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Symposium for Patients & Caregivers

Symposium for Patients & Caregivers. Endoscopic and Combined Surgical 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.

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Symposium for Patients & Caregivers

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  1. Symposium for Patients & Caregivers

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

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

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

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

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

  7. Risks of Treatment • Memory loss • Hypothalamic injury • Increased appetite • Diabetes inispidus • Other hormonal abnormalities • Cranial nerve/ vascular injuries

  8. Risk Spectrum • Lowest Risk • Highest Risk • Gamma Knife • Endoscopic • Transcallosal • Orbitozygomatic

  9. What Is An Endoscope?

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

  11. Terms • Contralateral • Ipsilateral

  12. 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)

  13. Endoscopic • Background

  14. Surgery From Above • Endoscopic series • 37 patients with seizures refractory to 3+ AED’s (32/37 started as gelastic) • Mean age of onset approx 10 months of age • 62 % with IQ < 70 • Always a contralateral approach • Preferred when attached to one ventricle • Results Ng, Rekate et al. Neurology 2008

  15. Surgery From Above • Percent of disconnect/resection (measured by blinded radiologist) • Not statistically tied to seizure-free rate • 100% resection gave 100% seizure-free postop course in two-thirds (8 of 12) • Compared to open approach • Shorter LOS endoscopic • 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 • 6 mm of space needed between top of tumor and roof of 3rd for endoscope

  16. Seizure control Abla et al., AANS Philadelphia. May 3, 2010

  17. 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

  18. Complications • Postoperative DI • Usually transient (< 1 week). DDAVP given in ICU • Weight gain (satiety center = VMH) • 19% in open TC • 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

  19. BNI Treatment Paradigm

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

  21. A Special Thanks To Our Sponsors • Aesculap • Barrow Neurological Institute @ St. Joseph’s Hospital • Barrow Neurological Institute @ Phoenix Children’s Hospital • Great Council for the Improved • Hope for Hypothalamic Hamartoma Foundation • KARL STORZ Endoskope

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