Name:
10.3171/2024.4.FOCVID2451
Description:
10.3171/2024.4.FOCVID2451
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/9e0d6125-3b72-441e-8b6f-0129d4d521c9/videoscrubberimages/Scrubber_226.jpg
Duration:
T00H10M43S
Embed URL:
https://stream.cadmore.media/player/9e0d6125-3b72-441e-8b6f-0129d4d521c9
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/9e0d6125-3b72-441e-8b6f-0129d4d521c9/12. 24-51.mp4?sv=2019-02-02&sr=c&sig=l6dpH9VqTpVxe1gYxJwo24DfWPPLbScywcKsOhOkleU%3D&st=2026-05-13T19%3A06%3A29Z&se=2026-05-13T21%3A11%3A29Z&sp=r
Upload Date:
2024-06-02T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
[MUSIC PLAYING]
SPEAKER: This video is related to the technique of hemispherotomy in children, the perisylvian technique. Rasmussen, in 1974, was the first neurosurgeon that proposed the term "disconnection" when he described his technique of functional hemispherectomy, meaning that his intention was to preserve the frontal and occipital poles but disconnecting them. After the introduction of the microsurgical techniques in the 1990s, Delalande was the first author to propose the term "hemispherotomy" in 1992 in the description of the vertical parasagittal hemispherotomy.
SPEAKER: He was soon followed by Villemure who, in 1993, described his technique peri-insular hemispherotomy. The aim of this video is to describe his technique in detail as published in 1995 and a modification proposed by Shimizu and Maehara in 2000. After general anesthesia, the patient's head is immobilized and rotated contralateral to the side of the surgery.
SPEAKER: A craniotomy, depicted in this picture, is then performed. Neuronavigation is always mandatory. The first step is to delimitate the operculum, the frontoparietal operculum, which will be resected. So this is the exposure of the frontoparietal operculum and dissection, subpial dissection.
SPEAKER: And at the end, we will resect this cortical portion of the frontoparietal cortex of the operculum. As you can see, the dissection is always subpial and the branches of the middle cerebral artery are completely exposed.
SPEAKER: Then after the exposure of the insula, we start the dissection of the branches of the middle cerebral artery. Here, you can see the M1 branches, which are followed and coagulated and cut. As you can see here, the M1 branches are totally exposed and coagulated.
SPEAKER: We follow then the M1 branches and one by one we dissect and coagulate and cut. So after that, we will have the completely dissected insular surface. After dissection of these branches, we expose the circular sulcus of the insula.
SPEAKER: And we proceed to the dissection and resection of the insula, exactly in the white matter, just under the cortex of the insula.
SPEAKER: If we stay perfectly in the white matter, there will be no bleeding. And at the end, the insula can be totally resected, I guess, giving this aspect, as in this specimen in the right-hand side. The next step is the exposure of the lateral ventricle for callosotomy, but we start from anterior to posterior.
SPEAKER: We start with the section of the horizontal fibers in the frontal region exposing in the skull base, in this sphenoid, and said subpial dissection until we find the olfactory nerve, which is the landmark for the exposure of the gyrus rectus, as you can see here with this arrow, and the midline.
SPEAKER: After this, we expose completely the lateral ventricle. And in the midline, we proceed to the callosotomy by exposing the anterior cerebral artery. The artery is followed anteriorly all the way in the direction of the midline, that we have already exposed in the frontal base.
SPEAKER: So you can see here, we find the anterior cerebral artery and anteriorly until the midline is exposed. And posteriorly, we do the same in the direction of the splenium.
SPEAKER: Anterior exposure of the midline as shown in this arrow and posteriorly until we find the blue line of the splenium that represents the vein of Galen. Then we take extreme precaution not to make any kind of lesion of this vein.
SPEAKER: The next step is the exposure of the temporal horn completely. And in the anterior direction, you follow the hippocampus and you the exposure of the amygdala. Amygdala is resected until we see the free edge of the tentorium. In the posterior direction, we expose completely the hippocampus and progressively the hippocampal tail and we find the fornix and the fimbria, which we'll be sectioning.
SPEAKER: By doing this, the temporal horn is completely disconnected. The resection of the temporal lobe, we perform only when indicated, for instance, in cases of hemimegalencephaly. You see the body of the hippocampus here, the tail as you can see by this arrowhead.
SPEAKER: Comparing the specimen on the right side in the same position, you see the tail of the hippocampus and the fimbria fornix. In children, the most common surgery that we perform in epilepsy centers is hemispherotomy now, completely different from the adults where the temporal lobectomy continues to be the first procedure. There are difficult cases, for instance, in cases of Sturge-Weber with leptomeningeal angiomatosis.
SPEAKER: But what is dangerous in these cases and in hemimegalencephaly cases are the veins that can be distorted and dilated, and we may have ischemic problems or even hemorrhage for deeply seated veins. The other cases are the hemispheric polymicrogyria, mainly in the perisylvian polymicrogyria that can be difficult for the neurosurgeon.
SPEAKER: So in conclusion, hemispheric epilepsy is frequent in children, and catastrophic progression is common. Surgery should be performed as early as possible. Hemispherotomy is procedure of choice, although good experiences have been reported with anatomic hemispherectomy in selected cases. The choice of the technique should take into consideration the experience of the surgeon, the anatomy, the etiology, and the age of the patient.
SPEAKER: Thank you very much.
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