Neuronavigated endoscopic aqueductoplasty with panventricular stent plus septostomy for isolated fourth ventricle in complex hydrocephalus and syringomyelia associated with myelomeningocele: how I do it.

BACKGROUND: Isolated fourth ventricle (IFV) is a challenging entity to manage. In recent years, endoscopic treatment for aqueductoplasty has been on the rise. However, in patients with complex hydrocephalus and distorted ventricular system, its implementation can be complex. METHODS: We present a 3-year-old patient with myelomeningocele and postnatal hydrocephalus treated by ventriculoperitoneal shunt. In follow-up, a progressive IFV and isolated lateral ventricle with symptoms of the posterior fossa developed. An endoscopic aqueductoplasty (EA) with panventricular stent plus septostomy guided with neuronavigation was decided due to the complexity of the ventricular system. CONCLUSION: In IFV associated with complex hydrocephalus with distortion of the ventricular system, navigation can be of great help for planning and as a guide for performing EA.

MRI diagnosis of spontaneous intraventricular tension-pneumocephalus in a 10-month-old male Saarloos Wolfdog.

A 10-month-old male Saarloos Wolfdog was presented with a history of multiple neurologic deficits that had acutely progressed. Neurologic examination findings localized signs to the cerebrum and brainstem. Magnetic resonance imaging revealed markedly enlarged and gas-filled lateral ventricles with a mass effect leading to cerebellar herniation. A right-sided defect of the cribriform plate with a dysplastic ethmoturbinate was identified as the inlet of air and origin of the intraventricular tension pneumocephalus. Surgical findings were consistent with a ruptured, congenital, nasal meningocele.

Dynamic Workflow Proposal for Continuous Frameless Electromagnetic Neuronavigation in Rigid Neuroendoscopy.

BACKGROUND: Ventriculoscopic neuronavigation has been described in several articles. However, there are different ventriculoscopes and navigation systems. Due to these different combinations, it is difficult to find detailed neuronavigation protocols. We describe, step-by-step, a simple method to navigate both the trajectory until reaching the ventricular system, as well as the intraventricular work. METHODS: We use a rigid ventriculoscope (LOTTA, KarlStorz) with an electromagnetic stylet (S8-StealthSystem, Medtronic). The protocol is based on a modified or 3-dimensionally printed trocar for navigating the extraventricular step and on a modified pediatric nasogastric tube for the intraventricular navigation. RESULTS: This protocol can be set up in less than 10 minutes. The extraventricular part is navigated by introducing the electromagnetic stylet inside the modified or 3-dimensionally printed trocar. Intraventricular navigation is done by combining a modified pediatric nasogastric tube with the electromagnetic stylet inside the endoscope's working channel. The most critical point is to obtain a blunt-bloodless ventriculostomy while achieving perfect alignment of all targeted structures via pure straight trajectories. CONCLUSIONS: This protocol is easy-to-set-up, avoids head rigid-fixation and bulky optical-based attachments to the ventriculoscope, and allows continuous navigation of both parts of the surgery. Since we have implemented this protocol, we have noticed a significant enhancement in both simple and complex ventriculoscopic procedures because the surgery is dramatically simplified.

Triangular fossa of the third cerebral ventricle - an original 3D model and morphometric study.

Introduction: The triangular recess (TR), also called triangular fossa or vulva cerebri, represents the anterior extension of the diencephalic ventricle, located between the anterior columns of the fornix and the anterior white commissure. Over time, this structure of the third cerebral ventricle generated many disputes. While some anatomists support its presence, others have opposite opinions, considering that it only becomes visible under certain conditions. The aim of the study is to demonstrate the tangible structure of the triangular recess. Secondly, the quantitative analysis allowed us to establish an anatomical morphometric standard, as well as the deviations from the standard. Materials and methods: Our study is both a quantitative and a qualitative evaluation of the triangular fossa. We dissected 100 non-neurological adult brains, which were fixed in 10% formaldehyde solution for 10 weeks. The samples are part of the collection of the Institute of Anatomy, "Grigore T. Popa" University of Medicine and Pharmacy, Iasi. We highlighted the triangular fossa by performing dissections in two stages at the level of the roof of the III ventricle. Results: The qualitative analysis is a re-evaluation of the classical data concerning the anatomy of the fossa triangularis. We proposed an original 3D model of the triangular recess in which we described a superficial part called vestibule and a deep part called pars profunda. We measured the sides of the communication between the two proposed segments, as well as the communication with the III ventricle. By applying the Heron's formula, we calculated the area of the two communications. Statistical evaluations have shown that these communications are higher than they are wide. In addition, there is a statistical difference between the surfaces of the two communications: 34.07 mm2 ± 7.01 vs. 271.43 mm2 ± 46.36 (p = 0.001). Conclusion: The outcome of our study is both qualitative and quantitative. Firstly, we demonstrated the existence of the triangular fossa and we conceived a spatial division of this structure. Secondly, the measurements carried out establish an anatomo-morphometric norm of the triangular recess, which is useful in assessing the degree of hydrocephalus during the third endoscopic ventriculoscopy.

The Future of Neuroendoscopy: Looking Ahead Through a Lens.

Neuroendoscopy has progressed remarkably in the past few decades. Ventriculoscopy, skull base endoscopy, and spinal endoscopy are now part of routine practice in the neurosurgical treatment of numerous pathologies. Like other developing fields, however, it faces numerous challenges and obstacles that must be overcome for the field to continue to evolve and expand. This brief review of new and exciting developments in neuroendoscopy describes some of the most interesting directions the field is starting to steer towards.

Non-communicating hydrocephalus from pork tapeworm obstructing the foramina of Monro and its endoscopic management; a case report from Europe.

Introduction: Taenia solium is the main causative agent of neurocysticercosis. The tapeworm can manifest inside the ventricles, usually in the form of intracranial hypertension. We present a case of hydrocephalus as a result of a neurocysticercosis lesion obstructing both foramina of Monro. Research question: A comprehensive review of the management is provided, as well as video footage (an invaluable resource to compare, critique and learn with other institutions). Material and methods: A 23-year-old female from Honduras presented with a 7-day complaint of headache. On exam, she was hyperreflexic, but otherwise normal. Magnetic resonance imaging (MRI) revealed a non-specific lesion at the level of the foramina of Monro, with associated hydrocephalus. Additional testing was normal. Results: The patient underwent an endoscopic ventriculoscopy with partial excision of the lesion and subsequent implantation of a ventriculoperitoneal shunt. On postoperative MRI, hydrocephalus resolved and pathological analysis identified the parasite as Taenia solium. Albendazole was administered for 14 days. Discussion and conclusion: Neurocysticercosis should be considered in patients presenting with hydrocephalus, especially those from endemic areas. The long-term prognosis of ventricular neurocysticercosis might be favourable, provided that adequate care is given timely. Endoscopic surgery seems to be effective for the removal of parasitic lesions. However, studies comparing open versus endoscopic surgery are lacking. The majority of cases in the literature correspond to America and Asia. This case shows that neurocysticercosis is also present in Europe, and that a high index of suspicion is necessary.

Pre-Clinical Development of Robot-Assisted Ventriculoscopy for 3D Image Reconstruction and Guidance of Deep Brain Neurosurgery.

Conventional neuro-navigation can be challenged in targeting deep brain structures via transventricular neuroendoscopy due to unresolved geometric error following soft-tissue deformation. Current robot-assisted endoscopy techniques are fairly limited, primarily serving to planned trajectories and provide a stable scope holder. We report the implementation of a robot-assisted ventriculoscopy (RAV) system for 3D reconstruction, registration, and augmentation of the neuroendoscopic scene with intraoperative imaging, enabling guidance even in the presence of tissue deformation and providing visualization of structures beyond the endoscopic field-of-view. Phantom studies were performed to quantitatively evaluate image sampling requirements, registration accuracy, and computational runtime for two reconstruction methods and a variety of clinically relevant ventriculoscope trajectories. A median target registration error of 1.2 mm was achieved with an update rate of 2.34 frames per second, validating the RAV concept and motivating translation to future clinical studies.

Cluster management in secondary hydrocephalus / 中华神经医学杂志

Objective:To explore the clinical value of cluster management in secondary hydrocephalus.Methods:Seventy-seven patients with secondary hydrocephalus admitted to Department of Neurosurgery, Shenzhen Second People's Hospital from January 2016 to June 2021 were chosen; they were divided into traditional management group ( n=30) and cluster management group ( n=47) according to different management methods. Patients in traditional management group accepted craniocerebral CT and 3 consecutive times of cerebrospinal fluid tests, and normal results were achieved and then ventriculoperitoneal shunt (VPS) was performed. In patients from the cluster management group, on the basis of management treatment, cranial plain and enhanced MRI and DNA metagenomic next generation sequencing of cerebrospinal fluid were performed before surgery, and rapid test of cerebrospinal fluid and ventriculoscope observation were performed during surgery; after exclusion of intracranial infection, VPS was performed. The differences of shunt failure rate were compared between the two groups and the positive rates of intracranial infection detected by above 4 methods were compared in the cluster management group. Results:There was significant difference in shunt failure rate between the cluster management group and traditional management group (2.1% vs. 20.0%, P<0.05). The positive rates of intracranial infection by DNA metagenomics (61.7%) and ventriculoscopy (68.1%) were significantly higher than those by preoperative cranial plain and enhanced MRI (14.9%) and rapid test of cerebrospinal fluid (6.4%, P<0.05). Conclusion:Cluster management can effectively decrease the VPS failure rate in secondary hydrocephalus; DNA metagenomics and ventriculoscopy have high efficiency in detecting intracranial infection.

Ventriculoscopic Approach for Intraventricular Neurocysticercosis: A Single Neurosurgical Center's Experience.

OBJECTIVE: To retrospectively analyze patients with intraventricular neurocysticercosis (NCC) who underwent a ventriculoscopic approach at a single neurosurgical center and assess the efficacy of this treatment in patients with intraventricular NCC. METHODS: Patients with intraventricular NCC patients who underwent surgery via a ventriculoscopic approach between January 2008 and March 2014 at Beijing Tiantan Hospital were analyzed. RESULTS: A total of 21 patients with intraventricular NCC (15 men and 6 women; mean age, 38.0 ± 16.8 years; range, 9-65 years) were enrolled in the study. Ten of the patients underwent complete resection. The median progression-free survival (PFS) was 53.7 months (95% confidence interval, 31.7-75.6 months). On univariate analysis, PFS was better in the patients who underwent total NCC resection compared with those who underwent nontotal resection (P < 0.05). CONCLUSIONS: The ventriculoscopic approach to NCC resection is an effective technique with unique advantages for intraventricular NCC. Radical resection is necessary for intraventricular NCC. Combined application of rigid and flexible endoscopes can improve the total removal rate of intraventricular NCC.

Intraoperative Hemorrhage in Ventriculoscopic Surgery: Experience of a Single Chinese Neurosurgery Center.

BACKGROUND: The ventriculoscopic approach has been considered to be more safe and effective in the treatment of hydrocephalus, arachnoid cysts and intraventricular lesions in neurosurgery. We found that intraoperative bleeding-related complications have the greatest impact on ventriculoscopic surgery. Until now, few studies fully discussed this complication. METHODS: Patients who underwent ventriculoscopic surgery between May 2011 and December 2012 at Beijing Tiantan Hospital were analyzed. RESULTS: A total of 126 patients were enrolled in the study. Intraoperative hemorrhage was observed in 75 cases (59.5%). Intraoperative hemorrhage classification of patients was as follows: stage I (n = 62); stage II (n = 11); stage III (n = 2). We found that there was no significant difference in complication rate and rate of symptom improvement between the patients who had hemorrhage and the patients who did not (P < 0.05). CONCLUSIONS: Intraoperative hemorrhage in ventriculoscopic surgery should be paid more attention. Generally, a skilled neurosurgeon can address hemorrhage with a low complication rate. Consequently, the ventriculoscopic approach is safe and effective in the treatment of specified brain ventricular disease.

The effect of ventriculoscopy combined with laparoscopy in ventriculoperironeal shunt on the treatment effect, inflammatory factors and immune function in patients with hydrocephalus / 中国医师进修杂志

Objective:To investigate the therapeutic effect of ventriculoscopy combined with laparoscopy in ventriculoperironeal shunt (VPS) on the treatment effect, inflammatory factors and immune function in patients with hydrocephalus.Methods:A retrospective study was conducted on 76 patients with hydrocephalus in Traditional Chinese Medicine Hospital of Jining from March 2017 to September 2019, and they were divided into observation group (39 cases) and control group (37 cases) according to different treatment procedures. The control group performed traditional VPS, and the observation group performed ventricoscopy combined with laparoscopy in VPS. The incidence of postoperative complications and the treatment effect at 6 months after the operation, serum inflammatory factors tumor necrosis factor-α (TNF-α), interleukin (IL)-10, IL-6, immune function indexes CD 3+, CD 4+, CD 4+/CD 8+before and 1 d and 3 d after the operation, Glasgow Outcome Scale (GOS) and Modified Rankin Scale (MRS), National Institutes of Health Stroke Scale (NIHSS), Barthel Index (BI) and Generic Quality of Life Inventory 74 (GQOL-74) before operation, 3 and 6 months after operation were compared between the two groups. Results:The total effective rate in the observation group at 6 months after operation was higher than that in the control group: 94.9% (37/39) vs. 73.0% (27/37), and the difference was statistically significant ( χ2 = 0.848, P<0.05). The GOS scores in the observation group were higher than those in the control group at 3 months and 6 months after surgery: (3.68 ± 0.49) scores vs. (3.02 ± 0.51) scores, (4.17 ± 0.24) scores vs. (3.59 ± 0.43) scores; and the MRS and NIHSS scores were lower than those in the control group: (2.05 ± 0.15) scores vs. (2.84 ± 0.17) scores and (1.62 ± 0.11) scores vs. (2.17 ± 0.14) scores, (12.97 ± 3.82) scores vs. (16.05 ± 4.61) scores and (10.90 ± 2.75) scores vs. (13.84 ± 3.29) scores; and the differences were statistically significant ( P<0.05). The serum levels of TNF-α and IL-6 in the observation group were lower than those in the control group at 1 and 3 d after surgery, and IL-10 level was higher than that in the control group, and the differences were statistically significant ( P<0.05). The CD 3+, CD 4+, and CD 4+/CD 8+ levels in the observation group were higher than those in the control group at 1 and 3 d after operation, and the differences were statistically significant ( P<0.05). The postoperative complications in the observation group was lower than that in the control group: 29.7% (11/37) vs. 10.3% (4/39), and the difference was statistically significant ( χ2 = 4.383, P<0.05). The BI and GQOL-74 scores in the observation group at 3 and 6 months after operation were higher than those in the control group ( P<0.05). Conclusions:The combination of ventricoscopy and laparoscopic in VPS can reduce the impact on immune function by reducing the inflammatory stress response, reduce the occurrence of postoperative complications, and further promote the improvement of prognosis.

Ventriculoscopic surgery for arachnoid cysts in the lateral ventricle: a comparative study of 21 consecutive cases.

OBJECTIVE: To evaluate neuronavigation-guided ventriculoscopic technique in the treatment of arachnoid cysts in the lateral ventricle. METHODS: Between January 2008 to November 2011, twenty-one neuronavigationguided ventriculoscopic surgery were performed for the treatment of symptomatic arachnoid cysts in 21 patients (14 male and 7 female patients, mean age 24.1 years [ranged 1.5-61 years]) Clinical presentations varied from headache, vomiting, hemiparesis and seizure. The trajectory of ventriculoscopy was dynamically monitored and guided in real time by neuronavigation system. Cysts fenestrations were performed in fourteen cases, and cysts resection in seven cases, respectively. All patients were prospectively had a regular follow-up. RESULTS: After operation, all patients achieved symptom resolution without surgical mortality and morbidity. Aseptic meningitis was noted in four cases with cyst resection, and all recovered quickly without advanced treatments. However, a later ependymal adhesion, occurred in one case during follow-up period. CONCLUSION: The combination of ventriculoscopy and neuronavigation is an accurate, effective and safe approach for the treatment of the patients with arachnoid cysts in the lateral ventricle, especially, for overcoming the topographic variation caused by intraventricular pathologies. Cystoventriculostomy is the best choice.