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

2. Acknowledgements Maggie Bobrowitz, RN, MBA HH team Harold Rekate, MD Adib Abla, 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? Camera Working end

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 contralateral approach 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. 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 Laser?

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