VI (Dorello canal), lower cranial nerves (lateral/lower extension), CN III/IV
4. Craniocervical junction stability (lower clival/condylar resection)

Equipment

• Endoscope + endonasal skull base set, navigation (CTA fusion), high-speed drill, micro-Doppler, ICG
• Nasoseptal flap, fascia lata/fat graft, sealant, lumbar drain
• CN stimulator

Monitoring

• SSEPs, MEPs, CN EMG (VI, lower CNs), BAER

Anesthesia

• Arterial line, crossmatched blood, ICA injury contingency (rapid transfusion, neuroIR on standby for sacrifice/embolization), long case

Potential Complications

1. ICA injury — life-threatening; pack, balloon/embolize, angiography
2. CSF leak (high) — robust reconstruction
3. CN deficits (VI common), brainstem injury
4. Craniocervical instability (may need occipitocervical fusion)
5. Recurrence (high — adjuvant radiation essential), meningitis

Operative Note Template

Preoperative Diagnosis: Clival chordoma [with brainstem compression / CN VI palsy]

Postoperative Diagnosis: Same

Procedure: Endoscopic endonasal transclival resection of clival chordoma with multilayer skull base reconstruction [nasoseptal flap]

Surgeon / Assistant: Neurosurgery + ENT skull base co-surgeon Anesthesia: General endotracheal EBL / Fluids / Blood products: [crossmatched; ICA-injury contingency ready] Adjuncts: Neuronavigation with CTA fusion, micro-Doppler, ICG, high-speed drill, CN EMG (VI, lower CNs)/SSEP/MEP; lumbar drain Implants: Fascia lata/fat graft, nasoseptal flap, sealant Complications: None

Indications: [Age]yo [M/F] with a clival chordoma causing [diplopia (CN VI)/brainstem compression]. Maximal safe resection followed by proton/photon radiation was planned. Risks (ICA injury, CSF leak, CN deficits, CCJ instability) discussed; rapid-transfusion and neuro-IR contingency arranged.

Description of Procedure: After consent and time-out, general anesthesia was induced, navigation registered with CTA fusion, and a lumbar drain placed. With the ENT co-surgeon, a nasal phase with nasoseptal flap harvest, wide sphenoidotomy, and posterior septectomy was performed. Both paraclival ICAs were identified and skeletonized with navigation and micro-Doppler, defining the safe intercarotid corridor.

The clival bone and tumor were drilled and removed, including involved bone. Working between the carotids, [the dura was opened for the intradural component and tumor debulked off the brainstem and basilar artery], preserving CN VI (Dorello canal), basilar perforators, and the brainstem. Maximal resection was achieved; residual encasing the ICA/basilar/brainstem was left. A robust multilayer skull base reconstruction was performed with fascia lata, fat, the vascularized nasoseptal flap, and sealant.

The patient was transferred to the ICU with CSF-leak precautions and the lumbar drain in place.

Postoperative Plan

• ICU, neuro checks q1h
• CSF leak precautions, lumbar drain management, DI/Na if sellar involvement
• CN VI and lower CN assessment, swallow eval
• MRI/CT postop (EOR), watch rhinorrhea/meningitis/pneumocephalus
• Adjuvant proton/photon radiation (essential), tumor board
• CCJ stability assessment; long-term surveillance MRI

Chief-Level Case Review

Use these as the senior-level mental model for Clival Chordoma Resection:

• Decision point: Decide the real endpoint before opening: cure, cytoreduction, diagnosis, decompression, separation from critical structures, or safe maximal resection.
• Technical lever: Map what must be left behind: perforators, cranial nerves, venous sinuses, eloquent cortex/tracts, hypothalamus/pituitary axis, and adherent capsule planes.
• Bailout: Sequence matters: devascularize early when safe, create CSF/working space, debulk before traction, and preserve the arachnoid plane unless oncologic goals justify violating it.
• Postop watch: The postop plan should match the risk structure: endocrine/vision/swallow/CN checks, steroid taper, seizure plan, MRI timing, CSF-leak watch, and adjuvant-treatment handoff.

Common Pimp Questions

Use these to pressure-test preparation for Clival Chordoma Resection:

1. What is the surgical goal: gross-total, maximal safe, decompression, diagnosis, or cytoreduction?
2. What eloquent cortex, tract, cranial nerve, vessel, or sinus defines the stopping point?
3. What adjunct changes the case: navigation, mapping, 5-ALA, ultrasound, endoscope, ICG, or neuromonitoring?
4. What is the edema, steroid, seizure, DVT, and postop imaging plan?
5. What complication would you check for first in PACU based on this lesion location?

Attending Preference Variables

Items that commonly vary by surgeon or institution:

• Extent-of-resection goal and functional stopping points: [attending-specific]
• Mapping/monitoring, 5-ALA, ultrasound, ICG, endoscope, or tractography preferences: [attending-specific]
• Steroid, antiepileptic, mannitol/hypertonic saline, and antibiotic plan: [attending-specific]
• Postop MRI timing, ICU/floor threshold, and adjuvant-referral workflow: [attending-specific]