Three-Dimensional versus 2-Dimensional Endoscopic Third Ventriculostomy: Surgical Results of a Preliminary Comparative Study.

BACKGROUND: Three-dimensional (3-D) endoscopes have been widely used for a large variety of approaches in neurosurgical practice. However, in the last decade, 3-D scopes were barely used for ventricular surgery. In this study, we illustrated our preliminary experience with a 3-D endoscope for third ventriculostomy using new dedicated endoscopic equipment. METHODS: Over a 12-month period, a high-definition 3-D endoscopic third ventriculostomy (ETV) was performed in 14 patients with obstructive hydrocephalus. Patients were followed prospectively and compared retrospectively with a matched group of 16 similar patients who underwent ETV with a standard 2-dimensional (2-D) endoscope. Surgical outcome and intra- and postoperative course were retrospectively reviewed. RESULTS: 3-D ETV provided excellent surgical results, and no significant difference was shown in terms of outcome, complication, and length of hospitalization between the 2 groups. Moreover, operative time (minutes) was significantly shorter in the 3-D group than the 2-D ETV group (19.9 ± 4.8 vs. 22.9 ± 1.4, respectively; P < 0.05), and the use of the 3-D endoscope provided subjective improvements of depth perception, hand-eye coordination, and surgeon comfort. CONCLUSIONS: Our preliminary study clearly demonstrated the effectiveness of 3-D ETV and provided a significant reduction of operative time. Depth information from the 3-D scope appears to facilitate rapid and stable ETV maneuvers, representing a critical development that may become a valuable tool for neuroendoscopy.

External ventricular drain related complications-whether continuous csf drainage via ommaya reservoir is the answer?

BACKGROUND AND AIMS: External ventricular drainage (EVD) is one of the commonest procedures in neurosurgical practice to manage acute hydrocephalus. We evaluated the infectious and non-infectious complications associated with a modified technique for EVD using an Ommaya reservoir. METHODS: Ommaya reservoir was placed in all patients who required EVD placement for CSF drainage. CSF drainage was achieved using a needle placed in a non-coring fashion percutaneously into the Ommaya reservoir to achieve CSF drainage externally. CSF was monitored for signs of infection regularly using CSF biochemistry and cultures. CSF infection was defined by a positive culture or a secondary infection in patients with already infected CSF. RESULTS: 59 patients required continuous CSF drainage during the study period from January 2014 to June 2017. 46 (77.96%) patients had non-infected CSF at time of starting drainage and 13 (22.03%) patients required external CSF drainage for primarily infected CSF. The study period had a total of 793 CSF drainage days (Range 3-64 days) with an average of 13.4 days per patient. The cumulative rate of new infection was 5.08%. No ventricular catheter blockage or dislodgement was seen in any of the patients. CONCLUSIONS: External ventricular drainage through an Ommaya chamber is a safe and effective method and can be used to reduce the catheter related complications like infection, catheter blockage and dislodgement.

A design of brain port with a built-in bi-directional check valve improves the ventriculostomy.

The increase of intracranial pressure is a life-threatening condition which requires urgent treatment to prevent the further neurologic problem. A design of the brain port is proposed, in which a bi-directional check valve controls the flow of the cerebrospinal fluid depending on the intracranial pressure in accordance with the other devices. Drug administration and cerebrospinal fluid drainage could be performed easily without any additional surgery other than the transplant of a brain port. The intracranial pressure value at which the cerebrospinal fluid should be drained is adjustable by altering the pressure of the drainage bag. The results of the experiment with the simulated brain system are supporting and verifying the substance of this article.

Purely neuroendoscopic resection of intraventricular tumors with an endoscopic ultrasonic aspirator.

Surgery for intraventricular tumors remains a controversial and evolving field, with endoscopic resection becoming more popular. We present a series of nine consecutive cases of purely endoscopic resection of intraventricular tumors with the aid of an ultrasonic aspirator specific for neuroendoscopy. Nine patients (five men, four women) aged 18-74 years (mean 43.7) underwent surgery. The most common symptom was headache. In all cases, magnetic resonance imaging showed single supratentorial intraventricular lesions (five lateral ventricle, four third ventricle). The average maximum diameter was 20.5 mm (range 11-42). Associated hydrocephalus was found in eight cases at diagnosis. Five patients underwent complete macroscopic resection. Three underwent subtotal resection and one underwent partial resection (two thirds of the tumor). The mean endoscopic procedure time was 70 min (37-209). The eight patients with associated hydrocephalus also underwent endoscopic septostomy to improve cerebral spinal fluid circulation, with one patient additionally requiring endoscopic third ventriculostomy and another requiring Monro foraminoplasty. One patient required ventriculoperitoneal shunting. The mean post-operative follow-up was 15.1 months (range 2-33). At the time of analysis, no patient showed recurrence or regrowth of the operated lesion. The histological diagnoses and degree of resection were three subependymomas with complete resection, three colloid cysts with two complete and one subtotal resection, one pilocytic astrocytoma with partial resection (approximately two thirds of the lesion), one epidermoid tumor with subtotal resection, and one central neurocytoma with subtotal resection. The endoscopic ultrasonic surgical aspirator can be a safe and effective tool for the removal of intraventricular tumors, even in firmer solid lesions.

Factors Predicting Ventriculostomy Revision at a Large Academic Medical Center.

BACKGROUND: Freehand bedside ventriculostomy placement can result in catheter malfunction requiring a revision procedure and cause significant patient morbidity. We performed a single-center retrospective review to assess factors related to this complication. METHODS: Using an administrative database and chart review, we identified 101 first-time external ventricular drain placements performed at the bedside. We collected data regarding demographics, medical comorbidities, complications, and catheter tip location. We performed univariate and multivariate statistical analyses using MATLAB. We corrected for multiple comparisons using the false discovery rate (FDR) procedure. RESULTS: Multivariate regression analyses revealed that revision procedures were more likely to occur after drain blockage (odds ratio [OR] 17.9) and hemorrhage (OR 10.3, FDR-corrected P values < 0.01, 0.05, respectively). Drain blockage was less frequent after placement in an "optimal location" (ipsilateral ventricle or near foramen of Monroe; OR 0.09, P = 0.009, FDR-corrected P < 0.03) but was more likely to occur after placement in third ventricle (post-hoc P values < 0.015). Primary diagnoses included subarachnoid hemorrhage (n = 30, 29.7%), intraparenchymal hemorrhage with intraventricular extravasation (n = 24, 23.7%), tumor (n = 20, 19.8%), and trauma (n = 17, 16.8%). Most common complications included drain blockage (n = 12, 11.8%) and hemorrhage (n = 8, 7.9%). In total, 16 patients underwent at least 1 revision procedure (15.8%). CONCLUSIONS: Bedside external ventricular drain placement is associated with a 15% rate of revision, that typically occurred after drain blockage and postprocedure hemorrhage. Optimal placement within the ipsilateral frontal horn or foramen of Monroe was associated with a reduced rate of drain blockage.

Outcome of single-trajectory rigid endoscopic third ventriculostomy and biopsy in the management algorithm of pineal region tumors: a case series and review of the literature.

BACKGROUND: Tumors within the pineal region represent 1.5 to 8.5% of the pediatric brain tumors and 1.2% of all brain tumors. A management algorithm has been proposed in several publications. The algorithm includes endoscopic third ventriculostomy (ETV) and biopsy in cases presenting with hydrocephalus. In this series, we are presenting the efficacy of a single-trajectory approach for both ETV and biopsy. METHODS: Eleven cases were admitted to Alexandria main university hospital from 2013 to 2016 presenting with pineal region tumors and hydrocephalus. Mean age at diagnosis was 11 years (1-27 years). All cases had ETV and biopsy using rigid ventriculoscope through a single trajectory from a burr hole planned on preoperative imaging. Follow-up period was 7-48 months. RESULTS: All 11 cases presented with hydrocephalus and increased intracranial pressure manifestations. Histopathological diagnosis was successful in 9 out of 11 cases (81.8%). Three cases were germ-cell tumors, two cases were pineoblastomas, two cases were pilocytic astrocytomas, and two cases were grade 2 tectal gliomas. Five of the ETV cases (45.5%) failed and required VPS later on. Other complications of ETV included one case of intraventricular hemorrhage and a case with tumor disseminated to the basal cisterns. CONCLUSION: In our series, we were able to achieve ETV and biopsy through a single trajectory and a rigid endoscope with results comparable to other studies in the literature.

Ventriculocisternal Shunt Redivivus: Third Ventricle-Cisterna Magna Intradural Shunt: A Technical Note and Case Report.

OBJECTIVE: To present a hitherto unreported modification of the classic Torkildsen procedure: passing a catheter intracranially, between the third ventricle and cisterna magna. METHODS: We applied our technique to a 56-year-old man who presented to our department for treatment of a pineal region mass. RESULTS: The patient was placed in sitting position and the mass was gross totally removed through a supracerebellar infratentorial approach. After the completion of the tumor resection, the patency of the cerebral aqueduct was checked, but the permeability was doubtful. During the same procedure, a shunt was inserted, under direct microsurgical control, into the third ventricle and passed over the cerebellar surface into the cisterna magna. The postoperative course was uneventful, and the patient was discharged from our unit with no neurological deficits and able to carry on with his day-to-day life. CONCLUSIONS: Our case illustrates that ventriculocisternal shunting can successfully be used in selected cases. The variation we describe can be a valuable surgical strategy in patients with pineal region masses, in whom a supracerebellar infratentorial route is used and in whom uncertainty exists regarding the patency of the sylvian aqueduct.

Modification of the BioMedicus centrifugal pump to provide continuous irrigation for neuroendoscopy: technical note.

Continuous irrigation is an important adjunct for successful intraventricular endoscopy, particularly for complex cases. It allows better visualization by washing out blood and debris, improves navigation by expanding the ventricles, and assists with tissue dissection. A method of irrigation delivery using a centrifugal pump designed originally for cardiac surgery is presented. The BioMedicus centrifugal pump has the desirable ability to deliver a continuous laminar flow of fluid that excludes air from the system. A series of modifications to the pump tubing was performed to adapt it to neuroendoscopy. Equipment testing determined flow and pressure responses at various settings and simulated clinical conditions. The pump was then studied clinically in 11 endoscopy cases and eventually used in 310 surgical cases. Modifications of the pump tubing allowed for integration with different endoscopy systems. Constant flow rates were achieved with and without surgical instruments through the working ports. Optimal flow rates ranged between 30 and 100 ml/min depending on endoscope size. Intraoperative use was well tolerated with no permanent morbidity and showed consistent flow rates, minimal air accumulation, and seamless irrigation bag replacement during prolonged surgery. Although the pump is equipped with an internal safety mechanism to protect against pressure buildup when outflow obstructions occur, equipment testing revealed that flow cessation is not instantaneous enough to protect against sudden intracranial pressure elevation. A commonly available cardiac pump system was modified to provide continuous irrigation for intraventricular endoscopy. The system alleviates the problems of inconsistent flow rates, air in the irrigation lines, and delays in changing irrigation bags, thereby optimizing patient safety and surgical efficiency. Safe use of the pump requires good ventricular outflow and, clearly, sound surgical judgment.

Robot-assisted endoscopic third ventriculostomy: institutional experience in 9 patients.

OBJECTIVE The endoscopic third ventriculostomy (ETV) is an established and effective treatment for obstructive hydrocephalus. In its most common application, surgeons plan their entry point and the endoscope trajectory for the procedure based on anatomical landmarks, then control the endoscope freehand. Recent studies report an incidence of neural injuries as high as 16.6% of all ETVs performed in North America. The authors have introduced the ROSA system to their ETV procedure to stereotactically optimize endoscope trajectories, to reduce risk of traction on neural structures by the endoscope, and to provide a stable mechanical holder of the endoscope. Here, they present their series in which the ROSA system was used for ETVs. METHODS At the authors' institution, they performed ETVs with the ROSA system in 9 consecutive patients within an 8-month period. Patients had to have a favorable expected response to ETV (ETV Success Score ≥ 70) with no additional endoscopic procedures (e.g., choroid plexus cauterization, septum pellucidum fenestration). The modality of image registration (CT, MRI, surface mapping, or bone fiducials) was dependent on the case. RESULTS Nine pediatric patients with an age range of 1.5 to 16 years, 4 girls and 5 boys, with ETV Success Scores ranging from 70 to 90, underwent successful ETV surgery with the ROSA system within an 8-month period. Their intracranial pathologies included tectal tumors (n = 3), communicating hydrocephalus from hemorrhage or meningeal disease (n = 2), congenital aqueductal stenosis (n = 1), compressive porencephalic cyst (n = 1), Chiari I malformation (n = 1), and pineal region mass (n = 1). Robotic assistance was limited to the ventricular access in the first 2 procedures, but was used for the entirety of the procedure for the following 7 cases. Four of these cases were combined with another procedural objective (3 stereotactic tectal mass biopsies, 1 Chiari decompression). A learning curve was observed with each subsequent surgery as registration and surgical times became shorter and more efficient. All patients had complete resolution of their preprocedural symptoms. There were no complications. CONCLUSIONS The ROSA system provides a stable, precise, and minimally invasive approach to ETVs.

Augmented reality in intraventricular neuroendoscopy.

BACKGROUND: Individual planning of the entry point and the use of navigation has become more relevant in intraventricular neuroendoscopy. Navigated neuroendoscopic solutions are continuously improving. OBJECTIVE: We describe experimentally measured accuracy and our first experience with augmented reality-enhanced navigated neuroendoscopy for intraventricular pathologies. PATIENTS AND METHODS: Augmented reality-enhanced navigated endoscopy was tested for accuracy in an experimental setting. Therefore, a 3D-printed head model with a right parietal lesion was scanned with a thin-sliced computer tomography. Segmentation of the tumor lesion was performed using Scopis NovaPlan navigation software. An optical reference matrix is used to register the neuroendoscope's geometry and its field of view. The pre-planned ROI and trajectory are superimposed in the endoscopic image. The accuracy of the superimposed contour fitting on endoscopically visualized lesion was acquired by measuring the deviation of both midpoints to one another. The technique was subsequently used in 29 cases with CSF circulation pathologies. Navigation planning included defining the entry points, regions of interests and trajectories, superimposed as augmented reality on the endoscopic video screen during intervention. Patients were evaluated for postoperative imaging, reoperations, and possible complications. RESULTS: The experimental setup revealed a deviation of the ROI's midpoint from the real target by 1.2 ± 0.4 mm. The clinical study included 18 cyst fenestrations, ten biopsies, seven endoscopic third ventriculostomies, six stent placements, and two shunt implantations, being eventually combined in some patients. In cases of cyst fenestrations postoperatively, the cyst volume was significantly reduced in all patients by mean of 47%. In biopsies, the diagnostic yield was 100%. Reoperations during a follow-up period of 11.4 ± 10.2 months were necessary in two cases. Complications included one postoperative hygroma and one insufficient fenestration. CONCLUSIONS: Augmented reality-navigated neuroendoscopy is accurate and feasible to use in clinical application. By integrating relevant planning information directly into the endoscope's field of view, safety and efficacy for intraventricular neuroendoscopic surgery may be improved.

Avoiding pullout complications in external ventricular drains: technical note.

This report describes a reliable and simple technique for securing external ventricular drains (EVDs) to the scalp and avoiding pullout complications. The operative technique consists of fixing the drain between 2 hydrocolloid dressings and securing it with staples. A 10-year retrospective analysis of EVD pullout complications was performed in a series of 435 consecutive patients who were treated at a single institution. The EVD pullout complication rate was 0.4%. No complications related to the fixation technique were found. The median operative time required to fix the drain was 60 seconds. The technique presented here is a simple and reliable procedure to fix the EVD to the scalp, preventing pullout complications and thus reducing the morbidity of EVD reimplantation.

Developing a new transparent sheath for endoscopic third ventriculostomy in treating hydrocephalus patients.

BACKGROUND: The sheath is a crucial piece of equipment during endoscopic third ventriculostomy (ETV). However, the normally used metal sheath can not provide clear images around the tube. OBJECTIVE: We developed a new transparent sheath (TS) in order to overcome the inherent disadvantages of the metal sheath (MS). MATERIAL AND METHODS: Between August 2010 and February 2013, a total of 120 hydrocephalus patients received ETV in our hospital. Patients were retrospectively divided into two groups, the transparent sheath group (TSG) and metal sheath group (MSG). The success rate of the first puncture, the operative time and the incidence of complications were used to compare the efficiency between transparent sheath and metal sheath. RESULTS: There were 32 patients in the TSG and 88 patients in the MSG. The success rate of the first puncture was 100% in the TSG and 87.5% in the MSG, respectively (p= 0.036). The operative time of the TSG was significant shorter than the MSG (p= 0.001). While the incidence of complications was similar between the two groups (p= 0.757). CONCLUSIONS: Compared with the tranditional metal sheath, the newly developed transparent sheath for ETV is more efficient and showed lower risk. This may be explained by the better surgical view of the whole puncture channel provide by the TS.

Smart stylet: the development and use of a bedside external ventricular drain image-guidance system.

BACKGROUND: Placement accuracy of ventriculostomy catheters is reported in a wide and variable range. Development of an efficient image-guidance system may improve physician performance and patient safety. OBJECTIVE: We evaluate the prototype of Smart Stylet, a new electromagnetic image-guidance system for use during bedside ventriculostomy. METHODS: Accuracy of the Smart Stylet system was assessed. System operators were evaluated for their ability to successfully target the ipsilateral frontal horn in a phantom model. RESULTS: Target registration error across 15 intracranial targets ranged from 1.3 to 4.6 mm (mean 3.1 mm). Using Smart Stylet guidance, a test operator successfully passed a ventriculostomy catheter to a shifted ipsilateral frontal horn 20/20 (100%) times from the frontal approach in a skull phantom. Without Smart Stylet guidance, the operator was successful 4/10 (40%) times from the right frontal approach and 6/10 (60%) times from the left frontal approach. In a separate experiment, resident operators were successful 2/4 (50%) times when targeting the shifted ipsilateral frontal horn with Smart Stylet guidance and 0/4 (0%) times without image guidance using a skull phantom. CONCLUSIONS: Smart Stylet may improve the ability to successfully target the ventricles during frontal ventriculostomy.

Hierarchical structure from motion optical flow algorithms to harvest three-dimensional features from two-dimensional neuro-endoscopic images.

Technical advances have led to an increase in the use of the endoscope in neurosurgery in recent years, particularly for intraventricular procedures and pituitary and anterior skull base surgery. Recently stereoscopic three-dimensional (3D) endoscopes have become available and may over time replace traditional two-dimensional (2D) imagery. An alternative strategy would be to use computer software algorithms to give monocular 2D endoscopes 3D capabilities. In this study our objective was to recover depth information from 2D endoscopic images using optical flow techniques. Digital images were recorded using a 2D endoscope and a hierarchical structure from motion algorithm was applied to the motion of the endoscope in order to calculate depth information for the generation of 3D anatomical structure. We demonstrate that 3D data can be recovered from 2D endoscopic images taken during endoventricular surgery where there is a mix of rapid camera motion and periods where the camera is nearly stationary. These algorithms may have the potential to give 3D visualization capabilities to 2D endoscopic hardware.

Application of indocyanine green (ICG) fluorescence for endoscopic biopsy of intraventricular tumors.

BACKGROUND: Many reports have already indicated the benefit of pathological diagnosis of intra- and periventricular tumors with neuroendoscopic biopsy. However, it is also well known that studies can be occasionally inconclusive because of the small and/or inadequate samples for identification of abnormal tissues. The application of indocyanine green (ICG) fluorescence for endoscopical tumor biopsy under the intraventricular surroundings is a new area not previously reported. We attempted visual differentiation of intraventricular lesions from the surrounding structure using ICG fluorescence and considered the most appropriate region for biopsy. METHODS: Three cases (13­14 year-old boys) with secondary hydrocephalus caused by intra- and periventricular tumors were operated for endoscopic transventricular biopsy combined with endoscopic third ventriculostomy. Final pathological diagnoses were suprasellar malignant lymphoma and germ cell tumors in two patients, both associated with intraventricular dissemination. Enhanced tumor visualization with 12.5 mg of ICG administration was obtained using the D-light P light equipment and ICG telescope 5.8 mm/19 cm. RESULTS: It was possible to identify the tumor mass margins themselves and detect the differences of intratumoral ICG accumulation. The areas of tumor dissemination were identifiable by neuroendoscopy but unable to be visualized by ICG fluorescence. CONCLUSIONS: We were able to obtain an ICG fluorescence imaging inside the cerebral ventricles by new D-light P system comprised of a camera head telescope. ICG fluorescence with neuroendoscopy can provide useful information for choosing the point of biopsy of intra- and periventricular tumors. However, we need to assess if the ICG accumulation site is the most appropriate for biopsy.

Transventricular fenestration of the lamina terminalis: the value of a flexible endoscope: technical note.

BACKGROUND: Recently, the authors demonstrated the technical feasibility of a transventricular translaminar terminalis ventriculostomy with a rigid endoscope. A major problem with this technique remains the contusion of the fornix at the foramen of Monro. Here, the authors evaluated alternative approaches and techniques, including the use of a flexible endoscope. MATERIAL AND METHODS: Feasibility of two approaches-anterior and posterior of the coronal suture-was evaluated on magnetic resonance images and in cadaveric brains. Two different trajectories were selected. Lamina terminalis (LT) fenestration was performed with a rigid and a flexible endoscope using two approaches in 10 fixed cadaver brains. RESULTS: Using the posterior approach 2 cm behind the coronal suture with the two endoscopes caused moderate to severe damage to foramen and fornix. Using the standard approach (Kocher point) with the flexible endoscope avoided damage of these structures. After completion of the anatomical investigation, the authors successfully performed a transventricular fenestration of the LT with the flexible endoscope in one clinical case. CONCLUSION: Rigid scopes provide brilliant optics and safe manipulation with the instruments. However, with the rigid scope, a transventricular opening of the LT is only possible with acceptance of structural damage to the foramen of Monro and the fornix. In contrast, opening of the LT via a transventricular route with preservation of the anatomical structures can be achieved with a flexible steerable endoscope even via a standard burr hole. Thus, if a standard third ventriculostomy is not feasible, endoscopic opening of the LT might represent an alternative, particularly with a flexible scope in experienced hands.

Cavitation-based third ventriculostomy using MRI-guided focused ultrasound.

OBJECT: Transcranial focused ultrasound is increasingly being investigated as a minimally invasive treatment for a range of intracranial pathologies. At higher peak rarefaction pressures than those used for thermal ablation, focused ultrasound can initiate inertial cavitation and create holes in the brain by fractionation of the tissue elements. The authors investigated the technical feasibility of using MRI-guided focused ultrasound to perform a third ventriculostomy as a possible noninvasive alternative to endoscopic third ventriculostomy for hydrocephalus. METHODS: A craniectomy was performed in male pigs weighing 13-19 kg to expose the supratentorial brain, leaving the dura mater intact. Seven pigs were treated through the craniectomy, while 2 pigs were treated through ex vivo human skulls placed in the beam path. Registration and targeting was done using T2-weighted MRI sequences. For transcranial treatments a CT scan was used to correct the beam from aberrations due to the skull and maintain a small, high-intensity focus. Sonications were performed at both 650 kHz and 230 kHz at a range of intensities, and the in situ pressures were estimated both from simulations and experimental data to establish a threshold for tissue fractionation in the brain. RESULTS: In craniectomized animals at 650 kHz, a peak pressure ≥ 22.7 MPa for 1 second was needed to reliably create a ventriculostomy. Transcranially at this frequency the ExAblate 4000 was unable to generate the required intensity to fractionate tissue, although cavitation was initiated. At 230 kHz, ventriculostomy was successful through the skull with a peak pressure of 8.8 MPa. CONCLUSIONS: This is the first study to suggest that it is possible to perform a completely noninvasive third ventriculostomy using ultrasound. This may pave the way for future studies and eventually provide an alternative means for the creation of CSF communications in the brain, including perforation of the septum pellucidum or intraventricular membranes.

Endoscopic treatment of in utero diagnosed multiloculated interhemispheric cyst in a newborn: case report.

Interhemispheric cysts, often associated with agenesis of corpus callosum, are rare lesions. The optimal treatment is still controversial. Placement of cystoperitoneal shunt and open microsurgery are traditional treatments. Neuroendoscopy in children is due to its minimal invasiveness a new emerging option. There have been a few published cases on neuroendoscopic treatment of interhemispheric cyst in children. The authors document the youngest reported child with multiloculated interhemispheric cyst that was treated with neuroendoscopy. The cyst was detected in a male fetus in 35th week of gestation and in utero magnetic resonance imaging was performed in 37th week of gestation. After delivery, progressive macrocrania with signs of raised intracranial pressure developed. Endoscopic cystoventriculocisternostomy was performed 28 days after the birth. There was a marked symptom relief. One month after the surgery, magnetic resonance showed shrinkage of the cyst and expansion of the brain parenchyma. After a 2-month follow up period, the child showed normal neurologic development and head circumference increased by only 0.5 cm. The created fenestrations enabled the brain to expand. Neuroendoscopic treatment,of interhemispheric cysts should be considered the operative technique of choice in newborns. Although the intracranial pressure and the size of the cyst have decreased, long-term follow up is necessary and future studies on more cases are needed.

The role of endoscopic third ventriculostomy in the treatment of hydrocephalus.

OBJECT: Hydrocephalus remains a major public health problem. Conventional treatment has relied on extracranial shunting of CSF to another systemic site, but this approach is associated with a high rate of complications. Endoscopic third ventriculostomy (ETV) is a novel treatment for select forms of hydrocephalus that can eliminate the need for implantation of a lifelong ventricular shunt system. However, the indications for ETV are contested and its long-term effectiveness is not well established. METHODS: The authors selected 100 consecutive patients who underwent ETV for hydrocephalus beginning in 1994. Patients were enrolled and treated at a single institution by a single surgeon. The primary outcome was success of ETV, with success defined as no need for subsequent surgery for hydrocephalus. RESULTS: Ninety-five patients satisfied the inclusion criteria. The mean follow-up period was 5.1 years (median 4.7 years) with follow-up data available for as long as 17 years. Patients commonly presented with headache (85%), ataxia (34%), emesis (29%), and changes in vision (27%). The success rate for ETV was 75%. Twenty-one patients (22%) in the series had malfunctioning shunts preoperatively and 13 (62%) were successfully treated with ETV. Preoperative inferior bowing of the third ventricle floor on MRI was significantly associated with ETV success (p < 0.05). CONCLUSIONS: Endoscopic third ventriculostomy is an effective and durable treatment for select patients with hydrocephalus. When successful, the procedure eliminates the lifelong complications associated with implanted ventricular shunts.

Evolving instrumentation for endoscopic tumour removal of CNS tumours.

BACKGROUND: Open surgical approaches to intraventricular tumours are complex and challenging. Neuro-endoscopy, however, has enabled us to biopsy and resect small intraventricular tumours with potentially reduced morbidity. Nevertheless, suitable methods/ instrumentation for resection have limited the use of the endoscope. The authors report the utilisation of endoscopic ultrasonic aspirator in the resection of an intraventricular tumour. This technique was compared to another case that utilised conventional endoscopic techniques for removal of an intraventricular tumour. METHODS: Using an endoscope, the third ventricle was entered and visualised, with the tumours clearly seen. Tumours were then either debulked via conventional or novel technique. RESULTS: Using the conventional technique, tumour was removed with rongeurs via the flexible scope. Irrigation was needed to improve vision due to bleeding. Postoperative magnetic resonance imaging (MRI) confirmed good excision. Histology was reported as anaplastic ependymoma World Health Organization (WHO) Grade III. Utilising the novel technique, the tumour was also debulked uneventfully. Histology confirmed Grade 1 glioneuronal tumour. Postoperative MRI revealed a small residuum. CONCLUSIONS: To date, endoscopic resection of tumours has been limited by suitable tools. The advent of an ultrasonic aspirator that can be used down an endoscope increases the possibilities for such resections. This is the first reported case of endoscopic resection of an intraventricular tumour using this technique.