Minimally invasive endoscopic transventricular hemispherotomy for medically intractable epilepsy: a new approach and cadaveric demonstration

Laboratory investigation

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Object

Surgery for medically intractable epilepsy secondary to unihemispheric pathology has evolved from more aggressive hemispherectomy to less aggressive variations of hemispherotomy. The authors propose a novel minimally invasive endoscopic hemispherotomy that should give results comparable to conventional open craniotomy and microsurgery.

Methods

Endoscopic transventricular hemispherotomy was performed in 5 silicon-injected cadaveric heads in the authors' minimally invasive neurosurgery laboratory. The lateral ventricle was accessed endoscopically through a frontal and occipital bur hole. White matter disconnections were performed to unroof the temporal horn and to disconnect the frontobasal region, corpus callosum, and fornix.

Results

Using an endoscopic transventricular approach, all white matter disconnections were successfully performed in all 5 cadavers.

Conclusions

The authors have demonstrated the feasibility of endoscopic transventricular hemispherotomy in a cadaveric model. The technique is simple and could be useful in a subgroup of patients with parenchymal volume loss and ventriculomegaly.

Article Information

Address correspondence to: Alan R. Cohen, M.D., Division of Pediatric Neurosurgery, Case Western Reserve University School of Medicine, Rainbow B-501, 11100 Euclid Avenue, Cleveland, Ohio 44106. email: alan.cohen@uhhs.com.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Schematic drawing illustrating entry into the right lateral ventricle through anterior and posterior bur holes. Left Inset: View through the anterior bur hole. Right Inset: View through the posterior bur hole.

  • View in gallery

    Approach through the right anterior bur hole showing the frontal horn of the lateral ventricle. A: Normal anatomy showing septum pellucidum (SP), head of the caudate nucleus (CN), and the foramen of Monro (FM). B: Normal anatomy with lines depicting the proposed white matter disconnections, including the anterior callosotomy (arrowhead), frontobasal disconnection (arrow), and anterior temporal horn unroofing (asterisk). C: Posthemispherotomy image showing the anterior callosotomy (arrowhead), frontobasal disconnection (arrow), and anterior temporal horn unroofing (asterisk).

  • View in gallery

    Approach through the right posterior bur hole showing the lateral ventricular anatomy. A: Normal anatomy showing the corpus callosum (CC), bulb of the corpus callosum (X), fornix (arrowhead) and the calcar avis (CA). B: Normal anatomy with lines depicting the proposed white matter disconnections, including posterior callosotomy (asterisk), fornix disconnection (arrowhead), and plane of temporal horn unroofing (arrow). C: Postdissection image showing posterior callosotomy (asterisk), fornix disconnection (arrowhead), plane of temporal horn unroofing (arrow), and the pineal cistern after removal of the bulb of the corpus callosum (X).

References

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