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Faith C. Robertson, Muhammad M. Abd-El-Barr, Srinivasan Mukundan Jr. and William B. Gormley


Ventriculostomy entry sites are commonly selected by freehand estimation of Kocher's point or approximations from skull landmarks and a trajectory toward the ipsilateral frontal horn of the lateral ventricles. A recognized ventriculostomy complication is intracranial hemorrhage from cortical vessel damage; reported rates range from 1% to 41%. In this report, the authors assess hemorrhagic risk by simulating traditional ventriculostomy trajectories and using CT angiography (CTA) with venography (CTV) data to identify potential complications, specifically from cortical draining veins.


Radiographic analysis was completed on 50 consecutive dynamic CTA/CTV studies obtained at a tertiary-care academic neurosurgery department. Image sections were 0.5 mm thick, and analysis was performed on a venous phase that demonstrated high-quality opacification of the cortical veins and sagittal sinus. Virtual ventriculostomy trajectories were determined for right and left sides using medical diagnostic imaging software. Entry points were measured along the skull surface, 10 cm posteriorly from the nasion, and 3 cm laterally for both left and right sides. Cannulation was simulated perpendicular to the skull surface. Distances between the software-traced cortical vessels and the virtual catheter were measured. To approximate vessel injury by twist drill and ventricular catheter placement, veins within a 3-mm radius were considered a hemorrhage risk.


In 100 virtual lines through Kocher's point toward the ipsilateral ventricle, 19% were predicted to cause cortical vein injury and suspected hemorrhage (radius ≤ 3 mm). Little difference existed between cerebral hemispheres (right 18%, left 20%). The average (± SD) distance from the trajectory line and a cortical vein was 7.23 ± 4.52 mm. In all 19 images that predicted vessel injury, a site of entry for an avascular zone near Kocher's point could be achieved by moving the trajectory less than 1.0 cm laterally and less than 1.0 cm along the anterior/posterior axis, suggesting that empirical measures are suboptimal, and that patient-specific coordinates based on preprocedural CTA/CVA imaging may optimize ventriculostomy in the future.


In this institutional radiographic imaging analysis, traditional methods of ventriculostomy site selection predicted significant rates of cortical vein injury, matching described rates in the literature. CTA/CTV imaging potentiates identification of patient-specific cannulation sites and custom trajectories that avoid cortical vessels, which may lessen the risk of intracranial hemorrhage during ventriculostomy placement. Further development of this software is underway to facilitate stereotactic ventriculostomy and improve outcomes.

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Richard W. Byrne

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Robert E. Elliott, Robert J. Bollo, Jonathan L. Berliner, Alyson Silverberg, Chad Carlson, Eric B. Geller, William B. Barr, Orrin Devinsky and Werner K. Doyle


In this paper the authors' goal was to identify preoperative variables that predict long-term seizure freedom among patients with mesial temporal sclerosis (MTS) after single-stage anterior temporal lobectomy and amygdalohippocampectomy (ATL-AH).


The authors retrospectively reviewed 116 consecutive patients (66 females, mean age at surgery 40.7 years) with refractory seizures and pathologically confirmed MTS who underwent ATL-AH with at least 2 years of follow-up. All patients underwent preoperative MRI and video-electroencephalography (EEG); 106 patients (91.4%) underwent Wada testing and 107 patients (92.2%) had neuropsychological evaluations. The authors assessed the concordance of these 4 studies (defined as test consistent with the side of eventual surgery) and analyzed the impact of preoperative variables on seizure freedom.


The median follow-up after surgery was 6.7 years (mean 6.9 years). Overall, 103 patients (89%) were seizure free, and 109 patients (94%) had Engel Class I or II outcome. Concordant findings were highest for video-EEG (100%), PET (100%), MRI (99.0%), and Wada testing (90.4%) and lowest for SPECT (84.6%) and neuropsychological testing (82.5%). Using binary logistic regression analysis (seizure free or not) and Cox proportional hazard analysis (seizure-free survival), less disparity in the Wada memory scores between the ipsilateral and contralateral sides was associated with persistent seizures.


Seizure freedom of nearly 90% can be achieved with ATL-AH in properly selected patients with MTS and concordant preoperative studies. The low number of poor outcomes and exclusion of multistage patients limit the statistical power to determine preoperative variables that predict failure. Strong Wada memory lateralization was associated with excellent long-term outcome and adds important localization information to structural and neurophysiological data in predicting outcome after ATL-AH for MTS.

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Michael Westerveld, Kimberlee J. Sass, Gordon J. Chelune, Bruce P. Hermann, William B. Barr, David W. Loring, Esther Strauss, Max R. Trenerry, Kenneth Perrine and Dennis D. Spencer

Object. The authors sought to determine the impact of early temporal lobectomy (in patients younger than age 17 years) on intellectual functioning. The efficacy of temporal lobectomy for treating seizures is well established and the procedure is becoming more acceptable as a treatment for children whose seizures are intractable. However, cognitive outcomes of temporal lobectomy in children and adolescents are largely unreported. The present study takes advantage of a unique multicenter collaboration to examine retrospectively intellectual functioning in a large sample of children who underwent temporal lobectomy.

Methods. Intellectual functioning was assessed before and after temporal lobectomy for treatment of medication-resistant seizures in 82 patients at eight centers of epilepsy surgery. All children underwent standard presurgical examinations, including electroencephalography—video monitoring, magnetic resonance (MR) imaging, and neuropsychological testing, at their respective centers.

Forty-three children underwent left temporal lobectomy and 39 underwent right temporal lobectomy. For the entire sample, there were no significant declines in intelligence quotient (IQ) following surgery. Children who underwent left temporal lobectomy demonstrated no significant loss in verbal intellectual functioning and improved significantly in nonverbal intellectual functioning. Children who underwent right temporal lobectomy did not demonstrate significant changes in intellectual functioning. Although group scores showed no change in overall IQ values, an analysis of individual changes revealed that approximately 10% of the sample experienced a significant decline and 9% experienced significant improvement in verbal functioning. Significant improvement in nonverbal cognitive function was observed in 16% of the sample and only 2% of the sample showed significant declines. Risk factors for significant decline included older patient age at the time of surgery and the presence of a structural lesion other than mesial temporal sclerosis on MR imaging.

Conclusions. The present study provides preliminary data for establishing the risk of cognitive morbidity posed by temporal lobectomy performed during childhood. With respect to global intellectual functioning, a slight improvement was significantly more likely to occur than a decline. However, there were several patients in whom significant declines did occur. It will be necessary to study further the factors associated with such declines. In addition, further study of more specific cognitive functions, particularly memory, is needed.