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