Endoscope-assisted (with robotic guidance and using a hybrid technique) interhemispheric transcallosal hemispherotomy: a comparative study with open hemispherotomy to evaluate efficacy, complications, and outcome

Abstract

<jats:sec><jats:title>OBJECTIVE</jats:title><jats:p>Endoscope-assisted hemispherotomy (EH) has emerged as a good alternative option for hemispheric pathologies with drug-resistant epilepsy.</jats:p></jats:sec><jats:sec><jats:title>METHODS</jats:title><jats:p>This was a prospective observational study. Parameters measured included primary outcome measures (frequency, severity of seizures) and secondary outcomes (cognition, behavior, and quality of life). Blood loss, operating time, complications, and hospital stay were also taken into account. A comparison was made between the open hemispherotomy (OH) and endoscopic techniques performed by the senior author.</jats:p></jats:sec><jats:sec><jats:title>RESULTS</jats:title><jats:p>Of 59 cases (42 males), 27 underwent OH (8 periinsular, the rest vertical) and 32 received EH. The mean age was 8.65 ± 5.41 years (EH: 8.6 ± 5.3 years; OH: 8.6 ± 5.7 years). Seizure frequency per day was 7 ± 5.9 (EH: 7.3 ± 4.6; OH: 15.0 ± 6.2). Duration of disease (years since first episode) was 3.92 ± 1.24 years (EH: 5.2 ± 4.3; OH: 5.8 ± 4.5 years). Number of antiepileptic drugs per patient was 3.9 ± 1.2 (EH: 4.2 ± 1.2; OH: 3.8 ± 0.98). Values for the foregoing variables are expressed as the mean ± SD. Pathologies included the following: postinfarct encephalomalacia in 19 (EH: 11); Rasmussen’s syndrome in 14 (EH: 7); hemimegalencephaly in 12 (EH: 7); hemispheric cortical dysplasia in 7 (EH: 4); postencephalitis sequelae in 6 (EH: 2); and Sturge-Weber syndrome in 1 (EH: 1). The mean follow-up was 40.16 ± 17.3 months. Thirty-nine of 49 (79.6%) had favorable outcomes (International League Against Epilepsy class I and II): in EH the total was 19/23 (82.6%) and in OH it was 20/26 (76.9%). There was no difference in the primary outcome between EH and OH (p = 0.15). Significant improvement was seen in the behavioral/quality of life performance, but not in IQ scores in both EH and OH (p &lt; 0.01, no intergroup difference). Blood loss (p = 0.02) and hospital stay (p = 0.049) were less in EH.</jats:p></jats:sec><jats:sec><jats:title>CONCLUSIONS</jats:title><jats:p>EH was as effective as the open procedure in terms of primary and secondary outcomes. It also resulted in less blood loss and a shorter postoperative hospital stay.</jats:p></jats:sec>

Sturge-Weber syndrome: an update on the relevant issues for neurosurgeons

“…Early surgery in the case of refractory epilepsy and progressing neuro-cognitive deterioration is now largely (but not universally) accepted. Actually, if a strong correlation between age at surgery and/ or interval from seizure onset to surgery and seizure control is missing [12,19,31], the evidence about the earlier the surgical procedure (and, thus, the seizure control), the better the neurocognitive outcome is clear [48,52,84]. As far as the candidate to surgery is concerned, it is straightforward to elect children with intractable epilepsy, hemiparesis, and progressing mental retardation, while it is not the same for those patients with no significant deficits except epilepsy.…”

“…Being hemispherectomy/hemispherotomy a major neurosurgical procedure, such a success rate should be balanced with the relatively high risk of complications (especially in infants and small children), as perioperative hemorrhages, aseptic meningitis, and hydrocephalus [9,50,98]. However, the modifications and the refinements brought to the functional hemispherectomy and, in particular, to the hemispherotomy over the time have made these techniques safer and comparable with other major neurosurgical procedures [8,14,19,44,92]. The main techniques are here shortly summarized:…”

“…The second step is an interhemispheric approach to the interhemispheric commissures which are then disconnected [49]; -Peri-insular hemispherotomy, in this procedure, the surgical maneuvers are focused on the realization of all disconnections from the inside of the ventricles (body and temporal horn of the lateral ventricle) [70,139]; -E n d o s c o p e a s s i s t e d h e m i s p h e r o t o m y , the hemispherotomy is here performed trough small corticectomies, thanks to the use of the endoscope (possibly, with robotic guidance). An interhemispheric approach is used to make a complete callosotomy as well as the anterior, middle, and posterior disconnections [19].…”

Recent advances in the neurosurgical treatment of pediatric epilepsy

“…9,65 Chandra et al subsequently added to the technique, as described in their 2018 article, by using a hybrid endoscopic setup that sits between the extracranial position of an exoscope and the near-to-field location of a narrow endoscope. 10 They used a thicker (10-mm) endoscope with a wider field of view to position the end of the scope further away from the working field but still intracranially, providing a less hindered space for movement. In addition, they compared several metrics of the open versus endoscopic hemispherotomies and reported less blood loss (mean 719 vs 210 ml, respectively, p = 0.02), shorter hospital stay (18.6 vs 14.6 days, respectively, p = 0.049), and a nonsignificant difference in operative time (352 vs 302 minutes, respectively, p = 0.06).…”

“…In addition, they compared several metrics of the open versus endoscopic hemispherotomies and reported less blood loss (mean 719 vs 210 ml, respectively, p = 0.02), shorter hospital stay (18.6 vs 14.6 days, respectively, p = 0.049), and a nonsignificant difference in operative time (352 vs 302 minutes, respectively, p = 0.06). 10 Part of the hemispherotomy entails a disconnection of the corpus callosum, and so the endoscopic techniques learned for one procedure directly translate to the other. 59 In a 2017 article, Smyth et al detail the procedures for open and endoscopic corpus callosotomy, both of which they perform through a frontal craniotomy, with the craniotomy in the endoscopic version being smaller.…”