Roy Thomas Daniel and Vedantam Rajshekhar
Daniele Starnoni, Roy Thomas Daniel, Constantin Tuleasca, Mercy George, Marc Levivier and Mahmoud Messerer
During the last decade, the primary objective for large vestibular schwannoma (VS) management has progressively shifted, from tumor excision to nerve preservation by using a combined microsurgical and radiosurgical approach. The aim of this study was to provide a systematic review and meta-analysis of the available literature regarding the combined strategy of subtotal resection (STR) followed by stereotactic radiosurgery (SRS) for large VSs.
The authors performed a systematic review and meta-analysis in compliance with the PRISMA guidelines for article identification and inclusion using the PubMed, Embase, and Cochrane databases. Established inclusion criteria were used to screen all identified relevant articles published before September 2017 without backward date limit.
The authors included 9 studies (248 patients). With a weighted mean follow-up of 46 months (range 28–68.8 months), the pooled rate of overall tumor control was 93.9% (95% CI 91.0%–96.8%). Salvage treatment (second STR and/or SRS) was necessary in only 13 (5.24%) of 18 patients who experienced initial treatment failure. According to the House-Brackmann (HB) grading scale, functional facial nerve preservation (HB grade I–II) was achieved in 96.1% of patients (95% CI 93.7%–98.5%). Serviceable hearing after the combined approach was preserved in 59.9% (95% CI 36.5%–83.2%).
A combined approach of STR followed by SRS was shown to have excellent clinical and functional outcomes while still achieving a tumor control rate comparable to that obtained with a total resection. Longer-term follow-up and larger patient cohorts are necessary to fully evaluate the rate of tumor control achieved with this approach.
Giulia Cossu, Mahmoud Messerer and Roy Thomas Daniel
Giulia Cossu, Pablo González-López, Etienne Pralong, Judith Kalser, Mahmoud Messerer and Roy Thomas Daniel
Surgery for frontal lobe epilepsy remains a challenge because of the variable seizure outcomes after surgery. Disconnective procedures are increasingly applied to isolate the epileptogenic focus and avoid complications related to extensive brain resection. Previously, the authors described the anterior quadrant disconnection procedure to treat large frontal lobe lesions extending up to but not involving the primary motor cortex. In this article, they describe a surgical technique for unilateral disconnection of the prefrontal cortex, while providing an accurate description of the surgical and functional anatomy of this disconnective procedure.
The authors report the surgical treatment of a 5-month-old boy who presented with refractory epilepsy due to extensive cortical dysplasia of the left prefrontal lobe. In addition, with the aim of both describing the subcortical intrinsic anatomy and illustrating the different connections between the prefrontal lobe and the rest of the brain, the authors dissected six human cadaveric brain hemispheres. These dissections were performed from lateral to medial and from medial to lateral to reveal the various tracts sectioned during the three different steps in the surgery, namely the intrafrontal disconnection, anterior callosotomy, and frontobasal disconnection.
The first step of the dissection involves cutting the U-fibers. During the anterior intrafrontal disconnection, the superior longitudinal fasciculus in the depth of the middle frontal gyrus, the uncinate fasciculus, and the inferior frontooccipital fasciculus in the depth of the inferior frontal gyrus at the level of the anterior insular point are visualized and sectioned, followed by sectioning of the anterior limb of the internal capsule. Once the frontal horn is reached, the anterior callosotomy can be performed to disconnect the genu and the rostrum of the corpus callosum. The intrafrontal disconnection is deepened toward the falx, and at the medial surface, the cingulum is sectioned. The frontobasal disconnection involves cutting the anterior limb of the anterior commissure.
This technique allows selective isolation of the epileptogenic focus located in the prefrontal lobe to avoid secondary propagation. Understanding the surface and white matter fiber anatomy is essential to safely perform the procedure and obtain a favorable seizure outcome.
Pablo Gonzalez-Lopez, Giulia Cossu, Etienne Pralong, Matias Baldoncini, Mahmoud Messerer and Roy Thomas Daniel
Anterior quadrant disconnection represents a safe surgical option in well-selected pediatric patients with a large frontal lobe lesion anterior to the motor cortex. The understanding of the anatomy of the white matter tracts connecting the frontal lobe with the rest of the cerebrum forms the basis of a safe and successful disconnective surgery. The authors explored and illustrated the relevant white matter tracts sectioned during each surgical step using fiber dissection techniques.
Five human cadaveric hemispheres were dissected to illustrate the frontal connections in the 3 planes. The dissections were performed from lateral to medial, medial to lateral, and ventral to dorsal to describe the various tracts sectioned during the 4 steps of this surgery, namely the anterior suprainsular window, intrafrontal disconnection, anterior callosotomy, and frontobasal disconnection.
At the beginning of each surgical step, the U fibers were cut. During the anterior suprainsular window, the superior longitudinal fasciculus (SLF), the uncinate fasciculus, and the inferior fronto-occipital fasciculus (IFOF) were visualized and sectioned, followed by sectioning of the anterior limb of the internal capsule. During the intrafrontal disconnection, the SLF was cut, along with the corona radiata. At the medial surface the cingulum was sectioned. The anterior callosotomy disconnected the anterior third of the body of the callosum, the genu, and the rostrum. The frontobasal disconnection addressed the last remaining fibers connecting the frontal lobe with the rest of the hemisphere, namely the anterior limb of the anterior commissure.
The anterior peri-insular quadrantotomy aims at effectively treating children with large lesions of the frontal lobe anterior to the motor cortex. A precise understanding of the gyral anatomy of this lobe along with the several white matter connections is crucial to avoid motor complications and to ensure complete disconnection.
Rodolfo Maduri, Viviana Aureli, Vincent Dunet, Roy Thomas Daniel and Mahmoud Messerer
Mahmoud Messerer, Giulia Cossu, Roy Thomas Daniel and Emmanuel Jouanneau
Giulia Cossu, Sebastien Lebon, Margitta Seeck, Etienne Pralong, Mahmoud Messerer, Eliane Roulet-Perez and Roy Thomas Daniel
Refractory frontal lobe epilepsy has been traditionally treated through a frontal lobectomy. A disconnective technique may allow similar seizure outcomes while avoiding the complications associated with large brain resections. The aim of this study was to describe a new technique of selective disconnection of the frontal lobe that can be performed in cases of refractory epilepsy due to epileptogenic foci involving 1 frontal lobe (anterior to the motor cortex), with preservation of motor function. In addition to the description of the technique, an illustrative case is also presented.
This disconnective procedure is divided into 4 steps: the suprainsular window, the anterior callosotomy, the intrafrontal disconnection, and the frontobasal disconnection. The functional neuroanatomy is analyzed in detail for each step of the surgery. It is important to perform cortical and subcortical electrophysiological mapping to guide this disconnective procedure and identify eloquent cortices and intact neural pathways.
The authors describe the case of a 9-year-old boy who presented with refractory epilepsy due to epileptogenic foci localized to the right frontal lobe. MRI confirmed the presence of a focal cortical dysplasia of the right frontal lobe. A periinsular anterior quadrant disconnection (quadrantotomy) was performed. The postoperative period was uneventful, and the patient was in Engel seizure outcome Class I at the 3-year follow-up. A significant cognitive gain was observed during follow-up.
Periinsular anterior quadrantotomy may thus represent a safe technique to efficiently treat refractory epilepsy when epileptogenic foci are localized to 1 frontal lobe while preserving residual motor functions.