Endoscopic Endonasal Odontoidectomy.

Odontoidectomy is the treatment of choice for irreducible ventral cervical-medullary compression. The endonasal endoscopic approach is an innovative approach for odontoidectomy. The aim of this article is to identify in which conditions this approach is indicated, discussing variants of the technique for selected cases of craniovertebral malformation with platybasia. We believe that the technical difficulties of this approach are balanced by the advantages for patients. Some conditions related to the patient and to the anatomy of the craniovertebral junction may favor adoption of the endoscopic endonasal approach, which should be considered complementary and not alternative to standard approaches.

Endoscopic treatment of a fourth ventricle arachnoid cyst via the third ventricle: a case report.

BACKGROUND AND IMPORTANCE: Arachnoid cysts within the fourth ventricle have rarely been reported in the literature. Different procedures have been performed to restore a normal cerebrospinal fluid dynamic or pressure, including shunting and partial or complete excision of the cyst by open microsurgery. Cerebrospinal fluid shunts give only partial improvement of symptoms and are prone to malfunctions. The microsurgical excision of the cyst seems to offer the best chance of success. CLINICAL PRESENTATION: We report the case of a fourth ventricle arachnoid cyst successfully treated with a complete endoscopic cerebral procedure via the third ventricle. CONCLUSION: Endoscopic fenestration of fourth ventricle arachnoid cysts may be considered an effective neurosurgical treatment.

Endoscopic endonasal odontoidectomy: clinical series.

STUDY DESIGN: This study evaluates a series of consecutive endoscopic endonasal odontoidectomies performed since 2008 in our center. OBJECTIVE: The aim of the study was to analyze the outcome and the surgical technique to enlighten advantages and limitations of this procedure. SUMMARY OF BACKGROUND DATA: Odontoidectomy represents the treatment of choice in selected cases of basilar invagination. Transoral-transpharyngeal odontoidectomy is the "gold standard" and more experienced technique. Recently, the endoscopic endonasal approach has been proposed as an alternative route. METHODS: All patients underwent a pre- and postoperative evaluation of neurological status using physical neurological examination, assessment of American Spinal Injury Association impairment scale score, and neurophysiological investigations. Pre- and postoperative neuroradiological examinations consisted of magnetic resonance imaging, computed tomography, and radiography in flexion and extension. Surgical complications, time of orotracheal extubation and of resumption of oral feeding after surgery were considered, basing on medical records. RESULTS: The series is composed of 5 cases. All cases presented a progressive tetraparesis despite a posterior occipitocervical arthrodesis. Two patients presented with irreducible atlantoaxial subluxation in Down syndrome, whereas the others presented with an atlanto-occipital malformation with platybasia and basilar invagination. No complications were observed. In all except one case, orotracheal intubation was removed immediately at the end of surgery. Oral feeding was resumed 1 day after surgery in all but one case that initially required an orogastric tube. At follow-up (mean: 34.2 mo; range: 3-57 mo), neurological symptoms have been shown to improve in 2 cases and stabilization, arresting the neurological worsening, in 3 cases. CONCLUSION: Endoscopic endonasal odontoidectomy resulted in a safe, effective, and well-tolerated procedure. From our experience, we conclude that the different approaches for odontoidectomy should be considered to be complementary rather than alternative: the endonasal endoscopic can be advantageous in selected cases presenting some anatomical conditions related (micrognathia and macroglossia) to the oral cavity and to high position of the odontoid.

Safety and diagnostic accuracy of neuroendoscopic biopsies: an international multicenter study.

OBJECT: Analysis of the safety and morbidity of neuroendoscopic biopsies (NEBs), as well as the reliability in obtaining an accurate diagnosis, has until now been based on studies with relatively small sample sizes. Through the cooperative efforts of several international medical centers, authors of the present study collected data on a large number of patients to obtain better insight into this issue. When possible, they compared pathology obtained through an NEB with the "gold-standard" pathology obtained in open surgery. METHODS: Thirteen randomly chosen medical centers in 9 countries collected data for patients who had undergone NEB, which were then analyzed for universal complications, bleeding, navigation technique, pathology, mismatch between biopsy results and final diagnosis, and a number of other potentially influential factors. RESULTS: Data for 293 patients were analyzed. Sixty percent of the patients were male, and patient ages ranged from 0.1 to 78.7 years (median age 20.4 years). The most common tumor locations were pineal (33.1%), thalamic (16.7%), tectal (13%), and hypothalamic (4.4%). Fifty percent of the tumors were larger than 20 mm, 36% were between 10 and 20 mm, and 14% were smaller than 10 mm. Intraoperative bleeding was seen in 275 patients (94%). The amount of blood was noted as mild in 75%, moderate in 13%, and severe in 6%. Infection occurred in 8 patients (3%). Death occurred in 1 patient (0.3%), which was caused by severe intraoperative bleeding. Biopsies were informative in 265 patients (90.4%). Seventy-eight patients (26.6%) had open surgery following the NEB. For these patients, the pathology results from the NEB were compared with those from the open surgery that followed. In 14 cases (17.9%) there was disagreement on the pathology. Of these cases, a meaningful mismatch, in which the erroneous NEB pathology could have led to an inappropriate management decision, occurred in 9 cases (11.5%). Most of these meaningful mismatches were lesions diagnosed as low-grade or pilocytic astrocytoma on the NEB and later proved to be high-grade astrocytoma (4 cases) and 1 case each of meningioma, cavernoma, primitive neuroectodermal tumor, neurocysticercosis, and pineocytoma. CONCLUSIONS: In experienced hands, NEBs can be performed with low morbidity and mortality, providing meaningful pathological data for the majority of patients with a wide range of tumor types, locations, and presentations. These biopsies also offer other advantages, such as the ability to perform concomitant endoscopic third ventriculostomy and septum pellucidotomy. However, due caution must be maintained, since pathology obtained from an NEB, as with stereotactic biopsies, may be subject to sampling errors, especially when the results seem to indicate a low-grade glial tumor.

Neuroendoscopic biopsy of ventricular tumors: a multicentric experience.

OBJECT: Although neuroendoscopic biopsy is routinely performed, the safety and validity of this procedure has been studied only in small numbers of patients in single-center reports. The Section of Neuroendoscopy of the Italian Neurosurgical Society invited some of its members to review their own experience, gathering a sufficient number of cases for a wide analysis. METHODS: Retrospective data were collected by 7 centers routinely performing neuroendoscopic biopsies over a period of 10 years. Sixty patients with newly diagnosed intraventricular and paraventricular tumors were included. No patient harboring a colloid cyst was included. Data regarding clinical presentation, neuroimaging findings, operative techniques, pathological diagnosis, postoperative complications, and subsequent therapy were analyzed. RESULTS: In all patients, a neuroendoscopic tumor biopsy was performed. In 38 patients (64%), obstructive hydrocephalus was present. In addition to the tumor biopsy, 32 patients (53%) underwent endoscopic third ventriculostomy (ETV), and 7 (12%) underwent septum pellucidotomy. Only 2 patients required a ventriculoperitoneal shunt shortly after the endoscopy procedure because ETV was not feasible. The major complication due to the endoscopy procedure was ventricular hemorrhage noted on the postoperative images in 8 cases (13%). Only 2 patients were symptomatic and required medical therapy. Infection occurred in only 1 case, and the other complications were all reversible. In no case did clinically significant sequelae affect the patient's outcome. Tumor types ranged across the spectrum and included glioma (low- and high-grade [27%]), pure germinoma (15%), pineal parenchymal tumor (12%), primary neuroectodermal tumor (4%), lymphoma (9%), metastasis (4%), craniopharyngioma (6%), and other tumor types (13%). In 10% of patients, the pathological findings were inconclusive. According to diagnosis, specific therapy was performed in 35% of patients: 17% underwent microsurgical removal, and 18% underwent chemotherapy or radiotherapy. CONCLUSIONS: This is one of the largest series confirming the safety and validity of the neuroendoscopic biopsy procedure. Complications were relatively low (about 13%), and they were all reversible. Neuroendoscopic biopsy provided meaningful pathological data in 90% of patients, making subsequent tumor therapy feasible. Cerebrospinal fluid pathways can be restored by ETV or septum pellucidotomy (65%) to control intracranial hypertension. In light of the results obtained, a neuroendoscopic biopsy should be considered a possible alternative to the stereotactic biopsy in the diagnosis and treatment of ventricular or paraventricular tumors. Furthermore, it could be the only surgical procedure necessary for the treatment of selected tumors.

Endoscopic endonasal odontoidectomy in a patient affected by Down syndrome: technical case report.

OBJECTIVE: Atlantoaxial instability and odontoid invagination may occur in Down syndrome. The treatment of this lesion may require an odontoidectomy. In similar circumstances, a transoral procedure may be hampered by a macroglossia which is part of Down syndrome. In a situation occurring in an 11-year-old child affected by atloaxial instability and os odontoideum, the persistence of ventral compression after a previous atloaxial fixation induced us to perform an endoscopic endonasal odontoidectomy. We feel that this is an elective indication for endoscopic endonasal odontoidectomy. CLINICAL PRESENTATION: An 11-year-old child, affected by Down syndrome, presented with progressive tetraparesis with severe superior diplegia. He was wheelchair-bound. Recently, respiratory disturbances had appeared. INTERVENTION: The patient underwent an endoscopic endonasal odontoidectomy. The postoperative course was uneventful, and the patient experienced improvement of the preoperative symptoms. CONCLUSION: An endonasal technique is indicated for patients presenting with narrowness of the oral cavity, such as in the case reported, where the narrowness due to pediatric age and the macroglossia characteristic of Down syndrome hamper the transoral approach.

Application of neuroendoscopy to intraventricular lesions.

We present an overview of the history, development, technological advancements, current application, and future trends of cranial endoscopy. Neuroendoscopy provides a safe and effective management modality for the treatment of a variety of intracranial disorders, either tumoral or non-tumoral, congenital, developmental, and degenerative, and its knowledge, indications, and limits are fundamental for the armamentarium of the modern neurosurgeon.

Endoscopic third ventriculostomy in idiopathic normal pressure hydrocephalus: an Italian multicenter study.

OBJECTIVES: The aim of the report is to define the indications and results of endoscopic third ventriculostomy (ETV) in idiopathic normal pressure hydrocephalus and to discuss the physiopathological mechanism of this procedure. METHODS: The cases of 110 patients with idiopathic normal pressure hydrocephalus who underwent ETV in four Italian neurosurgical centers were retrospectively reviewed. The postoperative outcome was correlated with patient age, length of clinical history, preoperative clinical score, symptoms of clinical onset, type of hydrocephalus, and intraoperative findings. RESULTS: The follow-up period ranged from 2 to 12 years (average, 6.5 yr). The outcome evaluation was made 2 years after the procedure. Postoperative clinical improvement occurred in 76 (69.1%) of 110 patients. There was no correlation between success rate and patient age or type of ventricular enlargement (normal or enlarged fourth ventricle). Conversely, the rate of neurological improvement was higher in patients with shorter clinical history, better preoperative neurological score, and clinical onset with gait disturbances. Moreover, the intraoperative finding of the sudden reappearance of normal cerebral pulsations and significant downward and upward movements of the third ventricular floor after ETV was also correlated with a good outcome. CONCLUSION: ETV results in a relatively high rate of clinical improvement and a low complication rate in patients with idiopathic normal pressure hydrocephalus. Therefore, it may be easily performed with the same approach used for intracranial pressure monitoring with low morbidity. However, our data must be confirmed by additional studies.

En bloc vertebrectomy and dural resection for chordoma: a case report.

STUDY DESIGN: Case report. OBJECTIVES: Report a surgical technique for dural reconstruction after vertebrectomy. SUMMARY OF BACKGROUND DATA: None available. METHODS: Clinical case analysis: chordoma from T12 to L2 with infiltration of the dura. RESULTS: Forty-six months after vertebral resection and reconstruction, the patient is disease free. CONCLUSIONS: Wide en bloc resection is required for local control in chordoma. When the tumor permeates the dura, resection not including the dura is intralesional with high risk of local recurrence. Therefore, a proper wide resection consists in vertebrectomy removing the dura infiltrated by the tumor. The two-stage dural reconstruction had strongly limited the leakage of liquor during surgery, and the dural patch provided extra strength anteriorly, where the dural suture is more difficult.