The Journal of Craniofacial Surgery • Volume 26, Number 2, March 2015
Brief Clinical Studies
and zygomatic arch. Mandibular outer cortex splitting ostectomy, mandibular “V-line” ostectomy, and rotation genioplasty can be applied to correct asymmetric mandibula. These techniques result in positive changes in the patients' facial contour with high patient satisfaction.
23. Kim YH, Seul JH. Reduction malarplasty through an intraoral incision: a new method. Plast Reconstr Surg 2000;106:1514 –1519 24. Lee JG, Park YW. Intraoral approach for reduction malarplasty: a simple method. Plast Reconstr Surg 2003;111:453– 460
ACKNOWLEDGMENT The research protocol was approved by the local ethical committee.
REFERENCES 1. Severt TR, Proffit WR. The prevalence of facial asymmetry in the dentofacial deformities population at the University of North Carolina. Int J Adult Orthodon Orthognath Surg 1997;12:171–176 2. Legg JW. Enlargement of the temporal and masseter muscles on both sides [M]. Trans Pathol Soc (Lond) 1880;31:361–374 3. Han K, Kim J. Reduction mandibuloplasty: ostectomy of the lateral cortex around the mandibular angle. J Craniofac Surg 2001;12:314–325 4. Coffey RJ. Unilateral hypertrophy of the masseter muscle. Surgery 1942;11:815 5. Waldhart E, Lynch JB. Benign hypertrophy of the masseter muscles and mandibular angels. Arch Surg 1871;102:115–118 6. Lee Y, Kim JH. Mandibular contouring: A surgical technique for the asymmetrical lower face. Plast Reconstr Surg 1999;104:1165–1171 7. Deguchi M, Iio Y, Kobayashi K, et al. Angle splitting ostectomy for reducing the width of the lower face. Plast Reconstr Surg 1997;99:1831–1839 8. Adams WM. Bilateral hypertrophy of masseter muscle: An operation for correction (case report). Br J Plast Surg 1949;2:78–81 9. Baek SM, Baek RM, Shin MS. Refinement in aesthetic contouring of the prominent mandibular angle. Aesthetic Plast Surg 1994;18:283–289 10. Converse JM. Deformities of the jaws. In: JM Converse, ed. Reconstructive Plastic Surgery. Philadelphia: Saunders, 1977:140 11. Jiang N, Hsu Y, Khadka A, et al. Total or partial inferior border ostectomy for mandibular contouring: indications and outcomes. J Craniomaxillofac Surg 2012;40:e277–e284 12. Cui J, Zhu S, Hu J, et al. The effect of different reduction mandibuloplasty types on lower face width and morphology. Aesthetic Plast Surg 2008;32:593–598 13. Hsu YC, Li J, Hu J, et al. Correction of square jaw with low angles using mandibular “V-line” ostectomy combined with outer cortex ostectomy. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;109:197–202 14. Li J, Hsu Y, Khadka A, et al. Contouring of square jaw on short face by narrowing and sliding genioplasty combined with mandibular outer cortex ostectomy in Orientals. Plast Reconstr Surg 2011; 127:2083–2092 15. Li J, Hsu Y, Khadka A, et al. Surgical designs and techniques for mandibular contouring based on categorization of square face with low gonial angle in orientals. J Plast Reconstr Aesthet Surg 2012;65:e1–e8 16. Li X, Hsu Y, Hu J, et al. Comprehensive consideration and design for treatment of square face in Orientals. J Oral Maxillofac Surg 2013;71:1761.e1–1761.e14 17. Satoh K. Mandibular contouring surgery by angular contouring combined with genioplasty in Orientals. Plast Reconstr Surg 1998;101:461– 472 18. Onizuka T, Watanabe K, Takasu K, et al. Reduction malarplasty. Aesthetic Plast Surg 1983;7:121–125 19. Uhm KI, Lew JM. Prominent zygoma in Orientals: classification and treatment. Ann Plast Surg 1991;26:164–170 20. Baek SM, Kim SS, Bindiger A. The prominent mandibular angle: preoperative management, operative technique, and results in 42 patients. Plast Reconstr Surg 1989;83:272–280 21. Baek SM, Chung YD, Kim SS. Reduction malarplasty. Plast Reconstr Surg 1991;88:53– 61 22. Kim JW. Laser-assisted endoscopic reduction malarplasty in Asians. Aesthetic Plast Surg 1998;22:289 –297
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Transsylvian-Transinsular Approach to Large Lateral Thalamus Hemorrhages Hong-Tian Zhang, PhD,*† Ai-Jia Shang, MD,‡ Bing-Juan He, MD,* Ru-Xiang Xu, PhD*† Abstract: Here, we aimed to evaluate the experience of transsylviantransinsular microsurgical approach (TTH) to the huge lateral thalamic hemorrhages (THs). A total of 37 patients with huge lateral TH (hematoma volumes between 30 and 90 cm3) who underwent surgical treatment through middle or distal TTH at the Bayi Brain Hospital from January 2007 to May 2012 were included in this series. By using TTH, near-complete (99%) evacuation was achieved in 29 patients (78.4%). Glasgow Coma Scale (GOS) scores were significantly improved at discharge compared with admission scores (P < 0.001). The overall survival rate at 3 months was 81.08% (30/37), including 51.35% (19/37) with good function (GOS, 4–5), 13.51% (5/37) with disability (GOS, 3), and 16.22% (6/37) in a vegetative state (GOS, 2). The mortality rate (GOS, 1) was 18.92% (7/37). Our series showed that, according to the extension direction of hematomas, to select middle or distal TTH is effective and safe for TH. Key Words: Thalamic hemorrhages, transsylvian-transinsular approach, minimal invasiveness
T
halamic hemorrhages (THs) have a high mortality and morbidity and account for approximately 30% of all intracerebral hemorrhages (ICH).1,2 Previous studies showed that patients with isolated TH show a differential clinical profile than patients with internal capsule-basal ganglia hemorrhage.3,4 However, separate analysis of TH as an individual clinical entity is rarely performed.5 The surgical indications for the treatment of TH remain controversial.6
From the *The Affiliated Bayi Brain Hospital, Military General Hospital of Beijing PLA; †Institute of Neurosurgery, Beijing Military Region PLA; and ‡Department of Neurosurgery, General Hospital of Chinese PLA, Beijing, China. Received July 1, 2014. Accepted for publication September 13, 2014. Address correspondence and reprint requests to Ru-Xiang Xu, PhD, The Affiliated Bayi Brain Hospital, the Military General Hospital of Beijing PLA and The Neurosurgical Research Center of Beijing Military Region PLA, No 5, Nanmencang, Dongcheng District, Beijing 100700, China; E-mail: [email protected] Supported by the Natural Scientific Research Funds of China (no. 81371345) and Beijing Nova Program (XX2013059) for Hong-Tian Zhang. Hong-Tian Zhang and Ai-Jia Shang contributed equally to this work. The authors report no conflicts of interest. Copyright © 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001323
© 2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery • Volume 26, Number 2, March 2015
Evacuation of a TH by craniotomy is generally considered controversial because the approach commonly causes damage to uninjured brain overlying the hematoma. Keyhole approach through transsylviantransinsular approach (TTA) is a new microsurgical procedure that has been carried out to treat hypertensive putaminal hemorrhage recently.7,8 However, no systemic written about the application of this approach to TH was reported. The location is deeper, and the anatomic structures around the thalamus are totally different and even more complex than those in the putamine. In the present study, we retrospectively summarized 37 patients with TH being treated surgically through TTH. In this report, we examine our experience with TTH to TH and describe microsurgical techniques.
MATERIALS AND METHODS Patients A total of 37 consecutive patients with huge lateral TH (hematoma volumes between 30 and 90 cm3) were included in this study. They underwent surgical management through TTA from January 2007 to May 2012 in the Affiliated Bayi Brain Hospital by the same group of 6 neurosurgeons (authors). The records were reviewed after obtaining clinic ethics committee approval. The study was retrospective. The `TH was defined as bleeding originating from the thalamus, including local TH and primary TH extending to other structures, but not including primary hematoma of another location extending to the thalamus. If 1 hematoma involved more than 2 structures (eg, thalamus and basal ganglia) at the same time, the hematoma must have been unanimously identified by 2 neurologists as primary TH. All patients with initial Glasgow Coma Scale (GCS) scores of 5 or higher who consented and underwent keyhole evacuation within 24 hours of the ictus had hematoma volumes between 30 and 90 cm3, and whose hemorrhages were not associated with tumor, trauma, aneurysms, arteriovenous malformations, cavernous malformations, cerebral infarctions with hemorrhagic transformation, or fibrinolysis were included in this retrospective review. All patients with TH underwent neurologic examination on admission. History was obtained from the patients, relatives, or medical personnel. Time of primary symptoms was recorded. If the onset was unobserved, it was considered to be at the last time that the patient was definitely normal. Medical history with particular attention to hypertension, diabetes, antiplatelet use, and anticoagulation as well as a history of drug abuse was recorded. Computerized tomography (CT) in all patients was evaluated to record the size and location of the hematoma as well as the absence of vascular lesions, tumor, ischemia, and signs of trauma. In patients in whom the location, age, history, and findings on CT did not rule out a possible vascular lesion, digital subtraction angiography was performed. The volume of the hematoma was calculated using the formula A B C / 2 (where A is the biggest diameter, B is the diameter at 90 degrees from A, and C is the number of slices slice thickness (10); the presence of intraventricular hemorrhage was not included in the formula). Postoperatively, CT was performed at the end of the procedure, on the first postoperative day, on days 5 to 7, and as needed. Patients on anticoagulants and prolonged prothrombin times were admitted to surgery as soon as this was reversed by the use of 10-mg vitamin K and 15-mL/kg fresh frozen plasma, except in large hematomas with clinical deterioration. Surgery in these patients was initiated before normalization of prothrombin times. Dexamethasone and phenytoin for all patients and mannitol for patients with larger hematomas were started on admission. All patients received cephazoline intraoperatively.
Brief Clinical Studies
Surgical Technique On the basis of our surgical experience, TH has been divided into 2 subtypes according to the extension direction of hematomas. One type of the TH was extended into the anterior part of the temporal lobe (type 1), and the other one was extended into the posterior part of the temporal lobe (type 2). For type 1, middle TTA was performed. The patients were placed supine with heads rotated toward the healthy sides 45 degrees and tilted back 15 degrees. Ipsilateral shoulder was propped up with padding to check excessive neck rotation. Approximately 5- to 6-cm skin incision (surface projection of the middle sylvian fissure approximately 1 cm posterior of the pterion point) was made, and the area of bone window was 3 to 3.5 cm2 (Fig. 1A). The enter point of the arachnoid membrane of the sylvian fissure is on the frontal side of the sylvian vein and along the pars opercular of the inferior frontal gyrus. It separates the opercular surfaces of the frontal, parietal, and temporal lobes and accesses the circular sulcus and long gyri of the insular cortex along M3 branches. A small insular cortex incision was made parallel to sylvian fissure. Splitting the insular cortex resulted in the exposure of TH. Accessing point on the insular cortex was determined by the largest point of hematoma to the surface of insular cortex on the CT scans of patient. Hematoma evacuation was performed using suction and bipolar cautery, and the use of brain plate was minimized. The operation was performed using mild suction, and the hematoma cavity was continuously irrigated with 30°C of saline (Figs. 2A–F). The hematoma located at the central part of the hematoma cavity was removed initially, and then the rest of hematoma was displaced into the operative field for the pressure differences, which facilitated complete evacuation of hematoma although it was very large. If possible, the responsible vessel was examined and properly handled. A minimal amount of hematoma remained untouched near the hematoma margin to avoid further injury of adjacent normal brain. Hematoma cavity was covered with Surgicell. For type 2, distal TTA was performed.9 The patients were placed supine with heads rotated to the contralateral side with an aim to bring sagittal suture parallel to the floor. Ipsilateral shoulder was propped up with padding to check excessive neck rotation. The head was held in this position with Mayfield head holder, and a linear incision was marked, centered at a point along the surface projection of the posterior sylvian fissure approximately 2 to 3 cm anterior to the parietal eminence. The incision was deepened through fascia, and the temporalis muscle and bone were exposed. A craniotomy was made as shown in Figure 1B, and the area of bone window was 3.5 to 4 cm2 (Fig. 1B). After opening the dura, posterior sylvian fissure was identified by the presence of prominent superficial middle cerebral vein and the M4 branches entering the fissure along both operculae. Arachnoid over the veins was sharply divided on the frontal side, and the sylvian fissure was
FIGURE 1. The design of incision and bone window of the middle (A) and distal (B) TTA.
© 2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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The Journal of Craniofacial Surgery • Volume 26, Number 2, March 2015
Brief Clinical Studies
layer. The following procedure was the same as mentioned previously.
Follow-up Review The volume of hematoma remaining obtained by CT scans at 24 hours after surgery and the postoperative GCS scores at 7 days postoperation were evaluated. Complications occurring within 30 days were recorded. All patients were followed for 90 days after stroke onset by telephone or in the clinic. The long-term effect was assessed using the 90-day GOS. A favorable outcome was defined prospectively as a 90-day GOS score of greater than 3, whereas an unfavorable outcome was defined as a 90-day GOS score of 3 or less.
RESULTS FIGURE 2. The surgical procedure of middle TTA (A–F).
opened. Sometimes, a minor bridging vein was sacrificed to widen the operating space. An effort was made to open the sylvian fissure along its entire visible length to allow atraumatic separation of the operacula. We adopt an “inside-out” technique for opening the sylvian fissure, separating the opercular arachnoid bands in the depth before slitting the superficial arachnoid. Attention was directed toward the temporal operculum, and transverse temporal gyri were identified by their oblique orientation and undulating appearance on an otherwise flat opercular surface. Normally, the posteromedial ends of these gyri converge toward the posterior half of the superior limiting sulcus of the insula, which is superficial to the posterior thalamus, the retro-lentiform internal capsule, and the anterior limit of the atrium. Mechanical retraction of the opercula was conscientiously avoided as initial hematoma decompression provided the required working space (Figs. 3A–F). For the initial approach, the opercula were held apart with cottonoids wedged into the fissure. However, keeping the normal relationship in mind, the posterior insular cortex (the long insular gyri posterior to the central sulcus) was entered, and the lesion was found beneath a thin cortical
FIGURE 3. The surgical procedure of distal TTA (A–F).
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Thirteen cases were divided into type 1 TH, and 24 belonged to type 2 TH. The hematoma volume was 24 to 88 mL (median, 49 mL) on admission, and hematoma volumes measured on CT scans obtained 24 hours postoperatively were 6.5 mL (range, 0.3–24.6 mL). In this group, near-complete (>90%) evacuation was achieved in 29 patients (78.4%), 70% to 90% in 6 patients (16.2%), and less than 70% in 2 patients (5.4%) (Figs. 4A–H). The mean (SD) operation time was 152 (12.66) minutes in types 1 and 2. On admission, median GCS score was 6 (range, 3–10). Neurologic examination on the third postoperative day showed that none of the patients had neurologic deterioration and that the GCS score was either unchanged or improved in all patients (P < 0.001). There was no rebleeding. The GCS scores (median, 14; range, 0–15) were significantly improved compared with admission scores (P < 0.001). The overall survival rate at 3 months was 81.08% (30/37), including 51.35% (19/37) with good function (GOS, 4–5), 13.51% (5/37) with disability (GOS, 3), and 16.22%
FIGURE 4. Four typical cases of putaminal ICH being treated by minimally invasive surgical treatment through middle (A–D) and distal (E–H) TTA. Preoperative brain CT showing large putaminal hematoma with midline shifting and immediate postoperative brain CT (A, C, E, and G). Immediate postoperative brain CT showing total evacuation of hematoma and cranial bone reposition (B, D, F, and H).
© 2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery • Volume 26, Number 2, March 2015
(6/37) in a vegetative state (GOS, 2). The mortality rate (GOS, 1) was 18.92% (7/37). The examination of the 30-day complication showed that 1 patient (2.7%) experienced epilepsy. It was well controlled after taking drugs. No patient experienced rebleeding. There were 4 (10.81%) of the 37 and 9 (24.32%) of the 37 patients who experienced pneumonia and digestive tract hemorrhage, respectively.
DISCUSSION As described by Kawahara et al,10 4 types of TH were determined, including anterolateral (including ventroanterior and ventrolateral nuclei), posterolateral (including posteroventrolateral and pulvinar nuclei), medial (including dorsomedial and intralaminar nuclei), and dorsal (including mainly dorsomedial nucleus) types. Approximately 76% of TH appeared as the anterolateral and posterolateral types.10 Mortality in patients with large TH is high.5,11 Thus, how to decrease the mortality rate of large lateral TH is a problem need to be cracked. Stereotaxic drainage, CT guided aspiration, and endoscopic removal of thalamic hematomas have been evaluated in small patient series.3,11–16 In endoscopic surgery for TH, an approach was reported from Keen point (located 3 cm posterior and 3 cm superior to the pinna) to the collateral trigone17 or from the forehead to the frontal horn of the lateral ventricle.18 These approaches help to evacuate ventricular hemorrhage and are suited for TH that extends to the ventricle, but the efficiency of clearance of the thalamic hematoma is lower. Drainage with puncture requires only a small incision in the skin and brain; however, the hematoma cannot be cleaned out all at once, and there is no opportunity to treat the offending vessel. Effective hemostasis cannot be performed, resulting in a certain incidence of recurrent hemorrhage after the operation.16 Craniotomy and evacuation of thalamic ICHs is infrequently used because of the high rates of mortality and morbidity observed after this procedure.6 The thalamus involved in many brain functions including sensation, motor control, mental, and consciousness status is close to other important structures, such as the internal capsule, midbrain, hypothalamus, and the upstream reticular activating system. The operative corridor is easy to destroy in these structures around the thalamus. In addition, TH is easily ruptured into the lateral ventricle. Intraventricular hemorrhage (IVH) is one of the important factors to influence the prognosis, and TH and TH associated IVH needed to be removed as quickly as possible.3,19,20 Therefore, in a long time, the surgery is considered difficult for TH. Several surgical approaches have been considered to remove the thalamic lesions. Transventricular approaches are the most frequent because of the intimate relationship of the thalamus with the lateral ventricles. Access to the ventricles and, subsequently, to the thalamus may be gained either by transcortical or interhemispheric routes. Traditional approaches to TH are transcortical, through the superior or middle temporal gyrus or the superior parietal lobule. Although the transcortical approach is more direct with a shorter working distance to the lesion, it has some distinct disadvantages. First, the transcortical approach traverses the normal brain, increasing the risk for neurologic deficits.21 Second, the transcortical approach is particularly difficult when the lateral ventricles are not dilated.22 Third, the approach can cause postoperative seizures.23,24 The interhemispheric approach is another way to the lateral ventricle. However, it may jeopardize the bridging cortical veins and may even sometimes be precluded by anomalous venous anatomy.25 The posterior interhemispheric approach takes advantage of the midline bridging veins being scarce posterior to the lambdoid suture. Approach to the atrium and posterior thalamus necessitates a small incision in the precuneus, which is inconsequential. In addition, it is difficult to deal with lateral thalamic lesions with this
Brief Clinical Studies
approach. However, these approaches are applicable mainly to pulvinar lesions and necessitate a long operative corridor. For the thalamic tumor resection, supracerebellar approach (Krause) was also used to the lateral thalamic lesions.9 However, the basal veins often limit the lateral reach of the Krause approach, and its variations are not preferable for lesions in the lateral thalamus.9 In 1972, Suzuki and Sato26 were the first to describe the middle TTA for evacuation of hypertensive basal ganglia hematomas. After that, several groups, including us, improved and developed this approach.7,8,27,28 All these studies showed that middle TTA is effective to evacuate hematoma located at the basal ganglia. Compared with a conventional transtemporal approach, middle TTA decreased the injury to normal cerebral tissue in the temporal lobe and shortened the distance from the cortex incision to the hematoma. The distance from the insular cortex to the hematoma when using middle TTA is shorter because of the sylvian fissure, which, in most cases, varies from 2 to 15 mm.8 In the transtemporal approach, the distance is approximately 20 to 40 mm deep to the cortex. Jianwei et al8 have summarized the advantages of middle TTA, including that it (1) allows deep decompression of important neurostructures because of the suitable angle and shorter distance from the cortex to the hematoma; (2) provides access to the responsible vessels, reducing the rate of rebleeding postoperatively; and (3) avoids damage to the temporal or frontal cortex. The abovementioned advantages of middle TTA still apply to TH. For type 1 TH, TTA combined with the appropriate head position, it is easily to gross totally remove the TA along the longest axis of the hematoma. For type 2 TH, the distal TTA avoided the surgical damage to the internal capsule and the structures around the thalamus. Furthermore, the distal TTA could deal with the IVH very easily. These reasons may responsible for the achievement of a good long-term outcome. Some technical nuances of TTA are the following: 1. Indications: TTA is not suitable for the small amount of TH (
Brief Clinical Studies
and zygomatic arch. Mandibular outer cortex splitting ostectomy, mandibular “V-line” ostectomy, and rotation genioplasty can be applied to correct asymmetric mandibula. These techniques result in positive changes in the patients' facial contour with high patient satisfaction.
23. Kim YH, Seul JH. Reduction malarplasty through an intraoral incision: a new method. Plast Reconstr Surg 2000;106:1514 –1519 24. Lee JG, Park YW. Intraoral approach for reduction malarplasty: a simple method. Plast Reconstr Surg 2003;111:453– 460
ACKNOWLEDGMENT The research protocol was approved by the local ethical committee.
REFERENCES 1. Severt TR, Proffit WR. The prevalence of facial asymmetry in the dentofacial deformities population at the University of North Carolina. Int J Adult Orthodon Orthognath Surg 1997;12:171–176 2. Legg JW. Enlargement of the temporal and masseter muscles on both sides [M]. Trans Pathol Soc (Lond) 1880;31:361–374 3. Han K, Kim J. Reduction mandibuloplasty: ostectomy of the lateral cortex around the mandibular angle. J Craniofac Surg 2001;12:314–325 4. Coffey RJ. Unilateral hypertrophy of the masseter muscle. Surgery 1942;11:815 5. Waldhart E, Lynch JB. Benign hypertrophy of the masseter muscles and mandibular angels. Arch Surg 1871;102:115–118 6. Lee Y, Kim JH. Mandibular contouring: A surgical technique for the asymmetrical lower face. Plast Reconstr Surg 1999;104:1165–1171 7. Deguchi M, Iio Y, Kobayashi K, et al. Angle splitting ostectomy for reducing the width of the lower face. Plast Reconstr Surg 1997;99:1831–1839 8. Adams WM. Bilateral hypertrophy of masseter muscle: An operation for correction (case report). Br J Plast Surg 1949;2:78–81 9. Baek SM, Baek RM, Shin MS. Refinement in aesthetic contouring of the prominent mandibular angle. Aesthetic Plast Surg 1994;18:283–289 10. Converse JM. Deformities of the jaws. In: JM Converse, ed. Reconstructive Plastic Surgery. Philadelphia: Saunders, 1977:140 11. Jiang N, Hsu Y, Khadka A, et al. Total or partial inferior border ostectomy for mandibular contouring: indications and outcomes. J Craniomaxillofac Surg 2012;40:e277–e284 12. Cui J, Zhu S, Hu J, et al. The effect of different reduction mandibuloplasty types on lower face width and morphology. Aesthetic Plast Surg 2008;32:593–598 13. Hsu YC, Li J, Hu J, et al. Correction of square jaw with low angles using mandibular “V-line” ostectomy combined with outer cortex ostectomy. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;109:197–202 14. Li J, Hsu Y, Khadka A, et al. Contouring of square jaw on short face by narrowing and sliding genioplasty combined with mandibular outer cortex ostectomy in Orientals. Plast Reconstr Surg 2011; 127:2083–2092 15. Li J, Hsu Y, Khadka A, et al. Surgical designs and techniques for mandibular contouring based on categorization of square face with low gonial angle in orientals. J Plast Reconstr Aesthet Surg 2012;65:e1–e8 16. Li X, Hsu Y, Hu J, et al. Comprehensive consideration and design for treatment of square face in Orientals. J Oral Maxillofac Surg 2013;71:1761.e1–1761.e14 17. Satoh K. Mandibular contouring surgery by angular contouring combined with genioplasty in Orientals. Plast Reconstr Surg 1998;101:461– 472 18. Onizuka T, Watanabe K, Takasu K, et al. Reduction malarplasty. Aesthetic Plast Surg 1983;7:121–125 19. Uhm KI, Lew JM. Prominent zygoma in Orientals: classification and treatment. Ann Plast Surg 1991;26:164–170 20. Baek SM, Kim SS, Bindiger A. The prominent mandibular angle: preoperative management, operative technique, and results in 42 patients. Plast Reconstr Surg 1989;83:272–280 21. Baek SM, Chung YD, Kim SS. Reduction malarplasty. Plast Reconstr Surg 1991;88:53– 61 22. Kim JW. Laser-assisted endoscopic reduction malarplasty in Asians. Aesthetic Plast Surg 1998;22:289 –297
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Transsylvian-Transinsular Approach to Large Lateral Thalamus Hemorrhages Hong-Tian Zhang, PhD,*† Ai-Jia Shang, MD,‡ Bing-Juan He, MD,* Ru-Xiang Xu, PhD*† Abstract: Here, we aimed to evaluate the experience of transsylviantransinsular microsurgical approach (TTH) to the huge lateral thalamic hemorrhages (THs). A total of 37 patients with huge lateral TH (hematoma volumes between 30 and 90 cm3) who underwent surgical treatment through middle or distal TTH at the Bayi Brain Hospital from January 2007 to May 2012 were included in this series. By using TTH, near-complete (99%) evacuation was achieved in 29 patients (78.4%). Glasgow Coma Scale (GOS) scores were significantly improved at discharge compared with admission scores (P < 0.001). The overall survival rate at 3 months was 81.08% (30/37), including 51.35% (19/37) with good function (GOS, 4–5), 13.51% (5/37) with disability (GOS, 3), and 16.22% (6/37) in a vegetative state (GOS, 2). The mortality rate (GOS, 1) was 18.92% (7/37). Our series showed that, according to the extension direction of hematomas, to select middle or distal TTH is effective and safe for TH. Key Words: Thalamic hemorrhages, transsylvian-transinsular approach, minimal invasiveness
T
halamic hemorrhages (THs) have a high mortality and morbidity and account for approximately 30% of all intracerebral hemorrhages (ICH).1,2 Previous studies showed that patients with isolated TH show a differential clinical profile than patients with internal capsule-basal ganglia hemorrhage.3,4 However, separate analysis of TH as an individual clinical entity is rarely performed.5 The surgical indications for the treatment of TH remain controversial.6
From the *The Affiliated Bayi Brain Hospital, Military General Hospital of Beijing PLA; †Institute of Neurosurgery, Beijing Military Region PLA; and ‡Department of Neurosurgery, General Hospital of Chinese PLA, Beijing, China. Received July 1, 2014. Accepted for publication September 13, 2014. Address correspondence and reprint requests to Ru-Xiang Xu, PhD, The Affiliated Bayi Brain Hospital, the Military General Hospital of Beijing PLA and The Neurosurgical Research Center of Beijing Military Region PLA, No 5, Nanmencang, Dongcheng District, Beijing 100700, China; E-mail: [email protected] Supported by the Natural Scientific Research Funds of China (no. 81371345) and Beijing Nova Program (XX2013059) for Hong-Tian Zhang. Hong-Tian Zhang and Ai-Jia Shang contributed equally to this work. The authors report no conflicts of interest. Copyright © 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001323
© 2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery • Volume 26, Number 2, March 2015
Evacuation of a TH by craniotomy is generally considered controversial because the approach commonly causes damage to uninjured brain overlying the hematoma. Keyhole approach through transsylviantransinsular approach (TTA) is a new microsurgical procedure that has been carried out to treat hypertensive putaminal hemorrhage recently.7,8 However, no systemic written about the application of this approach to TH was reported. The location is deeper, and the anatomic structures around the thalamus are totally different and even more complex than those in the putamine. In the present study, we retrospectively summarized 37 patients with TH being treated surgically through TTH. In this report, we examine our experience with TTH to TH and describe microsurgical techniques.
MATERIALS AND METHODS Patients A total of 37 consecutive patients with huge lateral TH (hematoma volumes between 30 and 90 cm3) were included in this study. They underwent surgical management through TTA from January 2007 to May 2012 in the Affiliated Bayi Brain Hospital by the same group of 6 neurosurgeons (authors). The records were reviewed after obtaining clinic ethics committee approval. The study was retrospective. The `TH was defined as bleeding originating from the thalamus, including local TH and primary TH extending to other structures, but not including primary hematoma of another location extending to the thalamus. If 1 hematoma involved more than 2 structures (eg, thalamus and basal ganglia) at the same time, the hematoma must have been unanimously identified by 2 neurologists as primary TH. All patients with initial Glasgow Coma Scale (GCS) scores of 5 or higher who consented and underwent keyhole evacuation within 24 hours of the ictus had hematoma volumes between 30 and 90 cm3, and whose hemorrhages were not associated with tumor, trauma, aneurysms, arteriovenous malformations, cavernous malformations, cerebral infarctions with hemorrhagic transformation, or fibrinolysis were included in this retrospective review. All patients with TH underwent neurologic examination on admission. History was obtained from the patients, relatives, or medical personnel. Time of primary symptoms was recorded. If the onset was unobserved, it was considered to be at the last time that the patient was definitely normal. Medical history with particular attention to hypertension, diabetes, antiplatelet use, and anticoagulation as well as a history of drug abuse was recorded. Computerized tomography (CT) in all patients was evaluated to record the size and location of the hematoma as well as the absence of vascular lesions, tumor, ischemia, and signs of trauma. In patients in whom the location, age, history, and findings on CT did not rule out a possible vascular lesion, digital subtraction angiography was performed. The volume of the hematoma was calculated using the formula A B C / 2 (where A is the biggest diameter, B is the diameter at 90 degrees from A, and C is the number of slices slice thickness (10); the presence of intraventricular hemorrhage was not included in the formula). Postoperatively, CT was performed at the end of the procedure, on the first postoperative day, on days 5 to 7, and as needed. Patients on anticoagulants and prolonged prothrombin times were admitted to surgery as soon as this was reversed by the use of 10-mg vitamin K and 15-mL/kg fresh frozen plasma, except in large hematomas with clinical deterioration. Surgery in these patients was initiated before normalization of prothrombin times. Dexamethasone and phenytoin for all patients and mannitol for patients with larger hematomas were started on admission. All patients received cephazoline intraoperatively.
Brief Clinical Studies
Surgical Technique On the basis of our surgical experience, TH has been divided into 2 subtypes according to the extension direction of hematomas. One type of the TH was extended into the anterior part of the temporal lobe (type 1), and the other one was extended into the posterior part of the temporal lobe (type 2). For type 1, middle TTA was performed. The patients were placed supine with heads rotated toward the healthy sides 45 degrees and tilted back 15 degrees. Ipsilateral shoulder was propped up with padding to check excessive neck rotation. Approximately 5- to 6-cm skin incision (surface projection of the middle sylvian fissure approximately 1 cm posterior of the pterion point) was made, and the area of bone window was 3 to 3.5 cm2 (Fig. 1A). The enter point of the arachnoid membrane of the sylvian fissure is on the frontal side of the sylvian vein and along the pars opercular of the inferior frontal gyrus. It separates the opercular surfaces of the frontal, parietal, and temporal lobes and accesses the circular sulcus and long gyri of the insular cortex along M3 branches. A small insular cortex incision was made parallel to sylvian fissure. Splitting the insular cortex resulted in the exposure of TH. Accessing point on the insular cortex was determined by the largest point of hematoma to the surface of insular cortex on the CT scans of patient. Hematoma evacuation was performed using suction and bipolar cautery, and the use of brain plate was minimized. The operation was performed using mild suction, and the hematoma cavity was continuously irrigated with 30°C of saline (Figs. 2A–F). The hematoma located at the central part of the hematoma cavity was removed initially, and then the rest of hematoma was displaced into the operative field for the pressure differences, which facilitated complete evacuation of hematoma although it was very large. If possible, the responsible vessel was examined and properly handled. A minimal amount of hematoma remained untouched near the hematoma margin to avoid further injury of adjacent normal brain. Hematoma cavity was covered with Surgicell. For type 2, distal TTA was performed.9 The patients were placed supine with heads rotated to the contralateral side with an aim to bring sagittal suture parallel to the floor. Ipsilateral shoulder was propped up with padding to check excessive neck rotation. The head was held in this position with Mayfield head holder, and a linear incision was marked, centered at a point along the surface projection of the posterior sylvian fissure approximately 2 to 3 cm anterior to the parietal eminence. The incision was deepened through fascia, and the temporalis muscle and bone were exposed. A craniotomy was made as shown in Figure 1B, and the area of bone window was 3.5 to 4 cm2 (Fig. 1B). After opening the dura, posterior sylvian fissure was identified by the presence of prominent superficial middle cerebral vein and the M4 branches entering the fissure along both operculae. Arachnoid over the veins was sharply divided on the frontal side, and the sylvian fissure was
FIGURE 1. The design of incision and bone window of the middle (A) and distal (B) TTA.
© 2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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Brief Clinical Studies
layer. The following procedure was the same as mentioned previously.
Follow-up Review The volume of hematoma remaining obtained by CT scans at 24 hours after surgery and the postoperative GCS scores at 7 days postoperation were evaluated. Complications occurring within 30 days were recorded. All patients were followed for 90 days after stroke onset by telephone or in the clinic. The long-term effect was assessed using the 90-day GOS. A favorable outcome was defined prospectively as a 90-day GOS score of greater than 3, whereas an unfavorable outcome was defined as a 90-day GOS score of 3 or less.
RESULTS FIGURE 2. The surgical procedure of middle TTA (A–F).
opened. Sometimes, a minor bridging vein was sacrificed to widen the operating space. An effort was made to open the sylvian fissure along its entire visible length to allow atraumatic separation of the operacula. We adopt an “inside-out” technique for opening the sylvian fissure, separating the opercular arachnoid bands in the depth before slitting the superficial arachnoid. Attention was directed toward the temporal operculum, and transverse temporal gyri were identified by their oblique orientation and undulating appearance on an otherwise flat opercular surface. Normally, the posteromedial ends of these gyri converge toward the posterior half of the superior limiting sulcus of the insula, which is superficial to the posterior thalamus, the retro-lentiform internal capsule, and the anterior limit of the atrium. Mechanical retraction of the opercula was conscientiously avoided as initial hematoma decompression provided the required working space (Figs. 3A–F). For the initial approach, the opercula were held apart with cottonoids wedged into the fissure. However, keeping the normal relationship in mind, the posterior insular cortex (the long insular gyri posterior to the central sulcus) was entered, and the lesion was found beneath a thin cortical
FIGURE 3. The surgical procedure of distal TTA (A–F).
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Thirteen cases were divided into type 1 TH, and 24 belonged to type 2 TH. The hematoma volume was 24 to 88 mL (median, 49 mL) on admission, and hematoma volumes measured on CT scans obtained 24 hours postoperatively were 6.5 mL (range, 0.3–24.6 mL). In this group, near-complete (>90%) evacuation was achieved in 29 patients (78.4%), 70% to 90% in 6 patients (16.2%), and less than 70% in 2 patients (5.4%) (Figs. 4A–H). The mean (SD) operation time was 152 (12.66) minutes in types 1 and 2. On admission, median GCS score was 6 (range, 3–10). Neurologic examination on the third postoperative day showed that none of the patients had neurologic deterioration and that the GCS score was either unchanged or improved in all patients (P < 0.001). There was no rebleeding. The GCS scores (median, 14; range, 0–15) were significantly improved compared with admission scores (P < 0.001). The overall survival rate at 3 months was 81.08% (30/37), including 51.35% (19/37) with good function (GOS, 4–5), 13.51% (5/37) with disability (GOS, 3), and 16.22%
FIGURE 4. Four typical cases of putaminal ICH being treated by minimally invasive surgical treatment through middle (A–D) and distal (E–H) TTA. Preoperative brain CT showing large putaminal hematoma with midline shifting and immediate postoperative brain CT (A, C, E, and G). Immediate postoperative brain CT showing total evacuation of hematoma and cranial bone reposition (B, D, F, and H).
© 2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery • Volume 26, Number 2, March 2015
(6/37) in a vegetative state (GOS, 2). The mortality rate (GOS, 1) was 18.92% (7/37). The examination of the 30-day complication showed that 1 patient (2.7%) experienced epilepsy. It was well controlled after taking drugs. No patient experienced rebleeding. There were 4 (10.81%) of the 37 and 9 (24.32%) of the 37 patients who experienced pneumonia and digestive tract hemorrhage, respectively.
DISCUSSION As described by Kawahara et al,10 4 types of TH were determined, including anterolateral (including ventroanterior and ventrolateral nuclei), posterolateral (including posteroventrolateral and pulvinar nuclei), medial (including dorsomedial and intralaminar nuclei), and dorsal (including mainly dorsomedial nucleus) types. Approximately 76% of TH appeared as the anterolateral and posterolateral types.10 Mortality in patients with large TH is high.5,11 Thus, how to decrease the mortality rate of large lateral TH is a problem need to be cracked. Stereotaxic drainage, CT guided aspiration, and endoscopic removal of thalamic hematomas have been evaluated in small patient series.3,11–16 In endoscopic surgery for TH, an approach was reported from Keen point (located 3 cm posterior and 3 cm superior to the pinna) to the collateral trigone17 or from the forehead to the frontal horn of the lateral ventricle.18 These approaches help to evacuate ventricular hemorrhage and are suited for TH that extends to the ventricle, but the efficiency of clearance of the thalamic hematoma is lower. Drainage with puncture requires only a small incision in the skin and brain; however, the hematoma cannot be cleaned out all at once, and there is no opportunity to treat the offending vessel. Effective hemostasis cannot be performed, resulting in a certain incidence of recurrent hemorrhage after the operation.16 Craniotomy and evacuation of thalamic ICHs is infrequently used because of the high rates of mortality and morbidity observed after this procedure.6 The thalamus involved in many brain functions including sensation, motor control, mental, and consciousness status is close to other important structures, such as the internal capsule, midbrain, hypothalamus, and the upstream reticular activating system. The operative corridor is easy to destroy in these structures around the thalamus. In addition, TH is easily ruptured into the lateral ventricle. Intraventricular hemorrhage (IVH) is one of the important factors to influence the prognosis, and TH and TH associated IVH needed to be removed as quickly as possible.3,19,20 Therefore, in a long time, the surgery is considered difficult for TH. Several surgical approaches have been considered to remove the thalamic lesions. Transventricular approaches are the most frequent because of the intimate relationship of the thalamus with the lateral ventricles. Access to the ventricles and, subsequently, to the thalamus may be gained either by transcortical or interhemispheric routes. Traditional approaches to TH are transcortical, through the superior or middle temporal gyrus or the superior parietal lobule. Although the transcortical approach is more direct with a shorter working distance to the lesion, it has some distinct disadvantages. First, the transcortical approach traverses the normal brain, increasing the risk for neurologic deficits.21 Second, the transcortical approach is particularly difficult when the lateral ventricles are not dilated.22 Third, the approach can cause postoperative seizures.23,24 The interhemispheric approach is another way to the lateral ventricle. However, it may jeopardize the bridging cortical veins and may even sometimes be precluded by anomalous venous anatomy.25 The posterior interhemispheric approach takes advantage of the midline bridging veins being scarce posterior to the lambdoid suture. Approach to the atrium and posterior thalamus necessitates a small incision in the precuneus, which is inconsequential. In addition, it is difficult to deal with lateral thalamic lesions with this
Brief Clinical Studies
approach. However, these approaches are applicable mainly to pulvinar lesions and necessitate a long operative corridor. For the thalamic tumor resection, supracerebellar approach (Krause) was also used to the lateral thalamic lesions.9 However, the basal veins often limit the lateral reach of the Krause approach, and its variations are not preferable for lesions in the lateral thalamus.9 In 1972, Suzuki and Sato26 were the first to describe the middle TTA for evacuation of hypertensive basal ganglia hematomas. After that, several groups, including us, improved and developed this approach.7,8,27,28 All these studies showed that middle TTA is effective to evacuate hematoma located at the basal ganglia. Compared with a conventional transtemporal approach, middle TTA decreased the injury to normal cerebral tissue in the temporal lobe and shortened the distance from the cortex incision to the hematoma. The distance from the insular cortex to the hematoma when using middle TTA is shorter because of the sylvian fissure, which, in most cases, varies from 2 to 15 mm.8 In the transtemporal approach, the distance is approximately 20 to 40 mm deep to the cortex. Jianwei et al8 have summarized the advantages of middle TTA, including that it (1) allows deep decompression of important neurostructures because of the suitable angle and shorter distance from the cortex to the hematoma; (2) provides access to the responsible vessels, reducing the rate of rebleeding postoperatively; and (3) avoids damage to the temporal or frontal cortex. The abovementioned advantages of middle TTA still apply to TH. For type 1 TH, TTA combined with the appropriate head position, it is easily to gross totally remove the TA along the longest axis of the hematoma. For type 2 TH, the distal TTA avoided the surgical damage to the internal capsule and the structures around the thalamus. Furthermore, the distal TTA could deal with the IVH very easily. These reasons may responsible for the achievement of a good long-term outcome. Some technical nuances of TTA are the following: 1. Indications: TTA is not suitable for the small amount of TH (
