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PubMed2006

Cooperative study by the Italian neuroendoscopy group on the treatment of 61 colloid cysts.

OBJECTS: Microsurgical resection, stereotactic aspiration and VP shunt have for years been the choice options for the treatment of colloid cysts of the third ventricle. Recently, endoscopic approaches have aroused increasing interest and gained acceptance. Although safer, this minimally invasive approach is considered less efficacious than microsurgery. Relatively long-term results are now available and some conclusions might be inferred on the usefulness of this procedure. MATERIALS AND METHODS: Between 1994 and 2005, 61 patients harbouring a colloid cyst of the third ventricle were treated with neuroendoscopic technique in 11 Italian neurosurgical centres. Cyst diameters ranged from 6 to 32 mm. A flexible endoscope was used in 34 cases, a rigid one in 21, both instruments in six. The technique consisted in cyst fenestrations, colloid aspiration, coagulation of the internal cyst wall and, occasionally, capsule excision. Mean postoperative hospital stay was 6.7 days. Early postoperative neuroimaging revealed a cyst residue in 36 cases (mean diameter 4.3 mm). There were two complications (3.2%). Follow-up varied between 1 and 132 months (mean 32 months, more than 5 years in 17 patients). There were seven asymptomatic recurrences, three of them evolving from a previous residue. CONCLUSION: The endoscopic approach to the treatment of colloid cysts is safe, effective and well accepted by patients. Although asymptomatic, recurrences (11.4%) cast a persisting shadow on the long-term results, and, therefore, the controversy with the traditional microsurgical treatment remains open.

Adolescent↗

PubMed2006

Long-term outcome and neurologic development after endoscopic third ventriculostomy versus shunting during infancy.

INTRODUCTION: Infants with obstructive hydrocephalus who were under 9 months old were initially treated by neuroendoscopic third ventriculostomy (ETV) after evaluation with magnetic resonance imaging (MRI). The clinical course and long-term outcome of these infants were examined. The outcome was also compared with that of similar infants who received ventriculoperitoneal shunting. METHODS: The patients were divided into three groups based on MRI findings: Group I was made up of six patients in whom mainly the frontal horns of the lateral ventricles were enlarged and the morphology of the cerebral cortex was normal; group II was made up of 13 patients in whom the entire lateral ventricle was enlarged bilaterally and the morphology of the cerebral cortex relatively normal; and group III was made up of six patients in whom the entire lateral ventricle was markedly enlarged bilaterally and there was periventricular leakage of cerebrospinal fluid. RESULTS: In group I, two patients were treated conservatively and four patients were treated with ETV. All of the patients in this group showed virtually normal development at 4 years of age. In group II, development was still delayed in six patients at 1 year after ETV, and two of these patients underwent shunting. All of the patients in this group showed near normal development at 5 to 6 years of age. In group III, all of the patients underwent shunting within 1 year after ETV because there was no appreciable improvement of development at 6 months after the initial procedure. CONCLUSIONS: In infants with obstructive hydrocephalus in whom the cerebral cortex is intact, adequate development can be achieved with ETV alone, although catch-up tends to be slow. In infants in whom cerebral development is inadequate or in whom the cerebrum has already been affected by hydrocephalus, sufficient improvement of development cannot be achieved with ETV alone, even if the intracranial pressure is controlled. It seems that early shunting is more useful for achieving cerebral recovery in this patient group.

Child↗

PubMed2001

Hydrocephalus and epilepsy.

Since the introduction of ventriculo-atrial and/or ventriculo-peritoneal shunting for hydrocephalic patients, controversies have developed regarding the likelihood of epileptic seizures developing as a result of the shunting itself and/or its complications. On the other hand, hydrocephalus is not commonly recognized as a cause of seizures in general, although epilepsy is reported to be frequently associated with shunt-treated hydrocephalus, especially in children. Several authors have reported an increased risk of epileptic seizures after shunt placement, but the underlying mechanisms are still controversial. The insult to the brain at the time of ventricular catheter insertion, the presence of the shunt tube itself as a foreign body, the burr hole location, the number of shunt revisions after malfunction, associated infection, the etiology of hydrocephalus, and associated mental retardation are thought to be related to the risk of epilepsy. Age at the time of initial shunt placement also seems to be an important factor. Early shunting is a well-known determinant of risk in shunt obstruction, and children less than 2 years old are consequently at a higher risk of developing epilepsy than older ones. It is reported that antiepileptic drug treatment is not so reliable as might be expected. Conscientious and more sophisticated EEG recording in those children may be beneficial during follow-up. The incidence of seizures in shunted children is reported to be quite high, ranging from 20% to approximately 50%, so that neurosurgeons should pay more attention to the issue of epilepsy in hydrocephalic children. Although ventriculo-extracranial shunts have been the standard treatment for hydrocephalus for decades, the long-term morbidity, including postshunt epileptic seizures, has to be taken seriously. The use of neuroendoscopic techniques when indicated may ameliorate this problem a great deal in the future.

Cerebrospinal Fluid Shunts↗

PubMed2001

Intramedullary spinal teratoma with spina bifida.

Spinal intramedullary teratoma is a rare tumor. We report a case of intramedullary teratoma of the conus medullaris with spina bifida. A 5-year-old boy was admitted to our hospital for removal of a lumbosacral tumor sited in an intramedullary location at the conus medullaris, which was totally resected with neuroendoscopic assistance. The pathological diagnosis was mature teratoma consisting of three germ cell layers. The pathogenesis of spinal intramedullary teratoma is discussed with special reference to spina bifida.

Adolescent↗

PubMedDate not supplied

Recent advances and racial differences in therapeutic strategy to the pineal region tumor.

The therapeutic modalities for pineal region tumors in Western countries differ from those in Japan, mainly because of the different patient populations. The majority of pineal region tumors in Japan are radio- and/or chemosensitive, and adjuvant therapy rather than extensive surgery plays the main part in the treatment of these tumors. The specific clinical features of and therapeutic modalities for pineal region tumors, together with racial differences, were analyzed at the joint symposium of the Japanese Society for Pediatric Neurosurgery and the Korean Society for Pediatric Neurosurgery. The results of a cooperative study, together with the collective experience in Korea, confirmed that this specific patient population is nearly identical to the Japanese one. The new therapeutic approaches to pineal region tumors recommended included neuroendoscopic or stereotactic biopsy as a "minimally invasive" initial procedure. The adjuvant therapeutic modalities were further analyzed and neoadjuvant chemotherapy, mainly with cisplatin or carboplatin with or without etoposide (VP-16), was recommended for the treatment of germinoma and nongerminomatous malignant germ cell tumors. "Target radiation therapy" with extensive chemotherapy is a hopeful regimen and a future subject of research.

Adolescent↗

PubMedDate not supplied

Identical characteristics of the patient populations with pineal region tumors in Japan and in Korea and therapeutic modalities.

The therapeutic modalities used for tumors of the pineal region in Western countries differ from those in Japan, mainly because of the different patient populations. An extensive survey was conducted to delineate the racial differences in Japan and in Korea in the epidemiology and recent therapeutic modalities for this tumor group. Among the members of International Society for Pediatric Neurosurgery (ISPN), 15 from Japan and 5 from Korea reported their recent findings in 118 (1-25 years of age, mean 7.38-year period) and 125 (1-12 years of age, mean 6.69-year period) histologically verified cases, respectively. The patient populations in the two countries were found to be almost identical, with an extremely high incidence of germ cell tumors representing 71.2% (in Japan) and 80.0% (in Korea) of all pineal region tumors and neuroectodermal tumors representing only 15.2% and 16.8%, respectively. The most common type of pineal region tumor was germinoma (46.6% in Japan and 47.2% in Korea). The majority of tumors were radio- and/or chemosensitive, and adjuvant therapy rather than extensive surgery played the major role in the treatment in both countries. Radical resection of the tumor was recommended as the initial procedure by only 22.2% of neurosurgeons in Japan and 16.6% in Korea. Biopsy was recommended by 38.9% and 50.0%, and radiation therapy by 38.9% and 37.5%, respectively. A minimally invasive procedure, by either a neuroendoscopic (33.3% of biopsies in Japan) or a stereotactic approach (33.3% of biopsies in Korea), was considered to be appropriate as the initial procedure. The study disclosed the almost identical epidemiology of this brain tumor in Japan and in Korea and clarified the consequent therapeutic modalities. The authors emphasize that minimally invasive tissue diagnosis with or without tumor debulking should be considered as the initial step for the treatment planning of the pineal region tumor, followed by the most commonly indicated major procedures, including radiation therapy, chemotherapy and/or radical resection with various methodologies.

Adolescent↗

PubMed1999

Alternatives to shunting.

The growing awareness of mechanical and infectious complications related to the implantation of extracranial CSF shunts and the rapid developments in neuroendoscopic surgery have given pediatric neurosurgeons the possibility of choosing between the two types of treatment. The decision will depend on a number of factors, such as whether it is possible to identify the etiology of the hydrocephalus on the preoperative examinations, the surgeon's familiarity with the endoscopic technique, and his or her personal opinions about the efficacy of the alternative techniques to shunt implantation. The history and the state of the art of the alternatives to shunting are briefly reviewed for each of the main pathophysiological groups of pediatric hydrocephalus: aqueductal stenosis, posterior fossa tumors, meningomyelocele, Dandy-Walker malformation, posthemorrhagic hydrocephalus and others.

Cerebrospinal Fluid Shunts↗

PubMed2000

Hemorrhagic subdural effusion complicating an endoscopic III ventriculostomy.

Subdural effusion, a common postoperative complication of extracranial shunting for hydrocephalus, is usually caused by excessive drainage of cerebrospinal fluid. Subdural effusion is thought to occur less frequently after a neuroendoscopic III ventriculostomy, and no reported cases have been symptomatic. We encountered a symptomatic subdural effusion with a component of hemorrhage 5 days after the latter procedure was performed to treat massive hydrocephalus in a 2-year-old boy.

Brain↗

PubMed2000

Initial experience with stereoscopic visualization of three-dimensional ultrasound data in surgery.

Initial in vivo and in vitro experiments were performed to evaluate the feasibility of stereoscopically displaying three-dimensional (3D) ultrasound data from neurosurgery, laparoscopic surgery, and vascular surgery. Stereoscopic visualization was illustrated by four video sequences, which can be downloaded from http://www.us.unimed. sintef.no/. These sequences show a brain tumor, hepatic arteries in relation to the gallbladder, a model that mimics a neuroendoscope in a cyst, and a "flight" into model of an artery with an intima flap. The experiments indicate that stereoscopic display of ultrasound data is feasible when there is sufficient contrast between the objects of interest and the surrounding tissue. True 3D vision improves perception, thus enhancing the ability to understand complex anatomic structures such as irregular lesions and tortuous vessels.

Filtration↗

PubMed2004

Robot-assisted navigated endoscopic ventriculostomy: implementation of a new technology and first clinical results.

BACKGROUND: Important landmarks in the evolution of advanced neurosurgical techniques during the past decades include microneurosurgery, neuro-endoscopy and its minimally invasive nature, as well as neuronavigation and advanced intra-operative imaging. With conventional neuroendoscopic techniques, e.g. free-hand endoscopy or the use of mechanical or pneumatic holding devices, a definitive and controlled movement of the endoscope within the brain does depend on the experience and manual skill of the individual neurosurgeon. Therefore, the development of robotic systems to assist surgeons in performing complex neurosurgical procedures is a growing field of interest. METHOD: With the precision robot "Evolution 1" (U.R.S. Universal Robot Systems, Schwerin, Germany) a new neurosurgical tool has just become available for the precise steering of instruments within the cranium. After preclinical anatomical as well as precision studies the system was used for robot-assisted navigated endoscopic third ventriculostomies in six patients with hydrocephalus related to aqueductal stenosis. FINDINGS: All robot-assisted navigated endoscopic procedures were successfully completed. The time for the registration procedure and setup of the robot decreased from 60 min. for the first procedure down to 30 min. The time for the surgical part of the neuro-endoscopic procedure itself ranged from 17 to 35 min. During all procedures no system-related complications occurred. INTERPRETATION: The use of robotic technology for neuro-endoscopic third ventriculostomies is a major step towards the controlled movement of the neuro-endoscope within the cranium. The start up procedure and calibration of the robot is still time consuming, but the real operation time is comparable to free hand neuro-endoscopy. The steering of the endoscope is facilitated and the precision of the endoscopic movements is noteworthy.

Adolescent↗

PubMed2004

Endoscopic third ventriculostomy for obstructive hydrocephalus.

The indications for neuroendoscopy are not only constantly increasing, but even the currently accepted indications are constantly being adjusted and tailored. This is also true for one of the most frequently used neuroendoscopic procedures, the endoscopic 3rd ventriculostomy (ETV) for obstructive hydrocephalus. ETV has gained popularity and widespread acceptance during the past few years, but little attention has been paid to the techniques of the procedure. After a short introduction describing the history of ETV, an overview is given of all the different techniques that have been and still are employed to open the floor of the 3rd ventricle. The spectrum of indications for ETV has been widely enlarged over the last years. Initially, the use of this procedure was restricted to patients older than 2 years, to patients with an obvious triventricular hydrocephalus, and to those with a bulging, translucent floor of the 3rd ventricle. Nowadays, indications include all kinds of obstructive hydrocephalus but also communicating forms of hydrocephalus. The results of endoscopic procedures in treating these pathologies are given under special consideration of shunt technologies. In summary, from the review of the publications since the first ETV performed by Mixter in 1923, this technique is the treatment of choice for obstructive hydrocephalus caused by different etiologies and is an alternative to cerebrospinal fluid shunt application.

Age Factors↗

PubMed1993

Aqueductal stenosis due to mesencephalic venous malformation: case report.

The authors report the case of a 43-year-old woman with a venous malformation of the mesencephalon occluding the sylvian aqueduct. Neuroradiological investigations suggested aqueductal stenosis, while the presence of a venous malformation was diagnosed by both magnetic resonance imaging and an angiogram, and was visualized using a neuroendoscope. This is the first reported instance of a venous malformation being observed in situ and the subependymal course taken.

Adult↗

PubMed1996

Endoscopic treatment of septated chronic subdural hematoma.

BACKGROUND: Chronic subdural hematomas are well delineated collections of fluid (blood) between the dura mater and the arachnoid space. Two types of encapsulated chronic subdural hematoma can be distinguished: the nonseptated and the septated form. The nonseptated form can be treated easily using the burrhole-drainage method, whereas treatment of septated chronic subdural hematoma remains a therapeutical problem. The main problem is the division of the hematoma by neomembranes into compartments, which hinder the efflux of the hematoma fluid through one or two burrholes. METHODS: Since 1991 we have operated on 14 patients with septated subdural hematoma using flexible steerable endoscopes through a burrhole approach. The flexible endoscopes are fixed and guided with the help of the Marburg Neuroendoscopy Fixation and Guiding System. For resection of neomembranes small microscissors or microforceps were used. This technique avoids blunt rupture of the membranes which may cause bleeding. A closed drainage system is applied temporarily to guarantee the efflux of the remaining hematoma. RESULTS: From January 1991 to May 1994, 14 patients with the septated variant of chronic subdural hematoma were operated on using the endoscopic technique. After the neuroendoscopic intervention 12 patients had a sufficient or complete hematoma evacuation. One patient had to be operated on a second time, and there was one postoperative subdural infection. Long term follow up of all patients shows no recurrence of the subdural hematoma. CONCLUSION: Treatment of membraneous septated CSH using an endoscopic operative technique combined with the application of a closed drainage system is a minimally invasive method and a therapeutic alternative to the craniostomy-membranectomy technique.

Adult↗

PubMed1998

Advances in endoscopic neurosurgery.

This article describes the authors' experience using neuroendoscopes to perform a variety of intracranial procedures with minimal invasiveness to neural tissue. The article also presents the history of neuroendoscopy and provides information about current practice. Surgical technique and intraoperative and postoperative nursing considerations are reviewed.

Endoscopy↗

PubMed1999

Endoscopic surgery for monoventricular hydrocephalus.

BACKGROUND: Monoventricular hydrocephalus is usually treated with extrathecal shunting. However, today endoscopic fenestration of the septum pellucidum seems to be a very useful and less invasive technique. METHODS: Five patients with monoventricular hydrocephalus have been treated with neuroendoscopic techniques. In three cases with an excluded lateral ventricle due to contralateral shunt overdrainage, the normal-sized ventricle was first cannulated and fenestration of the septum pellucidum from the normal to the enlarged lateral ventricle was performed. RESULTS: Complete remission of intracranial hypertension symptoms and decrease in size of the enlarged ventricle were observed in all five patients. CONCLUSIONS: Endoscopic fenestration of the septum pellucidum is the technique of choice for treating monoventricular hydrocephalus. We advise first cannulating the normal lateral ventricle and then performing a septostomy from it to the enlarged ventricle. This approach allows one to easily recognize the protruding septum pellucidum and perform fenestration without difficulty using a direct trajectory. In exceptional cases of choroid plexus cyst obstructing one foramen of Monro, fenestration of the cyst wall is sufficient.

Adolescent↗

PubMed1997

Development of flexible ventriculoscope (Yamadori-type VII) and its application to experimental animals.

We developed a new ventriculoscope (Yamadori-type VII), a 2.1 mm calibrated fiberscope with a monopolar coagulator, that can be inserted from the cisterna cerebellomedullaris into the third cerebral ventricle of experimental animals, like dogs. With the improved performance of the neuroendoscope compared to its prototype, Yamadori III, it was possible to inspect clearly and to produce electrocoagulative lesions accurately on any part of the intraventricular structures with minimal injury to nearby vital brain areas.

Animals↗

PubMed2001

[Endoscopic treatment of suprasellar arachnoid cysts].

Arachnoid cysts account for only 1% of all intracranial space-occupying lesions. In adults suprasellar cysts represent 9% of all the arachnoid cysts while in pediatric population this percentage reaches 15%. In spite of being a problem relatively common in daily neurosurgical practice there are still a number of questions to be solved concerning pathogenesis and evolution, natural history and treatment. Located in the suprasellar cistern and closely related to the ventricular system, suprasellar arachnoid cysts conform a perfect indication for endoscopic treatment. The development and spreading of neuroendoscopic techniques have surpassed the standard microsurgical approaches as an elective treatment. However there is still controversy on the management of associated hydrocephalus, need for cystoperitoneal shunt after endoscopic fenestration or the superiority of ventriculocystocisternostomy over simple ventriculocystostomy. The authors present a serie of seven consecutive patients with "de novo" diagnosis of suprasellar arachnoid cyst. In every case the treatment consisted in endoscopic fenestration and removal of the cyst membranes, with or without associated ventriculostomy of the IIIrd ventricle. Preoperative symptoms improved in all the patients and five out of seven remain shunt free. One patient maintains a cystoperitoneal shunt and another one, previously shunted, remains shunt dependent. The clinical presentation and postoperative evolution are commented with discussion on the alternative therapeutic options from the endoscopic point of view.

Arachnoid Cysts↗

PubMed2001

SPAMM, cine phase contrast imaging and fast spin-echo T2-weighted imaging in the study of intracranial cerebrospinal fluid (CSF) flow.

AIM: To compare the qualitative assessment of cerebrospinal fluid (CSF) flow using a SPAMM (spatial modulation of magnetization) technique with cine phase contrast images (cine PC) and fast spin echo (FSE) T2-weighted images. MATERIALS AND METHODS: SPAMM, PC and T2-weighted sequences were performed on 22 occasions in 19 patients. Eleven of the studies were performed following a neuroendoscopic third ventriculostomy (NTV), and in these cases, the success of the NTV was determined by clinical follow-up. Two observers used consensus to grade the presence of CSF flow at nine different sites for each study. RESULTS: At 14 of the 178 matched sites, which could be assessed by both SPAMM and cine PC, SPAMM CSF flow grade was higher than that of cine PC. At a further 14/178 matched sites, the cine PC grade was higher than that of SPAMM. There was definite CSF flow at 113/182 (62%) of all the cine PC sites assessed, and 110/181 (61%) of all SPAMM sites assessed whilst 108/198 (54%) of FSE T2-weighted image sites demonstrated flow voids. Cine PC grades were higher than SPAMM at the cerebral aqueduct (P < 0.05, Wilcoxon sign rank test). Definite CSF flow within the anterior third ventricle was present in 4/5 (SPAMM) and 3/5 (cine PC) successful NTVs, 0/2 (SPAMM and cine PC) unsuccessful NTVs and 1/10 (SPAMM and cine PC) patients without NTV. CONCLUSION: SPAMM provides a comparable assessment of intracranial CSF flow to that of cine phase contrast imaging at all CSF sites except the cerebral aqueduct.

Adolescent↗