Minimally Invasive and Cost-Effective Access to Deep-Seated Intracranial Lesions Using 19F Peel-Away Sheath Introducer and "Dynamic" Retraction: Technical Note and a Case Series.

Background And Objectives: Minimally invasive (MIS) techniques for resection of deep-seated brain lesions (DSL) have become widespread in the past 2 decades. Various devices for endoscopic and open microscopic procedures are now common in many institutions. Most setups use image-guided tubular brain retractors inserted along the paths sparing the eloquent cortical and subcortical structures. The cost of the commercially available retractors may be significant, making them unaffordable in the developing world and even in countries with well-developed economies. The authors introduce a novel, cost-effective technique involving the use of the 19F peel-away sheath introducer and subsequent "dynamic" retraction to remove DSL. The objective of this study was to evaluate the feasibility and safety of a new MIS technique in patients with various cerebral pathologies.

Methods: We report on 13 patients who underwent transcortical resection of the DSL. Six patients (46%) had the diagnosis of glioblastoma (2 of which were recurrent). The remaining 7 patients had metastases (3 cases), cavernous malformation (2 cases), thalamic pilocytic astrocytoma, and colloid cyst of the third ventricle.

Results: All 13 patients underwent aggressive resection of the brain lesions without any complications, except one 37-year old patient with large left basal ganglia glioblastoma experienced worsening of the contralateral hemiparesis and transient expressive aphasia, which improved the baseline over 4 weeks after surgery. Gross total resection was achieved in 11 of the 13 cases after the initial surgery.

Conclusion: The described MIS technique appears safe, technically feasible, and cost-effective alternative to the commonly used tubular retraction systems. The use of "dynamic" retraction through narrow surgical tract may become a viable surgical option in patients with deep-seated lesions. It could serve as an affordable alternative to the commercially available systems, particularly in medical centers with limited resources.