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Sinha S, Kalyal N, Gallagher MJ, Richardson D, Kalaitzoglou D, Abougamil A, Silva M, Oviedova A, Patel S, Mirallave-Pescador A, Bleil C, Zebian B, Gullan R, Ashkan K, Vergani F, Bhangoo R, Pedro Lavrador J. Impact of Preoperative Mapping and Intraoperative Neuromonitoring in Minimally Invasive Parafascicular Surgery for Deep-Seated Lesions. World Neurosurg 2024; 181:e1019-e1037. [PMID: 37967744 DOI: 10.1016/j.wneu.2023.11.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 11/07/2023] [Indexed: 11/17/2023]
Abstract
BACKGROUND Transsulcal tubular retractor-assisted minimally invasive parafascicular surgery changes the surgical strategy for deep-seated lesions by promoting a deficit-sparing approach. When integrated with preoperative brain mapping and intraoperative neuromonitoring (IONM), this approach may potentially improve patient outcomes. In this study, we assessed the impact of preoperative brain mapping and IONM in tubular retractor-assisted neuro-oncological surgery. METHODS This retrospective single-center cohort study included patients who underwent transsulcal tubular retractor-assisted minimally invasive parafascicular surgery for resection of deep-seated brain tumors from 2016 to 2022. The cohort was divided into 3 groups: group 1, no preoperative mapping or IONM (17 patients); group 2, IONM only (25 patients); group 3, both preoperative mapping and IONM (38 patients). RESULTS We analyzed 80 patients (33 males and 47 females) with a median age of 46.5 years (range: 1-81 years). There was no significant difference in mean tumor volume (26.2 cm3 [range 1.07-97.4 cm3]; P = 0.740) and mean preoperative depth of the tumor (31 mm [range 3-65 mm], P = 0.449) between the groups. A higher proportion of high-grade gliomas and metastases was present within group 3 (P = 0.003). IONM was related to fewer motor (P = 0.041) and language (P = 0.032) deficits at hospital discharge. Preoperative mapping and IONM were also related to shorter length of stay (P = 0.008). CONCLUSIONS Preoperative and intraoperative brain mapping and monitoring enhance transsulcal tubular retractor-assisted minimally invasive parafascicular surgery in neuro-oncology. Patients had a reduced length of stay and prolonged overall survival. IONM alone reduces postoperative neurological deficit.
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Affiliation(s)
- Siddharth Sinha
- Department of Neurosurgery, King's College Hospital Foundation Trust, London, United Kingdom.
| | - Nida Kalyal
- Department of Neurosurgery, King's College Hospital Foundation Trust, London, United Kingdom
| | - Mathew J Gallagher
- Department of Neurosurgery, King's College Hospital Foundation Trust, London, United Kingdom
| | - Daniel Richardson
- Department of Neurosurgery, King's College Hospital Foundation Trust, London, United Kingdom
| | - Dimitrios Kalaitzoglou
- Department of Neurosurgery, King's College Hospital Foundation Trust, London, United Kingdom
| | - Ahmed Abougamil
- Department of Neurosurgery, King's College Hospital Foundation Trust, London, United Kingdom
| | - Melissa Silva
- Department of Neurosurgery, Intraoperative Neurophysiology, King's College Hospital Foundation Trust, London, United Kingdom
| | - Anna Oviedova
- Department of Neurosurgery, King's College Hospital Foundation Trust, London, United Kingdom
| | - Sabina Patel
- Department of Neurosurgery, King's College Hospital Foundation Trust, London, United Kingdom
| | - Ana Mirallave-Pescador
- Department of Neurosurgery, King's College Hospital Foundation Trust, London, United Kingdom; Departamento de Neurocirurgia, Hospital Garcia de Orta, Almada, Portugal
| | - Cristina Bleil
- Department of Neurosurgery, King's College Hospital Foundation Trust, London, United Kingdom
| | - Bassel Zebian
- Department of Neurosurgery, King's College Hospital Foundation Trust, London, United Kingdom
| | - Richard Gullan
- Department of Neurosurgery, King's College Hospital Foundation Trust, London, United Kingdom
| | - Keyoumars Ashkan
- Department of Neurosurgery, King's College Hospital Foundation Trust, London, United Kingdom
| | - Francesco Vergani
- Department of Neurosurgery, King's College Hospital Foundation Trust, London, United Kingdom
| | - Ranjeev Bhangoo
- Department of Neurosurgery, King's College Hospital Foundation Trust, London, United Kingdom
| | - José Pedro Lavrador
- Department of Neurosurgery, King's College Hospital Foundation Trust, London, United Kingdom
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Ibrahim N, Scullen T, Tucci M, Delashaw J, Khan P, Dumont A, Wang A. Minimally Invasive Hematoma Evacuation Using the MindsEye Expandable Tubular Retractor: A Technical Note. World Neurosurg 2023; 176:162-167. [PMID: 37201792 DOI: 10.1016/j.wneu.2023.05.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 05/09/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND Recent advances in intraoperative neuronavigation and cranial access devices have facilitated an increasing interest in the use of minimally invasive techniques (minimally invasive surgery) to safely treat subcortical lesions via a parafascicular approach. Newly developed expandable retractors, such as the MindsEye system further optimize such approaches. In this technical report, we describe the nuances in minimally invasive surgery parenchymal hematoma evacuation using the MindsEye device. METHODS After placement of the device, the inner stylet and inner obturator are removed, and the expandable sheath is left in place and secured into place with a Greenberg refractor. The sheath easily dilates to the surgeonss preference with a dial, and the walls of the sheath are composed of a thin, clear, membrane to allow easy visualization of the lesion. We additionally retrospectively reviewed clinical characteristics and outcomes across three patients treated at our facility with spontaneous multicompartment intracranial hematoma using the MindsEye system. RESULTS We provide a video case demonstrating the use of the MindsEye retractor in a transfrontal parenchymal hematoma evacuation. Successful evacuation with achieved in less than 90 minutes with near total clot removal and resolution of mass effect for all reviewed cases with no patients experiencing procedure-related postoperative decline. CONCLUSIONS Minimally invasive catheter-based and parafascicular approaches using tubular retractors are increasingly recognized as a viable option in the treatment of subcortical lesions. The MindsEye is the first expandable brain access port designed for removal of deep intracranial lesions. We believe it represents a recent addition in the armament of cranial surgeons.
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Affiliation(s)
- Naser Ibrahim
- Department of Neurological Surgery, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Tyler Scullen
- Department of Neurological Surgery, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Marissa Tucci
- Department of Neurological Surgery, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Johnny Delashaw
- Department of Neurological Surgery, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Pervez Khan
- Department of Neurological Surgery, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Aaron Dumont
- Department of Neurological Surgery, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Arthur Wang
- Department of Neurological Surgery, Tulane University School of Medicine, New Orleans, Louisiana, USA.
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Achey R, Kashkoush A, Potter T, Davison M, Moore NZ, Kshettry VR, Bain M. Surgical Resection of Deep-Seated Arteriovenous Malformations Through Stereotactically Guided Tubular Retractor Systems: A Case Series. Oper Neurosurg (Hagerstown) 2023; 24:499-506. [PMID: 36716066 DOI: 10.1227/ons.0000000000000599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Accepted: 10/24/2022] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Arteriovenous malformations (AVMs) in the subcortical and/or periventricular regions can cause significant intraventricular and intracranial hemorrhage. These AVMs can pose a unique surgical challenge because traditional, open approaches to the periventricular region require significant cortical/white matter retraction to establish sufficient operative corridors, which may result in risk of neurological injury. Minimally invasive tubular retractor systems represent a novel, feasible surgical option for treating deep-seated AVMs. OBJECTIVE To explore 5 cases of NICO BrainPath-assisted resection of subcortical/periventricular AVMs. METHODS Five patients from a single institution were operated on for deep-seated AVMs using tubular retractor systems. Collected data included demographics, AVM specifications, preoperative neurological status, postoperative neurological status, and postoperative/intraoperative angiogram results. RESULTS Five patients, ranging from age 10 to 45 years, underwent mini-craniotomy for stereotactically guided tubular retractor-assisted AVM resection using neuronavigation for selecting a safe operative corridor. No preoperative embolization was necessary. Mean maximum AVM nidal diameter was 8.2 mm. All deep-seated AVMs were completely resected without complications. All AVMs demonstrated complete obliteration on intraoperative angiogram and on 6-month follow-up angiogram. CONCLUSION Minimally invasive tubular retractors are safe and present a promising surgical option for well-selected deep-seated AVMs. Furthermore, study may elucidate whether tubular retractors improve outcomes after microsurgical AVM resection secondary to mitigation of iatrogenic retraction injury risk.
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Affiliation(s)
- Rebecca Achey
- Department of Neurological Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Ahmed Kashkoush
- Department of Neurological Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Tamia Potter
- Case Western Reserve School of Medicine, Cleveland, Ohio, USA
| | - Mark Davison
- Department of Neurological Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Nina Z Moore
- Department of Neurological Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA.,Cerebrovascular Center, Neurological Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Varun R Kshettry
- Department of Neurological Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA.,Cerebrovascular Center, Neurological Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Mark Bain
- Department of Neurological Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA.,Cerebrovascular Center, Neurological Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Falcone J, Chen JW. Early Minimally Invasive Parafascicular Surgery for Evacuation of Spontaneous Intracerebral Hemorrhage in the Setting of Computed Tomography Angiography Spot Sign: A Case Series. Oper Neurosurg (Hagerstown) 2022; 22:123-130. [PMID: 35030111 DOI: 10.1227/ons.0000000000000078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 10/03/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Spontaneous intracerebral hemorrhage (sICH) is associated with high morbidity and mortality, and the role of surgery is uncertain. Spot sign on computed tomography angiography (CTA) has previously been seen as a contraindication for minimally invasive techniques. OBJECTIVE To demonstrate the use of minimally invasive parafascicular surgery (MIPS) for early evacuation of sICH in patients with spot sign on CTA. METHODS Retrospective review of patients presenting to a US tertiary academic medical center from 2018 to 2020 with sICH and CTA spot sign who were treated with MIPS within 6 h of arrival. RESULTS Seven patients (6 men and 1 woman, mean age 54.4 yr) were included in this study. There was a significant decrease between preoperative and postoperative intracerebral hemorrhage volumes (75.03 ± 39.00 cm3 vs 19.48 ± 17.81 cm3, P = .005) and intracerebral hemorrhage score (3.1 ± 0.9 vs 1.9 ± 0.9, P = .020). The mean time from arrival to surgery was 3.72 h (±1.22 h). The mean percentage of hematoma evacuation was 73.78% (±21.11%). The in-hospital mortality was 14.29%, and the mean modified Rankin score at discharge was 4.6 (±1.3). No complications related to the surgery were encountered in any of the cases, with no abnormal intraoperative bleeding and no pathology demonstrating occult vascular lesion. CONCLUSION Early intervention with MIPS appears to be a safe and effective means of hematoma evacuation despite the presence of CTA spot sign, and this finding should not delay early intervention when indicated. Intraoperative hemostasis may be facilitated by the direct visualization provided by a tubular retractor system.
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Affiliation(s)
- Joseph Falcone
- Department of Neurosurgery, University of California Irvine, Orange, California, USA
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Echeverry N, Mansour S, MacKinnon G, Jaraki J, Shapiro S, Snelling B. Intracranial Tubular Retractor Systems: A Comparison and Review of the Literature of the BrainPath, Vycor, and METRx Tubular Retractors in the Management of Deep Brain Lesions. World Neurosurg 2020; 143:134-146. [DOI: 10.1016/j.wneu.2020.07.131] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 07/17/2020] [Accepted: 07/18/2020] [Indexed: 12/19/2022]
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Chakravarthi SS, Lyons L, Bercu M, Singer JA. Minimally Invasive Parafascicular Surgical Approach for the Management of a Pediatric Third Ventricular Ependymoma: Case Report and Review of Literature. World Neurosurg 2020; 141:311-317. [PMID: 32387401 DOI: 10.1016/j.wneu.2020.04.201] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 04/26/2020] [Accepted: 04/27/2020] [Indexed: 01/21/2023]
Abstract
BACKGROUND Minimally invasive parafascicular surgery (MIPS) has evolved into a safe alternative to access deep-seated subcortical and intraventricular pathologies. We present a case of a port-mediated resection of a pediatric third ventricular tumor. CASE DESCRIPTION The patient is a 7-year-old boy who presented with worsening headache, nausea, vomiting, dizziness, unsteady gait, photophobia, and blind spots with positional changes. Magnetic resonance imaging (MRI) scan revealed a large isointense mass, with areas of hyperintensities suggestive of intratumoral hemorrhage, centered in the posterior segment of the third ventricle with extension into the aqueduct of Sylvius. The superior frontal sulcus was used as an access corridor for the port to the frontal horn of the lateral ventricle en route to the third ventricle. Intraoperative visualization was aided with a 3-dimensional exoscopic system. After cannulation, the tumor was seen within the foramen of Monro and tethered to the thalamostriate vein. The tumor was removed completely, with the exception of small residual attached to the thalamostriate vein, which was left intentionally. A flexible endoscope was placed through the port to verify the absence of residual along the superior wall of the third ventricle. Intraoperative MRI scan confirmed presence of residual, along with normal postoperative changes, including pneumocephalus. Postoperative MRI scan revealed cortical recovery along the sulcal path and resolution of ventriculomegaly. CONCLUSIONS The patient improved from baseline, with no remaining visual deficits, headaches, or balance issues. Pathology reported a World Health Organization grade II tanycytic ependymoma. To our knowledge, few cases have reported the utilization of port-based MIPS in pediatric patients.
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Affiliation(s)
- Srikant S Chakravarthi
- Neuroanatomy Laboratory, Aurora Research Institute, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin, USA
| | - Leah Lyons
- Department of Clinical Neurosciences (Division of Neurosurgery), Spectrum Health, Grand Rapids, Michigan, USA
| | - Marian Bercu
- Department of Clinical Neurosciences (Division of Neurosurgery), Spectrum Health, Grand Rapids, Michigan, USA
| | - Justin A Singer
- Department of Clinical Neurosciences (Division of Neurosurgery), Spectrum Health, Grand Rapids, Michigan, USA.
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Zhu J, Wen G, Tang C, Zhong C, Yang J, Ma C. A Practical 3D-Printed Model for Training of Endoscopic and Exoscopic Intracerebral Hematoma Surgery with a Tubular Retractor. J Neurol Surg A Cent Eur Neurosurg 2020; 81:404-411. [PMID: 32294793 DOI: 10.1055/s-0039-1697023] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To present a three-dimensional (3D)-printed model that simulates endoscopic and exoscopic intracerebral hematoma (ICH) surgery with a tubular retractor. METHODS We used 3D printing technology to develop the model that consisted of the skull frame and a replaceable inserted module. Edible gelatin and animal blood were placed into the module to mimic brain tissue and the hematoma. Twenty neurosurgeons were recruited to participate in our training program that required the use of an endoscope and an exoscope to aspirate the hematoma with a tubular retractor. Five postgraduates were asked to complete the entire training with the endoscope five times. Questionnaires were distributed for feedback after the training program. RESULTS The more experienced surgeons obviously performed better than the rather inexperienced surgeons, verifying that our model could reflect the ability of the trainees. As the training progressed, the scores of the postgraduates increased, and the average score of the fifth training was obviously higher than the first score. No significant differences were observed in the trainees' performance with the endoscope and the exoscope. The feedback questionnaires showed the average score for value of the simulator as a training tool was a 3.65 (on a 4-point scale). Our model received better comments regarding the bone texture (mean: 3.20), the brain tissue texture (mean: 3.20), and the experience in aspirating the hematoma (mean: 3.10). The surgical position (mean: 2.95), surgical approach (mean: 2.90), and simulated brain tissue (mean: 2.85) should be improved. CONCLUSION Our model was practical for endoscopic and exoscopic ICH surgery training. The results of our program showed that prior surgical experience benefited the mastery of both the endoscopic and the exoscopic ICH surgery in the 3D-printed model. Our model could make mastering basic skills more efficient.
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Affiliation(s)
- Junhao Zhu
- Jinling Hospital, Nanjing Medical University, Nanjing, China.,Department of Neurosurgery, Nanjing Jinling Hospital, Nanjing, China
| | - Guodao Wen
- Department of Neurosurgery, Dongguan Tungwah Hospital, School of Medicine, Sun Yat-sen University, Dongguan, China
| | - Chao Tang
- Department of Neurosurgery, Nanjing Jinling Hospital, Nanjing, China
| | - Chunyu Zhong
- Jinling Hospital, Nanjing Medical University, Nanjing, China
| | - Jin Yang
- Department of Neurosurgery, Nanjing Jinling Hospital, Nanjing, China
| | - Chiyuan Ma
- Department of Neurosurgery, Nanjing Jinling Hospital, Nanjing, China
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8
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Mansour S, Echeverry N, Shapiro S, Snelling B. The Use of BrainPath Tubular Retractors in the Management of Deep Brain Lesions: A Review of Current Studies. World Neurosurg 2020; 134:155-163. [DOI: 10.1016/j.wneu.2019.08.218] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 08/26/2019] [Accepted: 08/28/2019] [Indexed: 01/05/2023]
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O'Connor KP, Strickland AE, Bohnstedt BN. A contralateral transventricular approach for microsurgical clip ligation of a ruptured intrathalamic aneurysm. J Clin Neurosci 2019; 68:329-332. [PMID: 31327587 DOI: 10.1016/j.jocn.2019.07.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 07/06/2019] [Indexed: 10/26/2022]
Abstract
Intrathalamic aneurysms are a cause of patient morbidity and mortality. Aneurysms in this location can be accessed microsurgically when they cannot be accessed endovascularly. Care must be taken to avoid critical white matter tracts when approaching the thalamus microsurgically. Use of a tubular retractor can offer safe brain retraction during the approach. A 53-year-old female with a history of hypertension and cerebrovascular accidents presented with slurred speech, altered mental status, and right-sided weakness. CT demonstrated an acute parenchymal hemorrhage within the left thalamus and the internal capsule. CT angiography demonstrated a left dorsal thalamic aneurysm. Following angiography with consideration for embolization, the patient was taken to the operating room for microsurgical clip ligation with the use of minimally invasive techniques. The aneurysm was accessed using a contralateral transventricular approach with a tubular retractor for microsurgical clip ligation. Postoperative imaging demonstrated successful interval clipping of the aneurysm within the thalamus. This is the first report using our described surgical approach for treatment of a dorsal intrathalamic aneurysm. We combined the use of diffusion tensor imaging with a tubular retractor to clip a dorsal thalamic aneurysm.
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Affiliation(s)
- Kyle P O'Connor
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States.
| | - Allison E Strickland
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Bradley N Bohnstedt
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States.
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Zammar SG, Cappelli J, Zacharia BE. Utility of Tubular Retractors Augmented with Intraoperative Ultrasound in the Resection of Deep-seated Brain Lesions: Technical Note. Cureus 2019; 11:e4272. [PMID: 31157134 PMCID: PMC6529054 DOI: 10.7759/cureus.4272] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Traditional brain retraction has been associated with significant damage to the healthy brain tissue particularly when attempting to expose a deep-seated lesion of the brain. Tubular retractors tend to provide a surgical corridor to treat these lesions while minimizing the extent of retraction on the brain. Intraoperative ultrasound can be used as a handy adjunct in maximizing the safe resection primarily by identifying the entry point, visualizing the lesion, and providing real-time feedback on the extent of resection. The authors provide a technical note with case illustrations on the use of tubular retractors augmented with intraoperative ultrasound to ensure a maximal safe resection of deep-seated brain lesions.
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Affiliation(s)
- Samer G Zammar
- Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
| | - Jared Cappelli
- Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
| | - Brad E Zacharia
- Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
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11
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Chakravarthi SS, Kassam AB, Fukui MB, Monroy-Sosa A, Rothong N, Cunningham J, Jennings JE, Guenther N, Connelly J, Kaemmerer T, Nash KC, Lindsay M, Rissell J, Celix JM, Rovin RA. Awake Surgical Management of Third Ventricular Tumors: A Preliminary Safety, Feasibility, and Clinical Applications Study. Oper Neurosurg (Hagerstown) 2019; 17:208-226. [DOI: 10.1093/ons/opy405] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 02/07/2019] [Indexed: 11/12/2022] Open
Abstract
AbstractBACKGROUNDEndoscopic and microneurosurgical approaches to third ventricular lesions are commonly performed under general anesthesia.OBJECTIVETo report our initial experience with awake transsulcal parafascicular corridor surgery (TPCS) of the third ventricle and its safety, feasibility, and limitations.METHODSA total of 12 cases are reviewed: 6 colloid cysts, 2 central neurocytomas, 1 papillary craniopharyngioma, 1 basal ganglia glioblastoma, 1 thalamic glioblastoma, and 1 ependymal cyst. Lesions were approached using TPCS through the superior frontal sulcus. Pre-, intra-, and postoperative neurocognitive (NC) testing were performed on all patients.RESULTSNo cases required conversion to general anesthesia. Awake anesthesia changed intraoperative management in 4/12 cases with intraoperative cognitive changes that required port re-positioning; 3/4 recovered. Average length of stay (LOS) was 6.1 d ± 6.6. Excluding 3 outliers who had preoperative NC impairment, the average LOS was 2.5 d ± 1.2. Average operative time was 3.00 h ± 0.44. Average awake anesthesia time was 5.05 h ± 0.54. There were no mortalities.CONCLUSIONThis report demonstrated the feasibility and safety of awake third ventricular surgery, and was not limited by pathology, size, or vascularity. The most significant factor impacting LOS was preoperative NC deficit. The most significant risk factor predicting a permanent NC deficit was preoperative 2/3 domain impairment combined with radiologic evidence of invasion of limbic structures – defined as a “NC resilience/reserve” in our surgical algorithm. Larger efficacy studies will be required to demonstrate the validity of the algorithm and impact on long-term cognitive outcomes, as well as generalizability of awake TPCS for third ventricular surgery.
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Affiliation(s)
- Srikant S Chakravarthi
- Aurora Neuroscience Innovation Institute, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin
| | - Amin B Kassam
- Aurora Neuroscience Innovation Institute, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin
| | - Melanie B Fukui
- Aurora Neuroscience Innovation Institute, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin
| | - Alejandro Monroy-Sosa
- Aurora Neuroscience Innovation Institute, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin
| | - Nichelle Rothong
- Department of Neuropsychology, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin
| | - Joseph Cunningham
- Department of Neuropsychology, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin
| | - Jonathan E Jennings
- Aurora Neuroscience Innovation Institute, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin
| | - Neil Guenther
- Department of Anesthesiology, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin
| | - Jeremy Connelly
- Department of Neuropsychology, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin
| | - Tobias Kaemmerer
- Department of Neuropsychology, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin
| | - Kenneth C Nash
- Department of Psychiatry, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - Janie Rissell
- Department of Neuropsychology, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin
| | - Juanita M Celix
- Aurora Neuroscience Innovation Institute, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin
| | - Richard A Rovin
- Aurora Neuroscience Innovation Institute, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin
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