Long-term outcome of endoscopic third ventriculostomy in obstructive hydrocephalus.

This multicentric study reports on 140 patients who underwent endoscopic third ventriculostomy for obstructive hydrocephalus in four Italian neurosurgical centers between 1994 and 1999. Its aim is to define the long-term outcome of these patients many years (6-12) after the initial procedure. The study includes both children and adults; the etiology of the hydrocephalus was malformative aqueductal stenosis in 88 cases (62.8%), compression by tumors of the mesencephalic and pineal regions and posterior fossa in 45 (32.2%) and post-infection aqueductal stenosis in 7 (5%). The ETV was performed by using the standard technique. The overall rate of good results (shunt-independent patients with clinical remission or improvement) was 87.1%. Eighteen patients (12.9%) required a shunt because of ETV failure. The long-term outcome of ETV in this study was not influenced by the patient's age and the etiology of the hydrocephalus (although cases secondary to cisternal hemorrhage and infections are not included). Other series including cases with long follow-up are analyzed. In conclusion, ETV results in a high rate of good long-term outcome in patients with obstructive hydrocephalus. Because postoperative failures occur early, clinical and radiological control studies must be performed particularly in the first years after the neuroendoscopic procedure.

Cooperative study by the Italian neuroendoscopy group on the treatment of 61 colloid cysts.

OBJECTS: Microsurgical resection, stereotactic aspiration and VP shunt have for years been the choice options for the treatment of colloid cysts of the third ventricle. Recently, endoscopic approaches have aroused increasing interest and gained acceptance. Although safer, this minimally invasive approach is considered less efficacious than microsurgery. Relatively long-term results are now available and some conclusions might be inferred on the usefulness of this procedure. MATERIALS AND METHODS: Between 1994 and 2005, 61 patients harbouring a colloid cyst of the third ventricle were treated with neuroendoscopic technique in 11 Italian neurosurgical centres. Cyst diameters ranged from 6 to 32 mm. A flexible endoscope was used in 34 cases, a rigid one in 21, both instruments in six. The technique consisted in cyst fenestrations, colloid aspiration, coagulation of the internal cyst wall and, occasionally, capsule excision. Mean postoperative hospital stay was 6.7 days. Early postoperative neuroimaging revealed a cyst residue in 36 cases (mean diameter 4.3 mm). There were two complications (3.2%). Follow-up varied between 1 and 132 months (mean 32 months, more than 5 years in 17 patients). There were seven asymptomatic recurrences, three of them evolving from a previous residue. CONCLUSION: The endoscopic approach to the treatment of colloid cysts is safe, effective and well accepted by patients. Although asymptomatic, recurrences (11.4%) cast a persisting shadow on the long-term results, and, therefore, the controversy with the traditional microsurgical treatment remains open.

Endoscope-controlled microneurosurgery for the treatment of intracranial fluid cysts.

OBJECTIVE: This study assessed the role of endoscope-controlled microneurosurgery (ECM) in the treatment of intracranial cerebrospinal fluid (CSF) cysts. METHODS: Twelve patients affected by symptomatic arachnoid cysts (11 in the sylvian fissure and 1 in the cerebellopontine angle) underwent ECM, in which the endoscope is used to view the operating field while microsurgical instruments can be passed alongside the endoscope for surgical maneuvers. All the cysts were superficially located and could be reached directly through a burr hole on their surface, so that the endoscope was inserted into the cyst without passing through the brain parenchyma. We used a rigid endoscope, performing a wide fenestration of the cyst in the basal cisterns (cystocisternostomy). The excellent endoscopic vision facilitated the surgical procedure with safe maneuvers through a minimally invasive approach. In 11 patients, we observed the resolution of symptoms. A radiological reduction in the cyst was observed in 7 cases. No mortality or major complications were observed. CONCLUSIONS: Endoscope-controlled microsurgery is a valid minimally invasive procedure for treating superficially located intracranial arachnoid cysts.

Bobble-head doll syndrome due to a suprasellar arachnoid cyst: endoscopic treatment in two cases.

OBJECT: We report two cases of bobble-head doll syndrome associated with a large suprasellar arachnoid cyst successfully treated with a minimally invasive endoscopic approach. METHODS: The clinical history, surgical treatment and results of two children, a 9-year-old boy and a 1-year-old girl, both presenting the clinical features of the bobble-head doll syndrome, are described. As a first procedure, a ventriculo-cystostomy was endoscopically performed in both patients, obtaining either resolution of the symptoms or notable cyst reduction. In the girl, a re-closure of the stoma, with cyst re-expansion, was observed after 18 months. She then underwent a second procedure, a ventriculo-cysto-cisternostomy, with a good result. After 3 years' follow-up, the neurological condition of both patients remains good with complete resolution of abnormal head movement. CONCLUSION: In our opinion, endoscopic treatment is the procedure of choice for this condition, as it involves few complications and gives good results.

Spondylectomy (thoracolumbar spine) combined with dural resection for bone tumor: surgical technique.

The authors describe the technique of vertebral resection combined with resection and reconstruction of the dura mater for bone tumor. The literature relevant to this topic is reviewed.

Endoscopic treatment of para- and intraventricular cerebrospinal fluid cysts.

This study has been made to define the role of endoscopy and the most appropriate approach and technique of endoscopic fenestration of paraventricular and intraventricular CSF cysts according to the cyst size and location. Twenty-two patients with intraventricular (13 cases) and paraventricular (9 cases) CSF cysts, operated upon by endoscopic technique in three Italian neurosurgical centers, are reviewed. Paraventricular hemispheric cysts have been treated by endoscopic fenestration from the cyst to the lateral ventricle. Midline intraventricular cysts (2 of the septum pellucidum and 4 of the velum interpositum) underwent fenestration from the right lateral ventricle to the cyst, with fenestration in both lateral ventricles in one case. Cysts of the choroid plexus have been fenestrated from the homolateral enlarged ventricle (4 cases) or from the contralateral compressed ventricle (2 cases). Twenty patients (more than 90%) were definitively cured by the endoscopic procedure, whereas only 2 patients required a shunt or a direct approach. We think that the endoscopic fenestration must be considered the treatment of choice of intraventricular and paraventricular CSF cysts.

Endoscopic third ventriculostomy for hydrocephalus.

The authors report on 125 patients who underwent endoscopic third ventriculostomy for obstructive hydrocephalus in three Italian Neurosurgical Centers. The series includes 77 cases of primary aqueductal stenosis, 33 with triventricular hydrocephalus due to external tumor compression, and 15 with tetraventricular hydrocephalus. The operations were carried out mainly under general anesthesia, using a flexible endoscope. Decrease of size of the third ventricle and the presence of a signal void at the level of the fenestration are the main postoperative MRI findings. Signs of intracranial hypertension, increased head circumference and Parinaud syndrome respond more frequently to the endoscopic treatment. The overall rate of good results (shunt-independent patients) in this series is 86.4%; primary aqueductal stenosis (93.5%) and triventricular hydrocephalus due to external compression (84.8%) are associated to the higher rate of good postoperative results than tetraventricular hydrocephalus (53.3%). Because of the very low invasivity of this technique, the absence of postoperative mortality and the scarce and usually transient postoperative complications, the authors advise to enlarge the indications for endoscopic third ventriculostomy to all patients with obstructive hydrocephalus when the third ventricle is large enough and there are no alterations of the CSF resorption.

Female rats are more susceptible to the development of neuropathic pain using the partial sciatic nerve ligation (PSNL) model.

A comparison study was conducted to determine if a gender difference could be detected using an animal model for causalgia. The sciatic nerve was tightly ligated so that 1/3 to 1/2 of the nerve thickness was trapped by the ligature, just distal to the point at which the posterior biceps semitendinosus nerve branches off the common sciatic nerve. By measuring paw withdrawal from innocuous stimulation with Von Frey filaments, the percent of rats displaying average mechanical sensitivity of the injured paw that was significantly elevated compared to sham or unoperated control animals (days 22-24) was 28.6% for the male group versus 63.6% for the female group. Our animals did not display a consistent response in withdrawal latency to heat applied to the plantar surface of the root (hyperpathia). The data suggests that female rats are significantly more susceptible to developing neuropathic pain than male rats using this experimental model for causalgia.