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Pravin Salunke, Sushanta K. Sahoo, Ramesh Doddamani, Chirag K. Ahuja and Kanchan K. Mukherjee

Posttraumatic true irreducible C1–2 lateral dislocation is rare. The mechanism of injury is likely to be different for this kind of dislocation. The management of such an injury and the technique for direct posterior reduction remain unclear because of its rarity. The authors describe the case of a 34-year-old man who sustained injury in a vehicular accident, leading to neck pain. Radiological studies revealed fixed right lateral and posterior C1–2 dislocation. Direct posterior open reduction was achieved by distracting the facets and rotating them in a counterclockwise direction. Care was taken to avoid direct or indirect injury to the vertebral arteries. Segmental C1–2 fusion was performed. Distraction with lateral extension injury possibly gives rise to this unique fracture dislocation. Preoperative imaging including angiography for vertebral arteries helps in defining the cause of fixity and in surgical planning. Direct posterior reduction is possible in such fixed C1–2 lateral dislocation, circumventing transoral surgery—provided the facets are preserved.

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P. Sarat Chandra, Heri Subianto, Jitin Bajaj, Shabari Girishan, Ramesh Doddamani, Bhargavi Ramanujam, Mahendra Singh Chouhan, Ajay Garg, Madhavi Tripathi, Chandrasekhar S. Bal, Chitra Sarkar, Rekha Dwivedi, Savita Sapra and Manjari Tripathi

OBJECTIVE

Endoscope-assisted hemispherotomy (EH) has emerged as a good alternative option for hemispheric pathologies with drug-resistant epilepsy.

METHODS

This was a prospective observational study. Parameters measured included primary outcome measures (frequency, severity of seizures) and secondary outcomes (cognition, behavior, and quality of life). Blood loss, operating time, complications, and hospital stay were also taken into account. A comparison was made between the open hemispherotomy (OH) and endoscopic techniques performed by the senior author.

RESULTS

Of 59 cases (42 males), 27 underwent OH (8 periinsular, the rest vertical) and 32 received EH. The mean age was 8.65 ± 5.41 years (EH: 8.6 ± 5.3 years; OH: 8.6 ± 5.7 years). Seizure frequency per day was 7 ± 5.9 (EH: 7.3 ± 4.6; OH: 15.0 ± 6.2). Duration of disease (years since first episode) was 3.92 ± 1.24 years (EH: 5.2 ± 4.3; OH: 5.8 ± 4.5 years). Number of antiepileptic drugs per patient was 3.9 ± 1.2 (EH: 4.2 ± 1.2; OH: 3.8 ± 0.98). Values for the foregoing variables are expressed as the mean ± SD. Pathologies included the following: postinfarct encephalomalacia in 19 (EH: 11); Rasmussen’s syndrome in 14 (EH: 7); hemimegalencephaly in 12 (EH: 7); hemispheric cortical dysplasia in 7 (EH: 4); postencephalitis sequelae in 6 (EH: 2); and Sturge-Weber syndrome in 1 (EH: 1). The mean follow-up was 40.16 ± 17.3 months. Thirty-nine of 49 (79.6%) had favorable outcomes (International League Against Epilepsy class I and II): in EH the total was 19/23 (82.6%) and in OH it was 20/26 (76.9%). There was no difference in the primary outcome between EH and OH (p = 0.15). Significant improvement was seen in the behavioral/quality of life performance, but not in IQ scores in both EH and OH (p < 0.01, no intergroup difference). Blood loss (p = 0.02) and hospital stay (p = 0.049) were less in EH.

CONCLUSIONS

EH was as effective as the open procedure in terms of primary and secondary outcomes. It also resulted in less blood loss and a shorter postoperative hospital stay.

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Shabari Girishan, Manjari Tripathi, Ajay Garg, Ramesh Doddamani, Jitin Bajaj, Bhargavi Ramanujam and P. Sarat Chandra

Objective

The authors sought to analyze the residual connections formed by the temporal stem as a cause for seizure recurrence following endoscopic vertical interhemispheric hemispherotomy and to review and compare lateral approach (perisylvian) with vertical approach surgical techniques to highlight the anatomical factors responsible for residual connections.

METHODS

This study was a retrospective analysis of patients who underwent endoscopic hemispherotomy for drug-resistant epilepsy. Postoperative MR images were analyzed. Specific attention was given to anatomical 3D-acquired thin-section T1 images to assess the extent of disconnection, which was confirmed with a diffusion tensor imaging sequence. Cadaver brain dissection was done to analyze the anatomical factors responsible for persistent connections.

RESULTS

Of 39 patients who underwent surgery, 80% (31/39) were seizure free (follow-up of 23.61 ± 8.25 months) following the first surgery. Thirty patients underwent postoperative MRI studies, which revealed persistent connections in 14 patients (11 temporal stem only; 3 temporal stem + amygdala + splenium). Eight of these 14 patients had persistent seizures. In 4 of these 8 patients, investigations revealed good concordance with the affected hemisphere, and repeat endoscopic disconnection of the residual connection was performed. Two of the 8 patients were lost to follow-up, and 2 had bihemispheric seizure onset. The 4 patients who underwent repeat endoscopic disconnection had seizure-free outcomes following the second surgery, increasing the good outcome total among all patients to 90% (35/39). Cadaveric brain dissection analysis revealed the anatomical factors responsible for the persistence of residual connections.

CONCLUSIONS

In endoscopic vertical approach interhemispheric hemispherotomy (and also vertical approach parasagittal hemispherotomy) the temporal stem, which lies deep and parallel to the plane of disconnection, is prone to be missed, which might lead to persistent or recurrent seizures. The recognition of this limitation can lead to improved seizure outcome. The amygdala and splenium are areas less commonly prone to be missed during surgery.