Endoscopic anatomy and approaches of the cavernous sinus cadaver study.
Endoscopic and Combined Approaches
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Transcript of Endoscopic and Combined Approaches
Endoscopic and Combined Approaches
Ruth E. Bristol, MD
Assistant Professor of Neurosurgery
Acknowledgements
• Maggie Bobrowitz, RN, MBA• HH team• Harold Rekate, MD• Adib Abla, MD• Patients and Families
Outline
• How do we choose the right surgery?• What does “endoscopic” mean?
• How an endoscope works• Choosing the endoscopic approach• Risks
• What does “combined” mean?• Why we choose a combined approach
How Do We Get There?
Blow up of lesion
Patient Selection
• Type II, III, and IV: Endoscopic +
• Type III and IV: Combined
What Is An Endoscope?
Camera
Working end
Risks of Treatment
• Memory loss
• Hypothalamic injury• Increased appetite• Diabetes inispidus• Other hormonal abnormalities
• Vascular injuries (stroke)
• Cranial nerve
Case 1
Endoscopic Video
Post-op: Resection Cavity
Endoscopy
• Endoscope approaching lesion from side contralateral to attachment.
• Micromanipulator on the endoscope, and stereotactic guidance frame.
Terms
• Contralateral• Ipsilateral
Endoscopic
• Pros• Comparable seizure
control (49% vs 54%)• Shorter length of stays
(4.1 vs 7.7 days)
• Cons• Short term memory
loss• Less working room
(bad for large lesions)• Thalamic infarct
reported (~85 % asymptomatic)
Endoscopic
• Background
Surgery From Above
• Endoscopic series• 37 patients with refractory seizures• Mean age of onset approx 10 months of age• 62 % with IQ < 70• Always a contralateral approach
Ng, Rekate et al. Neurology 2008
Open Vs. Endoscopic
• Percent of disconnect/resection• Not statistically tied to seizure-free rate• 100% resection gave 100% seizure-free postop course in 8 of 12
• Compared to open approach• Endoscopic: Shorter stay: 4.5 versus 7.7 days
• Comparable seizure-free rates: 49 % vs. 54 % (endo vs. TC)
• Tumors smaller in endoscopic: 1.01 vs 2.43 cc (p=0.0322)
• Reasons to favor open approach• Larger tumors (>1.5 cm) with bilateral attachments• Better for children younger than adolescent age
Seizure Control
Abla et al., AANS Philadelphia. May 3, 2010
Case 2
• 7 yo female• Gelastic epilepsy• Behavioral problems
(impulsivity)• Rapid progression of
seizures in summer
Case 2 Post op
Case 3
• 20 months old• Multiple medical
problems• Gelastic epilepsy
Case 3 Post op
Endoscopic Approach
Combined Approach
Combined Video
Combined Approach
Outcome
• Seizure freedom: 29-49%• Seizure Reduction: 55-73%• In older patients, higher IQ correlated with better
chance of seizure freedom• Memory loss 8% permanent• Adults had more complications than children
Complications
• Postoperative DI• Usually transient (< 1 week). DDAVP given in ICU
• Weight gain (satiety center = VMH)• 19%
• Short-term memory loss• Transient
• 58 % in TC group / 14 % in endoscopic group (< 2 wks)
• Permanent• ~ 8 % in both (2/26 and 3/37)Ng, Rekate et al. Epilepsia 2006
SMALL LARGE
Type I OZ OZ
Gamma Knife (stable)
Type II Endoscopic Transcallosal
Gamma Knife (bilateral, clinically stable)
Type III Endoscopic +/- OZ ---
Gamma Knife (stable)
Type IV --- Staged : target main component 1st
BNI Treatment Paradigm
Laser?
Conclusions
• PROPER SELECTION• No single approach is appropriate or advantageous
for all patients
• Decisions individualized• Surgical anatomy• Presence of acute clinical deterioration