Endoscopic third ventriculostomy in hydrocephalus secondary to vestibular schwannomas / Tercer ventriculostomía endoscópica en la hidrocefalia secundaria a schwanomas vestibulares

Introduction: Treatment options for hydrocephalus related to posterior fossa tumors have been extensively studied in the pediatric population, but the value of endoscopic third ventriculostomy in hydrocephalus secondary to vestibular schwannoma in adults, is controversial. A systematic search of the medical literature was carried out in Pubmed/Medline and SciElo for the identification and inclusion of articles, in addition to the preprint servers bioRxiv and medRxiv. The following descriptors were used: hydrocephalus and vestibular schwannomas or acoustic neuromas or acoustic neurinomas and endoscopic third ventriculostomy. The initial search found 195 articles. After selection, 5 articles were chosen for the study. Objective: To specify the role of the endoscopic third ventriculostomy in hydrocephalus secondary to vestibular schwannomas. Development: The articles included a total of 82 patients, in which an improvement of the symptoms was achieved in 86.6 percent of the cases. The decrease in ventricular diameter was reported in 82.9 percent of the cases and was only found explicit in 3 articles. Although the failure criteria used were varied, 2 of them predominated: the persistence of progressive symptomatic hydrocephalus and/or the need for shunt placement. Endoscopic third ventriculostomy failure only represented 14.6 percent. Conclusions: Third ventriculostomy is an acceptable technique with relative success for the treatment of symptomatic obstructive hydrocephalus secondary to vestibular schwannomas(AU)

Introducción: Las opciones de tratamiento para la hidrocefalia relacionada con tumores de fosa posterior han sido ampliamente estudiadas en la población pediátrica, pero es controvertido el valor de la tercer ventriculostomía endoscópica, en la hidrocefalia secundaria a schwanoma vestibular en adultos, previo a la resección del tumor. Se realizó una búsqueda sistemática de la literatura médica en Pubmed/Medline y SciElo para la identificación e inclusión de artículos, además de los servidores de preprint bioRxiv y medRxiv. Se utilizaron los siguientes descriptores: hydrocephalus y vestibular schwannomas o acoustic neuromas o acoustic neurinomas y endoscopic third ventriculostomy. La búsqueda inicial encontró 195 artículos. Después de la selección, se eligieron 5 artículos para el estudio. Objetivo: Especificar el papel de la tercer ventriculostomía endoscópica en la hidrocefalia secundaria a schwanomas vestibulares. Desarrollo: Los artículos incluyeron un total de 82 pacientes, en los que se logró una mejoría de los síntomas en el 86,6 por ciento de los casos. La disminución del diámetro ventricular se reportó en el 82,9 por ciento de los casos y solo se encontró explícita en 3 artículos. Aunque los criterios de fracaso utilizados fueron variados, predominaron dos de ellos: la persistencia de hidrocefalia sintomática progresiva o la necesidad de colocación de derivación. La falla de la tercer ventriculostomía endoscópica solo representó el 14,6 por ciento. Conclusiones: La tercera ventriculostomía endoscópica es una técnica aceptable y con relativo éxito para el tratamiento de la hidrocefalia obstructiva sintomática secundaria a schwanomas vestibulares(AU)

Factores de riesgo asociados a la persistencia de hidrocefalia posterior a la resección de tumores de fosa posterior / Risk factors associated with hydrocephalus persistence after posterior fossa tumors resection

Introducción. Las neoplasias de fosa posterior son los tumores de sistema nervioso central más frecuentes en la población pediátrica y una causa frecuente de hidrocefalia. El objetivo del presente trabajo es analizar los factores de riesgo asociados a hidrocefalia luego de las cirugías de resección de tumores de fosa posterior en una población pediátrica. Material y métodos. Se realizó un estudio observacional retrospectivo de pacientes pediátricos operados de tumores de fosa posterior en un único hospital. Se analizaron potenciales factores de riesgo pre y post quirúrgicos. Se consideró como variable respuesta la necesidad de derivación definitiva para tratar la hidrocefalia a los 6 meses de la resección tumoral. Resultados. En el análisis univariado se detectaron múltiples factores de riesgo significativos. Sin embargo, solamente 3 se mantuvieron en el modelo multivariado: grado de resección (Subtotal: OR 7.86; Parcial: OR 20.42), infección postoperatoria (OR 17.31) y ausencia de flujo de salida postoperatorio en IV ventrículo (OR 4.29). Éste modelo presentó una buena capacidad predictiva (AUC: 0.80, Sensibilidad 80.5%, Especificidad 76.3%). Conclusión. La realización de tercer ventriculostomía endoscópica preoperatoria no redujo la incidencia de hidrocefalia postoperatoria. El grado de resección tumoral, la presencia de infección postoperatoria y la obstrucción de salida del IV ventrículo fueron los factores de riesgo más importantes para el requerimiento de sistema derivativo definitivo luego de la resección de un tumor de fosa posterior. Ésto podría influir en la toma de decisiones respecto al tratamiento en este grupo de pacientes pediátricos

Background. Posterior fossa tumors are the most frequent central nervous system neoplasms in the pediatric population and a frequent cause of hydrocephalus. The objective of this study is to analyze the risk factors associated with hydrocephalus after posterior fossa tumors resection in a pediatric population. Methods. A retrospective observational study was conducted on pediatric patients who underwent posterior fossa tumor resection in a single hospital. Potential pre- and post-operative risk factors were analyzed. The need for definitive shunt placement to treat hydrocephalus at 6 months after tumor resection was considered as the outcome variable. Results. Univariate analysis identified multiple significant risk factors. However, only 3 factors remained in the multivariate model: extent of resection (subtotal: OR 7.86; partial: OR 20.42), postoperative infection (OR 17.31), and absence of postoperative outflow of the fourth ventricle (OR 4.29). This model showed good predictive capacity (AUC: 0.80, Sensitivity 80.5%, Specificity 76.3%). Conclusion. Preoperative endoscopic third ventriculostomy did not reduce the incidence of postoperative hydrocephalus. The extent of tumor resection, presence of postoperative infection, and obstruction of fourth ventricle outflow were the most important risk factors for the requirement of a definitive shunt system after posterior fossa tumor resection. This could influence treatment decisions in this group of pediatric patients

Factores de riesgo asociados a la persistencia de hidrocefalia posterior a la resección de tumores de fosa posterior / Risk factors associated with hydrocephalus persistence after posterior fossa tumors resection

Introducción: Las neoplasias de fosa posterior son los tumores de sistema nervioso central más frecuentes en la población pediátrica y una causa frecuente de hidrocefalia. Objetivo: Analizar los factores de riesgo asociados a hidrocefalia luego de las cirugías de resección de tumores de fosa posterior en una población pediátrica. Material y Métodos: Se realizó un estudio observacional retrospectivo de pacientes pediátricos operados de tumores de fosa posterior en un único hospital. Se analizaron potenciales factores de riesgo pre y post quirúrgicos. Se consideró como variable respuesta la necesidad de derivación definitiva para tratar la hidrocefalia a los 6 meses de la resección tumoral. Resultados: En el análisis univariado se detectaron múltiples factores de riesgo significativos. Sin embargo, solamente 3 se mantuvieron en el modelo multivariado: grado de resección (Subtotal: OR 7.86; Parcial: OR 20.42), infección postoperatoria (OR 17.31) y ausencia de flujo de salida postoperatorio en IV ventrículo (OR 4.29). Éste modelo presentó una buena capacidad predictiva (AUC: 0.80, Sensibilidad 80.5%, Especificidad 76.3%). Conclusión: La realización de tercer ventriculostomía endoscópica preoperatoria no redujo la incidencia de hidrocefalia postoperatoria. El grado de resección tumoral, la presencia de infección postoperatoria y la obstrucción de salida del IV ventrículo fueron los factores de riesgo más importantes para el requerimiento de sistema derivativo definitivo luego de la resección de un tumor de fosa posterior. Ésto podría influir en la toma de decisiones respecto al tratamiento en este grupo de pacientes pediátricos(AU)

Background: Posterior fossa tumors are the most frequent central nervous system neoplasms in the pediatric population and a frequent cause of hydrocephalus. Objective: Analyze the risk factors associated with hydrocephalus after posterior fossa tumors resection in a pediatric population. Methods: A retrospective observational study was conducted on pediatric patients who underwent posterior fossa tumor resection in a single hospital. Potential pre- and post-operative risk factors were analyzed. The need for definitive shunt placement to treat hydrocephalus at 6 months after tumor resection was considered as the outcome variable. Results: Univariate analysis identified multiple significant risk factors. However, only 3 factors remained in the multivariate model: extent of resection (subtotal: OR 7.86; partial: OR 20.42), postoperative infection (OR 17.31), and absence of postoperative outflow of the fourth ventricle (OR 4.29). This model showed good predictive capacity (AUC: 0.80, Sensitivity 80.5%, Specificity 76.3%). Conclusion: Preoperative endoscopic third ventriculostomy did not reduce the incidence of postoperative hydrocephalus. The extent of tumor resection, presence of postoperative infection, and obstruction of fourth ventricle outflow were the most important risk factors for the requirement of a definitive shunt system after posterior fossa tumor resection. This could influence treatment decisions in this group of pediatric patients

Configuración endoscópica del piso anterior del tercer ventrículo en relación al tiempo de hidrocefalia / Endoscopic Configuration Of The Anterior Floor Of The Third Ventricle In Relation To The Time Of Hydrocephalus

Introducción: Las variantes en la anatomía del piso del tercer ventrículo (PTV) son determinantes en las limitaciones y complicaciones de la tercerventriculostomía endoscópica (TVE). Objetivo: Describir variaciones anatómicas del PTV halladas en casos de hidrocefalia, evaluar incidencia, estratificarlas según tiempo de evolución y correlacionarlas con dificultad quirúrgica. Materiales y Métodos: Análisis retrospectivo de videos intraoperatorios de n=62 casos de hidrocefalia tratados durante el período 2015-2020 en nuestro centro. Incluyéndose n=51 casos donde el PTV se pudo evidenciar claramente en las imágenes. Resultados: Identificamos 10 variedades de PTV de las 14 descriptas en la bibliografía; piso opaco 54,9%, parcialmente borrado 29,4%, intervalo prepontino reducido 23,5%, piso estrecho 17,6%, piso herniado 17,65%. En la hidrocefalia aguda prevalecieron el piso opaco (71,8%) y el piso estrecho (25%). En la crónica predominó el piso delgado (31,5%), el cual se observó exclusivamente en esta categoría. En los pacientes en que se realizó una TVE (43 de 51), el grado de dificultad quirúrgica fue 15 veces mayor en los que presentaban un piso opaco (p 0,00041) y menor en los que presentaban un piso parcialmente borrado (OR de 0,0615; p 0,00092). Conclusión: Las variaciones anatómicas del tercer ventrículo son frecuentes en pacientes hidrocefálicos. Las relacionadas al grosor del piso pueden aumentar el riesgo operatorio. Esta característica no es visualizable en los estudios prequirúrgicos, pero es posible predecirlo conociendo el tiempo de clínica de hidrocefalia y observando la disposición de los cuerpos mamilares en la resonancia(AU)

Background: Variants in the anatomy of the floor of the third ventricle (PTV) are determining factors in the limitations and complications of endoscopic third ventriculostomy (EVT). Objective: Describe anatomical variations of the PTV found in cases of hydrocephalus, evaluate incidence, stratify them according to time of evolution and correlate them with surgical difficulty. Methods: Retrospective analysis of intraoperative videos of n=62 cases of hydrocephalus treated during the period 2015-2020 in our center. Including n=51 cases where the PTV could be clearly evidenced in the images. Results: We identified 10 PTV varieties out of the 14 described in the bibliography; opaque floor 54.9%, partially erased 29.4%, reduced prepontine interval 23.5%, narrow floor 17.6%, herniated floor 17.65%, thin floor 11.76%. In acute hydrocephalus, the opaque floor (71.8%) and the narrow floor (25%) prevailed. In the chronicle, the thin floor predominated (31.5%), which was demonstrated exclusively in this category. In the patients who underwent an EVT (43 of 51), the degree of surgical difficulty was 15 times greater in those who presented an opaque floor (p < 0.00041) and less in those who presented an opaque floor. partially erased (OR of 0.0615; p 0.00092). Conclusion: Anatomical variations of the third ventricle are frequent in hydrocephalic patients. Those related to the thickness of the floor can increase the surgical risk. This characteristic cannot be seen in pre-surgical studies, but it is possible to predict it knowing the time of the hydrocephalus clinic and observing the disposition of the mammillary bodies in the cranial resonance(AU)

Punción ventricular transorbitaria: Revisión de la técnica y reporte de un caso / Transorbital Ventricular Puncture: Review of the technique and report of a case

La punción ventricular transorbitaria (PTO) es una técnica rápida y sencilla aunque poco utilizada en la actualidad. Como puede realizarse en la cama del paciente, resulta ideal en aquellos con hidrocefalia aguda rápidamente evolutiva o con enclavamiento transtentorial inminente o reciente, en quienes el acceso expeditivo a las cavidades ventriculares puede salvarles la vida. Revisamos aquí el desarrollo histórico de la técnica desde su descripción original en 1933. Por último, presentamos el caso de una paciente con hidrocefalia aguda secundaria a edema cerebeloso, en quien el empleo de la PTO dio tiempo para implementar el tratamiento definitivo. La técnica utilizada por nosotros consistió en un ingreso transpalpebral, por detrás del reborde orbitario superior y a nivel mediopupilar, con una trayectoria dirigida hacia la sutura sagital, dos a tres traveses de dedo por detrás de la sutura coronal(AU)

Transorbital ventricular puncture (TOP) is a fast and simple but poorly understood technique. As it can be performed at the patient's bedside, it is ideal in patients with rapidly evolving acute hydrocephalus or with imminent or recent transtentorial herniation, in whom expeditious access to the ventricular cavities can be life-saving. We review the historical development of the technique since its original description in 1933. Finally we present the case of a patient with acute hydrocephalus secondary to cerebellar edema, in whom the use of TOP allowed time to implement definitive treatments. The technique used by us consisted of an entry point through the upper eyelid, behind the superior orbital rim, and at the midpupillary line, with a trajectory aimed towards the sagittal suture two to three finger widths behind the coronal suture(AU)

Diagnosis and treatment of negative pressure hydrocephalus: analysis of 5 cases and literature review / 中国综合临床

Objective:To investigate the clinical manifestations, pathogenesis,diagnosis and treatment of negative pressure hydrocephalus (NPH).Methods:A retrospective analysis was performed on the 5 patients with NPH admitted to the Department of Neurosurgery, Tianjin Huanhu Hospital from January 2019 to December 2021. All of the patients underwent lumbar puncture and ventricular puncture to test the pressure. Three patients underwent endoscopic third ventriculostomy (ETV), the outcome of the patients was observed.Results:The pressure of subarachnoid was not equal to intraventricular, and the pressure of intraventricular was negative. Cisternography showed cerebrospinal fluid circulation obstruction in all 5 cases. The symptoms of 1 patient were improved after external negative pressure drainage, 3 patients were improved after further ETV and 1 patient had pulmonary infection without further surgical treatment.Conclusion:With the obstruction of cerebrospinal fluid circulation, the pressure of lateral ventricle and subarachnoid is different, when the pressure of brain or subarachnoid drop, the ventricular expansion under the effect of pressure gradient, intraventricular pressure drop even for the negative pressure. CT cisternography provides strong evidence for the diagnosis of this disease. External ventricular drainage with negative pressure and ETV are effective treatment methods.

Right Ventriculostomy for Resection of Cardiac Metastasis from Cervical Cancer / 日本心臓血管外科学会雑誌

Cardiac metastasis from cervical cancer is rare. We herein present a case involving a 54-year-old woman with cervical cancer who was undergoing radiotherapy for left supraclavicular lymph node metastasis. The patient was admitted to the hospital because of shortness of breath. Transthoracic echocardiography showed a large mass in the right ventricle. To rescue the patient from circulatory collapse, we surgically resected the intracardiac mass via a right ventricular incision parallel to the posterior descending artery and left anterior descending artery. This approach prevented right ventricular outflow tract obstruction and perioperative pulmonary embolization, which could have led to death. The intracardiac mass was diagnosed as squamous cell carcinoma. After hospital discharge, the patient underwent chemotherapy. An echocardiography performed 3 months postoperatively showed recurrence of the cardiac metastasis, and the patient died 5 months later. Cardiac metastasis in the right ventricle can present as pulmonary embolization. Although rare, most cases of metastasis from cervical carcinoma to the heart have an extremely poor prognosis.

Risk Factors for Malfunction of Ventriculoperitoneal Shunts Performed by Medical Residents in Children: An Exploratory Study / Fatores de risco para disfunção de derivações ventrículo-peritoneais realizadas por médicos residentes em crianças: Estudo exploratório

Introduction Ventriculoperitoneal shunts (VPSs) are common neurosurgical procedures, and in educational centers, they are often performed by residents. However, shunts have high rates of malfunction due to obstruction and infection, especially in pediatric patients. Monitoring the outcomes of shunts performed by trainee neurosurgeons is important to incorporate optimal practices and avoid complications. Methods In the present study, we analyzed the malfunction rates of VPSs performed in children by residents as well as the risk factors for shunt malfunction. Results The study included 37 patients aged between 0 and 1.93 years old at the time of surgery. Congenital hydrocephalus was observed in 70.3% of the patients, while 29.7% showed acquired hydrocephalus. The malfunction rate was 54.1%, and the median time to dysfunction was 28 days. Infections occurred in 16.2% of the cases. Cerebrospinal fluid leukocyte number and glucose content sampled at the time of shunt insertion were significantly different between the groups (p » 0.013 and p » 0.007, respectively), but did not have a predictive value for shunt malfunction. In a multivariate analysis, the etiology of hydrocephalus (acquired) and the academic semester (1st) in which the surgery was performed were independently associated with lower shunt survival (p » 0.009 and p » 0.026, respectively). Conclusion Ventriculoperitoneal shunts performed in children by medical residents were at a higher risk of malfunction depending on the etiology of hydrocephalus and the academic semester in which the surgery was performed.

Introdução As derivações ventrículo-peritoneais (DVPs) são procedimentos neurocirúrgicos comuns e, em centros educacionais, muitas vezes são realizados por residentes. No entanto, os shunts apresentam altas taxas de mau funcionamento devido a obstrução e infecção, especialmente em pacientes pediátricos. O monitoramento dos resultados das válvulas realizadas por neurocirurgiões em treinamento é importante para incorporar as práticas ideais e evitar complicações. Métodos No presente estudo, analisamos as taxas de mau funcionamento de DVPs realizados em crianças por residentes, assim como os fatores de risco para mau funcionamento da válvula. Resultados O estudo incluiu 37 pacientes com idades entre 0 e 1,93 anos na época da cirurgia. Hidrocefalia congênita foi observada em 70,3% dos pacientes, enquanto 29,7% apresentaram hidrocefalia adquirida. A taxa de disfunção foi de 54,1% e o tempo médio para disfunção foi de 28 dias. Infecções ocorreram em 16,2% dos casos. O número de leucócitos do líquido cefalorraquidiano e o conteúdo de glicose coletados no momento da inserção da válvula foram significativamente diferentes entre os grupos (p » 0,013 e p » 0,007, respectivamente), mas não tiveram um valor preditivo para o mau funcionamento da válvula. Em uma análise multivariada, a etiologia da hidrocefalia (adquirida) e o semestre letivo (1°) em que a cirurgia foi realizada foram independentemente associados a menor sobrevida do shunt (p » 0,009 e p » 0,026, respectivamente). Conclusão: Derivações ventrículo-peritoneais realizadas em crianças por médicos residentes apresentaram maior risco de mau funcionamento dependendo da etiologia da hidrocefalia e do semestre letivo no qual a cirurgia foi realizada.

Endoscopic Third Ventriculostomy in the Pediatric Population: Case Series Report / Terceiro ventriculostomia endoscópica na população pediátrica: Relato de série de casos

Objective Hydrocephalus is characterized by multi- or uniloculated ventricular dilatation, and there are differences between the etiology and therapeutic response of each type. Endoscopic third ventriculostomy (ETV) is indicated for the treatment of obstructive hydrocephalus, with a reported efficacy between 50% and 76%. Reduced efficacy of the procedure has been demonstrated in communicating hydrocephalus due to multifactorial pathogenesis, and, in patients with myelomeningocele, its efficacy ranges from 15% to 20% at birth. The present study aims to compare the efficacy of ETV in the treatment of congenital obstructive hydrocephalus (COH) and acquired obstructive hydrocephalus (AOH) in the pediatric population. Methods A retrospective study of 169 endoscopic surgeries performed by the senior author in two institutions, one public (Hospital João XXIII, Belo Horizonte, Minas Gerais) and another private (Hospital Felício Rocho, Belo Horizonte, Minas Gerais), in the period from 2003 a 2020. From the selection of 169 patients, only 77 cases fit the age profile12 years of the present study. Of these, 46 were male, and the age range ranged from 10 days to 12 years. The study included multiple etiologies, which were divided into 2 groups, 34 related to COH, and 43 to AOH. Results Regarding the cases of COH, 22 were submitted to ETV as the main treatment, with 14 (63.63%) effective and 8 (36.36%) ineffective procedures. As for the cases of AOH, 13 patients underwent ETV, and 8 (61.53%) procedures were effective, and 5 (38.46%), ineffective. Conclusions Through the calculation of the p-value of 0.49, we concluded that it cannot stated that the efficacy of ETV is greater in COH than in AOH.

Objetivo A hidrocefalia é caracterizada por dilatação ventricular multi ou uniloculada, e há diferenças entre a etiologia e a resposta terapêutica de cada tipo. A terceiro ventriculostomia endoscópica (TVE) está indicada no tratamento da hidrocefalia obstrutiva, com uma eficácia relatada entre 50% e 76%. O procedimento demonstrou eficácia reduzida em hidrocefalia comunicante devido à patogênese multifatorial, sendo que, em pacientes com mielomeningocele, sua eficácia é de 15% a 20% no nascimento. Este estudo visa comparar a eficácia da TVE no tratamento da hidrocefalia obstrutiva congênita (HOC) e hidrocefalia obstrutiva adquirida (HOA) na população pediátrica. Métodos Realizou-se um estudo retrospectivo de 169 cirurgias endoscópicas realizadas pelo autor sênior em duas instituições, uma pública (Hospital João XXIII, Belo Horizonte, Minas Gerais) e outra privada (Hospital Felício Rocho, Belo Horizonte, Minas Gerais), no período de 2003 a 2020. Da seleção de 169 pacientes, apenas 77 casos se enquadraram no perfil de idade 12 anos do presente estudo. Destes, 46 eram do sexo masculino, e a faixa etária variou de 10 dias a 12 anos. O estudo contemplou múltiplas etiologias, que foram divididas em 2 grupos, sendo 34 relacionadas à HOC, e 43, à HOA. Resultados Entre os casos de HOC, 22 foram submetidos a TVE como tratamento principal, sendo que 14 (63,63%) procedimentos foram eficazes, e 8 (36,36%), ineficazes. Já entre os casos de HOA,13 pacientes foram submetidos a TVE, sendo 8 (61,53%) procedimentos eficazes, e 5 (38,46%), ineficazes. Conclusões Por meio do cálculo do valor de p de 0,49, concluiu-se que não se pode afirmar que a eficácia da TVE é maior nas HOCs do que nas HOAs.

Weaning rápido vs. weaning gradual de ventriculostomía externa en hidrocefalia secundaria a hemorragia subaracnoidea: Revisión sistemática de la literatura y metaanálisis / Weaning fast vs. Gradual Weaning of External Ventriculostomy in Hydrocephalus Secondary to Subarachnoid Hemorrhage: A Systematic Review of the Literature and Meta-analysis

Objetivo: Realizar una revisión sistemática comparando dos estrategias de weaning de Derivación Ventricular externa (DVE) en pacientes con hidrocefalia aguda y su asociación con la proporción de derivación definitiva, infección del sistema nervioso central y duración de la estancia hospitalaria en cada una de las estrategias. Diseño: Revisión sistemática de la literatura. Fuentes de datos: Se realizaron búsquedas en PubMed, Embase, Lilacs. Se incluyò literatura gris, realizando búsquedas en Google académico, Dialnet, Open gray, Teseo y Worldcat hasta el 10 de septiembre de 2019. Métodos: Se realizó una búsqueda exhaustiva de estudios de los últimos 20 años en inglés, español y portugués, que compararan dos estrategias de weaning de DVE: rápida (WR) vs gradual (WG) en pacientes con hidrocefalia aguda. El resultado primario para esta Revisión Sistemática fue la proporción de derivación definitiva en cada uno de los regímenes. Se evaluó además, la proporción de infección del sistema nervioso central y la duración de la estancia hospitalaria. Dos investigadores extrajeron de forma independiente la información de los estudios y los resultados en concordancia con la Guía PRISMA. Resultados: La revisión arrojó en total 3 artículos que cumplían con los criterios de inclusión y que se consideraron de calidad metodológica aceptable, con un número de 1198 participantes no superpuestos, 569 que fueron sometidos a weaning rápido (WR), 629 en el grupo de weaning gradual (WG). No se encontró asociación estadisticamente significativa entre las estrategias de weaning y DVP OR 0.78 (Intervalo de confianza del 95% 0.3 a 2.06; P= 0.001; I2=85%), ni para infección del sistema nervioso central OR 0.54 (IC 95% 0,07 a 4.24); P= 0,05; I2= 74%) pero si se encontró diferencia estadísticamente significativa en la duración de la estancia hospitalaria a favor de la estrategia de weaning ràpido, OR -4.34 (IC 95% -5.92 a -2.75, P= <0,00001; I2= 57%). Conclusión: Con la evidencia disponible actualmente no es posible concluir cuál es la mejor estrategia de weaning para DVE con respecto a la proporción de derivación definitiva o infecciones del sistema nervioso central; sin embargo, si se observa una tendencia clara frente a la duración de la estancia hospitalaria en la estrategia de WR. Se requiere establecer criterios claros en cuanto a la definición de WR o WG y a crear estándares en cuanto los tiempos y la definiciòn precisa de falla terapeutica respecto a estas pruebas, para posteriormente integrar y probar estos métodos en estudios idealmente prospectivos y aleatorizados.

Objective: To conduct a systematic review by comparing two strategies of external ventricular drain (EVD) in patients with acute hydrocephalus and its association with the proportion of definite drain, infection of the central nervous system, and duration of hospital stay in each strategy. Design: Systematic review of literature.Data sources: PubMed, Embase, Lilacs. Grey literature was included by conducting searches through Scholar Google, Dialnet, Open Gray, Teseo and Worldcat until the 10th September, 2019. Methods: An exhaustive search of studies was done of the last 20 years in English, Spanish and Portuguese, which compares two strategies of external ventricular drain weaning (EVD): Rapid (WR) Vs Gradual (WG)in patients with acute hydrocephalus. The primary result for this systematic review was the proportion of Ventriculoperitoneal (VP) shunt placement in each of the regimes. Besides, the proportion of the infection of the central nervous system and the duration of the hospital stay was evaluated. Two researchers extracted in an independent way the information of the studies and results according to the guide PRISMA. Results: The review produced 3 articles in total which followed with the criteria of inclusion and which were considered of acceptable methodological quality, with 1198 non-superimposed participants, 569 who were subjected to rapid weaning (RW), 629 in the group of Gradual Weaning (GW). There were no significant differences between the 2 weaning ́s groups and DVP OR 0.78 (IC 95% 0.3 a 2.06; P= 0.001; I2=85%), for the infection of the Central Nervous System (CNS) OR 0.54 (IC 95% 0,07 a 4.24); P= 0,05; I2= 74%) but a significant differences was found in the duration of the hospital stay in favour of the strategy of RW, OR -4.34 (IC 95% -5.92 a -2.75, P= <0,00001; I2= 57%). Conclusion: With the current available evidence is not possible to conclude which is the best strategy of weaning for EVD regarding to the proportion of definite shunt or infections of the CNS; but if there is a clear trend regarding the length of hospital stay in the WR strategy. It is necessary to establish clear criteria as to the definition of WR or WG and to create standards as to the times and the precise definition of therapeutic failure with respect to these tests, to later integrate and test these methods in ideally prospective and randomized studies.

renaje ventricular al exterior de tunelización larga: un método costo-efectivo para reducir las complicaciones / Long Tunnel Outward Ventricular Drainage: A Cost-Effective Method to Reduce Complications

Introducción: La colocación de drenajes ventriculares al exterior (DVE) es uno de los procedimientos más frecuentes de la neurocirugía, tanto en pediatría como en adultos, sin embargo, no se encuentra exento de complicaciones. La tasa de infección asociada al drenaje puede serdel 25%. En nuestro Hospital encontramos una incidencia del 22% anual. Al ser sistemas que no cuentan con una regulación de la salida del líquido, el paciente debe permanecer en decúbito dorsal estricto todo el tratamiento.Nuestro objetivo es diseñar un nuevo sistema de drenaje ventricular al exterior de tunelización larga (DVET) que lidie con estos problemas al mismo tiempo que reduzca los costos hospitalarios. Material y métodos: Se realizó un ensayo clínico prospectivo en el que se colocaron 25 DVETL entre el 1/9/2018 al 1/5/2019 que se compararon con el sistema tradicional de DVE. Resultados: La presencia de fístula se asoció más frecuentemente a los DVE en comparación con los DVETL, esta diferencia fue estadísticamente significativa (30% vs 8% p=0,029). La presencia de infección asociada al drenaje fue significativamente mayor en los DVE en comparación con los DVETL, esta diferencia fue estadísticamente significativa (22% vs 0% p=0,009). Los pacientes con DVE tradicional utilizaron el doble de recursos y generaron el doble de costos que los pacientes con DVETL. Conclusión: Se realizó una presentación detallada del nuevo sistema de DVETL que presenta una disminución en la incidencia de fístula de LCR e infección asociada al drenaje. A su vez aparenta ser costo-efectiva en comparación con el sistema tradicional de DVE.

Introduction: External ventricular drain (EVD) placement is one of the most frequent procedures in neurosurgery, both in pediatrics and in adults. The global rate of ventriculostomy-associated infections could rich 25%. In our Hospital, we found an annual incidence of 22%.In addition, since it does not have a regulation of cerebral spinal fluid (CSF) flow, the patient must remain in strict dorsal decubitus throughout the entire treatment.Our goal is to design a new long-tunneled external ventricular drain (LTEVD) that deals with these problems while reducing hospital costs. Material and method: A prospective clinical trial was conducted in which 25 LTEVD were placed between 1/9/2018 and 1/5/2019 that were compared with the traditional EVD system. Results: The presence of CSF fistula was associated more frequently with EVD compared to LTEVD; this difference was statistically significant (30% vs. 8% p = 0.029). The presence of associated infection was significantly higher in EVD compared to LTEVD, and this difference was statistically significant (22% vs. 0% p = 0.009). Patients with traditional EVD used twice as many resources and generated twice the cost as patients with DVETL. Conclusion: A detailed presentation was made of the new LTEVD system that presents a decrease in the incidence of CSF fistula and associated infection. At the same time, it appears to be cost-effective in comparison with the traditional DVE system

Repercussão de intervenção educativa no conhecimento da equipe de enfermagem sobre os cuidados no uso da derivação ventricular externa em pediatria / Repercussion of an educational intervention on the knowledge of the nursing team regarding the use of external ventricular drains in pediatrics / Repercusión de la intervención educativa en el conocimiento del personal de enfermería sobre cuidados en el manejo del drenaje ventricular externo en pediatría

Objetivo: este estudo objetivou analisar a repercussão de intervenção educativa no conhecimento teórico da equipe de Enfermagem sobre os cuidados no uso da derivação ventricular externa em Pediatria. Trata-se de estudo de intervenção não controlado, com delineamento do tipo antes e depois. Método: procedeu-se à aplicação de pré e pós-teste para a coleta de informações sobre os conhecimentos dos profissionais sobre os cuidados aos pacientes pediátricos com derivação ventricular externa. Entre o pré e o pós-teste realizou-se intervenção educativa usando-se a simulação clínica como estratégia de ensino. Participaram do estudo 41 profissionais de Enfermagem. Constatou-se mais assertividade após a intervenção educativa, principalmente na questão que versa sobre o uso da técnica asséptica para esvaziamento da bolsa coletora (p=0,021). As análises de correlação no préteste revelaram que o maior número de erros não esteve correlacionado a qualquer das variáveis sociodemográficas. Contudo, no pós-teste, identificou-se correlação significativa entre o número de erros com a idade dos profissionais (rho=0,340; p=0,015); tempo de formação dos profissionais (rho= 0,414; p=0,004); e tempo de atuação na unidade (rho=0,428; p=0,004). O resultado sinaliza, portanto, que profissionais com idades mais elevadas, mais tempo de profissão e de atuação na unidade tiveram menos aproveitamento da intervenção educativa, apresentando maior número de erros. A intervenção educativa usando a estratégia da simulação clínica possibilitou incremento no conhecimento dos participantes, podendo ser utilizado para a educação permanente, melhorando a qualidade da assistência.(AU)

Objective: This study aimed to analyze the repercussion of an educational intervention on the theoretical knowledge of the Nursing team regarding the use of external ventricular drains in Pediatrics. This is an uncontrolled intervention study, with a before and after study design. Method: A pre- and post-test was applied to collect information on the nurses' knowledge regarding the care of pediatric patients with external ventricular drains. Between the pre- and post-test, an educational intervention was performed using clinical simulation as a teaching strategy. 41 nursing professionals participated in the study. The professionals were more assertive after the educational intervention, especially regarding the use of an aseptic technique for emptying the collection bag (p=0.021). Correlation analyses in the pre-test revealed that the greatest number of errors was not correlated to any of the socio-demographic variables. However, in the post-test, a significant correlation was identified between the number of errors and the participants' age (rho=0.340; p=0.015); years since graduation (rho=0.414; p=0.004); and years of professional experience in the unit (rho=0.428; p=0.004). Therefore, the result shows that older professionals, with more...(AU)

Objetivo: analizar la repercusión de la intervención educativa en el conocimiento teórico del personal de enfermería sobre cuidados en el manejo del drenaje ventricular externo en pediatría. Estudio de intervención no controlado, con diseño antes ­ después. Método: se aplicó la prueba antes y después para la recogida de datos sobre el conocimiento de los profesionales acerca de los cuidados de pacientes pediátricos con drenaje ventricular externo. Entre las pruebas antes y después se realizó la intervención educativa con simulación clínica como estratégia de enseñanza. En el estudio participaron 41 profesionales de enfermería. Se constató más asertividad después de la intervención educativa, principalmente en lo referente al uso de la técnica aséptica para realizar el vaciado de la bolsa recolectora (p=0,021). Los análisis de correlación de la prueba anterior revelaron no haber ninguna correlación entre la cantidad de errores y alguna de las variables sociodemográficas. Sin embargo, en la prueba posterior se identificó la correlación significativa entre la cantidad de errores y la edad de los profesionales (rho=0,340; p=0,015); el tiempo de graduación (rho= 0,414; p=0,004); y el tiempo de trabajo en la unidad (rho=0,428; p=0,004). El resultado indica que los profesionales con más edad, más tiempo de profesión y de trabajo en la unidad aprovecharon menos la intervención educativa y que cometieron más errores. La intervención educativa usando la estrategia de la simulación clínica ha permitido aumentar el conocimiento de los participantes y podría adoptarse en la educación permanente con miras a mejorar la calidad asistencial.(AU)

Effect of third ventriculostomy under neuroendoscopy on neurological function in children with obstructive hydrocephalus / 中华实用儿科临床杂志

Objective To explore the effect of third ventriculostomy under neuroendoscopy in the treatment of children with obstructive hydrocephalus.Methods Thirty-eight cases of obstructive hydrocephalus treated at Zhumadian Central Hospital from January 2015 to December 2017 were selected,and among them there were 20 males and 18 females,aged ＜ 12 months in 4 cases,1-3 years in 17 cases and 3-6 years in 17 cases.The children were treated by third ventriculostomy under neuroendoscopy,the therapeutic effect was observed,and the brain cognitive function was evaluated by Gesell child intelligence development diagnostic scale.Results After treatment,81.58％ (31/38 cases) of children were improved,the conditions of 10.53％ (4/38 cases) of patients did not change,and 7.89％ (3/38 cases) of patients got aggravated.The development quotient(DQ) scores of 1 month,3 months and 6 months after operation were (57.20 ± 5.81) scores,(75.12 ± 6.02) scores and (80.43 ± 7.00) scores,respectively,which were significantly higher than those of the preoperative scores [(50.12 ± 6.11) scores] (t =6.933,8.192,10.033,all P ＜0.05),and the DQ scores at 6 months after operation were (80.43 ± 7.00),which were significantly higher than those of 1 month and 3 months after operation (t =5.192,7.022,all P ＜0.05).The width of ventricle frontal horn at 1,3 and 6 months after operation was (37.82 ± 6.01) mm,(38.00 ± 5.89) mm and (37.03 ± 5.25) mm,respectively,which was significantly lower than that of preoperative width [(44.01 ± 5.61) mm] (F =24.292,P ＜ 0.05).The width of third ventricle at 1,3 and 6 months after operation was (16.89 ± 3.82) mm,(16.72 ± 4.10) mm and (16.11 ± 4.11) mm,respectively,which was significantly lower than that of preoperative width [(21.02 ± 4.37)mm] (F =19.143,P ＜ 0.05).The levels of adrenomedullin and neuron specific enolase decreased significantly at 1 month,3 months and 6 months after operation (F =45.281,11.022,all P ＜ 0.05).No serious complications occurred.Conclusions Third ventriculostomy under neuroendoscopy is effective in treating obstructive hydrocephalus in children and may improve the cognitive function in children.

Observation of cerebrospinal fluid circulation of fistula after ETV in obstructive hydrocephalus by PC-cine MRI / 实用放射学杂志

Objective To observe the feasibility of PC-cine MRI for estimating the cerebrospinal fluid circulation of fistula after endoscopic third ventriculostomy (ETV)in obstructive hydrocephalus.Methods 25 cases with obstructive hydrocephalus were scanned with routine MR protocol and PC-cine sequence before and after ETV.Qualitative and quantitative evaluation of the cerebro-spinal fluid flow through the fistula were performed and the results were compared with 25 cases of healthy volunteers.Results One week after operation,the cerebrospinal fluid flow through the fistula showed obviously positive in 23 patients,while negative in the other 2 patients,and the waveform was similar to that in the normal midbrain aqueduct.The outflow and inflow peak velocity of the cerebrospinal fluid through the fistula were lower than that in normal midbrain aqueduct(P<0.05),while the quantity of outflow,inflow and netflow were much higher(P<0.05).6 patients showed ventricular narrowing one week after operation and 17 cases maintained the same finding.During follow-up of half year,the ventricular size still showed no obvious narrowing in 14 patients.Ventricular expanding was observed in 2 post-operative patients.Conclusion PC-cine MRI can provide intuitive and reliable evidences in evaluation of ETV for obstructive hydrocephalus.

O papel da membrana de Liliequist na terceiro ventriculostomia endoscópica / The role of the Liliequist membrane in endoscopic third ventriculostomy

A Terceiro Ventriculostomia Endoscópica (TVE) é operação intracerebral que trata a hidrocefalia. Para sua realização é necessário conhecimento da anatomia cirúrgica da membrana aracnoidea de Liliequist, que deve ser aberta durante o procedimento. Porém, a anatomia do ponto de vista neuroendoscópico é pouco conhecida, já que os ângulos de abordagem são diferentes da anatomia descritiva clássica e mesmo da anatomia cirúrgica microscópica. Há discrepância na literatura quanto a eficácia da TVE, sobretudo em crianças, em que pode ocorrer a não abertura completa da membrana de Liliequist (ML). Para compreensão do comportamento da ML, a sua associação com o Tuber Cinereo (TC) e o assoalho do III Ventrículo (IIIVT) e outras peculiaridades, foi realizada, prospectivamente, a observação sistemática destas características durante 57 operações. Os dados foram registrados após o procedimento e posteriormente estudados. Os objetivos eram sistematizar as características anatômicas destas estruturas do ponto de vista neuroendoscópico, avaliar se as alterações seguiam algum padrão e se interferiam no procedimento técnico, correlacionando com a evolução. Pela análise dos dados percebeu-se que as características da ML são variáveis e dificultam, em uma percentagem considerável de vezes, a sua interpretação e seu manejo pelo neurocirurgião. Também, que o TC alterado e separado da ML são fatores associados à maior dificuldade de realização da TVE. Que as TVE realizadas nas hidrocefalias por malformações congênitas, processos inflamatórios e pós sangramento (prevalentes na infância) estão associadas a maior dificuldade de manejar a ML e podem explicar o índice de insucesso maior observado na literatura em crianças abaixo de 2 anos.

Endoscopic Third Endoscopic (ETV) is a neurosurgical procedure to treat hydrocephalus. To be fully performed it is necessary opening an arachnoid structure, the Liliequist Membrane (LM). However the LM surgical anatomy from the neuroendoscopic point of view is not yet completely studied, since approach angles are different from classics descriptive and microsurgical anatomies. There is a literature discrepancy regarding the ETV efficacy, especially in children over 2 years old, which may be due to LM incomplete opening. In order to understand the LM anatomical behavior, the relationship with tuber cinereo (TC), the floor of the III Ventricle and other peculiarities, a systematic prospective observation of these characteristics was performed during the 57 surgeries. Data were recorded after the procedure and studied. Objectives were to systematize LM anatomical characteristics from neuroendoscopic perspective, understand if anatomical changes follows a pattern interfering on the procedure, and if there is correlation with patients evolution. The data analysis shows that LM characteristics are variable, making difficult the neurosurgeon management. Whenever TC anatomy modifies, or when TC and ML are separated, difficulty to perform ETV increases. When hydrocephalies are due to congenital malformations, inflammatory processes and post bleeding (prevalent in childhood), LM management is much harder, witch may explain the higher failure rate in children under 2 years of age observed in literature.

Sonda uretral flexível como método alternativo para aferição invasiva da pressão intracraniana em trauma cranioencefálico induzido em coelhos / Flexible urethral catheter as alternative method to invasive measurement of intracranial pressure in induced head trauma in rabbits

O objetivo deste estudo foi utilizar a sonda uretral flexível como método alternativo para aferição da pressão intracraniana em coelhos com trauma cranioencefálico induzido pelo cateter de Fogarty 4 Fr (balão epidural) e comparar os dados obtidos com o método convencional de cateter de ventriculostomia. Foram utilizados 12 coelhos, machos, adultos, distribuídos aleatoriamente em dois grupos, denominados de G1: mensuração da PIC com cateter de ventriculostomia (n=6) e G2: mensuração com sonda uretral (n=6). Foram realizadas duas craniotomias na região parietal direita e esquerda para a implantação do cateter de ventriculostomia ou sonda uretral flexível e o balão epidural, respectivamente. A PAM, a PPC, a FC, a FR e a TR foram mensurados antes e após a craniotomia. A PIC foi avaliada após a craniotomia e a cada 10 minutos depois do preenchimento do balonete com 0,3mL de NaCl 0,9%, durante 40 minutos, e com 0,6mL, pelo mesmo período de tempo, totalizando 80 minutos. A PIC aumentou em ambos os grupos, sendo menores os valores registrados com a sonda uretral flexível. Foi possível reproduzir o aumento da PIC com o modelo experimental de TCE utilizando o cateter de Fogarty 4 Fr na região epidural e, embora haja a necessidade de outros estudos, a sonda uretral flexível demonstra ser um método alternativo de mensuração da PIC em coelhos com trauma cranioencefálico.(AU)

The aim of this study was to evaluate the use of flexible urethral catheter as an alternative method for measuring intracranial pressure in rabbits with head trauma induced by 4 F Fogarty catheter (epidural balloon) and compare the data obtained with the conventional method of ventriculostomy catheter. In this study, New Zealand rabbits were randomly distributed into two groups, G1: measuring the ICP with ventriculostomy catheter (n=6) and G2: measuring the ICP with urethral catheter (n=6). Two craniotomies were performed in the right and left parietal region for the implantation of a ventriculostomy catheter and/or flexible urethral catheter and epidural 4 Fr Fogarty arterial embolectomy catheter, respectively. MAP, CPP, HR, RF and RT values were measured before and after of the craniotomy. The ICP value was measured after craniotomy, every five minutes during 40 minutes after the balloon was inflated with 0.3 ml with NaCl and further 40 minutes after the balloon was inflated with 0.6 ml. The ICP value increased in both groups; however, the ICP values were lower in the flexible urethral catheter. The flexible urethral catheter can be used as an alternative method to measure ICP values in rabbits with head injury.(AU)

Ventriculitis asociada a drenaje ventricular externo

RESUMEN Introducción: el drenaje ventricular externo es una herramienta útil en el manejo de muchos pacientes neurocríticos. Sin embargo este dispositivo no está exento de complicaciones. La ventriculitis es la más importante complicación infecciosa asociada. Objetivos: determinar la prevalencia de ventriculitis en pacientes adultos con drenaje ventricular externo del Hospital Nacional, describir los factores de riesgo asociados e identificar gérmenes más frecuentemente aislados. Resultados: se incluyeron 92 pacientes con drenaje ventricular externo de los cuales el 20% desarrolló ventriculitis. La totalidad de los pacientes con ventriculitis presentaron síntomas de infección luego de 7 días de instalación del drenaje, además la mitad de los mismos requirieron recambio del catéter lo cual constituyó factor de riesgo. Los gérmenes aislados más frecuentes fueron Staphylococcus epidermidis y Acinetobacter baumanii. Conclusiones: la ventriculitis asociada a catéter de drenaje ventricular externo fue 20%. El factor de riesgo estadísticamente asociado fue el recambio del catéter. Los gérmenes aislados más frecuentes fueron Staphylococcus epidermidis y Acinetobacter baumanii.

ABSTRACT Introduction: External ventricular drainage is a useful tool in the handling of neurocritical patients. However, this device is not free from complications. Ventriculitis is the most important related complication. Objectives: To determine the prevalence of ventriculitis in adult patients with external ventricular drainage of the National Hospital, to describe the associated risk factors and to identify the most frequently isolated microorganisms. Results: Ninety two patients with external ventricular drainage were included and 20% developed ventriculitis. All patients with ventriculitis presented symptoms of infection seven days after drainage installation and half of them required a change of the catheter which was a risk factor. The most frequent isolated microorganisms were Staphylococcus epidermidis and Acinetobacter baumanii. Conclusions: The prevalence of ventriculitis related to the external ventricular drainage catheter was 20%. The statistically associated risk factor was the change of catheter. The most frequent isolated microorganisms were Staphylococcus epidermidis and Acinetobacter baumanii.

Neuroendoscopy: Current and Future Perspectives

Neuroendoscopic surgery is performed because it causes minimal damage to normal structures, carries a lower rate of complications, and achieves excellent outcomes. Surgeons using an endoscope and related instruments can perform complex operations through very small incisions, which is especially useful for minimally invasive procedures for the brain and spine. Neuroendoscopic surgery is now performed in cases of obstructive hydrocephalus, various intraventricular lesions, hypothalamic hamartomas, craniosynostosis, skull base tumors, and spinal lesions. This review discusses the brief history of neuroendoscopy and the current state and future perspectives of endoscopic surgery.

"Somewhere up there": A case of pineal gland tumor in a 20-year-old male

BACKGROUND: Pineal region tumor is a rare and reportable case. Incidence rate adults is 0.025 in 10,000 hence there is no established guidelines among adults  for diagnosis and management of this case.CASE: A case of a 20-year-old male with a two-month history of  intermittent  headache,  occipital  area  with  VAS  5/10,increasing in severity. Until two days prior to admission with severe headache VAS 9-10/10, occipital, and nonradiating.Patient  noted  episodes  of  projectile  vomiting  hence,admitted. Patient presented with non-lateralizing symptoms but  noted  papilledema  and  parinaud  syndrome.Cranial  MRI with contrast revealed a 2.5cm pineal gland tumor with obstructive  hydrocephalus.  Serum  AFP  (alpha-fetoprotein  )  and  beta-HCG  (beta subunit of human chorionic gonadotropin) were requested and revealed elevated levels.The patient underwent endoscopic third ventriculostomy but no biopsy was done due to high risk of bleeding. Patient underwent series of radiotherapy and was advised to undergo chemotherapy but patient refused. Patient had improved upward gaze but with residuals, no recurrence of headache or vomiting, had normalization of the serum tumor markers but noted increase in size of the tumor despite radiotherapy.CONCLUSION: Case  reports  of  pineal  region  tumors  will  help doctors  in  the  primary  hospitals  diagnose  such  cases  and differentiate it from benign causes of headache. This will aid in early referral to specialists and early intervention.

"Somewhere up there": A case of pineal gland tumor in a 20-year-old male

BACKGROUND: Pineal region tumor is a rare and reportable case. Incidence rate adults is 0.025 in 10,000 hence there is no established guidelines among adults  for diagnosis and management of this case.CASE: A case of a 20-year-old male with a two-month history of  intermittent  headache,  occipital  area  with  VAS  5/10,increasing in severity. Until two days prior to admission with severe headache VAS 9-10/10, occipital, and nonradiating.Patient  noted  episodes  of  projectile  vomiting  hence,admitted. Patient presented with non-lateralizing symptoms but  noted  papilledema  and  parinaud  syndrome.Cranial  MRI with contrast revealed a 2.5cm pineal gland tumor with obstructive  hydrocephalus.  Serum  AFP  (alpha-fetoprotein  )  and  beta-HCG  (beta subunit of human chorionic gonadotropin) were requested and revealed elevated levels.The patient underwent endoscopic third ventriculostomy but no biopsy was done due to high risk of bleeding. Patient underwent series of radiotherapy and was advised to undergo chemotherapy but patient refused. Patient had improved upward gaze but with residuals, no recurrence of headache or vomiting, had normalization of the serum tumor markers but noted increase in size of the tumor despite radiotherapy.CONCLUSION: Case  reports  of  pineal  region  tumors  will  help doctors  in  the  primary  hospitals  diagnose  such  cases  and differentiate it from benign causes of headache. This will aid in early referral to specialists and early intervention.