Risk assessment methodology for trajectory planning in keyhole neurosurgery using genetic algorithms.

BACKGROUND: Preoperative assessment to find the safest trajectory in keyhole neurosurgery can reduce post operative complications. METHODS: We introduced a novel preoperative risk assessment semiautomated methodology based on the sum of N maximum risk values using a generic genetic algorithm for the safest trajectory search. RESULTS: A set of candidates trajectories were found for two surgical procedures. The trajectories search is done using a risk map considering the proximity of voxels within risk structures in multiple points and a genetic algorithm to avoid an exhaustive search. The trajectories were validated by a group of neurosurgeons. CONCLUSIONS: The trajectories obtained with the proposal method were shorter in 5% and have greater distance from the voxels within the blood vessels in 4.7%. The use of genetic algorithm (GA) speeds up the search for the safest trajectory, decreasing in 99.9% the time required for an exhaustive search.

Comparison of cerebrospinal fluid obtained by ventricular endoscopy and by lumbar puncture in patients with hydrocephalus secondary to neurocysticercosis.

BACKGROUND: Compare the differences between proteins, glucose, and morphological cellular counts from ventricular cerebrospinal fluid obtained by neuroendoscopy and lumbar puncture. METHODS: This was a retrospective, transversal study. From January 2003 until June 2006, 30 neuroendoscopies were performed on patients with hydrocephalus secondary to NCC. Samples of CSF were extracted by lumbar puncture and ventricular neuroendoscopy, and their levels of glucose, proteins, number of leukocytes, and morphological differences (PMN including eosinophiles, monocytes, and lymphocytes) were subsequently measured and studied. Traumatic CSF results were excluded. Twenty-five patients with histopathologic confirmation of the NCC diagnosis were analyzed. The average age of the patients was 42 years (SD, 19.8 years) and female-male ratio was 10:15. RESULTS: The differences in glucose values, between lumbar and ventricular CSF, were not statistically significant-lumbar, 45.28 mg/dL and ventricular, 53.92 mg/dL (P = .129). The differences in the protein values and leukocyte counts were statistically significant (P < .05) with the highest values found in lumbar CSF. The presence of monocytes was higher than that of PMNs in both fluids (P < .05). We did not find eosinophiles in any CSF. CONCLUSIONS: We did not find differences in the glucose values as described by previous studies, but our findings showed differences in the values of proteins, PMN leukocytes, and monocytes. The presence of more monocytes could be explained by their incremented activation by the parasite antigen and chronicity of the disease. Translational trials with uniform criteria are needed to determinate the immune process in the several presentations of the disease in humans.

Intraventricular and subarachnoid basal cisterns neurocysticercosis: a comparative study between traditional treatment versus neuroendoscopic surgery.

OBJECTIVE: The purpose of this study was to evaluate the efficacy of traditional treatment and minimal invasive flexible endoscopy surgery (MIFNES) in the treatment of intraventricular and subarachnoid basal cisterns neurocysticercosis (NCC). METHODS: This was an observational comparative study of two independent series with a total of 140 patients with extremely severe forms of NCC from two different institutions. All 83 patients submitted for traditional treatment series received albendazole, and some of them received additionally praziquantel. Each cycle of both regimens lasted 4 weeks. The majority of these patients had at least one ventriculoperitoneal (VP) shunt. The rest 57 patients were submitted to the MIFNES treatment. The follow-up period was at least 6 months. RESULTS: In all patients of both series cysticercal cysts disappeared, became calcified, or were removed. Symptoms of 136 patients improved. Four patients died. The average in the quality of life measured using the Karnofsky scale improved from a mean of 52.22 and 52.44 at the beginning to 85.48 and 90.37 at 6 months (p < 0.003), in the traditional treatment and MIFNES series, respectively. From traditional treatment, almost all patients remained with at least one VP shunt, and from the MIFNES series only 12 patients. CONCLUSIONS: The authors postulate that MIFNES is a good alternative for the management of intraventricular and subarachnoid basal cisterns NCC because it allows removal of most of the parasites, rapid recovery of the patients, and removal and placement of shunt under direct vision when necessary. Traditional treatment is a second option where the MIFNES procedure is not available.

The Role of Flexible Neuroendoscopy in Spinal Neurocysticercosis: Technical Note and Report of 3 Cases.

BACKGROUND: Neurocysticercosis, caused by the larval form of the tapeworm Taenia solium, is the most common parasitic disease affecting the human central nervous system. The incidence of spinal neurocysticercosis in endemic regions ranges from 0.25% to 5.85%. Surgery is preferred when medical treatment fails to achieve control of the symptoms or when multiple cysts are present. METHODS: We describe the use of spinal flexible endoscopy for patients with spinal neurocysticercosis who failed to achieve control with standard treatment. Three patients with limb weakness and pain underwent a midline interspinous approach at the L5-S1 level to access the lumbar cistern. The flexible endoscope was introduced, the subarachnoid space was inspected, and the cysticerci were extracted. In 1 patient with cervical subarachnoid blockage, a 3-cm suboccipital craniotomy and removal of the posterior arch of C1 were performed to place a subarachnoid-to-subarachnoid catheter going from the craniocervical junction to the thoracic region. RESULTS: Removal of the cysticerci was possible in all cases. No complications related to the surgery were observed. All patients received medical treatment for 2-3 months, and all symptoms were solved. CONCLUSIONS: Flexible spinal endoscopy is a feasible and valuable tool in patients with spinal neurocysticercosis that do not respond adequately to standard treatment. It helps restore cerebrospinal fluid dynamics and can be used to place shunt catheters under guided vision. Longer endoscopes are needed to explore the entire spinal subarachnoid space with a single approach, and more research in this area is needed.

Effect of rosuvastatin on amnesia and disorientation after traumatic brain injury (NCT003229758).

Amnesia is a common sequela following traumatic brain injury (TBI), for which there is no current treatment. Pleiotropic effects of statins have demonstrated faster recovery of spatial memory after TBI in animals. We conducted a double-blind randomized clinical trial add-on of patients with TBI (16-50 years of age), with Glasgow Coma Scale (GCS) scores of 9-13, and intracranial lesions as demonstrated by computed tomography (CT) scan. We excluded those patients with recent head injury or severe disability; administration of known drugs as modifiers of statin metabolism; multisystemic trauma; prior use of mannitol, barbiturate, corticosteroids, indomethacin or calcium antagonists; surgical or isolated lesion in brainstem; allergy to statins; previous hepatopathy or myopathy; previous management in another clinic; or pregnancy. Each patient received the same treatment and was randomly allocated to receive either rosuvastatin (RVS) or placebo over a period of 10 days. The primary outcome measures assessed were amnesia and disorientation times using Galveston Orientation Amnesia Test. Additionally, we evaluated plasma levels of interleukin (IL) 1beta, tumor necrosis factor (TNF) alpha, and IL-6, as well as disability at 3 months. We analyzed eight patients with RVS and 13 controls with similar basal characteristics. Using Cox regression analysis, administration of RVS showed a reduction of amnesia time with a hazard ratio of 53.76 (95% confidence interval [CI], 1.58-1824.64). This was adjusted for early intubation, basal leukocytes, basal Marshall and Fisher score, change of IL-1beta levels, and lesion side. IL-6 values at day 3 were increased in the RVS group (p = 0.04). No difference was detected in disability at 3 months. While statins may reduce amnesia time after TBI, possibly by immunomodulation, further trials are needed in order to confirm this positive association.

Flexible Neuroendoscopic Diagnosis and Management of Ventricular Tumors: A Retrospective Cohort Study.

BACKGROUND: Ventricular tumors (VTs) represent approximately 10% of intracranial lesions and are associated with hydrocephalus in 73.9%-100% of patients. We present our experience using flexible neuroendoscopy as a diagnostic and hydrocephalus-related treatment strategy for paraventricular and intraventricular tumors. METHODS: This retrospective cohort included 27 pediatric and 21 adult patients with paraventricular or intraventricular tumors treated with flexible neuroendoscopy. Terminally ill patients and patients with incomplete data were excluded. RESULTS: Male and female patients comprised 52% and 48% of the population, respectively. Mean patient age was 20.45 years (±18.65 SD). The most common tumor location was the thalamic and pineal region. Conclusive pathologic diagnosis was obtained in 40 patients (83.3%); the most common type of tumor was astrocytoma. Hydrocephalus was present in 38 (79.1%) patients, who were treated successfully with endoscopic procedures. There were no major complications. CONCLUSIONS: Flexible neuroendoscopy is a strategic tool for diagnosis of VTs, especially in patients with associated hydrocephalus and VTs unreachable by other means. Flexible neuroendoscopy has a high rate of definitive diagnosis with low associated complications. More studies evaluating the long-term efficacy of flexible neuroendoscopy for hydrocephalus associated with VTs are needed.

A Novel Approach of Navigation-Assisted Flexible Neuroendoscopy.

BACKGROUND AND IMPORTANCE: Neuronavigation-assisted endoscopy is commonly used for skull base and intraventricular surgery. Flexible neuroendoscopy offers certain advantages over rigid endoscopy; however, a major disadvantage of the flexible endoscope has been easy disorientation in the flexed position. Neuronavigation-assisted flexible neuroendoscopy was not available until now. This is the first report of the use of navigation-assisted flexible neuroendoscopy in a patient with hydrocephalus. CLINICAL PRESENTATION: A 10-mo-old girl presented with irritability and vomiting to the emergency department and was found to have severe hydrocephalus. The patient underwent successful endoscopic third ventriculostomy and exploration of the ventricles (lateral, third, cerebral aqueduct, fourth) and basal cisterns with the flexible neuroendoscopy assisted with electromagnetic neuronavigation. CONCLUSION: As demonstrated by this initial experience, neuronavigation-assisted flexible neuroendoscopy is a feasible and safe tool, endoscopic procedures with the flexible endoscope may be possible in a safer manner. We report the first use of neuronavigation-assisted flexible neuroendoscopy to perform an ETV and exploration of the entire ventricular system. Further evaluation will be necessary to define and expand its applications in neurosurgery.

Influence of the State of the Subarachnoid Space of the Cranial Base in Hydrocephalus Resolution after Endoscopy.

Objective To compare the resolution rate of hydrocephalus after endoscopy (predominantly endoscopic third ventriculostomy [ETV]) using flexible endoscopes during a 5-year period in patients with a permeable and a nonpermeable subarachnoid space (SAS). Material and Methods We conducted a retrospective cohort study of the videos and records of 150 hydrocephalic patients chosen randomly who underwent ETV (and other endoscopic procedures) with a flexible endoscope. The patients were classified into two groups based on the neuroendoscopic findings. The first group included patients with a permeable SAS, and the second group included patients with a nonpermeable SAS. A normal SAS or one with slight arachnoiditis was considered permeable. Adhesive arachnoiditis and immature or mechanically obliterated SASs were considered nonpermeable. Results We found a success rate of 70% in patients with a permeable SAS versus 33% in patients with a nonpermeable SAS. The baseline characteristics of both groups were homogeneous. We obtained a statistically significant difference (p < 0.0001) with hazard ratio (HR) 3.42 (95% confidence interval [CI], 1.88-6.22). Another important factor involved was age that showed a statistically significant difference (p < 0.0018) with HR 3.28 (95% CI, 1.55-6.93). Conclusion The permeability of the SAS is an important prognostic factor in the resolution rate of hydrocephalus after ETV (and other endoscopic procedures) using flexible neuroendoscopes. Therefore we recommend that the characteristics of the SAS be examined following every endoscopic procedure for hydrocephalus to identify patients at risk of recurrence.

Bruns syndrome caused by intraventricular neurocysticercosis treated using flexible endoscopy.

OBJECT: Neurocysticercosis is the most frequent cause of hydrocephalus in adults in regions where the disease is endemic, including Latin America. The prognosis for intraventricular neurocysticercosis is worse than that for the intraparenchymal form of the disease, making treatment especially important. Although active and viable intraventricular cysts produce no reaction in the host, they can cause noncommunicating hydrocephalus, whose onset is frequently abrupt. Sometimes the increasing intracranial pressure due to obstruction of the cerebral aqueduct (ball-valve mechanism) is intermittent, producing relapsing/remitting symptoms; this life-threatening phenomenon is called "Bruns syndrome." METHODS: Between 1996 and 2004, among a group of 285 patients with neurocysticercosis and Bruns syndrome caused by cysticercal cysts of the third ventricle was diagnosed in seven patients by using magnetic resonance imaging. An endoscopic procedure with a flexible cerebral endoscope was performed, intact parasitic cysts were removed, and a complete exploration was undertaken to look for more cysticercal cysts in the whole ventricular system and the subarachnoid basal cisterns. There were no deaths or complications. All seven patients were asymptomatic during a follow-up period ranging from 1 to 5 years. CONCLUSIONS: Flexible cerebral endoscopy allows one, in a minimally invasive manner, to approach the ventricular system and subarachnoid basal cisterns and to remove intraventricular neurocysticercal cysts. Flexible endoscopy is an alternative treatment for Bruns syndrome caused by neurocysticercosis of the third ventricle.

Endoscopic transventricular exploration with biopsy of the basal cisterns and the role of endoscopic third ventriculostomy in patients suffering with basal cistern meningitis and consecutive hydrocephalus.

OBJECTIVES: The purpose of this work is to elucidate the efficacy of endoscopic basal cisterns exploration, biopsy, and third ventriculostomy (ETV) in patients with basal cistern meningitis and arachnoiditis. MATERIALS AND METHODS: The cases and videos of all patients in whom flexible neuroendoscopy was performed during the period of January 2005-June 2012 at the University Hospital 'Dr. Ignacio Morones Prieto' in San Luis Potosí, México. A group of 47 patients with radiological diagnosis of basal meningitis, arachnoiditis, and negative cerebrospinal fluid analysis were included. RESULTS: From the 28 (60%) patients with histological diagnosis, 22 (47%) were made from biopsy from the arachnoid membranes of the basal cisterns only, 4 (9%) only from the cerebral cortex, and 2 (4%) from both sites. There were no complications related to the endoscopic procedure. In 23 patients from the 42 with hydrocephalus, ETV was successful. The grade of diagnostic accuracy of both biopsies in detect etiology was 68% (28 of 47 patients), the diagnostic accuracy of arachnoid biopsy was 60%, and diagnostic accuracy of convexity brain biopsy was 21% with 24 and 6 patients, respectively. DISCUSSION: Endoscopic transventricular biopsy of the basal cisterns seems to be a safe and a relatively accurate procedure. As longs as frozen subarachnoid space was not seen, the possibilities of performing ETV in hydrocephalus condition are elevated depending on the causal micro-organism.

[Observation of the ventricular system and subarachnoid space in the skull base by flexible neuroendoscopy: normal structures]. / Observación del sistema ventricular y espacio subaracnoideo de la base del cráneo por neuroendoscopia flexible: Estructuras normales.

Worldwide in the last two decades, in Latin America in the last decade, and Mexico in particular cerebral endoscopy as part of the minimally invasive neurological surgery, has constituted a significant advance for the treatment of neurological diseases such as congenital or acquired hydrocephalus, Chiari malformation, neurocysticercosis, stroke, ventricular and paraventricular tumors and cysts, arachnoidal cyst and hydrocephalus secondary to shunt malfunction. The lateral ventricles, the third ventricle, the cerebral aqueduct, the fourth ventricle, and the subarachnoid basal cisterns are among the most non-accessible regions of the central nervous system. Due to light-rand fiber optic-systems in combination with the experiences of nine consecutive year's and more than 600 endoscopies, most of them flexible neuroendoscopies, we present the neuroendoscopic approach with flexible cerebral endoscope to the anatomy and its normal variants of the whole ventricle system and the subarachnoid basal cisterns including the subarachnoid space of the cervical spine. We also describe their site related structures including veins, arteries, cranial nerves, pituitary gland, choroidal plexus and their normal anatomic variants.

Biopsy of Brainstem Gliomas Using Flexible Endoscopes.

OBJECTIVES: To describe our experience and the results obtained in performing transventricular brainstem biopsy with the use of flexible neuroendoscops. METHODS: We identified patients who underwent a neuroendoscopic procedure with brainstem lesion biopsy to obtain histopathologic diagnosis and to treat obstructive hydrocephalus. All patients had follow-up examinations at months 1, 3, 6, and 12 postsurgery and then annually. RESULTS: Seven patients had a transventricular biopsy of the brainstem performed. Of those, five were pediatric patients. The median age was 10 years (range: 3-26 years). Five of them were female and two male. Four patients presented with secondary obstructive hydrocephalus. The main clinical presentations were intracranial hypertension syndrome in four patients, motor neuron disease in four patients, two with decreased state of alertness, two with gait ataxia, and one with Parinaud syndrome. The types of tumors found in the histopathology and their location were one ventral (pons) and one aqueductal anaplastic astrocytoma, two ventral, one aqueductal, and one attached to the floor of the fourth ventricle pilocytic astrocytoma and one ventral low-grade astrocytoma. The route taken to approach the ventral tumors was made through premammillary fenestration. The tumors of the aqueduct and floor of the fourth ventricle were approached transaqueductally. CONCLUSION: The use of flexible endoscops for biopsy of ventral, dorsal (tectum lamina quadrigemina), and diffuse brainstem tumors is a useful, effective, and safe procedure that also allows to treat obstructive hydrocephalus secondary to the tumors.

Endoscopic transventricular transaqueductal Magendie and Luschka foraminoplasty for hydrocephalus.

BACKGROUND: Routinely, hydrocephalus related to fourth ventricular outlet obstruction (FVOO) has been managed with ventriculoperitoneal (VP) shunting or endoscopic third ventriculostomy (ETV). Few reports on Magendie foraminoplasty exist, and Luschka foraminoplasty has not been described. OBJECTIVE: To present an alternative technique in the management of FVOO via an endoscopic transventricular transaqueductal Magendie and Luschka foraminoplasty and to discuss the indications, technique, findings, and outcomes. METHODS: Between 1994 and 2011, all patients who underwent endoscopic Magendie and Luschka foraminoplasty were analyzed. RESULTS: A total of 33 Magendie (28) and/or Luschka (5) foraminoplasties were performed in 30 patients. Twenty-three were adult and 7 were pediatric patients. The etiology of the FVOO was divided into primary etiologies (congenital membrane in 5 and atresia in 2) and secondary causes (neurocysticercosis in 14 patients, bacterial meningitis in 9). Fifteen (50%) had previously failed procedures. Intraoperative findings that led to Magendie/Luschka foraminoplasty were ETV not feasible to perform, nonpatent basal subarachnoid space, or primary FVOO. Minor postoperative complications were seen in 3 patients. Only 26 patients had long-term follow-up; 17 (65.3%) of these had clinical improvement and did not require further procedures. Nine (34.7%) did not improve. Eight required another procedure (7 shunts, and 1 endoscopic procedure). One patient died. CONCLUSION: Flexible neuroendoscopic transventricular transforaminal Magendie and Luschka foraminoplasty is feasible and safe. These procedures may prove to be viable alternatives to standard ETV and VP shunt in appropriate patients. Adequate intraoperative assessment of ETV success is necessary to identify patients who will benefit.

Endoscopic scoring system for extraparenchymal neurocysticercosis.

OBJECTIVE: To propose a scoring system using endoscopy for assessment of the inflammatory alterations caused by neurocysticercosis (NCC) inside the ventricular cavities and the basal subarachnoid space. METHODS: Video recordings of the endoscopic procedures in patients with hydrocephalus secondary to NCC were assessed in a two-phase study. In the first phase (n = 10), the assigned score of each patient was correlated with the cerebrospinal fluid values obtained by lumbar and ventricular puncture. Reproducibility was determined using an intraclass correlation coefficient. In the second phase (n = 30), the prognostic value of the score was tested by comparing it with the patient's Karnofsky performance score (KPS) 3 months after endoscopy. RESULTS: The score included four main components: ependymal findings, number of involved sites, abnormalities in the subarachnoid space, and other alterations. These values were summed to produce a total score, which correlated strongly with both protein and cell counts from ventricular cerebrospinal fluid. The intraclass correlation coefficient of the global score was 0.85. In the second phase, the scores were divided into mild, moderate, and severe categories (6, 15, and 9 patients). The initial KPS was similar between the groups (P = 0.56); however, when measured 3 months later, there were significant differences (P = 0.02). The logistic regression analysis of patients with a score in the severe range (odds ratio = 0.09; 95% confidence interval, 0.06-0.64) showed a reduced chance for achieving a good outcome (KPS ≥90) after 3 months. CONCLUSIONS: Our scoring system enables endoscopic classification of the damage caused by NCC in the ventricular and basal subarachnoid space. The score has a biologic basis and a good internal reproducibility. The score seems to be useful for determining the short-term prognosis, and patients with high scores require additional therapeutic measures to improve their outcomes.

Effect of rosuvastatin on cytokines after traumatic head injury.

OBJECT: The favorable effect of statin treatment after traumatic brain injury (TBI) has been shown in animal studies and is probably true in humans as well. The objective of this study was to determine whether acute statin treatment following TBI could reduce inflammatory cytokines and improve functional outcomes in humans. METHODS: The authors performed a double-blind randomized clinical trial in patients with moderate to severe TBI. Exclusion criteria were as follows: prior severe disability; use of modifiers of statin metabolism; multisystem trauma; prior use of mannitol, barbiturates, corticosteroids, or calcium channel blockers; isolated brainstem lesions; allergy to statins; previous hepatopathy or myopathy; previous treatment at another clinic; and pregnancy. Patients were randomly selected to receive 20 mg of rosuvastatin or placebo for 10 days. The main goal was to determine the effect of rosuvastatin on plasma levels of tumor necrosis factor-α, interleukin (IL)-1ß, IL-6, and IL-10 after 72 hours of TBI. Amnesia, disorientation, and disability were assessed 3 and 6 months after TBI. RESULTS: Thirty-six patients were analyzed according to intention-to-treat analysis; 19 patients received rosuvastatin and 17 received placebo. The best-fit mixed model showed a significant effect of rosuvastatin on the reduction of tumor necrosis factor-α levels (p = 0.004). Rosuvastatin treatment did not appear to affect the levels of IL-1ß, IL-6, and IL-10. The treatment was associated with a reduction in disability scores (p = 0.03), indicating a favorable functional outcome. Life-threatening adverse effects were not observed. CONCLUSIONS: The authors' data suggest that statins may induce an antiinflammatory effect and may promote recovery after TBI. The role of statins in TBI therapy should be confirmed in larger clinical trials.

Efficacy and safety of endoscopic transventricular lamina terminalis fenestration for hydrocephalus.

BACKGROUND: Endoscopic third ventriculostomy (ETV) has become the procedure of choice in the treatment of obstructive hydrocephalus. In certain cases, standard ETV might not be technically possible or may engender significant risk. OBJECTIVE: To present an alternative through the lamina terminalis (LT) by a transventricular, transforaminal approach with flexible neuroendoscopy and to discuss the indications, technique, neuroendoscopic findings, and outcomes. METHODS: Between 1994 and 2010, all patients who underwent endoscopic LT fenestration as an alternative to ETV were analyzed and prospectively followed up. The decision to perform an LT fenestration was made intraoperatively. RESULTS: Twenty-five patients, ranging in age from 7 months to 76 years (mean, 28.1 years), underwent endoscopic LT fenestration. Patients had obstructive hydrocephalus secondary to neurocysticercosis (11 patients), neoplasms (6 patients), congenital aqueductal stenosis (3 patients), and other (5 patients). Thirteen patients (52%) had had at least 1 ventriculoperitoneal shunt that malfunctioned; 6 patients (24%) had undergone a previous endoscopic procedure. Intraoperative findings that led to an LT fenestration were the following: ETV not feasible to perform, basal subarachnoid space not sufficient, or adhesions in the third ventricle. No perioperative complications occurred. The mean follow-up period was 63.76 months. Overall, 19 patients (76%) had resolutions of symptoms, had no evidence of ventriculomegaly, and did not require another procedure. Six (24%) required a ventriculoperitoneal shunt. CONCLUSION: Endoscopic transventricular transforaminal LT fenestration with flexible neuroendoscopy is feasible with a low incidence of complications. It is a good alternative to standard ETV. Adequate intraoperative assessment of ETV success is necessary to identify patients who will benefit.

Transventricular neuroendoscopic exploration and biopsy of the basal cisterns in patients with Basal meningitis and hydrocephalus.

BACKGROUND: Management of communicating hydrocephalus associated with infectious meningitis and arachnoiditis of the basal cisterns can be challenging if no microorganism or pathological diagnosis is established. The purpose of our series is to elucidate the efficacy of endoscopic basal cistern exploration, biopsy, and endoscopic third ventriculostomy (ETV) in patients with basal cistern meningitis and hydrocephalus. METHODS: Between 2005 and 2010, all patients who underwent transventricular endoscopic exploration biopsy and biopsy of the basal cisterns were analyzed and prospectively followed up. Particular attention was given to neuroendoscopic findings, sensitivity of biopsy, and the role of ETV. RESULTS: Twenty-four patients, ranging in age from 2 to 63 years, underwent transventricular endoscopic biopsy and exploration of the basal cisterns. All patients had negative cerebrospinal fluid analysis obtained by lumbar puncture. Successful ETV, exploration, dissection, and biopsy of the basal cisterns were performed successfully in all patients with a flexible neuroendoscope. Neuroendoscopic findings included: unusually thick Liliequist membrane, moderate to severe adhesive arachnoiditis, inflammatory and cotton-like exudates, granulations, and narrow subarachnoid space. Definitive histopathological diagnosis from the basal cisterns specimen was obtained in 79% of patients. There were no complications related to the procedure. At 15 months of follow-up, 70% of the patients with hydrocephalus did not require a ventriculoperitoneal shunt. CONCLUSIONS: Endoscopic transventricular basal cisterns exploration is feasible with a flexible neuroendoscope. It is a viable alternative in the management of patients with basal cistern meningitis and arachnoiditis without histopathological diagnosis. It yields to an accurate diagnosis in 79% of the patients. ETV is a good alternative in the management of intracisternal extraventricular obstructive hydrocephalus.

[Evaluation of changes in the treatment of spontaneous intracerebral haemorrhage in a regional hospital in Mexico]. / Evaluacion de cambios en el tratamiento de la hemorragia intracerebral espontanea en un hospital regional mexicano.

INTRODUCTION: The spontaneous intracerebral hemorrhage (ICH) shows a high lethal rate. In 1999 appeared the first therapeutic guidelines, after that new therapies have been assessed without substantial success. AIM: To describe treatment changes for ICH in a regional Mexican hospital and to assess their impact on clinical evolution. PATIENTS AND METHODS: We accomplished a retrospective study of patients admitted between 2000 and 2006. We included those elder than 15 years with tomographyc diagnostic of ICH. Patients with head injury four weeks before or undetermined initial National Institute of Health Stroke Scale (NIHSS) were excluded. Epidemiological, clinical characteristics and kind of therapy were studied. RESULTS: We analyzed 175 patients with mean age of 62 years. Etiology and localization more frequently were arterial hypertension and lobar, respectively. More than 20% were intubated and approximately one half of these admitted in intensive care unit. Angiotensin converter enzyme inhibitors were the medicaments more usually used for controlling blood pressure. An initial NIHSS > 15 or Glasgow < 9 were associated to poor outcome. Additional administration of calcium antagonist, statins and surgical decompression was associated to a better outcome. CONCLUSIONS: Use of intensive care units is a measure highly suggested as standard for ICH-therapy. In our center it was not regularly accomplished because of infrastructural deficiencies. This problem could be generated in other Mexican hospitals; attention to that phenomenon is urgently required. Evaluation of new therapeutic strategies is required.

Endoscopic management of hydrocephalus due to neurocysticercosis.

OBJECTIVE: Hydrocephalus due to neurocysticercosis usually shows poor prognosis and shunt failure is a common complication. Neuroendoscopy has been suggested as treatment, but the indications remain unclear. METHODS: A cohort of patients with clinical/radiological diagnosis of hydrocephalus due to NCC, treated between January 2002 and September 2006, were the subjects of the study. We excluded patients with tumors or those in whom diagnosis was not confirmed (histology/positive ELISA in CSF). Neuroendoscopy was offered as the first line of treatment. Shunt failure rate and Karnofsky index at 12 months were assessed. RESULTS: Eighty-six patients (47 male) with a median age of 38 (9-79) were included in the study. Of them, 36.1% had a shunt before endoscopy and 97.7% had a Karnofsky index <80. We did not find the parasite in 18.6%, extraction was achieved in 79%, and in 87.2% an endoscopic third ventriculostomy (ETV) was performed. The median follow-up time was 43 months (1-72). Shunt failure was seen in 6.6% of patients with ETV in comparison to 27.2% in those without ETV. A hazard ratio of 0.22 (95% CI, 0.05-0.93) for shunt failure after ETV was calculated. At 12 months, 20.9% had a Karnofsky index <80. CONCLUSION: Early extraction of parasite plus ETV might allow improving outcome and reducing shunt failure. Limitation of inflammatory stimulation by parasite antigens and improvement of CSF dynamics could be an explanation for these findings.