Long-term quality of life after ETV or ETV with consecutive VP shunt placement in hydrocephalic pediatric patients.

PURPOSE: Endoscopic third ventriculostomy (ETV) and ventriculoperitoneal shunting are well-established treatments of obstructive hydrocephalus (HCP) in adult and pediatric patients. However, there is a lack of data with regard to the quality of life (QoL) of these patients during long-term follow-up METHODS: Inclusion criteria were pediatric patients with endoscopic treatment of hydrocephalus at the University Medicine Greifswald between 1993 and 2016. Patients older than 14 years at present were assessed with the Short Form-12 (SF-12) questionnaire. Patients younger than 14 years of age were assessed with the KINDL-R questionnaire that was completed by their parents. Patients' values were compared with the scores of a corresponding age-matched group of the healthy population and with patients who received later shunt treatment. Information about comorbidities, current symptoms, and educational level were gained by an additional part. Comparative analysis between patients with ETV success and failure (defined as shunt implantation after ETV) was performed. RESULTS: A total of 107 patients (53 m, 54f) were included. Fifty-seven/107 patients (53.3%) were considered as ETV success. Mean age at ETV was 6.9 ± 5.9 years. Fifty-four statements of 89 patients that are still alive were gained (response rate 63%). Of these, 49 questionnaires were complete and evaluable (23 m, 26f; mean age 19.8 ± 10.0 years with an average follow-up period of 13.7 ± 7.2 years). Twenty-six/49 patients (53.1%) are considered ETV success. No statistically significant differences could be obtained between patients with ETV success and ETV failure. Patients older 14 years show QoL within normal range, patients younger than 14 years show significantly lower result regarding their environment of peers and social contacts. Patients younger than 6 months at the time of ETV and patients with posthemorrhagic HCP show significantly lower physical QoL. Gait disturbance, fatigue, and seizures are associated with a lower QoL, and educational level is lower than in the normal population. CONCLUSIONS: Patients who underwent ETV in childhood do not have a lower health-related QoL in general. Subsequent insertions of ventriculoperitoneal (vp) shunts do not lower QoL. Certain subgroups of the patients show lower results compared to the healthy population.

Mononostril endoscopic transsphenoidal approach to sellar and peri-sellar lesions: Personal experience and literature review.

OBJECTIVE: The endonasal endoscopic approach to skull base is still under investigation. The main goal is the minimal invasive approach to pathologies with a better rate of resection without retraction of the brain tissue. Here, the authors report their technique of transnasal endoscopic neurosurgery using a mononostril approach and its development. METHODS: The supplementary video demonstrates the different steps of the mononostril approach and resection of a pituitary adenoma. All video-recorded procedures that were carried out between 2000 and 2013 using this technique were analysed. The patients were followed prospectively. RESULTS: Visualization and handling were good in 246/251 (98%). In three cases, we had to switch to microscopy because of severe bleeding of the cavernous sinus. On follow-up, magnetic resonance imaging revealed radical tumour resection in 92% of all cases when intended. There was no mortality, and the low complication rate was remarkable. CONCLUSION: Our mononostril approach of transnasal transsphenoidal surgery shows better results compared with previously published reports in regards to radicality, low cerebrospinal fluid leaks and morbidity. The very low rate of nasal complains is particularly remarkable.

Prognostic significance of immunohistochemical expression of VEGFR2 and iNOS in spinal chordoma.

PURPOSE: To clarify whether vascular endothelial growth factor receptor 2 (VEGFR2) and inducible nitric oxide synthase (iNOS) are involved in the angiogenesis and recurrence of spinal chordoma tissues and influence the overall survival. METHODS: All patients affected by a spinal chordoma surgically treated between 1986 and 2007 were reviewed. We examined the expression of VEGFR2 and iNOS with immunohistochemistry using a tissue microarray containing 120 chordoma samples. Local recurrence and overall survival (OS) were analyzed. RESULTS: A series of 40 chordoma patients who underwent surgery for a total of 120 lesions (including 80 recurrent lesions) were identified (sacrum 77.5 %, lumbar spine 17.5 %, cervical/thoracic spine 5 %). Surgical margins were wide in 30 (75 %), marginal in 8 (20 %) and intralesional in 2 (5 %) patients. Median follow-up was 120 months. The 5- and 10-year OS of the entire series of patients was 78.6 and 30 %, respectively. There were five primary chordomas (12.5 %) with moderate and 35 (87.5 %) with strong expression of VEGFR-2. All recurrent spinal chordomas displayed strong expression of VEGFR-2. The expression of iNOS was predominately moderate to high in primary chordomas: There were 15 tumors (37.5 %) with moderate and 25 tumors (62.5 %) with strong expression. All recurrent chordomas displayed strong expression of iNOS. CONCLUSION: The high expression of VEGFR-2 and iNOS affected the OS. The OS at 10 years was only 30 %.

Endoscopic diagnosis and treatment of far distal obstructive hydrocephalus.

PURPOSE: Obstruction of the CSF circulation distal to the fourth ventricle is a rare cause of noncommunicating hydrocephalus. Endoscopic third ventriculostomy (ETV) represents one of the treatment options, but reports of results are rare. METHODS: Between March 1997 and June 2008, 20 ETVs in 20 patients (mean 32.4 years, range 1 month-79 years) for noncommunicating hydrocephalus distal to the fourth ventricle were undertaken. All patients suffered from severe internal hydrocephalus and typical clinical symptoms. In addition to the standard ETV, a transaqueductal inspection of the posterior fossa with a flexible scope was performed. All patients were prospectively followed. RESULTS: An ETV was achieved in all patients. It was clinically successful in 15 of 20 patients (75%) with an improvement of 50% (three out of six) of the pediatric and of 83% (12 out of 14) of the adult population. A reduction of ventricle size was found in ten (50%). Five patients (25%) received ventriculoperitoneal shunting. A transaqueductal inspection of the posterior fossa cerebrospinal fluid (CSF) pathways was performed in 16. In the remaining four patients, no inspection with the flexible scope was done. One clinically silent fornix contusion and one CSF fistula which was treated conservatively occurred. There was no permanent morbidity. CONCLUSIONS: ETV is a successful treatment option in CSF pathway obstructions distal to the fourth ventricle. Although the success rate particularly of the pediatric population appears to be lower than with other indications of obstructive hydrocephalus, a relevant part of the patient population improves after ventriculostomy and shunting can be avoided.

Endoscopic Treatment of Intracranial Arachnoid Cysts: A Retrospective Analysis of a 25-Year Experience.

BACKGROUND: Since the development of neuroendoscopy, pure endoscopic fenestration for intracranial arachnoid cysts (ACs) became more and more popular and is actually preferred by many neurosurgeons. OBJECTIVE: To explore their techniques and experiences with endoscopic treatment of intracranial ACs over a 25-yr period. METHODS: A total of 95 endoscopic procedures in 87 patients with 88 intracranial ACs performed at the authors' departments between February 1993 and October 2018 were retrospectively analyzed. Particular respect was given to surgical technique, complications, patients' outcome, and radiological benefit in relation to cyst location. RESULTS: Patients' ages ranged from 23 d to 81 yr (mean: 29.9 yr). Cysts were located temporobasal (n = 31; 35.2%), paraxial supratentorial (n = 14; 15.9%), suprasellar/prepontine (n = 14; 15.9%), quadrigeminal (n = 12; 13.6%), infratentorial (n = 11; 12.5%), and supratentorial intraventricular (n = 6; 6.8%). Four different endoscopic techniques were applied: cystocisternostomies (n = 48; 50.5%), ventriculocystostomies (n = 23; 24.2%), cystoventriculostomies (n = 14; 14.7%), and ventriculocystocisternostomies (n = 10; 10.5%). Pure endoscopic technique was feasible in 89 of the 95 surgeries (93.7%). Clinical improvement was documented after 82 surgeries (86.3%) and radiological benefit after 62 surgeries (65.3%). Recurrences developed in 8 cases (8.4%). Overall complication rate was 21.1% (n = 20), postoperative new shunt dependency was observed in 4.2% of the cases (n = 4). CONCLUSION: Pure endoscopic AC fenestration is a safe, effective, and less invasive technique providing high success and low permanent complication rates. The most frequent temporobasal cysts are the most difficult to treat endoscopically. A long-term follow-up is recommended because recurrences may occur many years after first treatment.

Endoscopic third ventriculostomy in obstructive hydrocephalus due to giant basilar artery aneurysm.

OBSTRUCTIVE: hydrocephalus due to giant basilar artery (BA) aneurysm is a rare finding, and endoscopic treatment has not been reported. Here the authors present their experience with endoscopic third ventriculostomy (ETV) in obstructive hydrocephalus due to giant BA aneurysm. Between December 2000 and March 2007, 3 patients (2 men and 1 woman; age range 32-80 years) underwent an ETV for the treatment of obstructive hydrocephalus caused by a giant BA aneurysm. All 3 patients presented with cephalgia, nausea, vomiting, and a variable decrease in consciousness. An obstructive hydrocephalus caused by a giant BA aneurysm was found in each case as the underlying pathological entity. Intraoperatively, a narrowing of the third ventricle by upward displacement of the tegmentum was found in all 3 patients. A standard ETV was performed and included an inspection of the prepontine cisterns. The endoscopic treatment was successful in all patients with respect to clinical signs and radiological ventricular enlargement. No complications were observed. In all, the endoscopic ventriculostomy was proven to be a successful treatment option in obstructive hydrocephalus even if it is caused by untreated giant BA aneurysm.

Waterjet dissection of the vestibulocochlear nerve: an experimental study.

OBJECT: Waterjet dissection has been shown to protect intracerebral vessels, but no experience exists in applying this modality to the cranial nerves. To evaluate its potential, the authors examined waterjet dissection of the vestibulocochlear nerve in rats. METHODS: Lateral suboccipital craniectomy and microsurgical preparation of the vestibulocochlear nerve were performed in 42 rats. Water pressures of 2-10 bar were applied, and the effect was microscopically evaluated. Auditory brainstem responses (ABRs) were used to define nerve function compared with preoperative values and the healthy contralateral side. The final anatomical preparation documented the morphological and histological effects of waterjet pressure on the nerve. RESULTS: In using up to 6 bar, the cochlear nerve was preserved in all cases. Eight bar moderately damaged the nerve surface. A 10-bar jet markedly damaged or even completely dissected the nerve. Time course analysis of the ABR demonstrated complete functional nerve preservation up to 6 bar after 6 weeks in all rats. Waterjet dissection with 8 bar was associated with a 60% recovery of ABR. In the 10-bar group, no recovery was seen. CONCLUSIONS: Microsurgical dissection of cranial nerves is possible using waterjet dissection while preserving both morphology and function. The aforementioned jet pressures are known to be effective in neurosurgical treatment of tumors. Thus, waterjet dissection may be useful in skull base surgery including dissection of cranial nerves from tumors. Further studies on this subject are encouraged.

Endoscopic cystoventriculostomy for treatment of paraxial arachnoid cysts.

OBJECT: The optimal therapy of arachnoid cysts is controversial. In symptomatic extraventricular arachnoid cysts, fenestration into the basal cisterns is the gold standard. If this is not feasible, shunt placement is frequently performed although another endoscopic option is available. METHODS: Between March 1997 and June 2006, 12 endoscopic cystoventriculostomies were performed for the treatment of arachnoid cysts in 11 patients (4 male and 7 female patients, mean age 52 years [range 14-71 years]). All patients were prospectively followed up. RESULTS: In 11 cases, the arachnoid cysts were frontotemporoparietal and fenestration was performed into the lateral ventricle. In 1 case, the arachnoid cyst was located in the cerebellum and the cyst was fenestrated into the fourth ventricle. Neuronavigational guidance was used in all but 1 case. Endoscopic cystoventriculostomy was performed in all cases without complications. No stents were placed. The mean surgical time was 71 minutes (range 30-110 minutes). The mean follow-up period was 42.7 months (range 19-96 months) per surgical case and 48.8 months (range 19-127 months) per patient. Symptoms improved after 11 of the 12 procedures; 7 of the 11 patients became symptom-free and the others had only mild residual symptoms. The patient who did not experience clinical improvement suffered from depression and demonstrated a significant decrease of the cyst size on the postoperative MR imaging. After 11 of 12 procedures, a decrease in cyst size was observed. In 1 case, a subdural hematoma developed; it required surgical treatment 3 months after surgery. In another case, reclosure of the stoma required repeated endoscopic cystoventriculostomy more than 7 years after the initial procedure. CONCLUSIONS: Overall, endoscopic cystoventriculostomy represents a useful treatment option for patients with paraxial arachnoid cysts in whom a standard cystocisternotomy is not feasible. Based on the results in this case series, stent placement appears not to be required. Despite the long mean follow-up of almost 4 years, however, a longer follow-up period seems to be required before definite conclusions can be drawn.

German neuroendoscopy above the skull base.

Endoscopy plays an important part in current minimally invasive neurosurgery. The concepts, indications, and standards of current neuroendoscopy were developed in the beginning of the 1990s by several groups of neurosurgeons. Several factors contributed to its success and acceptance, including technical development, influence of other disciplines, and adaptation to neurosurgical requirements. This historical survey focuses on the period when this technique initially emerged, including the scientific discussions of each group as well as the arguments and reasons that led to present intraventricular neuroendoscopy. Interestingly, despite the almost independent development of neuroendoscopic systems and techniques, the available systems and techniques applied these days grossly correspond. Rigid rod-lens endoscopes are generally accepted as the best option among the various available instrument sets. Nevertheless, frameless as well as frame-based stereotactic endoscopy and flexible steerable endoscopes might have their applications as well.

A new endoscopic spine system: the first results with "Easy GO".

PURPOSE: Endoscopy meets increasing interest by spine surgeons. However, endoscopic results are diverging and many spinal endoscopic systems are difficult to apply and handle. METHODS: A system for endoscopic spinal surgery was developed where the main goals were: (1) easy intraoperative handling with standard microsurgical techniques, and (2) avoidance of a prolonged learning curve. The system consists of various dilators, two different work sheaths, two different 30 degrees endoscopes, and an endoscope holder. RESULTS: Between August 2006 and April 2008, 80 spinal surgeries were performed in degenerative lumbar spine cases (mean age 52 years, range 22-85 years). Intraoperatively, the system was easy to handle. Standard microsurgical techniques were used. Mean surgical time scored 75 min (range 28-168 min). There was no intraoperative complication, no new postoperative deficit and no infection. In four cases, the endoscope was abandoned and the procedure microsurgically continued (5%). At the last follow-up (mean FU 10 months, range 2 weeks up to 21 months), 89% of the patient were pain free (71/80). Four patients suffered from recurrent disc prolapses (5%). Another five patients (6%) were not satisfied without evidence of re-prolaps. Of those who answered the questionnaire of patient satisfaction, 83% (45/54) considered their postoperative status as excellent, 13% as good (7/54), 4% were not satisfied (2/54). CONCLUSIONS: The Easy GO system was easy and safe to handle with the standard bimanual microsurgical technique and good postoperative results. Further studies are needed to show a significant advantage of the technique in comparison to the microsurgical standard procedure.

PEEK cage cervical ventral fusion in spondylodiscitis.

PURPOSE: Cervical spondylodiscitis is a quite rare finding regarding the number and the common location of spinal abscesses in the lumbar region. While in thoracic and lumbar discitis, single-step surgery with neural decompression, disc space evacuation, and subsequent fusion is well known, there is no such report in cervical discitis. Here the authors present their experience with ventral polyetherketone (PEEK) cage fusion in cervical spondylodiscitis in a single-step procedure. METHODS: Between January 2006 and November 2008, five patients (three men, two woman; ages 71, 77, 58, 66 and 66 years) suffering from cervical spondylodiscitis and epidural abscess underwent disc evacuation, myelon decompression and subsequent ventral fusion using an empty PEEK cage disc replacement in one single setting. All five patients presented with significant neurological symptoms like cervicobrachialgia, tetraparesis and disturbance of the urinary incontinence. In all five patients, disc evacuation, myelon decompression and cervical fusion using a PEEK cage disc replacement in a single-stage surgery were performed. All wounds were closed primarily. Postoperatively, all patients received a specific antibiotic therapy for at least 6 weeks. RESULTS: This treatment strategy was successful in all patients with respect to clinical signs, laboratory parameters and radiological findings. All patients improved neurologically. Follow-up revealed a stable osteosynthesis without signs of instability. One cage was explanted despite neurological improvement and normal infectious parameters at another surgical department. No complications were observed. CONCLUSIONS: In all, abscess drainage and ventral fusion with PEEK-cage disc replacement in one single setting was proven to be a successful treatment option in cervical discitis and spinal epidural abscess.

Comparison of the long-term results of anterior transposition of the ulnar nerve or simple decompression in the treatment of cubital tunnel syndrome--a prospective study.

OBJECTIVE: In order to assess their late benefits we present the long-term results of a comparison of treating cubital tunnel syndrome with anterior submuscular transposition or simple decompression. METHODS: Of 40 patients initially recruited to this study 33 were available for long term follow-up. Sixteen patients underwent anterior submuscular transposition (group A); simple decompression was performed in 17 of the patients (group B). The indications for inclusion were a typical clinical presentation confirmed by abnormal nerve conduction studies. The mean duration of the symptoms before operation was 13 months (range 2 to 84 months) in group A and 8.4 months (range 1.5 to 36 months) in group B. All patients were seen 2 months after surgery and at least 3 years later. The mean duration of follow-up was 63.1 month in the first group and 52 months in the second group. RESULTS: No complications were seen in either group. In the group treated by anterior transposition, ten of 16 patients were completely free of signs and symptoms; slight residual hypesthesia or paresthesia was observed in two patients. Paresis and atrophy was observed in only one person. In the simple decompression group, 11 of 17 patients were completely free of signs and symptoms. In five patients slight residual symptoms were observed; no paresis or atrophy was reported in any of this group. CONCLUSION: These long-term results show that both surgical techniques have a good outcome. Thus, the less invasive simple decompression should be preferred.

Chronic subdural hematoma--craniotomy versus burr hole trepanation.

The authors present a series of more than 200 surgical procedures for chronic subdural hematoma in a 5-year-period. Clinical presentation and neurosurgical treatment were regarded with a special focus on the surgical technique. Between March 2003 and July 2008, 193 patients (113 male and 80 female, mean age 72.5 yrs [range 26-97 yrs]) suffering from chronic subdural hematoma were retrospectively analyzed. One-hundred-fifty-one craniotomies and 42 burr holes were performed. Forty-two craniotomy patients (27.8%) in contrast to 6 burr hole patients (14.3%) required surgical revision. A craniectomy was performed as an ultima ratio after at least 2 prior evacuations in 3 cases. Chronic subdural hematoma is a disease of the elderly. A craniotomy seems to possess a higher rate of recurrence of the chronic subdural hematoma so that a burr hole evacuation should be preferred. Craniectomy might be a good therapeutic option in complicated recurrent chronic subdural hematomas.

Long-Term Reliability of Neuroendoscopic Aqueductoplasty in Idiopathic Aqueductal Stenosis-Related Hydrocephalus.

BACKGROUND: During the 1990s, endoscopic aqueductoplasty (AP) was considered to be a valuable alternative to endoscopic third ventriculostomy (ETV) in treating hydrocephalus related to idiopathic aqueductal stenosis (iAS), with promising short-term outcomes. OBJECTIVE: To evaluate the long-term outcome of AP in the treatment of iAS. METHODS: Long-term follow-up clinical examinations and magnetic resonance (MR) imaging were performed for patients treated by an AP for iAS in our department. RESULTS: Twenty patients (14 female, 6 male, mean age 41.7 yr, range 0.5-67 yr) were treated between 1996 and 2002. Two patients were lost to long-term follow-up. One patient died 6 mo after AP, but death was not related to the procedure. The mean follow-up for the remaining 17 patients was 120 mo. Clinically relevant aqueductal reclosure was observed in 11/17 patients after a mean follow-up of 53.4 mo. These 11 patients underwent ETV, which has been successful during further follow-up. Four of the six remaining patients presented with no clinical symptoms, although aqueductal restenosis was observed on MR imaging. Thus, the overall failure rate of AP was 88.2%. The failures were homogeneously distributed over the entire follow-up period. CONCLUSION: AP has a high risk of failure during long-term follow-up and is not recommended as the first choice of treatment in hydrocephalus caused by iAS. ETV should be done instead. AP may be reserved for a limited number of patients in whom ETV is not feasible but should be combined with stenting to avoid reclosure of the aqueduct.

Long-Term Results After Endoscopic Resection of Colloid Cysts.

BACKGROUND: Endoscopic resection of colloid cysts is a widely accepted treatment option instead of microsurgery. However, there is still a debate about a potentially higher rate of incomplete resections and recurrence. OBJECTIVE: The aim of this retrospective study was to evaluate long-term results after endoscopic removal of colloid cysts. METHODS: Twenty patients underwent endoscopic treatment in our department. Eighteen patients agreed to follow-up examinations. In 17 patients, magnetic resonance images were obtained. RESULTS: Total cyst resection was achieved in 16 procedures. In 1 patient, only plexus coagulation and widening of the ipsilateral foramen of Monro were performed. In 3 patients, small remnants of the cyst membrane were left behind. Conversion to microsurgery became necessary in 1 patient. Mild temporary complications occurred in 6 patients. Preoperative symptoms were completely relieved in 16 patients and improved in 2 patients. The average follow-up period was 188 months. In the patient with plexus coagulation, the cyst did not change. Recurrence occurred in 2 of 3 patients with cyst remnants. To date, no cyst remnant or recurrence has caused any symptoms or required surgical treatment. CONCLUSIONS: Our results indicate that endoscopic treatment of colloid cysts is a safe and effective treatment option that provides excellent long-term results. However, we determined that a significant risk for recurrence exists when even small parts of the cyst capsule were left behind. Therefore, we advocate an attempt at total endoscopic cyst resection.

Ultrasonic aspiration in neuroendoscopy: first results with a new tool.

Neuroendoscopic techniques are often considered inapplicable to lesion resection because most lesions are too large for effective endoscopic resection in an appropriate time frame. To evaluate the potential of ultrasonic aspiration in neuroendoscopic procedures, the authors developed a new handpiece for endoscopic application. The instrument was subsequently tested in 10 cadaveric pig brains and applied in 5 clinical cases. In the pig brain, a precise and accurate aspiration of ventricular ependyma and brain parenchyma was obtained. Clinically, the device was applied in 3 patients with obstructive hydrocephalus, and via an endonasal transsphenoidal approach in 2 patients with pituitary macroadenomas. In all cases, the lesion was effectively aspirated without complications. Ultrasonic aspiration can be applied safely and successfully in selected endoscopic procedures. The use of this technique could expand the indications for endoscopic approaches to include intraventricular lesions and in minimally invasive transsphenoidal endonasal approaches.

Endoscopic Third Ventriculostomy before Posterior Fossa Tumor Surgery in Adult Patients.

OBJECTIVE: Obstructive hydrocephalus in patients with posterior fossa tumors is frequently seen. Treatment options include immediate tumor removal or prior cerebrospinal fluid (CSF) diversion procedures. The necessity and feasibility of an ETV in these situations has not yet been proven in adult patients. METHODS: We retrospectively reviewed our prospectively maintained database for ETVs before surgery of posterior fossa tumors in adults. The primary focus of data analyses was the question of whether the ETV was suitable to treat the acute situation of hydrocephalus without an increased rate of complications due to the special anatomical situation with a posterior fossa tumor. We also analyzed whether any further CSF diverting procedures were necessary. RESULTS: A total of 40 adult patients who underwent an ETV before posterior fossa tumor surgery were analyzed. Overall, 33 patients (82.5%) had clinical signs of hydrocephalus, and all of them improved in their clinical course after ETV. Seven patients (17.5%) did not demonstrate clinical signs of hydrocephalus, but ETV was performed with prophylactic or palliative intent in six patients and one patient, respectively. No complications were observed due to ETV itself. No permanent shunting procedure was necessary in a mean follow-up of 76.5 months. Early additional CSF diverting procedures (redo ETV, external ventricular drain) were performed in five patients (12.5%). CONCLUSION: The present series confirms the feasibility and safety of ETV before posterior fossa tumor surgery in adult patients. If patients had symptomatic hydrocephalus before tumor surgery, an ETV can be performed, followed by early elective tumor surgery. A prophylactic ETV in asymptomatic patients is not advised. Early elective tumor surgery should be performed in these patients.

Results of Combined Intraventricular Neuroendoscopic Procedures in 130 Cases with Special Focus on Fornix Contusions.

OBJECTIVE: Increasing experience with intraventricular neuroendoscopic procedures shows good results in the combination of endoscopic third ventriculostomy (ETV) and tumor biopsy. Other possible combinations are mainly presented in subgroups in the literature. Here, we present our experience with combined intraventricular procedures within 1 setting over the last 2 decades. METHODS: This study retrospectively analyzes data from neuroendoscopic intraventricular procedures between 1993 and 2015 in 3 different departments of neurosurgery. Inclusion criteria were a combination of at least 2 intraventricular endoscopic procedures (e.g. third ventriculostomy, cyst fenestration, tumor surgery or aqueductoplasty) within 1 setting. RESULTS: One-hundred and thirty cases with more than 300 procedures fulfilled the inclusion criteria. The most frequent combinations were ETV and tumor biopsy (n = 36), ETV and aqueductoplasty/stenting (n = 30), and ETV and cyst fenestration (n = 18). The complication rate was 16.9% with an overall morbidity of 1.6% and mortality of 0.8%. Fornix contusion was one of the most frequent intraoperative complications (16.4%). Shunt independency was achieved in 82.9% of cases with hydrocephalic symptoms. CONCLUSIONS: A combination of different intraventricular endoscopic procedures is safe and reliable, bearing similar risks of morbidities and mortality to single neuroendoscopic procedures. This study is one of the largest series in the literature and has similar low complication rates to others. Fornix contusion is the most frequent intraoperative complication in these patients. However, obvious clinical correlation is rare.

The use of waterjet dissection in endoscopic neurosurgery. Technical note.

Waterjet dissection enables vessel preservation and a reduction in intraoperative blood loss. Because even minimal bleeding should be avoided during neuroendoscopy, the waterjet device may be a particularly valuable tool in such procedures. The authors used this instrument in experimental endoscopic procedures in 20 cadaveric porcine brains and clinically in four patients with obstructive hydrocephalus. A precise and accurate septostomy was achieved in all of the pig brains. In two patients the hydrocephalus was due to intraventricular hemorrhage, in one a posterior fossa tumor, and in one a cystic craniopharyngioma. In all patients the surgical view was kept clear with waterjet irrigation and suction. Using a pressure setting of 10 bars, the waterjet device successfully perforated the cyst wall of the craniopharyngioma in one patient and the floor of the third ventricle in three patients. The use of the waterjet device in selected endoscopic procedures appears safe, and may help reduce intraoperative bleeding. However, further studies are needed to confirm the utility of the waterjet tool in endoscopy.