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Theodore H. Schwartz and Dennis D. Spencer

Object. Prior reports of seizure control following reoperation for failed epilepsy surgery have shown good results. These studies included patients who presented during the era preceding magnetic resonance (MR) imaging, and the patients were often not monitored intracranially or underwent subtotal hippocampal resections. In this study, the authors hypothesized that reoperation for recurrent seizures following a more comprehensive initial workup and surgery would not yield such good results.

Methods. The authors examined a consecutive series of patients who underwent two operations at Yale—New Haven Hospital for medically intractable epilepsy and in whom there was a minimum of 1-year follow up after the second surgery. All patients were evaluated and treated according to a standard protocol, including preoperative MR imaging, a low threshold for invasive monitoring, and a radical amygdalohippocampectomy when indicated.

Twenty-seven patients were identified (five with mesial temporal sclerosis, 20 with neocortical disease, and two with multifocal sites of seizure onset) of whom six (22%) underwent intentionally palliative second surgery (corpus callostomy or placement of a vagus nerve stimulator [VNS]). Of the remaining 21 patients, only four (19%) became seizure free after a second resective operation. The most common causes of treatment failure were dual pathology, recurrent tumor, limited resection to preserve function, widespread developmental abnormalities, and electrographic sampling error. Successful outcomes resulted from removal of recurrent tumors, completion of a functional hemispherectomy, or repeated invasive monitoring to correct a sampling error. Five (83%) of the six intentionally palliative second operations resulted in more than a 50% decrease in seizure frequency.

Conclusions. If an aggressive preoperative evaluation and surgical resection are performed, reoperation for recurrent seizures has a much lower likelihood of cure than previously reported. Intentionally palliative surgery such as placement of a VNS unit may be considered for patients in whom the initial operation fails to decrease seizure frequency.

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Theodore H. Schwartz and Michael W. McDermott

The Simpson grading scale, developed in 1957 by Donald Simpson, has been considered the gold standard for defining the surgical extent of resection for WHO grade I meningiomas. Since its introduction, the scale and its modifications have generated enormous controversy. The Simpson grade is based on an intraoperative visual assessment of resection, which is subjective and notoriously inaccurate. The majority of studies in which the grading system was used were performed before routine postoperative MRI surveillance was employed, rendering assessments of extent of resection and the definition of recurrence inconsistent. The infiltration and proliferation potential of tumor components such as hyperostotic bone and dural tail vary widely based on tumor location, as does the molecular biology of the tumor, rendering a universal scale for all meningiomas unfeasible. While extent of resection is clearly important at reducing recurrence rates, achieving the highest Simpson grade resection should not always be the goal of surgery.

Donald Simpson’s name and his scale deserve to be recognized and preserved in the historical pantheon of pioneering and transformative neurosurgical concepts. Nevertheless, his eponymous scale is no longer relevant in modern meningioma surgery. While his message of maximizing extent of resection and minimizing morbidity is still germane, a single measure using subjective criteria cannot be applied universally to all meningiomas, regardless of location. Meningioma surgery should be performed with the goal of achieving maximal safe resection, ideally guided by molecularly tagged fluorescent labeling and assessed using objective criteria, including postoperative MRI as well as molecularly tagged scans such as [68Ga]-DOTATATE-PET.

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Ankit Bansal and Sumit Sinha

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Mark M. Souweidane, Caitlin E. Hoffman and Theodore H. Schwartz

Object

Intraventricular anatomy has been detailed as it pertains to endoscopic surgery within the third ventricle, particularly for performing endoscopic third ventriculostomy (ETV) and endoscopic colloid cyst resection. The expanding role of endoscopic surgery warrants a careful appraisal of these techniques as they relate to frequent anatomical variants. Given the common occurrence of cavum septum pellucidum (CSP) and cavum vergae (CV), the endoscopic surgeon should be familiar with that particular anatomy especially as it pertains to surgery within the third ventricle.

Methods

From a prospective database of endoscopic surgical cases were selected those cases in which the defined pathology necessitated surgery within the third ventricle and there was coexistent CSP and CV. Pertinent radiographic studies, operative notes, and archived video files were reviewed to define the relevant anatomy. Features of the intracavitary anatomy were assessed regarding their importance in approaching the third ventricle.

Results

Four cases involving endoscopic surgery within the third ventricle (2 colloid cyst resections and 2 ETVs) were identified in which the surgical objective was accomplished through a septal cavum. In each case the width of the body of the lateral ventricle was reduced and the foramen of Monro was obscured. Because of the ventricular distortion, a stereotactic transcavum route was used for approaching the third ventricle. Entry into the third ventricle was accomplished through an interforniceal fenestration immediately behind the anterior commissure. The surgical goal was met in each case without any neurological change or postoperative morbidity. During the follow-up period, there has been no recurrence of a colloid cyst and no need of a secondary cerebrospinal fluid diversionary procedure.

Conclusions

In the presence of a CSP and CV, endoscopic navigation into the third ventricle can be problematic via a transforaminal approach. Alternatively, a transcavum interforniceal route for endoscopic surgery in the third ventricle is suggested, with the rostral lamina and the anterior commissure as important anatomical landmarks. Endoscopic third ventriculostomy and endoscopic colloid cyst resection performed via a transcavum interforniceal route in patients with a coexistent septal cavum is a feasible and safe option.