Bur Hole–Based Resections of Intrinsic Brain Tumors with Exoscopic Visualization

Abstract

Background The primary goal of brain tumor surgery is maximal safe resection while avoiding iatrogenic injury. As surgical technology increases, it is becoming more possible to resect these lesions using minimally invasive approaches. While keyhole surgeries are being advocated, the lower limit of these approaches is unclear. Bur hole–based approaches may represent a standardized minimally invasive approach. The exoscope may provide increased visualization over standard microscopic visualization, making this approach possible. This approach has yet to be described strictly for intra-axial brain tumors.

Material and Methods All patients who underwent a bur hole–based surgery of an intra-axial tumor with exoscopic visualization by the senior author from January 2018 to December 2019 were prospectively identified and patient information and outcomes were collected.

Results Fifteen consecutive patients underwent surgical resection of an intrinsic brain tumor using a bur hole–based approach with exoscopic visualization. The average ± standard deviation age was 57.9 ± 24.2 years. The pathology was a metastatic brain tumor in eight patients (53%), low-grade glioma in four patients (27%), and high-grade glioma in three patients (20%). The average percent resection was 100 ± 1%, where 14 (93%) underwent gross total resection. Following surgery, the median (interquartile range) Karnofsky performance scale (KPS) score was 90 (90–90), where 11 (73%) and four patients (27%) had improved and stable KPS, respectively. Zero patients had complications. The average length of stay following surgery was 1.4 ± 0.5 days, where nine patients (60%) were discharged on postoperative day 1.

Conclusion This study shows that intra-axial tumors can be resected through a bur hole–based approach with exoscopic visualization with extensive resection, minimal morbidity, and early discharge rates.

Keywords

bur hole - exoscope - keyhole - minimally invasive

Publication History

Received: 24 February 2020

Accepted: 08 June 2020

Article published online:
22 December 2020

• References

• 1 Chaichana KL, Jusue-Torres I, Navarro-Ramirez R. et al. Establishing percent resection and residual volume thresholds affecting survival and recurrence for patients with newly diagnosed intracranial glioblastoma. Neuro-oncol 2014; 16 (01) 113-122
• 2 Chaichana KL, Parker SL, Mukherjee D, Cheng JS, Gokaslan ZL, McGirt MJ. Assessment of the extent of surgical resection as a predictor of survival in patients with primary osseous spinal neoplasms. Clin Neurosurg 2011; 58: 117-121
• 3 McGirt MJ, Chaichana KL, Attenello FJ. et al. Extent of surgical resection is independently associated with survival in patients with hemispheric infiltrating low-grade gliomas. Neurosurgery 2008; 63 (04) 700-707 , author reply 707–708
• 4 McGirt MJ, Chaichana KL, Gathinji M. et al. Independent association of extent of resection with survival in patients with malignant brain astrocytoma. J Neurosurg 2009; 110 (01) 156-162
• 5 McGirt MJ, Mukherjee D, Chaichana KL, Than KD, Weingart JD, Quinones-Hinojosa A. Association of surgically acquired motor and language deficits on overall survival after resection of glioblastoma multiforme. Neurosurgery 2009; 65 (03) 463-469 , discussion 469–470
• 6 Chaichana KL, Cabrera-Aldana EE, Jusue-Torres I. et al. When gross total resection of a glioblastoma is possible, how much resection should be achieved?. World Neurosurg 2014; 82 (1-2): e257-e265
• 7 Burks JD, Conner AK, Bonney PA. et al. Management of intracranial meningiomas using keyhole techniques. Cureus 2016; 8 (04) e588
• 8 Burks JD, Conner AK, Bonney PA. et al. Frontal keyhole craniotomy for resection of low- and high-grade gliomas. Neurosurgery 2018; 82 (03) 388-396
• 9 Charalampaki P, Filippi R, Welschehold S, Conrad J, Perneczky A. Tumors of the lateral and third ventricle: removal under endoscope-assisted keyhole conditions. Neurosurgery 2008; 62 (06) (Suppl. 03) 1049-1058
• 10 Conner AK, Burks JD, Baker CM. et al. Method for temporal keyhole lobectomies in resection of low- and high-grade gliomas. J Neurosurg 2018; 128 (05) 1388-1395
• 11 Duckworth EA, Vale FL. Trephine epilepsy surgery: the inferior temporal gyrus approach. Neurosurgery 2008; 63 (01) (Suppl. 01) ONS156-ONS160 , discussion ONS160–ONS161
• 12 Hoshide R, Faulkner H, Teo M, Teo C. Keyhole retrosigmoid approach for large vestibular schwannomas: strategies to improve outcomes. Neurosurg Focus 2018; 44 (03) E2
• 13 Little AS, Smith KA, Kirlin K. et al. Modifications to the subtemporal selective amygdalohippocampectomy using a minimal-access technique: seizure and neuropsychological outcomes. J Neurosurg 2009; 111 (06) 1263-1274
• 14 Lucas JW, Zada G. Endoscopic endonasal and keyhole surgery for the management of skull base meningiomas. Neurosurg Clin N Am 2016; 27 (02) 207-214
• 15 Mostafa BE, El Sharnoubi M, Youssef AM. The keyhole retrosigmoid approach to the cerebello-pontine angle: indications, technical modifications, and results. Skull Base 2008; 18 (06) 371-376
• 16 Pitskhelauri D, Konovalov A, Kudieva E. et al. Burr hole microsurgery for intracranial tumors and mesial temporal lobe epilepsy: results of 200 consecutive operations. World Neurosurg 2019; 126: e1257-e1267
• 17 Renovanz M, Hickmann AK, Gutenberg A, Bittl M, Hopf NJ. Does size matter? Minimally invasive approach in pediatric neurosurgery: a review of 125 minimally invasive surgeries in children: clinical history and operative results. Childs Nerv Syst 2015; 31 (05) 665-674
• 18 Shahinian HK, Ra Y. 527 fully endoscopic resections of vestibular schwannomas. Minim Invasive Neurosurg 2011; 54 (02) 61-67
• 19 Yang PF, Zhang HJ, Pei JS. et al. Keyhole epilepsy surgery: corticoamygdalohippocampectomy for mesial temporal sclerosis. Neurosurg Rev 2016; 39 (01) 99-108 , discussion 108
• 20 Ricciardi L, Chaichana KL, Cardia A. et al. The exoscope in neurosurgery: an innovative “point of view.” A systematic review of the technical, surgical, and educational aspects. World Neurosurg 2019; 124: 136-144
• 21 Gassie K, Alvarado-Estrada K, Bechtle P, Chaichana KL. Surgical management of deep-seated metastatic brain tumors using minimally invasive approaches. J Neurol Surg A Cent Eur Neurosurg 2019; 80 (03) 198-204
• 22 Gassie K, Wijesekera O, Chaichana KL. Minimally invasive tubular retractor-assisted biopsy and resection of subcortical intra-axial gliomas and other neoplasms. J Neurosurg Sci 2018; 62 (06) 682-689
• 23 Iyer R, Chaichana KL. Minimally invasive resection of deep-seated high-grade gliomas using tubular retractors and exoscopic visualization. J Neurol Surg A Cent Eur Neurosurg 2018; 79 (04) 330-336
• 24 Jackson C, Gallia GL, Chaichana KL. Minimally invasive biopsies of deep-seated brain lesions using tubular retractors under exoscopic visualization. J Neurol Surg A Cent Eur Neurosurg 2017; 78 (06) 588-594
• 25 Bakhsheshian J, Strickland BA, Jackson C. et al. Multicenter investigation of channel-based subcortical trans-sulcal exoscopic resection of metastatic brain tumors: a retrospective case series. Oper Neurosurg (Hagerstown) 2019; 16 (02) 159-166
• 26 Lin M, Bakhsheshian J, Strickland B. et al. Exoscopic resection of atrial intraventricular meningiomas using a navigation-assisted channel-based trans-sulcal approach: case series and literature review. J Clin Neurosci 2020; 71: 58-65
• 27 Mampre D, Bechtle A, Chaichana KL. Minimally invasive resection of intra-axial posterior fossa tumors using tubular retractors. World Neurosurg 2018; 119: e1016-e1020
• 28 Marenco-Hillembrand L, Alvarado-Estrada K, Chaichana KL. Contemporary surgical management of deep-seated metastatic brain tumors using minimally invasive approaches. Front Oncol 2018; 8: 558