Endoscope-assisted hemispherotomy: translation of technique from cadaveric anatomical feasibility study to clinical implementation

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OBJECTIVE

Appropriately chosen candidates with medically refractory epilepsy may benefit from hemispheric disconnection. Traditionally, this involves a large surgical exposure with significant associated morbidity. Minimally invasive approaches using endoscopic assistance have been described by only a few centers. Here, the authors report on the feasibility of endoscope-assisted functional hemispherotomy in a cadaver model and its first translation into clinical practice in appropriately selected patients.

METHODS

Three silicone-injected, formalin-fixed cadaver heads were used to establish the steps of the procedure in the laboratory. The steps of disconnection were performed using standard surgical instruments and a straight endoscope. The technique was then applied in two patients who had been referred for hemispherectomy and had favorable anatomy for an endoscope-assisted approach.

RESULTS

All disconnections were performed in the cadaver model via a 4 × 2–cm paramedian keyhole craniotomy using endoscopic assistance. An additional temporal burr hole approach was marked in case the authors were unable to completely visualize the frontobasal and insular cuts from the paramedian vertical view. Their protocol was subsequently used successfully in two pediatric patients. Full disconnection was verified with postoperative tractography.

CONCLUSIONS

Full hemispheric disconnection can be accomplished with minimally invasive endoscope-assisted functional hemispherotomy. The procedure is technically feasible and can be safely applied in patients with favorable anatomy and pathology; it may lead to less surgical morbidity and faster recovery.

Article Information

Correspondence Sandi Lam: Baylor College of Medicine, Texas Children’s Hospital, Houston TX. sklam@texaschildrens.org.

INCLUDE WHEN CITING Published online November 2, 2018; DOI: 10.3171/2018.8.PEDS18349.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Disconnections for functional hemispherotomy. A: Callosotomy and insular disconnection. B: Frontobasal and mesial temporal lobe disconnections. Green lines indicate lines of disconnection. Image created by Katherine Relyea, MS, CMI, and printed with permission from Baylor College of Medicine. Figure is available in color online only.

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    A: Incision and mini craniotomy (solid red line) compared to the standard incision for open hemispherotomy (dashed red line). Green circle indicates burr hole. Ghosted light green burr hole shows a supplemental access point to the temporal horn through the middle temporal gyrus. B: Supine, fixed patient position for endoscope-assisted procedure. Image created by Katherine Relyea, MS, CMI, and printed with permission from Baylor College of Medicine. Figure is available in color online only.

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    Positioning and opening in the cadaver head (A) and the patient (B, for left hemispherotomy). Midline and coronal suture marked in the cadaver head (C) for right hemispherotomy and middle temporal gyrus access. Planned incisions (D) for case 1 for right hemispherotomy by external landmarks and neuronavigation. Note the possible temporal incision and full craniotomy incision indicated with marking pen. Midline coronal suture and right craniotomy marked on the cadaver head (E). For left hemispherotomy (F): two burr holes over the sagittal sinus with one lateral burr hole on the coronal suture for a 4-cm-long × 2-cm-wide craniotomy in case 1. Figure is available in color online only.

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    Endoscopic disconnection of the right hemisphere in a cadaver model (A–D) and intraoperative endoscopic pictures (E–H). A: Parafalcine approach to the corpus callosum. B: Callosotomy at the genu. C: Callosotomy at the splenium with a view of the pineal cistern deep to the arachnoid membrane. D: Atrium of the right lateral ventricle, with the choroid plexus leading into the temporal horn. E: Interhemispheric approach to the corpus callosum. F: Callosotomy at the genu. G: Exposure into the left temporal horn. H: View into the left lateral ventricle with white matter disconnections and associated arachnoid planes. ACA = anterior cerebral artery; CC = corpus callosum; R = right. Figure is available in color online only.

  • View in gallery

    Workflow of endoscope-assisted hemispherotomy. Patient is positioned and the operative field is exposed. Callosotomy is performed to enter the ventricle. The frontobasal disconnection and temporal horn unroofing can proceed in a dynamic order. Finally, a partial hippocampectomy for mesial temporal disconnection is performed. Figure is available in color online only.

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    Case 1. Preoperative baseline (A) and postoperative (B) tractography images showing full hemispheric disconnection. Figure is available in color online only.

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    Case 1. Preoperative axial T1-weighted (A) and T2-weighted (B) MR images. Case 2. Preoperative axial T1-weighted (C) and T2-weighted (D) MR images.

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