Case report
Complications of interhemispheric transcallosal approach in children: Review of 15 years experience

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Abstract

Objective

The interhemispheric transcallosal approach to deep-seated lesions in and around the ventricular system avoids cortical manipulation and injury. Few case series discuss the morbidity associated with this approach. This study describes the 15-year experience of the senior author in Southern California.

Methods

All pediatric patients who have undergone interhemispheric, transcallosal resections of mass lesions over a 15-year period were identified. The surgical approach was uniform with respect to positioning of the patient. Intra-operative and post-operative data were collected retrospectively from the medical records. The need for bridging vein ligation as well as the incidence of hemiparesis, seizures, memory disturbances, and the need for subsequent cerebrospinal fluid (CSF) diversion were identified.

Results

Sixty-five patients were identified. The incidence of transient post-operative hemiparesis appeared to be higher in those patients who required ligation of one or two parasagittal veins (44.6% versus 18.5%) with no difference in long-term outcome. Nineteen percent (18.5%) of patients had post-operative seizures; however, no long-term seizure disorder was identified. Nine percent (9.2%) had reports of transient short-term memory deficits. Thirty-four percent (33.8%) of patients required secondary operative intervention for CSF diversion. The total complication rate, including need for CSF diversion, transient hemiparesis, infection, post-operative seizures, and memory disturbance was 36.9%. By 1 year, the total number of patients with persistent hemiparesis, memory disturbance, or seizures refractory to medication was 4 (6.2%).

Conclusion

This series demonstrates that the interhemispheric transcallosal corridor is a versatile and safe approach in childhood, resulting in low post-operative permanent morbidity.

Introduction

Studies of the corpus callosum were first undertaken by the humoral anatomists of ancient times who believed that the structure's function was purely of support—allowing air, phlegm, cerebrospinal fluid, and blood through the cavities of the brain [5]. This view persisted for a millennium until “traffic anatomists” such as Thomas Willis began thinking in terms of communication (or traffic) between the hemispheres. This was further detailed around the turn of the century with a report of a right-handed patient whose callosal lesion caused a left apraxia and a left-handed agraphia in the absence of aphasia. It was not until 1913, however, that German surgeon Brunner found that a unilateral occipital flap allowed the ligation of veins to the sagittal sinus and retraction of the hemisphere laterally with the subsequent cutting of the posterior portion of the corpus callosum allowing exposure of the pineal region.

In 1921, Dandy reported similar sectioning of the posterior two-thirds of the callosum in three patients with tumors [8]. One patient died “presumably of the shock due to the magnitude of the operation.” One mass was unable to be removed at all. The third, a 4 cm × 5 cm tuberculoma, was easily removed. French and Bucy reported five cases of septum pellucidum tumors all exposed by transcortical approaches [10]. In their publication they mentioned that the transcallosal approach could also have been utilized. Similarly, Cassinari and Bernasconi described 19 patients with third ventricular tumors, and favored the transcallosal approach [7].

Since the introduction of the operative microscope, the approach has become increasingly popular. There are a number of distinct advantages of the interhemispheric transcallosal corridor, especially in the pediatric patient population. The incidence of midline and intraventricular lesions are significantly higher in children. The approach allows access to the corpus callosum, septum pellucidum, lateral and third ventricles, and their periventricular structures, as well as the suprasellar region. This exposure can be accomplished without cortical destruction, theoretically decreasing the incidence of neurologic deficits and post-operative seizures. In addition, the approach is viable even without an enlarged ventricular system. Complications of this approach, however, include hemiparesis, seizures, memory disturbances, and, although not a complication, the inability to re-establish CSF circulation without having to insert a CSF diverting shunt. “Disconnection syndrome” is a rare complication that can also be seen after total callosotomy. However, it is unusual for the effects of disconnection after anterior callosotomy to represent significant handicap.

Section snippets

Materials and methods

A retrospective chart review was performed. The records of children who have undergone anterior interhemispheric, transcallosal operations for deep midline lesions from 1989 to 2005 were reviewed. Surgery was performed at the Children's Hospital Los Angeles or the Children's Hospital San Diego. These years were chosen given the regional availability of high-resolution magnetic resonance (MR) imaging.

At the time of surgery, each patient was placed in a lateral decubitus position with the head

Results

The series included 65 patients whose pathology consisted of 31 astrocytomas of varying types, 7 arachnoid cysts, 6 arteriovenous malformations, 4 teratomas, and 4 choroid plexus tumors. Smaller numbers of ependymomas, meningiomas, gangliogliomas, cavernomas, sarcomas, and craniopharyngiomas were also included (Table 1). Pineal tumors were not included in this series. The ages ranged from newborn to 18 years with a mean of 8.2 years and included 38 (58.5%) males and 27 (41.5%) females. Minimum

Discussion

A review of the literature in the microsurgery era, since the mid-1970s, reveals some series that provide information regarding the incidence of complications related to this approach. Scattered throughout the literature is the occurrence of hemiparesis, memory loss, and mutism, but few series actually detail morbidity [18], [19]. No literature could be found with regard to post-operative seizures, and there is only occasional mention of the need for permanent CSF diversion [4]. Additionally,

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