Neuroendoscopic transventricular transchoroidal approach for access to the posterior zone of the third ventricle or pineal region.

The endoscopic transventricular transchoroidal approach facilitates entry into the posterior part of the third ventricle, allowing a visualization field from the foramen of Monro to the pineal region through this anatomical corridor. Combined surgery to treat the target lesion and possible endoscopic third ventriculostomy (ETV) can be performed through a single burr hole. A detailed description of this surgical technique is given, and a series of cases from our center is presented. This retrospective study included patients with lesions in the pineal region or posterior zone of the third ventricle who underwent surgery between 2004 and 2022 in our center for tumor biopsy or endoscopic cyst fenestration. In nine cases, the transchoroidal approach was performed. Demographic and clinical variables were collected: sex, age at diagnosis, clinical presentation, characteristics of the lesion, pathological diagnosis, characteristics of the procedure, complications, subsequent treatments, evolution, follow-up time, and degree of success of the endoscopic procedure. The mean and range of the quantitative variables and frequency of the qualitative variables were analyzed, together with the statistical significance (p < 0.05). Surgical planning was carried out by performing a preoperative MRI, calculating the ideal entry point and trajectory for each case. The preoperative planning of the surgical technique is described in detail. Of our sample, 55.6% were women, with a mean age of 35 years (7-78). The most common clinical presentation was intracranial hypertension (55.6%), with or without a focus. Eight patients presented hydrocephalus at diagnosis. The most frequent procedure was endoscopic biopsy with ETV (66.7%). The pathological diagnosis varied widely. Procedure-related complications included one case of self-limited bleeding of the choroidal fissure at its opening and one intraventricular hemorrhage due to tumor bleeding in the postoperative period. Non-procedure-related complications comprised two ETV failures and one case of systemic infection, while late complications included one case of disease progression and one case of radionecrosis. Four patients died, one due to poor neurological evolution after post-surgical tumor bleeding and three due to causes unrelated to the procedure. The rest of the patients had a favorable evolution and were asymptomatic or stable. The transchoroidal approach through a single burr hole is a feasible and safe option for access to the posterior part of the third ventricle. Proper planning of each case is necessary to avoid complications.

Analysis of complications in intraventricular neuroendoscopy in children: proposal for a standardization system.

Although intraventricular neuroendoscopy is considered a minimally invasive technique with good results, there is nevertheless a risk of developing certain complications. As no agreement apparently exists concerning the classification of these complications, we aim to propose a form of classification based on the results of our series, comparing them with recent publications. We undertook a retrospective study of 170 children who underwent intraventricular neuroendoscopy between 2003 and September 2020 at our center. Data were recorded on demographic and clinical variables: age, gender, presenting symptoms, etiology, number of procedures, type of procedure, and complications. Complications were divided into two main groups, intraoperative and postoperative, and in subgroups. The intraoperative complications included one group of systemic alterations and another group of surgical problems. The postoperative complications were divided into six groups: systemic, neurologic, hormone, fluid, hemorrhagic and death. A total of 202 neuroendoscopic procedures were performed in 170 children. The mean age at first surgery was 71 months (22-122). The most common etiology of the hydrocephalus was intraventricular tumors (32.9%), followed by aqueductal stenosis (13.5%). The most usual presenting sign was intracranial hypertension. The procedure most used was third ventriculostomy (62.9%). During the procedures, we experienced 5 surgical intraoperative complications (2.47% per procedure). In the postoperative period, there were 23.7% systemic complications per procedure, 12.87% neurologic, 8.41% hormone, 10.9% fluid, 0.5% hemorrhagic, and 0.99% for postoperative death. The rate of complications associated with intraventricular neuroendoscopy was similar in our series to those already published. Comparative studies require standardization for the analysis of neuroendoscopic complications.

Neuroplasticity and Epilepsy Surgery in Brain Eloquent Areas: Case Report.

Introduction: Neuronal plasticity includes changes in any component of the central nervous system in response to intrinsic or extrinsic stimuli. Brain functions that depend on the epileptogenic cortex pose a challenge in epilepsy surgery because many patients are excluded from pre-surgical evaluation for fear of the possible sequelae. Some of these patients may be rescued by enhancing neuronal plasticity with brain neuromodulation techniques. Case Report: We describe a 6-year-old child with refractory focal motor seizures symptomatic to a neuroepithelial dysembryoblastic tumor in the left temporo-parietal region. He underwent limited resection of the lesion in order to avoid sequelae in his language function. A functional study at age of 17 years revealed an overlap of Wernicke's area with the tumor and areas of incipient language reorganization in the contralateral hemisphere. An invasive neuromodulation procedure was designed to enhance neuroplasticity. After craniotomy, he underwent language training and simultaneous electrical inhibition of language using an electrode grid placed over the lesion. The intensity of the language inhibitory stimulus was increased every day to force the use of accessory language areas in the right hemisphere by neuroplasticity. Results: The language of the patient improved for six consecutive days until he was able to speak and understand while undergoing maximum electrical inhibition. The tumor was resected using a cortical mapping guide. Discussion: Application of direct cortical stimulation techniques and language pre-habilitation before epilepsy surgery can be useful to rescue patients excluded from resective surgery, especially young patients with long-term lesions.

Evaluación prequirúrgica mediante resonancia magnética funcional en pacientes con tumores neuroepiteliales disembrioplásicos: una serie de casos / Preoperative evaluation by functional magnetic resonance imaging in patients with dysembryoplastic neuroepithelial tumours: A case series

INTRODUCCIÓN: Los tumores neuroepiteliales disembrioplásicos (DNET) son un tipo de neoplasia glioneuronal benigna de localización típicamente temporal que producen crisis epilépticas resistentes al tratamiento farmacológico en niños y adultos jóvenes. OBJETIVO: Se muestran 4 casos valorando la utilidad de la resonancia magnética funcional en el estudio prequirúrgico de pacientes con tumores neuroepiteliales disembrionarios. Para la obtención de imágenes se utilizó un equipo de resonancia magnética Philipps Intera de 3.0 Tesla y la técnica Blood Oxygenation Level-Dependent, permitiendo localizar las áreas elocuentes de lenguaje y motora mediante la aplicación de paradigmas específicos. RESULTADOS: En un caso el tumor se encontraba adyacente al área de Broca, en 2 casos coincidía con Wernicke, en un paciente estaba menos de 1cm del área motora de la mano y en otro próximo a la memoria. Solo 2 de los pacientes fueron operados, no produciéndose déficit funcional postoperatorio. Se observó activación hemisférica contralateral al tumor sugestivo de neuroplasticidad en uno de los pacientes. CONCLUSIONES: La resonancia magnética funcional supone un método no invasivo que permite evaluar la proximidad de las lesiones a las áreas elocuentes, clave en la evaluación del riesgo quirúrgico. Además, ha permitido detectar probable neuroplasticidad en un caso, la cual ha garantizado el éxito de la cirugía

INTRODUCTION: Dysembryoplastic neuroepithelial tumours (DNET) are a type of benign glioneuronal neoplasia of typically temporal location that produce drug-resistant epileptic seizures in children and young adults. OBJECTIVE: This work aims to assess the usefulness of functional magnetic resonance imaging (fMRI) in the preoperative study in four patients with DNET. A Philips Intera 3.0 Tesla magnetic resonance imaging scanner and the Blood-Oxygen-Level-Dependent (BOLD) technique were used to obtain the images, making it possible to locate the eloquent areas for language and motor areas through the application of specific paradigms. RESULTS: In one case the tumour was adjacent to Broca's area, in two cases it coincided with Wernicke's area, in one patient it was < 1cm from the motor area for the hand and in another close to memory. Only two of the patients were operated on, without postoperative functional deficit. Hemispheric activation contralateral to the tumour suggestive of neuroplasticity was observed in one of the patients. CONCLUSIONS: fMRI is a non-invasive method that allows us to assess the proximity of lesions to eloquent areas, which is key in the evaluation of surgical risk. In addition, it allowed the detection of probable neuroplasticity in one case, which guaranteed the success of the surgery

Tratamiento neuroendoscópico de quistes aracnoideos en edad pediátrica. Resultados de una serie de 20 pacientes / Neuroendoscopic treatment of arachnoid cysts in the paediatric population. Series results for 20 patient

INTRODUCCIÓN: La neuroendoscopia se ha posicionado como un tratamiento eficaz y seguro en los quistes aracnoideos en la edad pediátrica. Realizamos una revisión de los pacientes pediátricos con quistes aracnoideos tratados mediante neuroendoscopia en nuestro servicio y analizamos los resultados. MATERIAL Y MÉTODOS: Análisis retrospectivo de una serie de 20 pacientes intervenidos entre los años 2005 y 2018. Las variables recogidas son: género, edad, presentación clínica, localización del quiste, presencia de hidrocefalia o colecciones extraaxiales, maniobras endoscópicas realizadas y complicaciones. Se consideró éxito del procedimiento cuando se produjo mejoría de los síntomas y reducción del tamaño del quiste, manteniéndose esta situación hasta final de seguimiento. RESULTADOS: La serie consta de 13 varones y 7 mujeres (edad media: 64,6 meses; rango 4-172 meses). La localización más repetida fue supraselar/prepontina (7), seguida de intraventricular (6), después cuadrigeminales (3), interhemisféricos (2) y silvianos (2). Un 70% (14/20) de pacientes asociaba hidrocefalia en el momento del diagnóstico, elevándose hasta el 85% en quistes supraselares/prepontinos o el 100% en cuadrigeminales. Solo 4/14 pacientes precisaron un sistema de derivación ventriculoperitoneal (mediana de edad al diagnóstico: 12,5 meses). De estos 4, 3 desarrollaron un sobredrenaje valvular grave. Se consideró éxito del procedimiento en 12/20 pacientes (60%) de la serie. Diferenciando por localización: 4/7 en supraselares (57%), 1/3 en cuadrigeminales (33%), 4/6 en intraventriculares (66%), 2/2 en interhemisféricos (100%) y 1/2 en silvianos (50%). Por tanto, se registraron 8 fallos de tratamiento, con un tiempo medio hasta el fallo de 12,12 meses (rango: 0-45). De esos 8 pacientes, en 4 se realizó una nueva neuroendoscopia (éxito de 2/4), en 2 casos se optó por la colocación de derivación ventriculoperitoneal, en un caso por la colocación de derivación cistoperitoneal y en el restante se mantuvo una actitud conservadora. El seguimiento medio fue de 52,45 meses (rango 3-129 meses). CONCLUSIONES: El tratamiento neuroendoscópico es efectivo y seguro en el tratamiento de los quistes aracnoideos en edad pediátrica, permitiendo además en muchos casos el control de la hidrocefalia asociada. El tipo de procedimiento neuroendoscópico y el porcentaje de éxito dependen de la localización del quiste. Se observa una tendencia de mayor dependencia valvular en pacientes de menor edad. En esos casos, sería recomendable la aplicación de medidas de prevención de sobredrenaje

INTRODUCTION: Neuroendoscopy has become an effective and safe treatment for arachnoid cysts in the paediatric population. We review the paediatric patients with arachnoid cysts treated by neuroendoscopy in our hospital and analyse the results. MATERIAL AND METHODS: A retrospective analysis of 20 patients operated on from 2005 to 2018. The variables assessed are: gender, age, clinical presentation, cyst site, presence of hydrocephalus and/or extra-axial collections, endoscopic procedures and complications. Procedure success is defined as an improvement in symptoms and reduction in cyst size until end of follow-up. RESULTS: Our series comprised 13 males and 7 females (mean age: 64.6 months, range: 4-172 months). The most frequent site was suprasellar-prepontine (7), followed by intraventricular (6), quadrigeminal (3), interhemispheric (2) and Sylvian (2). A total of 70% (14/20) of patients had hydrocephalus at diagnosis, which increased to 85% in suprasellar-prepontine cysts and 100% in quadrigeminal cysts. Only 4/14 patients with required a ventriculoperitoneal shunt (median age at diagnosis: 12.5 months). Of these 4 patients, 3 developed severe shunt overdrainage. The procedure was successful in 60% (12/20) of the patients in the series. Success by location was 57% (4/7) in suprasellar cysts, 33% (1/3) in quadrigeminal cysts, 66% (4/6) in intraventricular cysts, 100% (2/2) in interhemispheric cysts and 50% (1/2) in Sylvian cysts. Treatment thus failed in 8 cases, with a mean time to failure of 12.12 months (range: 0-45 months). A new neuroendoscopic procedure was performed in 4 of these 8 cases (success in 2/4), a ventriculoperitoneal shunt was placed in 2 cases, a cystoperitoneal shunt was placed in 1 case and the remaining case was managed conservatively. Mean follow-up time was 52.45 months (range: 3-129 months). CONCLUSIONS: Neuroendoscopy is an effective and safe treatment for arachnoid cysts in paediatric patients that also enables managing associated hydrocephalus in most cases. The choice of neuroendoscopic procedure and success rate depend on cyst location. Younger patients have been found to have a higher shunt dependency rate. In these cases, measures to prevent shunt overdrainage are recommended

Neuroendoscopic biopsy: analysis of a series of 80 patients.

Neuroendoscopy enables diagnostic biopsy of intraventricular and/or paraventricular tumors and the simultaneous treatment of associated hydrocephalus in selected cases. The objective of this paper was to analyze the effectiveness and safety of this procedure. This retrospective study included 80 patients between 2 months and 78 years old diagnosed with intraventricular and/or paraventricular expansive lesion who underwent neuroendoscopic biopsy from 2004 to 2016. Collected variables were gender, age at diagnosis, clinical presentation, tumor location, surgical technique, management of hydrocephalus, pathological findings, procedure-related complications, and follow-up time. Neuroendoscopic biopsy was performed in 80 patients. Mean age at diagnosis was 27 years, and 52.5% were men. According to the Depreitere Classification, 71 were level I (conclusive diagnosis), 1 level III (problematic categorization), and 8 level IV (non-interpretable diagnosis). The most frequent diagnosis was grade I astrocytoma (14%). Diagnostic success per patient was 88.7%. Sixty-nine patients had hydrocephalus at diagnosis, 37 of whom were treated with endoscopic third ventriculostomy (ETV), with septostomy (SPT) in 14, and only SPT in 4. Twenty-eight patients underwent ventricular peritoneal shunt (VPS), with SPT in 20. The ETV success rate was 70.9%. The complication rate per patient was 11%: five patients presented intraventricular hemorrhage, three of whom died; one patient presented cerebrospinal fluid fistula; three presented transient oculomotor impairment. Postoperative follow-up was from 1 month to 12.4 years (mean 45 months). Neuroendoscopy is an effective procedure for the pathological diagnosis of intraventricular and paraventricular tumors, allowing the treatment of associated hydrocephalus. Nevertheless, it is not exempt from serious complications and requires proper training.

Preoperative evaluation by functional magnetic resonance imaging in patients with dysembryoplastic neuroepithelial tumours: A case series. / Evaluación prequirúrgica mediante resonancia magnética funcional en pacientes con tumores neuroepiteliales disembrioplásicos: una serie de casos.

INTRODUCTION: Dysembryoplastic neuroepithelial tumours (DNET) are a type of benign glioneuronal neoplasia of typically temporal location that produce drug-resistant epileptic seizures in children and young adults. OBJECTIVE: This work aims to assess the usefulness of functional magnetic resonance imaging (fMRI) in the preoperative study in four patients with DNET. A Philips Intera 3.0 Tesla magnetic resonance imaging scanner and the Blood-Oxygen-Level-Dependent (BOLD) technique were used to obtain the images, making it possible to locate the eloquent areas for language and motor areas through the application of specific paradigms. RESULTS: In one case the tumour was adjacent to Broca's area, in two cases it coincided with Wernicke's area, in one patient it was<1cm from the motor area for the hand and in another close to memory. Only two of the patients were operated on, without postoperative functional deficit. Hemispheric activation contralateral to the tumour suggestive of neuroplasticity was observed in one of the patients. CONCLUSIONS: fMRI is a non-invasive method that allows us to assess the proximity of lesions to eloquent areas, which is key in the evaluation of surgical risk. In addition, it allowed the detection of probable neuroplasticity in one case, which guaranteed the success of the surgery.

Neuroendoscopic treatment of arachnoid cysts in the paediatric population. Series results for 20 patients. / Tratamiento neuroendoscópico de quistes aracnoideos en edad pediátrica. Resultados de una serie de 20 pacientes.

INTRODUCTION: Neuroendoscopy has become an effective and safe treatment for arachnoid cysts in the paediatric population. We review the paediatric patients with arachnoid cysts treated by neuroendoscopy in our hospital and analyse the results. MATERIAL AND METHODS: A retrospective analysis of 20 patients operated on from 2005 to 2018. The variables assessed are: gender, age, clinical presentation, cyst site, presence of hydrocephalus and/or extra-axial collections, endoscopic procedures and complications. Procedure success is defined as an improvement in symptoms and reduction in cyst size until end of follow-up. RESULTS: Our series comprised 13 males and 7 females (mean age: 64.6 months, range: 4-172 months). The most frequent site was suprasellar-prepontine (7), followed by intraventricular (6), quadrigeminal (3), interhemispheric (2) and Sylvian (2). A total of 70% (14/20) of patients had hydrocephalus at diagnosis, which increased to 85% in suprasellar-prepontine cysts and 100% in quadrigeminal cysts. Only 4/14 patients with required a ventriculoperitoneal shunt (median age at diagnosis: 12.5 months). Of these 4 patients, 3 developed severe shunt overdrainage. The procedure was successful in 60% (12/20) of the patients in the series. Success by location was 57% (4/7) in suprasellar cysts, 33% (1/3) in quadrigeminal cysts, 66% (4/6) in intraventricular cysts, 100% (2/2) in interhemispheric cysts and 50% (1/2) in Sylvian cysts. Treatment thus failed in 8 cases, with a mean time to failure of 12.12 months (range: 0-45 months). A new neuroendoscopic procedure was performed in 4 of these 8 cases (success in 2/4), a ventriculoperitoneal shunt was placed in 2 cases, a cystoperitoneal shunt was placed in 1 case and the remaining case was managed conservatively. Mean follow-up time was 52.45 months (range: 3-129 months). CONCLUSIONS: Neuroendoscopy is an effective and safe treatment for arachnoid cysts in paediatric patients that also enables managing associated hydrocephalus in most cases. The choice of neuroendoscopic procedure and success rate depend on cyst location. Younger patients have been found to have a higher shunt dependency rate. In these cases, measures to prevent shunt overdrainage are recommended.

Purely neuroendoscopic resection of intraventricular tumors with an endoscopic ultrasonic aspirator.

Surgery for intraventricular tumors remains a controversial and evolving field, with endoscopic resection becoming more popular. We present a series of nine consecutive cases of purely endoscopic resection of intraventricular tumors with the aid of an ultrasonic aspirator specific for neuroendoscopy. Nine patients (five men, four women) aged 18-74 years (mean 43.7) underwent surgery. The most common symptom was headache. In all cases, magnetic resonance imaging showed single supratentorial intraventricular lesions (five lateral ventricle, four third ventricle). The average maximum diameter was 20.5 mm (range 11-42). Associated hydrocephalus was found in eight cases at diagnosis. Five patients underwent complete macroscopic resection. Three underwent subtotal resection and one underwent partial resection (two thirds of the tumor). The mean endoscopic procedure time was 70 min (37-209). The eight patients with associated hydrocephalus also underwent endoscopic septostomy to improve cerebral spinal fluid circulation, with one patient additionally requiring endoscopic third ventriculostomy and another requiring Monro foraminoplasty. One patient required ventriculoperitoneal shunting. The mean post-operative follow-up was 15.1 months (range 2-33). At the time of analysis, no patient showed recurrence or regrowth of the operated lesion. The histological diagnoses and degree of resection were three subependymomas with complete resection, three colloid cysts with two complete and one subtotal resection, one pilocytic astrocytoma with partial resection (approximately two thirds of the lesion), one epidermoid tumor with subtotal resection, and one central neurocytoma with subtotal resection. The endoscopic ultrasonic surgical aspirator can be a safe and effective tool for the removal of intraventricular tumors, even in firmer solid lesions.

LOVA: the role of endoscopic third ventriculostomy and a new proposal for diagnostic criteria.

The diagnostic criteria and management of this condition continue to be a topic of debate in the literature. The term definitive symptomatic LOVA (longstanding overt ventriculomegaly in adults) is applied to patients that fulfil a series of diagnostic criteria,which are reviewed in our paper. The main subject of our study is to propose a rearrangement of the criteria for the diagnosis of this entity and adjusted treatment strategies. We present our data evaluating the role of endoscopy in this pathology. This descriptive and analytical study comprised 27 adult patients with LOVA who underwent endoscopic third ventriculostomy (ETV). Data regarding age, gender and onset of symptoms, a previously implanted shunt, clinical examination and radiological findings at the time of diagnosis, and the intracranial pressure (ICP) recordings in some cases, were carefully retrospectively reviewed. ETV success was determined based on clinical state and radiological criteria. ETV was performed in all 27 cases. Mean follow up period was 4.2 years (6 months to 8 years). 2/27 patients (7.40%) were lost to follow-up. The overall success rate for ETV was 76% (21/25 patients). ETV resulted in shunt independency in two of the three patients with a previous shunt. Based on our results, we believe that ETV must be considered as the treatment of choice for patients with symptomatic LOVA.

Neuroendoscopic treatment for hydrocephalus associated to midline arachnoid cysts in a series of nine pediatric patients.

BACKGROUND: Arachnoid cysts are extra-axial cerebrospinal fluid (CSF) collections surrounded by a membrane. Occasionally, hydrocephalus is associated due to a change in CSF circulatory dynamics. Neuroendoscopic treatment has been recommended for patients who develop symptoms resulting from the cyst location. METHODS: We retrospectively evaluate the results in our series of 9 patients with hydrocephalus associated to midline arachnoid cysts treated endoscopically. Success was rated on a scale of five degrees of neuroendoscopical success. RESULTS: We performed endoscopic third ventriculostomy (ETV) in three cases; ETV was associated to ventriculocystostomy (VC) in three cases; ETV, VC and septostomy (SPT) were performed in one patient; neuroendoscopic Monro foraminoplasty (NEFPMO) plus SPT were associated in one case; last patient was performed ETV, VC and cystocysternostomy (CC). For first procedures, 6 patients completed permanent Success (grade I). In one case success was transitory (grade II) and required a second procedure (ETV). In one patient VC success and ETV failure implied partial success (grade III). One patient's early failure (grade V) required a second procedure (ETV + NEFPMO). Success in second procedures was grade I in both patients. Follow-up period was over 12 months and altogether success was grade I in 8/9 patients and grade III in 1/9 patients. Shunt independency went over 88%. CONCLUSIONS: Endoscopy allows a solution avoiding the implantation of cerebrospinal fluid shunt devices. When possible, we likely approach both, hydrocephalus and arachnoid cyst, with different endoscopic maneuvers in a single procedure. It is important to expand the usage of success classifications for combined procedures.

Endoscopic Third Ventriculostomy in Children with Myelomeningocele: A Case Series.

Hydrocephalus develops in up to 80-90% of children with myelomeningocele (MM) after closure of the defect. Traditionally, ventriculoperitoneal shunts have been used to manage hydrocephalus in these patients. A role for endoscopic third ventriculostomy (ETV) in MM has provoked much debate, principally due to anatomical variants described, which may complicate the procedure. We present 7 cases of children with MM and hydrocephalus undergoing a total of 10 ETV procedures. All patients demonstrated clinical improvement (in acute/subacute cases) or stabilization (in chronic cases). Three patients requiring a second ETV have shown clinical stability and renewed radiological evidence of functioning ventriculostomies in follow-up since reintervention. ETV can be used, albeit cautiously, in selected cases of hydrocephalus associated with MM. However, the frequency with which anatomical variation is encountered and the difficulty of the assessment of success make the procedure more challenging than usual.