Feasibility of awake endoscopic third ventriculostomy in selected patients of obstructive hydrocephalus.

BACKGROUND: Endoscopic third ventriculostomy (ETV) is usually performed under general anesthesia (GA) with proper head immobilization. However a few patients with hydrocephalus (HCP) may not be suitable for GA. Once the surgeon is familiar with endoscopic ventricular anatomy and gains adequate surgical experience with the procedure, ETV can be attempted under local anesthesia (LA) in selected patients. Here we discuss our experience of treating 32 patients of HCP with ETV under LA. METHODS: 32 symptomatic HCP patients with in the age range of 13 and 65 years, conscious, alert, cooperative and at high risk for GA owing to deranged liver or renal function, associated co-morbidities, pregnancy were considered for ETV under scalp block. All patients were evaluated for any discomfort during the surgical intervention. RESULT: All procedures were completed under LA. Four patients needed additional sedation prior to the scalp block to alleviate their apprehension. Four patients complained of bilateral orbital pain. In three it coincided with irrigation of fluid lower than body temperature. One patient had pain while touching the dorsum sella and needed analgesic supplement. All of them improved and none required additional CSF diversion within the average follow up of 9.5 months. CONCLUSION: ETV can be performed under local anesthesia in conscious, alert and cooperative patients in experienced hands. Unnecessary stimulation of the painful structures should be avoided and fluid for irrigation should be at body temperature. This ensures patient comfort and safety of the procedure.

Extra-axial, dural-based atypical teratoid/rhabdoid tumor.

Atypical teratoid/rhabdoid tumors (ATRTs) are malignant central nervous system tumors that affect early childhood (< 3 years), and mostly located in the infratentorial space. Owing to an infrequent occurrence, their radiological features have not been completely defined. Nevertheless, these are characteristically intra-axial except for few instances in the cerebellopontine angle region. We describe a case of a 10-year-old boy who harbored an extra-axial, dural-based ATRT in the right parietal region. The lesion was totally excised followed by adjuvant chemo-radiotherapy. At 10-month follow-up, he was well with no recurrence. The report intends to highlight an atypical imaging presentation of ATRT in an older child, and adds to the radiological spectrum. This uncommon pathology should be borne in mind, even in a supratentorial dural-based location.