What is the appropriate shunt system for normal pressure hydrocephalus?

Normal pressure hydrocephalus (NPH) represents a common disorder among older people with mild elevation of cerebrospinal fluid pressure and certain clinical manifestations. We present a patient with such a disorder in whom a programmable valve was implanted. With the use of a lower opening pressure, the patient developed a subdural hematoma although the symptoms subsided. After evacuating the hematoma and by setting the valve pressure higher, the patient recovered without any symptomatology. We observed that only the higher pressure was the right one, although in two different pressure values the symptoms had subsided.

Benign cerebral aqueductal stenosis in an adult.

We present a patient with partial stenosis of aqueduct of Sylvius which was an incidental finding without any clinical symptoms. That in our opinion means that the ventricular brain system has many reserves that are being activated before symptoms appear.

Leptomeningeal carcinomatosis presenting as bilateral sensorineural deafness and unilateral facial palsy.

This paper describes the case of a 56-year-old man with a history of small cell lung cancer under chemotherapy, who presented with left-sided peripheral facial palsy and progressive bilateral sensorineural deafness due to leptomeningeal carcinomatosis (LMC). Brain magnetic resonance imaging (MRI) of the petrosal bones and posterior cranial fossa revealed 2 solid lesions in the internal acoustic meatuses bilaterally and LMC of the skull base. Whole brain radiation therapy and methotrexate intrathecally were applied to the patient.

Sectioning of filum terminale externum using a rigid endoscope through the sacral hiatus. Cadaver study.

AIM: Tethered cord syndrome (TCS) is a stretch-induced functional disorder of the spinal cord, which is directly related to filum fixation. Classic surgical approaches to the filum involve open surgery and include varying amounts of spinal bone removal. In an effort to reduce the morbidity and mortality of these procedures, the authors explored a less invasive method. They evaluated the ability, safety and feasibility for endoscopic sectioning of the filum terminale externum by performing upward orientated navigation in the extradural sacral spinal canal through the sacral hiatus using a rigid endoscope. METHODS: Four adult, phenol-formalin embalmed cadavers were used for endoscopic section of the filum terminale externum at the tip of thecal sac. After preparing the anatomical area of sacral hiatus, a rigid endoscope (Storz, of 3.8 mm external diameter with two working channels, of 1 mm each, one for suction-irrigation and one as working) was inserted into the extradural sacral spinal canal and the filum terminale externum was identified and cut easily at the distal end of thecal sac at the level of S2. In all cases, it was possible to manipulate the rigid endoscope and inspect the full length of the extradural sacral spinal canal, especially at the S1-S2 level. RESULTS: The results indicate that the tested transhiatal approach for upward orientated extradural endoscopy represents a minimally invasive procedure that provides an appropriate and feasible route to the extradural sacral spinal canal. CONCLUSION: Such approach is an attractive alternative for filum terminale externum sectioning in cases where tethered cord syndrome is not accompanied by any other pathology. Moreover if filum terminale internum sectiong is indicated, it can be performed in second stage.

Optimal treatment of a recurrent giant craniopharyngioma: lessons from a case.

A case of a 33-year-old man presented with symptoms of dramatic deterioration of the level of consciousness because of a recurrence of a previously aspirated and irradiated craniopharyngioma is described. The tumor had grown enormously in dimensions and was extending in the region of hypothalamus, third ventricle and brain stem, with signs of local compression and obstructive hydrocephalus. Radical surgical excision, despite the size and the location of the lesion, was the therapy of choice. The surgical technique is described. We conclude that in expert hands, microsurgery aiming at total removal should be the therapeutic option for the treatment of recurrent as well as primary craniopharyngiomas.

Endoscopic anatomy of the thecal sac using a flexible steerable endoscope.

In this study the ability for upward-orientated endoscopic visualization of thecal subarachnoid space using a flexible steerable endoscope was evaluated in order to compare endoscopic anatomical findings with the already known macroscopic ones of the incontained structures and to test the approach for clinical employment. For this purpose, four adult phenol-formalin embalmed cadavers were used and the approach selected was through a laminectomy window at the S1-S2 level. The dura mater was opened and a flexible steerable endoscope (Storz, of 2.8 mm external diameter with one working channel) was inserted subarachnoidally for upward-orientated observation of the content of thecal sac. By using this approach filum terminale, lower lumbar, sacral and coccygeal nerve rootlets were identified and observed in detail. By moving the endoscope even more upwards, inspection of the upper part of the thecal subarachnoid space and conus medullaris was also possible. The findings collected from the study indicate that this approach for upward-orientated intradural subarachnoid endoscopy gives an appropriate working and inspecting window to the lower, as well as to the upper part of the thecal subarachnoid space and even of the conus medullaris. Furthermore, inspection and identification of lower lumbar, sacral and coccygeal nerve rootlets is possible and efficient and the endoscopic anatomical observations coincide with the already known gross-anatomical ones.

Endoscopic treatment of lumbar arachnoiditis.

OBJECTIVE: The diagnosis of lumbar arachnoiditis remains complex and often inconclusive. Using the technique of lumbar subarachnoidal endoscopy (thecaloscopy), the pathology can be identified and the patient treated with long-term effects on the symptoms. METHOD: Endoscopic operations were performed on 23 patients suffering from varying symptoms with an enlarged lumbar subarachnoidal space. Having confirmed the diagnosis of lumbar arachnoiditis, a number of endoscopic operations ranging from adhesiolysis to subarachno-epidurostomy were carried out. RESULTS: Radicular symptoms in lumbar arachnoiditis were successfully relieved by various endoscopic dissection techniques, such as restoration of the improved CSF flow by subarachno-epidurostomy along the rootlet. This has been identified as one of the causal factors of the clinical symptoms. In cases where lumbar pain persists in spite of a previous thecaloscopy, further treatment with a lumboperitoneal shunt device has proved most successful.

[Adhesive lumbar arachnoiditis. Endoscopic subarachnoepidurostomy as a new treatment]. / Lumbale adhäsive Arachnoiditis. Endoskopische Subarachnoepidurostomie als neue Behandlungsmöglichkeit.

BACKGROUND: Adhesive lumbar arachnoiditis is essentially an unknown, unreported, and unrecognised disease. It was better known at a time when oil-based dye was used for myelography. The factors causing this pathogenesis remain unknown. In addition, diagnosis is hard to achieve and frequently attained only by an exclusion process. Only in severe cases, using high-resolution MRI, is evidence for the diagnosis obtainable. METHOD/PATIENTS: Modern neuroendoscopic techniques allow diagnosis at a reasonable risk (comparable with lumbar tap) and enable us substantially to treat the pain. Taken together, this means a radical new method of treatment for adhesive arachnoiditis. The treatment of a 23-patient research group suffering from adhesive lumbar arachnoiditis is monitored and described. RESULTS: Various endoscopic manoeuvres were carried out. Endoscopic reduction of adhesions and internal shunting for CSF flow between subarachnoidal and epidural space improved both the biomechanical abilities of rootlets and restoration of blocked CSF pathways. Its main result is the significant reduction of long-term pain registered by a visual analogue pain scale. No bad side effect other than temporary headache was found. No CSF leak syndrome was observed. DISCUSSION: The success of the method was directly influenced by the interventional procedure on the disturbed CSF circulation and its partial restoration (subarachnoepidurostomy). In cases of severe lumbar adhesive arachnoiditis, it was found very beneficial to implant special gravity-controlled valve systems for subarachnoid-peritoneal shunts. CONCLUSION: Adhesive lumbar arachnoiditis is no longer a devastating diagnosis. Due to a novel endoscopic treatment of the local CSF disturbances that restores physiologic pathways, the chance exists for long-lasting improvement of the clinical condition.

Middle cranial fossa endoscopy using a rigid endoscope.

Trigeminal neuralgia (TN), also known as tic douloureaux, is a craniofacial pain disorder which is typically associated with acute-onset severe pain on one side of the face usually. The condition is characterized by intermittent unilateral pain affecting the lower face and jaw. Although many potential causes have been implicated, in many patients the etiology remains obscure. Initially, patients with trigeminal neuralgia should be offered conservative medical management. If surgery is necessary, the simplest and least hazardous procedure should be chosen. The goals of modern surgical therapy are: Long-term pain control, minimal to no morbidity, and as low a mortality risk as possible. In this study, we attempted to perform middle cranial fossa endoscopic exploration in four adult phenol-formalin embalmed cadavers, using a rigid endoscope with 3.8 mm external diameter and two working channels of 1 mm in diameter each (Karl Storz, Tuttlingen, Germany), inserted through a burr-hole centered at the base of the middle cranial fossa, 1 cm in front and 1 cm upwards of the tragus. Our objective was to determine if this approach provides adequate access to the trigeminal ganglion for possible dissection of V2 and V3 trigeminal roots, the two typically radiating sites of TN. In all four cadavers, middle cranial fossa exploration was possible without difficulties. We offer this approach as a minimally invasive surgical procedure to access the trigeminal ganglion, for potential use as another alternative for the surgical management of medically refractory trigeminal neuralgia.

Percutaneous approach for thecaloscopy of the lumbar subarachnoidal space.

INTRODUCTION: Endoscopy of the lumbar subarachnoidal space is named thecaloscopy, which has been used for diagnostic and therapeutic purposes. However, the insertion of the endoscope required microsurgical assistance from the skin into thecal sac in the lumbar region. The current study was applied to explore the possibility of a percutaneous approach for lumbar thecaloscopy insertion, transferring from the previous microsurgical procedure. METHOD: A 2.8-mm fiberoptic endoscope (Storz and Co., Tuttlingen, Germany) was used in the study. In two fresh human cadavers, a thecaloscope was first inserted through a transsacral approach and the tip was advanced inside the thecal sac to the lumbar region for observation. A percutaneous endoscopic approach was performed with the Seldinger technique under fluoroscopic control into the lumbar subarachnoid space. After completing the endoscopic procedure, the lumbar subarachnoid space was exposed microsurgically for morphological investigation of rootlets and surrounding structures. RESULTS: By the observation through a live video in the thecal sac, the percutaneous insertion of a 2.8-mm endoscope into the lumbar subarachnoidal space is feasible without any neural structural damage seen. CONCLUSION: The percutaneous approach for flexible endoscopes into the lumbar subarachnoidal space is a practical option for the future of thecaloscopy.

Thecaloscopy through sacral bone approaches, cadaver study: further anatomic landmarks.

Endoscopy of the spinal canal, for interventional studies, diagnosis and therapy, is a scientific topic that has attracted the interest of neurosurgeons, anesthesiologists and orthopedic surgeons for the past twenty years. Endoscopy of the thecal sac was assumed to be less important than endoscopy of the ventricular system by neurosurgeons. Nevertheless, during the last years it has attained increasing scientific interest, firstly because of the introduction of small diameter flexible endoscopes and secondly due to the growing interest for minimal invasive diagnostic and therapeutic procedures in modern neurosurgery. Until now thecaloscopy was performed by the ISGT (International Study Group for Thecaloscopy) using co-axial downward orientated approaches. We have examined transsacral approaches to facilitate the navigation of flexible scopes in the lumbosacral subarachnoid space, and thus we now introduce further recognizable endoscopic anatomic landmarks.

Thecaloscopy part II: anatomical landmarks.

Endoscopic anatomy differs from microsurgical anatomy. Topographical orientation as well as the proportion of objects, is different as they depend on the lens/object distance. Orientation under endoscopic conditions requires structures with defined positions or recognisable structures previously identified radiolologically. Structures are anatomical landmarks if the topographical relation to their surroundings is constant and they are easy and reliable to recognise. The contents of the dural sack are nerve roots with their supplying vessels, arachnoid trabeculars, filum terminale, and CSF. Safe navigation of a thecaloscope in relation to the bony structures is only possible with the simultaneous use of intraoperative fluoroscopy. To facilitate the navigation of scopes and instruments in the subarachnoid space we attempted to identify and describe reliable, and therefore constant recognisable anatomical landmarks.