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 Adib Abla, 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. SMALLLARGE Type IOZ Gamma Knife (stable) Type IIEndoscopicTranscallosal Gamma Knife (bilateral, clinically stable) Type IIIEndoscopic +/- OZ--- Gamma Knife (stable) Type IV ---Staged : target main component 1 st 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