Surgical Anatomy and Technique of Peri-Insular Hemispherotomy in Pediatric Epilepsy.

BACKGROUND AND OBJECTIVES: Hemispherotomy is a highly complex procedure that demands a steep learning curve. An incomplete brain disconnection often results in failure of seizure control. The purpose of this article was to present a step-by-step guide to the surgical anatomy of this procedure. It is composed of a 7-stage approach, enhancing access to and improving visualization of deep structures. METHODS: A retrospective analysis of 39 pediatric patients with refractory epilepsy who underwent this technique was conducted. Engel scores were assessed 1 year postsurgery. Cadaveric dissections were performed to illustrate the procedure. RESULTS: Between 2015 and 2022, 39 patients were surgically treated using the peri-insular technique. The technique involved 7 stages: patient positioning, operative approach, opercular resection, transventricular callosotomy, fronto-orbital disconnection, anterior temporal disconnection, and posterior temporal disconnection. Most of the patients (92.30%) were seizure-free (Engel class I) at 1 year postoperative, 5.13% were nearly seizure-free (Engel II), and 2.56% showed significant improvement (Engel III). Complications occurred in 8% of cases, including 1 infection, 2 cases of aseptic meningitis, and 1 non-shunt-requiring acute hydrocephalus. CONCLUSION: The peri-insular hemispherotomy technique offers excellent seizure control with a low complication rate. Our visual documentation of surgical anatomy, complemented by detailed descriptions of surgical nuances, significantly contributes to a comprehensive understanding of this technique.

Results of training with a low-cost simulation model for endoscope-assisted scaphocephaly repair.

OBJECTIVE: Endoscope-assisted repair of sagittal craniosynostosis is an effective technique that requires a learning curve. Surgical simulation models can be applied to acquire the necessary skills for this procedure. Several models with a wide range of costs have been described for training in this technique. The aim of this work was to present the results of training with a low-cost simulation model for endoscope-assisted sagittal craniosynostosis repair. METHODS: A simulation model for sagittal craniosynostosis was developed using low-cost materials. The model is easily assembled and allows successive uses. Three neurosurgery residents, 3 fellows, and 2 neurosurgeons performed a 4-session training program in sagittal craniosynostosis repair. The Global Rating Scale (GRS) score, number of errors, and the time required to perform the task were reported by 2 independent evaluators using a checklist. Measurements were compared between the first and last training using the Wilcoxon signed-rank test. All participants completed a questionnaire (5-point Likert scale) regarding the realism of the simulation model. RESULTS: A model was developed to recreate the steps required to perform an endoscope-assisted scaphocephaly repair with the patient in a simulated sphinx position. All participants improved their GRS performance between the first and final training. The median time needed to perform the initial training was 47.5 minutes (interquartile range [IQR] 44.5-48 minutes, interrater difference [IRD] p = 0.77), and for the last training was 40.5 minutes (IQR 35.5-43 minutes, IRD p > 0.99). The median number of errors reported in the initial training was 5.5 (IQR 3-7.75 errors, IRD p = 0.8), and in the last training was 1 (IQR 0.75-2.25 errors, IRD p = 0.35). There was a statistically significant difference regarding the time and number of errors between the initial and final training (p < 0.001). More than 85% of the participants found that the surface anatomy, skull and anterior fontanel, fused sagittal suture, and epidural space of the model were realistic and had appropriate detail required to perform the surgery. All respondents agreed or strongly agreed that the endoscope handling was realistic, and that the steps and skills required to complete the task were representative of those required for the real procedure. CONCLUSIONS: A low-cost sagittal craniosynostosis simulation model was developed, allowing successive uses. The acquisition of skills within the simulation was demonstrated for all participants regarding the GRS score and the number of errors and time needed to perform the task. In addition, the model was found to be realistic in terms of anatomical references and the procedural steps required for this minimally invasive technique.

[Coma due to syndrome of the trephined]. / Coma secundario a síndrome del trefinado.

The syndrome of the trephined or craniectomized is commonly referred as neurological manifestations associated to skin flap depression and reversible after craneoplasty, which allows its differentiation from post-traumatic syndrome. We present the case of a male patient, 36 years old, with history of decompressive craniectomy. He evolved with sudden neurological worsening associated to syndrome of the trephined and recovery after craneoplasty. Physiopathology of the syndrome involves cerebrovascular, metabolic and cerebrospinal fluid hydrodynamic disturbances as well as parenchymal hyperdynamic mechanisms. Cranioplasty is the gold standard treatment. Still, studies with statistical power are needed to assess correct surgical timing.

Coma secundario a síndrome del trefinado / Coma due to syndrome of the trephined

El síndrome del trefinado o craniectomizado abarca manifestaciones neurológicas asociadas a la depresión del flap cutáneo y se distingue del síndrome postraumático por su reversibilidad con el tratamiento reparador del defecto craneano. El coma no es una forma habitual de presentación. Comunicamos un caso de presentación atípica en un hombre de 36 años de edad con antecedente de craniectomía descompresiva, que presentó un cuadro de deterioro neurológico profundo atribuible al síndrome del trefinado, el cual revirtió tras la craneoplastía. En la fisiopatología del síndrome intervienen trastornos cerebrovasculares, metabólicos, hidrodinámicos del líquido cefalorraquídeo e hiperdinamismo de las estructuras encefálicas. El gold standard terapéutico es la craneoplastía. Se requieren estudios de mayor peso estadístico para determinar el tiempo quirúrgico apropiado.

The syndrome of the trephined or craniectomized is commonly referred as neurological manifestations associated to skin flap depression and reversible after craneoplasty, which allows its differentiation from post-traumatic syndrome. We present the case of a male patient, 36 years old, with history of decompressive craniectomy. He evolved with sudden neurological worsening associated to syndrome of the trephined and recovery after craneoplasty. Physiopathology of the syndrome involves cerebrovascular, metabolic and cerebrospinal fluid hydrodynamic disturbances as well as parenchymal hyperdynamic mechanisms. Cranioplasty is the gold standard treatment. Still, studies with statistical power are needed to assess correct surgical timing.