Gradual Formation of an Operative Corridor by Balloon Dilation for Resection of Subependymal Giant Cell Astrocytomas in Children with Tuberous Sclerosis: Specialized Minimal Access Technique of Balloon Dilation

Abstract

Background: Major sources of morbidity and mortality in patients with tuberous sclerosis who develop subependymal giant cell astrocytomas (SEGAs) relate to tumor growth and resultant hydrocephalus. We describe a modification of a specialized minimal access resection technique in which an operative corridor is formed with balloon dilation over the course of a week prior to tumor resection. Methods: Three patients with tuberous sclerosis who had an enlarging SEGA and concomitant hydrocephalus underwent surgical resection with this modified technique. A frontal craniotomy was performed and the optimal trajectory for tumor resection was confirmed by image guidance. After initial insertion of the deflated balloon into the ventricle and removal of the peel-away sheath, inflation of the balloon with a 1-mL saline injection sealed the tract. Additional 1-mL saline injections were continued during the next week until the balloon reached a 15-mm diameter, thus creating the operative corridor. One week after the first operation, the balloon was deflated and removed, and the patient underwent tumor resection via the newly formed operative corridor. Results: Three patients with tuberous sclerosis underwent gross total resections of SEGAs and experienced subsequent resolution of ventricular dilation. Postoperative imaging confirmed minimal cortical disruption. Conclusions: Use of balloon dilation for the gradual formation of an operative corridor eliminated the need for additional retraction during SEGA resection, potentially decreasing injury to the surrounding neural tissue. In our three patients, the dilation tract retained its integrity during the operation and had sealed completely on postoperative imaging.

Key words

Balloon dilation - operative corridor - tuberous sclerosis - subependymal giant cell astrocytoma

References

• 1 Abraham RG, Shyam Kumar NK, Chacko AG. A minimally invasive approach to deep-seated brain lesions using balloon dilatation and ultrasound guidance.  Minim Invas Neurosurg. 2003;  46 138-141
• 2 Andrews RJ, Bringas JR. A review of brain retraction and recommendations for minimizing intraoperative brain injury.  Neurosurgery. 1993;  33 1052-1063
• 3 Beems T, Grotenhuis JA. Subependymal giant-cell astrocytoma in tuberous sclerosis: endoscopic images and the implications for therapy.  Minim Invas Neurosurg. 2001;  44 58-60
• 4 Couillard P, Karmi MZ, Abdelkader AM. Microsurgical removal of an intraventricular meningioma with ultrasound guidance, and balloon dilation of operative corridors: case report and technical report.  Surg Neurol. 1996;  45 155-160
• 5 Cuccia V, Zuccaro G, Sosa F, Monges J, Lubienieky F, Taratuto AL. Subependymal giant cell astrocytoma in children with tuberous sclerosis.  Childs Nerv Syst. 2003;  19 232-243
• 6 Di Rocco C, Iannelli A, Marchese E. On the treatment of subependymal giant cell astrocytomas and associated hydrocephalus in tuberous sclerosis.  Pediatr Neurosurg. 1995;  23 115-121
• 7 Hirsch J-F, Sainte-Rose C. A new surgical approach to subcortical lesions: balloon inflation and cortical gluing.  J Neurosurg. 1991;  74 1014-1017
• 8 Kelly PJ. Principles of stereotactic surgery. In: Youmans JR (ed): Neurological Surgery. Phildaelphia, W. B. Saunders 1990 pp 4208-4209
• 9 Kim SK, Wang KC, Cho BK, Jung HW, Lee YJ, Chung YS, Lee JY, Park SH, Kim YM, Choe G, Chi JG. Biological behavior and tumorigenesis of subependymal giant cell astrocytomas.  J Neuro-Oncol. 2001;  52 217-225
• 10 Madrazo I, Franco-Bourland R, Aguilera M, Reyes P, Guizar-Sahagun G. Balloon needle for the atraumatic transcortical ventricular approach: technical note.  Surg Neurol. 1990;  33 226-227
• 11 Nabbout R, Santos M, Rolland Y, Delalande O, Dulac O, Chiron C. Early diagnosis of subependymal giant cell astrocytoma in children with tuberous sclerosis.  J Neurol Neurosurg Psychiatry. 1999;  66 370-375
• 12 Narayanan V. Tuberous sclerosis: genetics to pathogenesis.  Pediatr Neurol. 2003;  29 404-409
• 13 Shahbabian S, Keller JT, Gould HJ, Dunsker SB, Mayfield FH. A new technique for making cortical incisions with minimal damage to cerebral tissue.  Surg Neurol. 1983;  20 310-312
• 14 Sinson G, Sutton LN, Yachnis AT, Duhaime AC, Schut L. Subependymal giant cell astrocytomas in children.  Pediatr Neurosurg. 1994;  20 233-239

Correspondence