Endoscopic ultrasonic aspirator-assisted resection for pediatric hypothalamic hamartomas: outcomes and technical nuances.
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BACKGROUND: Hypothalamic hamartomas (HHs) are rare developmental lesions frequently associated with drug-resistant epilepsy. Multiple surgical techniques have been described, but the optimal strategy remains controversial. Endoscopic approaches have emerged as minimally invasive options, yet technical limitations persist, particularly in larger or firm lesions. This article aims to describe the technical nuances, safety, and clinical outcomes of endoscopic resection of pediatric HHs assisted by a neuroendoscopic ultrasonic aspirator (NUA). METHODS: We retrospectively reviewed 21 pediatric patients who underwent purely endoscopic HH resection with NUA assistance between 2009 and 2025. Demographic, clinical, and radiological data were collected. Seizure outcomes were evaluated using the Engel classification at 12 months, and resection extent was assessed with postoperative MRI. RESULTS: Fourteen patients (66.6%) were male, with a mean age at surgery of 6.1 years (range, 0.4-17.5). According to the Delalande classification, lesions included 4 type I, 9 type II, 5 type III, and 3 type IV. The mean preoperative volume was 1.9 cc. Gross-total resection was achieved in 19 patients (90%). At 12 months, 14 of 18 evaluable patients (77.7%) achieved Engel class I seizure freedom, while 4 (22.2%) had Engel class IIB outcomes (> 90% reduction). There was no operative mortality. Complications included transient hyponatremia in 28% and obesity in 10%, all managed conservatively. CONCLUSION: Endoscopic resection of HHs using an ultrasonic aspirator is a safe and effective technique, providing high rates of seizure freedom with low morbidity. This approach expands the indications of purely endoscopic surgery for HHs, particularly in settings where laser ablation is not available.