How I do it: parietal trans-sulcal para-fascicular approach to lateral thalamic/internal capsule cavernous malformation.

BACKGROUND: The surgical management of deep brain lesions is challenging, with significant morbidity. Advances in surgical technology have presented the opportunity to tackle these lesions. METHODS: We performed a complete resection of a thalamic/internal capsule CM using a tubular retractor system via a parietal trans-sulcal para-fascicular (PTPF) approach without collateral injury to the nearby white matter tracts. CONCLUSION: PTPF approach to lateral thalamic/internal capsule lesions can be safely performed without injury to eloquent white matter fibres. The paucity of major vessels along this trajectory and the preservation of lateral ventricle integrity make this approach a feasible alternative to traditional approaches.

Exoscope aided trans-sulcal minimally invasive parafascicular resection of a paediatric brainstem pilocytic astrocytoma using a tubular retractor system.

The surgical management of brainstem glioma is challenging and has significant morbidity. Advances in surgical armamentarium has presented the opportunity to tackle these lesions. We present the case of a paediatric patient with a 2.3cm midbrain pilocytic astrocytoma. With the aid of tractography, neuro-navigation, 3-dimensional exoscope and a tubular retractor, near total resection of the tumour was achieved through a trans-sulcal para-fascicular approach without permanent injury to the corticospinal tract. To our knowledge this is the first report of a brainstem tumour resected using this approach and demonstrates what can be achieved with synergistic utility of evolving technologies in neurosurgery.

Decreasing the Cerebral Edema Associated with Traumatic Intracerebral Hemorrhages: Use of a Minimally Invasive Technique.

Traumatic brain injury (TBI) is a major public health problem worldwide that affects all age groups. In the United States alone, there are approximately 50,000 deaths from severe traumatic brain injuries each year. In most studies, about 40 % of severe TBI have associated traumatic intracerebral hemorrhages (tICHs). The surgical treatment of tICH is debated largely because of its invasive nature, particularly in reaching deep tICHs. tICHs have a clear contribution to mass effect and exacerbate cerebral edema and ICP because of the break-down products of hemorrhage. We introduce a modification of the Mi SPACE technique (Minimally Invasive Subcortical Parafascicular Transsulcal Access for Clot Evacuation) that is applicable to tICH. In brief, this technique utilizes a trans-sulcal, stereotactic-guided technique in which a specially designed cannula is used to introduce a 13.5-mm-diameter tube into the epicenter of the tICH. We identified eight tICHs that were treated entirely or in part with the modified Mi SPACE technique during the time period from August 15, 2014 to December 15, 2014. This modified technique was readily deployed safely and efficaciously with significant removal of the tICH as demonstrated by postoperative CT scans. The removal of tICH using this minimally invasive technique may help with the control of ICP and cerebral edema.

Use of the Image Guided Minimally Invasive BrainPath System to Evacuate Spontaneous Cerebellar Hemorrhages.

BrainPath (NICO, Indianapolis, Indiana) is a tool that can be used to evacuate supratentorial hematomas due to spontaneous intracerebral hemorrhage (ICH). However, when ICH occurs in the posterior fossa, an open approach is often undertaken to evacuate the hematoma. The application of minimally invasive technology, while available, has not been well established. Our objective was to describe the use of the image-guided, minimally invasive BrainPath system to evacuate a spontaneous cerebellar hemorrhage. We present the case of a sixty-four-year-old male patient with a cerebellar hematoma due to hypertensive hemorrhage. The patient's medical record, including the history and physical, progress notes, operative notes, discharge summary, and imaging studies were reviewed to document the clinical presentation as well as the details of the operative technique and postoperative outcomes in this paper. We discuss the technical nuances of the operative points in detail. In our example case, the BrainPath system was successfully used to evacuate the cerebellar hematoma and no procedural-related complications occurred. The patient's recovery remained uncomplicated at three months of follow-up. In summary, the BrainPath system offers a less invasive alternative to open evacuation for cerebellar bleeds.

Trans-sulcal parafascicular approach to subcortical lesions.

Historically, neoplasms which are located in the subcortical region of the brain are considered technically difficult to access. As such, tumours in these locations are usually avoided, due to the risks associated with traversing eloquent cortex, the disrupting of white matter tracts, or the need to use narrow corridors to approach the lesion. Tubular retractors are able to gently displace brain parenchyma and white matter in an atraumatic fashion to access these deep regions. We demonstrate a minimally invasive trans-sulcal parafascicular approach using the Brainpath system (NICO Corp, Indianapolis, Indiana) to a caudate head metastasis as a representative case.

The Use of BrainPath Tubular Retractors in the Management of Deep Brain Lesions: A Review of Current Studies.

BACKGROUND: Traditional retraction to access deep intraparenchymal brain lesions results in vascular disruption. Tubular retractors such as the BrainPath tubular retractor system were developed to reduce retractor-related force injuries via radial dispersion of force. Our study seeks to assess the indications, benefits, and complications associated with BrainPath retractors. METHODS: A literature search of PubMed MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Web of Science, and Cochrane Database of Systematic Reviews was performed. The search terminology used was "BrainPath OR Brain-Path." The BrainPath Web site was also examined. Postoperative morbidity and mortality were analyzed to estimate complications linked to using the retractor. RESULTS: Twenty-nine articles (n = 289 patients) met the inclusion criteria. BrainPath was used primarily for tumor resections and hematoma evacuations. These cases were subdivided into groups based on lesion location, size, and resection volume for further analysis. Gross total resection was achieved in 79% of tumor excisions and subtotal resection in 21%. Hematoma evacuation >90% of original hematoma volume was achieved in 65.1% of cases, 75%-90% of original volume in 21.7%, and <75% in the remaining 13.2%. The complication rate attributed to retractor use was 8.3%. CONCLUSIONS: This report is the first formal assessment of the BrainPath tubular retraction system, highlighting technical considerations of the retractor from the surgeon's perspective, patient outcomes, and complications. The retractor is a safe, efficacious system that can be used for tumor resection or biopsy and hematoma evacuation. However, further randomized controlled trials are indicated to accurately assess complication rates and outcomes.

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.

In neurosurgery, parenchymal injury resulting from focal exertion of pressure on retracted tissue is a common complication associated with the use of plate and self-sustaining retractors to access deep intraparenchymal lesions. Tubular retractors, including Vycor, BrainPath, and METRx, were developed to reduce retraction injuries via radial dispersion of force. Our study seeks to compare these retraction systems and assess their respective indications, benefits, and associated complications. A systematic review of PubMed MEDLINE, Cochrane Central Register of Controlled Trials, Web of Science, and Cochrane Database of Systematic Reviews was performed. Twenty-nine articles (n = 289 patients) for BrainPath, 12 articles (n = 106 patients) for Vycor, and 3 articles for METRx (n = 31 patients) met the inclusion criteria. This report is the first formal comparison of the BrainPath, Vycor, and METRx tubular retraction systems. We found that all 3 retractors were effective in accessing intraparenchymal lesions. Although we found that the retractor systems were used more commonly in different locations and for different diseases, there was no significant difference in complications or mortality among the 3 retractors.

Minimally Invasive Surgical Outcomes for Deep-Seated Brain Lesions Treated with Different Tubular Retraction Systems: A Systematic Review and Meta-Analysis.

BACKGROUND: Minimally invasive surgery using tubular retractors was developed to minimize injury of surrounding brain during the removal of deep-seated lesions. No evidence supports the superiority of any available tubular retraction system in the treatment of these lesions. We conducted a systematic review and meta-analysis to evaluate outcomes and complications after the resection of deep-seated lesions with tubular retractors and among available systems. METHODS: A PRISMA compliant systematic review was conducted on PubMed, Embase, and Scopus to identify studies in which tubular retractors were used to resect deep-seated brain lesions in patients ≥18 years old. RESULTS: The search strategy yielded 687 articles. Thirteen articles complying with inclusion criteria and quality assessment were included in the meta-analysis. A total of 309 patients operated on between 2008 and 2018 were evaluated. The most common lesions were gliomas (n = 127), followed by metastases (n = 101) and meningiomas (n = 19). Four different tubular retractors were used: modified retractors (n = 121, 39.1%); METRx (n = 60, 19.4%); BrainPath (n = 92, 29.7%); and ViewSite Brain Access System (n = 36,11.7%). Estimated gross total resection rate was 75% (95% confidence interval, 69%-80%; I2 = 9%), whereas the estimated complication rate was 9% (95% confidence interval: 6%-14%; I2 = 0%). None of the different brain retraction systems was found to be superior regarding extent of resection or complications on multiple comparisons (P > 0.05). CONCLUSIONS: Tubular retractors represent a promising tool to achieve maximum safe resection of deep-seated brain lesions. However, there does not seem to be a statistically significant difference in extent of resection or complication rates among tubular retraction systems.

Use of Tubular Retractors for Minimally Invasive Resection of Deep-Seated Cavernomas.

BACKGROUND: Cavernomas located in subcortical or eloquent locations are difficult lesions to access safely. Tubular retractors, which distribute retraction pressure radially, have been increasingly employed successfully. These retractors may be beneficial in subcortical cavernoma resection. OBJECTIVE: To review a single institution's case series to determine the safety profile and efficacy of transcortical-transtubular cavernoma resections and to describe our transtubular operative technique. METHODS: We reviewed a single institution's transcortical-transtubular cavernoma resections using either BrainPath (NICO, Indianapolis, Indiana) or ViewSite Brain Access System (Vycor Medical, Boca Raton, Florida) tubular retractors performed from 2013 to 2018 (n = 20). RESULTS: Gross total resection was achieved in all patients. When a developmental venous anomaly (DVA) was present, avoidance of DVA resection was achieved in all cases (n = 4). All patients had a supratentorial cavernoma with mean depth below cortical surface of 44.1 mm. Average postoperative clinical follow-up was 20.4 wk. Early neurologic deficit rate was 10% (n = 2); permanent neurologic deficit rate was 0%. One patient (5%) experienced early postoperative seizures (< 1 wk postop). No patients experienced late seizures (> 1 wk follow-up). Engel class 1 seizure control at final clinical follow-up was achieved in 87.5% of patients presenting with preoperative epilepsy. CONCLUSION: Tubular retractors provide a low-profile, minimally invasive operative corridor for resection of subcortical cavernomas. There were no permanent neurologic complications in our series of 20 cases, and long-term seizure control was achieved in all patients. Thus, tubular retractors appear to be a safe and efficacious tool for resection of subcortical cavernomas.

Minimally Invasive Evacuation of Severe Intraventricular Hemorrhage Using the BrainPath Endoport-Assisted Microsurgical System.

OBJECTIVE: We present the application of the BrainPath endoport-assisted microsurgical device (EAMD) as a treatment modality for patients with severe intraventricular hemorrhage (IVH) secondary to spontaneous supratentorial intracerebral hemorrhage (sICH). METHODS: Patients with severe secondary IVH (defined as Graeb score [GS] >6) who presented to Saint Louis University Hospital, St. Louis, Missouri, United States, from 2017 to 2019 were treated with the minimally invasive approach for IVH evacuation using the atraumatic BrainPath aspiration system. RESULTS: Three patients (2 men and 1 woman) with a mean age of 54 years were included in this study. The mean preoperative GS was 10.0 with a modified GS of 23.3. The mean postoperative GS was 4.0 (P = 0.001) with a modified GS of 10.67 (P = 0.001). There were no complications related to the surgery itself in any of the reported cases. CONCLUSIONS: BrainPath EAMD evacuation of severe IVH secondary to sICH appears to be a safe and effective treatment modality that significantly increases the extent of IVH clearance, which could also lead to improved long-term patient outcomes.

Outcomes After Minimally Invasive Parafascicular Surgery for Intracerebral Hemorrhage: A Single-Center Experience.

BACKGROUND: Spontaneous intracerebral hemorrhage (ICH) comprises 10%-15% of strokes with a high mortality (40%) and low rates of functional independence within 6 months (25%). Minimally invasive parafascicular surgery has emerged as a potentially safer option for ICH management. METHODS: Data from 25 patients who underwent channel-based ICH evacuation were retrospectively collected regarding demographics, clinical presentation, neuroimaging characteristics, follow-up modified Rankin Scale (mRS) score, Glasgow Coma Scale (GCS) score, and disposition. RESULTS: Sixteen patients were male (64%) and 9 were female (36%), with a mean age of 52 years. There were 4 frontal, 1 occipital, and 20 basal ganglia hemorrhages; 15 (60%) showed intraventricular extension. Seventeen ICHs (68%) and 6 of 7 patient deaths (86%) were left sided. The mean volume was 46 cm3 (range, 13.1-101.2 cm3), and the mean clot reduction was 92%. Left-sided ICH (P = 0.014) and the presence of intraventricular hemorrhage (P = 0.038) were associated with worsened postoperative GCS score. Larger hemorrhages were associated with mortality (66 cm3 vs. 38 cm3; P < 0.005). With a mean follow-up time of 5 months, the median follow-up mRS score was 3.5 (vs. 4 preoperatively), and median follow-up GCS was 15 (vs. 10 preoperatively). Patients with higher postoperative mRS scores and lower postoperative GCS were more likely to die. CONCLUSIONS: BrainPath-mediated transsulcal approaches are associated with improved mRS and GCS scores, with low rates of residual hematoma, although further data are needed via controlled studies to determine the importance of hemorrhage location and size, timing of surgical intervention, and long-term patient outcomes.

A contralateral transventricular approach for microsurgical clip ligation of a ruptured intrathalamic aneurysm.

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.

Use of Tubular Retractor for Resection of Colloid Cysts: Single Surgeon Experience and Review of the Literature.

BACKGROUND: Colloid cysts are challenging lesions to access. Various surgical approaches are utilized which all require brain retraction, creating focal pressure, local trauma, and potentially surgical morbidity. Recently, tubular retractors have been developed that reduce retraction pressure by distributing it radially. Such retractors may be beneficial in colloid cyst resection. OBJECTIVE: To retrospectively review a single neurosurgeon's case series, as well as the literature, to determine the efficacy and safety profile of transtubular colloid cyst resections. We also aim to describe our operative technique for this approach. METHODS: We conducted a retrospective review of colloid cyst resections using either ViewSite Brain Access System (Vycor Medical, Boca Raton, Florida) or BrainPath (NICO, Indianapolis, Indiana) tubular retractors performed by a single neurosurgeon from 2015 to 2017 (n = 10). A literature review was performed to find all published cases of transtubular colloid cyst resections. RESULTS: Gross total resection was achieved in all patients. Early neurologic deficit rate was 10% (n = 1), and permanent neurologic deficit rate was 0%. There were no postoperative seizures or venous injuries. Average hospital stay was 2.0 d. There was no evidence of recurrence at average follow-up length of 13.6 mo. A literature review demonstrated nine studies (n = 77) with an overall complication rate of 7.8%. CONCLUSION: Tubular retractors offer an attractive surgical corridor for colloid cyst resections, avoiding much of the morbidity of interhemispheric approaches, while minimizing damage to normal cortex. There were no permanent complications in our series of ten cases, and a literature review found a similarly benign safety profile.

Use of Tubular Retractor for Resection of Deep-Seated Cerebral Tumors and Colloid Cysts: Single Surgeon Experience and Review of the Literature.

INTRODUCTION: Brain retraction is often required to develop a surgical corridor during the resection of deep-seated intracranial lesions. Traditional blade retractors distribute pressure asymmetrically and may case local tissue damage. Tubular retractors minimize this pitfall by distributing pressure evenly, which has been shown to translate to significant safety and efficacy data. Further qualified reports regarding the use of tubular retractors are of interest. METHODS: We performed a retrospective analysis of 1 surgeon's experience with 20 cases of minimally invasive resection with the ViewSite Brain Access System (n = 7) and BrainPath (n = 13) systems. In addition, a comprehensive review of all published cases of tubular retractor systems used for resection of subcortical neoplastic, cystic, infectious, vascular, and hemorrhagic lesions was conducted. RESULTS: Of the 20 cases analyzed, gross total resection was achieved in 18, with an associated 10% immediate postoperative complication rate and 5% long-term complication rate. A comprehensive review of the literature showed 30 articles describing 536 cases of resection of deep neoplastic or colloid cysts with an overall complication rate of 9.1%. CONCLUSIONS: Tubular retractor systems have a favorable safety profile and are an important tool in the armamentarium of a neurosurgeon for the resection of deep intracranial lesions.

Initial Single-Center Technical Experience With the BrainPath System for Acute Intracerebral Hemorrhage Evacuation.

BACKGROUND: Surgical intervention has been proposed as a means of reducing the high morbidity and mortality associated with acute intracerebral hemorrhage (ICH), but many previously reported studies have failed to show a clinically significant benefit. Newer, minimally invasive approaches have shown some promise. OBJECTIVE: We report our early single-center technical experience with minimally invasive clot evacuation using the BrainPath system. METHODS: Prospective data were collected on patients who underwent ICH evacuation with BrainPath at the Cleveland Clinic from August 2013 to May 2015. RESULTS: Eighteen patients underwent BrainPath evacuation of ICH at our center. Mean ICH volume was 52.7 mL ± 22.9 mL, which decreased to 2.2 mL ± 3.6 mL postevacuation, resulting in a mean volume reduction of 95.7% ± 5.8% (range 0-14 mL, P < .001). In 65% of patients, a bleeding source was identified and treated. There were no hemorrhagic recurrences during the hospital stay. In this cohort, only 1 patient (5.6%) died in the first 30 days of follow-up. Median Glasgow Coma Score improved from 10 (interquartile range 5.75-12) preoperation to 14 (interquartile range 9-14.25) postoperation. Clinical follow-up in this cohort is ongoing. CONCLUSION: Evacuation of ICH using the BrainPath system is safe and technically effective. The volume of clot removed compares favorably with other published studies. Early improved clinical outcomes are suggested by improvement in Glasgow Coma Score and reduced 30-day mortality. Ongoing analysis is necessary to elucidate long-term clinical outcomes and the subsets of patients who are most likely to benefit from surgery.

Tractography for Optic Radiation Preservation in Transcortical Approaches to Intracerebral Lesions.

We present a case of intraventricular meningioma resected via a transcortical approach using tractography for optic radiation and arcuate fasciculus preservation. We include a review of the literature. A 54-year-old woman with a history of breast cancer presented with gait imbalance. Workup revealed a mass in the atrium of the left lateral ventricle consistent with a meningioma. Whole brain automated diffusion tensor imaging (DTI) was used to plan a transcortical resection while sparing the optic radiations and arcuate fasciculus. A left posterior parietal craniotomy was performed using the Synaptive BrightMatter™ frameless navigation (Synaptive Medical, Toronto, Canada) to minimally disrupt the white matter pathways. A gross total resection was achieved. Postoperatively, the patient had temporary right upper extremity weakness, which improved, and her visual fields and speech remained intact. Pathology confirmed a World Health Organization (WHO) Grade I meningothelial meningioma. While a thorough understanding of cortical anatomy is essential for safe resection of eloquent or deep-seated lesions, significant variability in fiber bundles, such as optic radiations and the arcuate fasciculus, necessitates a more individualized understanding of a patient's potential surgical risk. The addition of enhanced DTI to the neurosurgeon's armamentarium may allow for more complete resections of difficult intracerebral lesions while minimizing complications, such as visual deficit.

A novel combination of two minimally invasive surgical techniques in the management of refractory radiation necrosis: Technical note.

BACKGROUND: Minimally-invasive approaches are attractive alternative to standard craniotomy for large intracranial tumors with potentially lesser morbidity. In this report, we describe a sequential combination of two minimally-invasive surgical techniques to treat a large intracranial tumor. CLINICAL PRESENTATION: A 49year-old woman presented with a history of breast cancer and large left parietal metastasis with significant perilesional edema. This was initially managed by whole brain radiation therapy and stereotactic radiosurgery. The patient underwent laser ablation of the tumor followed by internal tumor debulking using an exoscopic-assisted tubular retractor system. Post-operative MRI showed gross total coverage of the tumor by laser ablation and alleviation of mass effect. The patient recovered well and discharged on second postoperative day. CONCLUSION: The minimally-invasive combination of laser ablation followed by internal debulking using a tubular retractor device could be done safely and effectively as a minimally invasive alternative to standard craniotomy for large intracranial tumors.