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PubMed2004

The physics of image formation in the neuroendoscope.

INTRODUCTION: The development of the neuroendoscope has allowed neurosurgeons to visualize anatomic structures deep within the nervous system with minimal disruption of the critical overlying structures. This has enabled the development of an entire system of tools and techniques for maximum effective action at the target point through minimal corridors for the treatment of an entire spectrum of pathologies. DISCUSSION: The design of an optical instrument with the ability to illuminate deep, hidden anatomic structures and transmit those images accurately and brightly to the eye of the neurosurgeon poses several challenges. These challenges have been met by advances in lens design and optical systems engineering over a period of several decades leading up to emergence of the modern neuroendoscope. In this paper, the basic concepts of the physics of image formation in optical systems are reviewed with emphasis on those elements critical to the endoscope. CONCLUSION: A consideration of these basic concepts is critical to the understanding of the limitations and capabilities of the key instrument for neuroendoscopy.

Humans↗
PubMed2004

Trapped fourth ventricle treated with shunt placement in the fourth ventricle by direct visualization with flexible neuroendoscope.

Shunt placement was the most common procedure used for ventricular dilatation, but in many neurosurgical centers it has been substituted by flexible neuroendoscope; however, none of them had solved the problem of the trapped and dilated fourth ventricle. The combination of the ventricle-peritoneal catheter placement in the center of the fourth ventricle by direct visualization with a flexible neuroendoscope using a single coronal burr-hole has solved this problem. Eleven patients with a trapped fourth ventricle, with previous third ventriculostomy and aqueductal plasty, were treated with this procedure; all patients were evaluated clinically and with computed tomography 8 to 24 months (mean, 18 months) later. Here, we describe the technical procedure.

Adolescent↗
PubMed2001

New virtual system for planning of neuroendoscopic interventions.

OBJECTIVE: The demands on virtual planning systems are increasing, particularly for technically pretentious surgical interventions such as intracranial endoscopy. In this article, a new virtual system for neuroendoscopy (VIVENDI) is presented. The main purpose of this system is to provide support for planning and training in neuroendoscopic interventions. MATERIALS AND METHODS: The software is applied for virtual endoscopic visualization of three-dimensional magnetic resonance datasets, using a clinical magnetic resonance scanner. Rendering is performed on a Hewlett-Packard UNIX workstation. RESULTS: Virtual endoscopy provides a three-dimensional view of the cerebral ventricles, with good visualization of anatomic details. The rendering system used allows the generation of fly-through sequences for the entire ventricular system in real time. Navigation is controlled by mouse movements, and the visualization of the computer-generated intraventricular spaces is adapted to the characteristics of the optical endoscope. CONCLUSIONS: The presented virtual neuroendoscopy system is a promising tool for planning and training in neuroendoscopic procedures. It enables these procedures to be simulated prior to surgery based on the patient's individual anatomy.

Algorithms↗
PubMed1992

Neuroendoscopic technique for the operative treatment of septated syringomyelia.

The management of septated, chambered syringomyelia has until now been problematic because the usual operative methods cannot secure drainage of all chambers of the cavity. The development of a flexible neuroendoscope affords the possibility to perforate the septa under visual control which subdivide the cavity. We present our experiences with 11 cases of septated syringomyelia, which have been operated upon using a flexible neuroendoscope.

Endoscopes↗
PubMed1997

Neuroendoscopic management of pineal region tumours.

The management of pineal tumours remains controversial. During 1994 we treated four consecutive adults (16-44 yrs) harbouring a pineal tumour with a neuroendoscopic procedure. All of them presented with hydrocephalus. Pre-operative workup included cranial computerized tomography (CT), craniospinal magnetic resonance imaging (MRI) and serum levels of biological tumour markers. The endoscopic procedure consisted of a third ventriculostomy followed by biopsy with a flexible, steerable neuroendoscope. Histological diagnosis was achieved in three patients who no longer required a shunt device. Recorded complications were: bleeding during ventriculostomy that prevented us from obtaining a good sample for biopsy, short-term memory loss that cleared over a two-week period, and transient increase of pre-operative hemiparesis. Complications and morbidity are emphasized so as to be avoided with further technical experience. Neuroendoscopy affords a minimally invasive way of reaching three objectives by one-step surgery in the management of pineal region lesions: 1) CSF sample for analysis of tumour markers. 2) Treatment of hydrocephalus by third ventriculostomy. 3) Several biopsy specimens can be obtained identifying tumours which will require further open surgery or adjuvant radiation and/or chemotherapy.

Adolescent↗
PubMed2004

Neuroendoscopic surgery of intracranial cysts in adults.

OBJECTS: The purpose of this study was to describe the indications, surgical techniques and postoperative outcome of neuroendoscopic interventions in a heterogeneous group of intracranial cystic pathologies. PATIENTS AND METHODS: Between 1992 and 2003, 127 patients with symptomatic intracranial cysts and cystic tumours underwent neuroendoscopic treatment in our department. In 22 patients indication for surgery was colloid cysts, in 9 patients pineal cysts and in 3 patients cavum vergae cysts. Twelve arachnoid cysts, 10 cystic craniopharyngiomas, 2 Rathke's cleft cysts and 69 malignant cystic tumours were operated on. The patients' mean age was 45 years and their clinical presentations varied from typical signs of increased intracranial pressure to focal neurological deficits. RESULTS: One hundred and twenty-seven patients with intracerebral cystic space-occupying lesions were operated on using stereotactic frameless or frame-based endoscopic techniques. There was no operative mortality. The operative morbidity was 3.1% including 1 memory deficit due to fornix injury, 1 hemiparesis due to postoperative haematoma after lesion biopsy, 1 aseptic meningitis and 1 subdural fluid collection. CONCLUSIONS: Endoscopic interventions enable neurosurgeons to manage intracranial cystic lesions. Via the same approach, the obstructed CSF pathways may be restored and consequently the increased intracranial pressure diminishes. With the aid of stereotactic guidance or a neuronavigation system, access to the lesion can be gained rapidly and with high accuracy.

Adult↗
PubMed2004

Purely neuroendoscopic transventricular management of cystic craniopharyngiomas.

INTRODUCTION: This paper reports our series of cystic craniopharyngiomas treated using a purely neuroendoscopic approach. METHODS: Drainage and wide marsupialization into CSF spaces (cysto-ventriculo-cisternostomy) were achieved to ensure mass effect control, continuous dilution, and reabsorption of the cyst's fluid. A steerable, flexible neuroendoscope and a pre-coronal approach were used in 7 patients harboring intra/paraventricular cysts (4 primary and 3 recurrent). RESULTS: These surgical goals were achieved in all but one case and no procedure-related complications were observed. During the follow-up period (range 6-72 months; average 38.3 months) one recurrence and one progression of undrained pouch were observed at 25 and 30 months. Both patients underwent successful repeat neuroendoscopy. CONCLUSIONS: In our hands, this technique has proven minimally invasive, safe, and effective; although oncologically palliative it can be implemented with other therapeutic modalities. Our preliminary experience should stimulate the recruitment of larger groups of patients in order to define the role of neuroendoscopy in the multimodal treatment of craniopharyngiomas.

Adolescent↗
PubMed2005

Hemodynamic and electrolyte changes in patients undergoing neuroendoscopic procedures.

OBJECTS: Intraoperative hemodynamic alterations and postoperative electrolyte disturbances related to endoscopic third ventriculostomy (E3V) have been reported. We aimed to evaluate prospectively those changes in patients undergoing neuroendoscopic procedures. METHODS: This study was carried out in 24 patients who underwent neuroendoscopic intervention. Sevoflurane was used for the induction and maintenance of anesthesia. Heart rate (HR), mean arterial pressure (MAP), peripheral oxygen saturation, end-tidal CO2, and body temperature values were recorded according to the stages of the operation. Blood gas and blood chemistry analyses were performed before and after endoscopic procedure and were repeated on the third postoperative day. CONCLUSIONS: There were no significant differences in intraoperative HR and MAP. Bradycardia occurred only in 1 of the 24 patients during the dilatation. In conclusion, we suggest the use of 0.9% NaCl for intravenous fluid replacement and a warm lactated ringer solution for ventricular irrigation during E3V to prevent intraoperative hemodynamic changes and postoperative electrolyte disturbances.

Adolescent↗
PubMed2001

Neuroendoscopic third ventriculostomy in dysmorphic brains.

Neuroendoscopic third ventriculostomy (NTV) has superseded shunting as the treatment of choice in non-communicating hydrocephalus. Intracranial developmental anomalies have been considered to be relative contraindications for this procedure. We present one patient with a Dandy-Walker malformation and another with septo-optic dysplasia who presented with hydrocephalus. An NTV was performed successfully in both patients using a flexible neuroendoscope and utilising transendoscopic Doppler ultrasound to ensure a safe target area for ventriculostomy.

Brain↗
PubMed2006

Primary midbrain cystic germinoma mimicking glioma: a case with neuroendoscopic biopsy.

Intracranial germinoma arising primarily in the midbrain is extremely rare. We present the first reported case of cystic midbrain germinoma that lacked evident solid components and mimicked a midbrain glioma. In a 22-year-old man with headache and diplopia, magnetic resonance imaging showed a ring-enhancing lesion in the midbrain. The preoperative diagnosis included brain stem glioma, metastasis, and neuroepithelial cyst. A neuroendoscopic biopsy specimen provided a histologic diagnosis of germinoma. The patient responded well to chemotherapy and radiotherapy. The case illustrates the diagnostic value of neuroendoscopic biopsy in the differential diagnosis of brainstem lesions in adult. The possibilities considered should now include germinoma.

Adult↗
PubMed1994

Percutaneous flexible neuroendoscopic ventriculostomy in patients with shunt malfunction as an alternative procedure to shunt revision.

Three patients with shunt malfunction, who had previously undergone a shunting procedure for noncommunicating hydrocephalus of adolescent and adult onset, successfully underwent a percutaneous flexible neuroendoscopic ventriculostomy. This procedure was performed as an alternative treatment for shunt revision by the use of our newly developed flexible fiberoptic ventriculoscope. All patients were able to remain independent of the shunt system after the ventriculostomy. These results thus suggest that a percutaneous flexible neuroendoscopic ventriculostomy can be effective for the treatment of shunt-dependent patients with shunt malfunction in adolescents and adults.

Adolescent↗
PubMed2003

Neuroendoscopic third ventriculostomy for failed shunts.

BACKGROUND: Neuroendoscopic third ventriculostomy has increased in frequency for the management of hydrocephalus. The objective of this paper is to study the outcome in patients with hydrocephalus whose shunt subsequently failed and who were treated with neuroendoscopic third ventriculostomy (NTV). METHOD: The departmental prospectively acquired database, kept since 1994, was researched to identify those patients who underwent NTV, having presented with a failed shunt. Subsequent failure of the NTV occurs when further treatment for the hydrocephalus is required. RESULTS: There were 88 patients identified, 45(51%) male and 43(49%) female. Median age at time of NTV was 14 years (range 1 day to 69 years). Median time from last shunt to NTV was 8 years (1 week to 35 years). Follow-up was for a median of 3 years (1 month to 6 years) after their NTV. Overall 42 (48%) failed and 46 (52%) were successful. In those with noncommunicating causes the success rate was 73%. Median time to failure was 1 month (immediate to 5 years) Median age of failed patients at time of NTV was 7 years. Serious complications occurred in 5 (5.6%). CONCLUSION: NTV in patients having previously been shunted for their hydrocephalus is safe and as successful as in primary NTV. Failure can be expected to occur with greater frequency in communicating than noncommunicating types of hydrocephalus. The fact that they have a malfunctioning shunt in situ is not a contraindication to this procedure. In cases of infected shunts it is a useful adjunct to the treatment of the infection.

Adolescent↗
PubMed2002

Neuroendoscopic third ventriculostomy in a patient with occluded foramen of Monro: a case report.

We treated recurrent hydrocephalus in a previously shunted patient by neuroendoscopic third ventriculostomy. A tear was noted in the septum pellucidum. As the foramen of Monro was found to be occluded, we first fenestrated the floor of the lateral ventricle and then performed third ventriculostomy through the fenestration. A tough membrane believed to be Liliequist's membrane isolated the space immediately beneath floor of the third ventricle from the cistern below. Cerebrospinal fluid pulsation appeared after fenestration of this membrane. These obstructions presumably resulted from congenital and/or inflammatory causes. In cases such as this, successful neuroendoscopic third ventriculostomy presents a challenge to surgical judgment.

Adolescent↗
PubMed2003

Neuroendoscopic Transnasal Repair of Cerebrospinal Fluid Rhinorrhea.

Cerebrospinal fluid (CSF) rhinorrhea is a common condition managed by most otolaryngologists with the help of nasal endoscopy (sinoscopy). In the last 2 years, we have used a neuroendoscope with a working sheath to treat nine patients with CSF rhinorrhea. One patient developed a recurrence 1 month after treatment but then responded to conservative treatment. We conclude that the treatment of CSF rhinorrhea by a neuroendoscope with a working sheath is safe, effective, and easy and obviates the need for a separate sinoscope.

Journal Article↗
PubMed2006

Virtual simulation of neuroendoscopic procedures: early clinical experience with ventricular lesions.

BACKGROUND: Virtual endoscopy (VE) is a new and promising imaging technology. Applied to neuroendoscopy it allows preoperative simulation of a procedure and evaluation of the individual intraventricular anatomy in selected cases. Along with neuronavigation and real time intraoperative imaging, VE is expected to improve the safety and efficacy of neuroendoscopic procedures. PATIENTS AND METHODS: Between April 2003 and February 2004 VE simulation was performed in 13 randomly selected patients subjected to endoscopic procedures. Pathological entities included 4 cases with aqueduct stenosis, 4 with suprasellar arachnoid cysts, 2 tumors of the posterior third ventricle, 1 colloid cyst, 1 hyperplasia of the choroid plexus and 1 case with multiloculated hydrocephalus due to intraventricular septations. In 8 patients VE was accomplished preoperatively, in another 5 it was done after the operation, using data sets from neuronavigation imaging planning in 4 patients, and in one case using postoperative imaging studies. T (1)-weighted 3D image sets were acquired on a 1.5 T GE Genesis SIGNA MR scanner and VE reconstruction was performed using the General Electric Navigator software. The VE images were compared with the real images obtained during the endoscopic procedures and evaluated for their impact on the planning of the operative approach. RESULTS: VE implementation succeeded in all 13 patients. Major neuroanatomic reference structures were easily recognizable in all cases. Membranous structures such as the thinned floor of the third ventricle or cyst walls were identifiable in only 46 % of the cases. In 6 cases (46 %) VE showed anatomical variants and details relevant for the endoscopic procedure that were not identified on conventional MR images. CONCLUSIONS: VE has proved to be an important adjunct to the preoperative planning of neuroendoscopic procedures and its routine application is suggested.

Adolescent↗
PubMed1996

Biportal neuroendoscopic microsurgical approaches to the subarachnoid cisterns. A cadaver study.

A preclinical cadaver study was performed to develop the technique of biportal neuroendoscopic dissection in the subarachnoid space of the basal cisterns and to test the feasibility, utility, and safety of this new technique. In 23 fresh post-mortem adult human cadavers and 2 formalin-fixed adult human head specimen a total of 33 biportal endomicrosurgical dissections into and within the basal cisterns were carried out. Following suction of cerebrospinal fluid from the subarachnoid space 0 degree-, 30 degrees-, and 70 degrees-lens-scopes (Aesculap AG, Tuttlingen, Germany) with outer diameters of 4.2 mm and trochars with outer diameters of 5 to 6.5 mm were introduced into the surgical field. 6 different endoscopic routes to the basal cisterns and a total of 10 different combinations of these approaches for biportal endoneurosurgery could be described, but it was found that not all of them were useful and safe. The transventricular approach to the prepontine cisterns through the foramen of Monro and the floor of the third ventricle, biportally combined with a subfrontal or a subtemporal approach, turned out to be not safe enough as it was accompanied by traumatization of the fornix at the interventricular foramen and of the hypothalamus at the level of the tuber cinereum due to relaxation and caudal shift of the brain following suction of cerebrospinal fluid to clear the basal cisterns for the subfrontal or subtemporal approaches. Useful and safe endomicrosurgical approaches to the basal cisterns were: 1st subfrontal, either epidural or intradural, 2nd subtemporal, either anterior or posterior, and 3rd frontal interhemispheric. Various biportal combinations of these approaches are estimated to be feasible, useful, and safe enough to be performed during microsurgical procedures in the operating room. The biportal endomicrosurgical strategy allows for effective and safe dissections within the subarachnoid spaces of the basal cisterns. The tip of the microinstruments as well as the neighboring anatomical structures can be nicely controlled at angles of about 60 degrees to 180 degrees depending on the viewing angles of the scopes used and depending on the individual shape of the head. A variety of microsurgical instruments has been tested. A number of these will have to be redesigned for this new technique. Regions suitable for biportal neuroendoscopic subarachnoid preparations are the olfactory groove, the prechiasmatic cistern, the region of the optic chiasm, the entire suprasellar area, parts of the parasellar area, the pre- and perimesencephalic cisterns, and the prepontine cistern.

Adult↗
PubMed1997

Intraoperative dislocation of the distal lens of a neuroendoscope: a very rare complication: technical case report.

OBJECTIVE AND IMPORTANCE: A very unusual complication of neuroendoscopy that was caused by equipment failure is described. CLINICAL PRESENTATION: Intraoperatively, the distal lens of a reusable rigid, lenscope-type neuroendoscope became dislodged. Fortunately, this did not have any adverse consequences for the patient. DISCUSSION: The cause remains obscure but probably relates to the repeated use of the scope. Perhaps the use of a disposable neuroendoscope could have prevented this, but reusable lenscopes are designed to be used many times. CONCLUSION: The risk of such equipment failure should be weighed against the distinct advantage of a much clearer image than is provided by fiberscopes.

Cerebral Ventricles↗
PubMed2000

Cerebral infarction after neuroendoscopic third ventriculostomy: case report.

OBJECTIVE AND IMPORTANCE: This case illustrates an unusual complication of neuroendoscopic third ventriculostomy. CLINICAL PRESENTATION: A 30-year-old man with established hydrocephalus was treated with neuroendoscopic third ventriculostomy during which bleeding occurred from a vessel deep in the floor of the third ventricle. He subsequently had a third nerve palsy and developed frontal lobe infarction. INTERVENTION: The complication was treated conservatively. The patient subsequently required shunting. CONCLUSION: The cause of the infarction is discussed. The general issue of complications of this procedure is explored with a call for more open reporting of such occurrences.

Adult↗