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Endoscopic and Combined Approaches. Ruth E. Bristol, MD Assistant Professor of Neurosurgery. Acknowledgements. Maggie Bobrowitz, RN, MBA HH team Harold Rekate, MD Adib Abla , MD Patients and Families. Outline. How do we choose the right surgery? What does “endoscopic” mean?

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Endoscopic and Combined Approaches


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  1. Endoscopic and Combined Approaches Ruth E. Bristol, MD Assistant Professor of Neurosurgery

  2. Acknowledgements • Maggie Bobrowitz, RN, MBA • HH team • Harold Rekate, MD • AdibAbla, MD • Patients and Families

  3. Outline • How do we choose the right surgery? • What does “endoscopic” mean? • How an endoscope works • Choosing the endoscopic approach • Risks • What does “combined” mean? • Why we choose a combined approach

  4. How Do We Get There? Blow up of lesion

  5. Patient Selection • Type II, III, and IV: Endoscopic + • Type III and IV: Combined

  6. What Is An Endoscope? Working end Camera

  7. Risks of Treatment • Memory loss • Hypothalamic injury • Increased appetite • Diabetes inispidus • Other hormonal abnormalities • Vascular injuries (stroke) • Cranial nerve

  8. Case 1

  9. Endoscopic Video

  10. Post-op: Resection Cavity

  11. Endoscopy • Endoscope approaching lesion from side contralateral to attachment. • Micromanipulator on the endoscope, and stereotactic guidance frame.

  12. Terms • Contralateral • Ipsilateral

  13. Endoscopic • Pros • Comparable seizure control (49% vs 54%) • Shorter length of stays (4.1 vs 7.7 days) • Cons • Short term memory loss • Less working room (bad for large lesions) • Thalamic infarct reported (~85 % asymptomatic)

  14. Endoscopic • Background

  15. Surgery From Above • Endoscopic series • 37 patients with refractory seizures • Mean age of onset approx 10 months of age • 62 % with IQ < 70 • Always a contralateralapproach Ng, Rekate et al. Neurology 2008

  16. Open Vs. Endoscopic • Percent of disconnect/resection • Not statistically tied to seizure-free rate • 100% resection gave 100% seizure-free postop course in 8 of 12 • Compared to open approach • Endoscopic: Shorter stay: 4.5 versus 7.7 days • Comparable seizure-free rates: 49 % vs. 54 % (endo vs. TC) • Tumors smaller in endoscopic: 1.01 vs 2.43 cc (p=0.0322) • Reasons to favor open approach • Larger tumors (>1.5 cm) with bilateral attachments • Better for children younger than adolescent age

  17. Seizure Control Abla et al., AANS Philadelphia. May 3, 2010

  18. Case 2 • 7 yo female • Gelastic epilepsy • Behavioral problems (impulsivity) • Rapid progression of seizures in summer

  19. Case 2 Post op

  20. Case 3 • 20 months old • Multiple medical problems • Gelastic epilepsy

  21. Case 3 Post op

  22. Endoscopic Approach

  23. Combined Approach

  24. Combined Video

  25. Combined Approach

  26. Outcome • Seizure freedom: 29-49% • Seizure Reduction: 55-73% • In older patients, higher IQ correlated with better chance of seizure freedom • Memory loss 8% permanent • Adults had more complications than children

  27. Complications • Postoperative DI • Usually transient (< 1 week). DDAVP given in ICU • Weight gain (satiety center = VMH) • 19% • Short-term memory loss • Transient • 58 % in TC group / 14 % in endoscopic group (< 2 wks) • Permanent • ~ 8 % in both (2/26 and 3/37) Ng, Rekate et al. Epilepsia 2006

  28. BNI Treatment Paradigm Laser?

  29. Conclusions • PROPER SELECTION • No single approach is appropriate or advantageous for all patients • Decisions individualized • Surgical anatomy • Presence of acute clinical deterioration