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PubMed2004

Results of endoscopic third ventriculostomy.

ETV is emerging as the treatment of choice for aqueductal stenosis caused by anatomic, inflammatory, and selected neoplastic etiologies. The technique has also proven useful in the pathologic diagnosis and treatment of these conditions. Long-term results of this procedure and comparison to standard shunting procedures are necessary to define indications for patients with pathologic findings in the intermediate response groups. Development of new studies for pre-operative assessment of CSF absorptive capacity and quantitative postoperative measures of ventriculostomy function would be invaluable additions to our ability to assess candidates for this procedure and their eventual outcome. Further study and technical refinements will, no doubt, lead to many more potential uses for these procedures in the treatment of hydrocephalus and its associated etiologies. The challenge for neuro-surgeons will be to define the operative indications and outcomes, while refining techniques for safely performing these useful procedures.

Humans↗

PubMed2004

Neuro-oncologic applications of endoscopy.

Neurooncology, in all its aspects, provides an ideal venue for the application of endoscopy. The main obstacle to its use has been neuro-surgeons' lack of familiarity with the techniques and their advantages. As the neurooncologic surgeon uses the endoscope more, endoscopy will take its rightful place in the surgeon's armamentarium. The advantages of improved visualization of intraventricular pathology, better management of tumor-related hydrocephalus, less morbid biopsies, and minimally invasive removal of intraventricular tumors are invaluable adjuncts to traditional tumor management. Furthermore, endoscopy is the logical next step for surpassing the limitations of traditional microsurgery. Endoscopy is still in its infancy. Rigorous application of the technology is increasingly allowing us to provide our patients the most maximally effective and minimally invasive surgery possible.

Biopsy↗

PubMed2004

The endoscopic management of arachnoidal cysts.

I have little doubt that most arachnoidal cysts will be managed endoscopically in the future given the advances we have seen over the last decade in our instrumentation. Our excitement to employ this new technology should be governed by the reality that we are still learning and that our current success rate is not quite as good as what can be expected when using microneurosurgery.

Arachnoid Cysts↗

PubMed2004

Loculated ventricles and isolated compartments in hydrocephalus: their pathophysiology and the efficacy of neuroendoscopic surgery.

The neuroendoscopic procedures applied inpatients with isolated compartments, including IUH, LV, IFV, IRF, and multiloculated ventricles were foramen of Monro reconstruction, septostomy, septal wall removal, cyst wall fenestration, fourth ventriculostomy, and endoscopic shunt placement. It was found that the operative goal, creating a state of arrested hydrocephalus, could be achieved by communicating the trapped space to the rest of the ventricular system, opening the ventricular isolation. The associated hydrocephalus could not always be managed endoscopically, however, and shunting of the ventricular system was frequently required, especially in infants. This may be because of the immaturity of the subarachnoid CSF dynamics in infants. What does seem to be logical is to continue to consider managing these conditions with the assistance of the endoscope.

Cerebral Ventricles↗

PubMed2004

Selecting patients for endoscopic third ventriculostomy.

ETV using contemporary instrumentation has been used for more than 50 years, but its use has become widespread only in the last 10 to 15 years. Randomized prospective trials comparing ETV with shunts are needed before definitive statements can be made about the role of the former in managing the many forms of hydrocephalus. The absolute and relative contraindications for the use of ETV in the management of hydrocephalus are shown in the Box 1 on this page. It is important not to presume that a specific radiographic or clinical feature would prevent a patient from responding to this rather new procedure without testing the hypothesis. Patients should be given as much information as possible regarding the risks and benefits of ETV so they can participate in the decision-making process. When should the role of ETV in the management of hydrocephalus be discussed with a patient? At the initial diagnosis of hydrocephalus, the patient or family should be informed of this potential alternative to shunting for the management of hydrocephalus. I also believe that patients with working shunts who are being followed chronically should be informed about ETV as a potential treatment option when their shunt fails. Every shunt failure or infection should be viewed as an opportunity to explore the possibility that the patient could become shunt independent.

Cerebral Ventricles↗

PubMed2005

[Endoscopic ventricular anatomy].

Neurosurgical endoscopy enables in situ exploration of the dilated ventricular system, primarily for therapeutic rather than diagnostic purposes. Ventriculocisternostomy in patients with obstructive hydrocephalus is the most widely performed endoscopic procedure. Perfect knowledge of the intraventricular anatomy is necessary for proper endoscopic navigation so the operator always recognizes the position of the endoscope and the anatomic structures encountered. Endoscopic anatomy in this situation is different from normal anatomy because of the hydrocephalus. Anatomic landmarks must be reassessed. We present here this "new" anatomy.

Cerebral Ventricles↗

PubMedDate not supplied

Transforaminal endoscopic decompression for radiculopathy secondary to intracanal noncontained lumbar disc herniations: outcome and technique.

BACKGROUND CONTEXT: In 1973 Kambin and Gellman introduced the concept of percutaneous posterolateral extracanal approach in the management of radiculopathy secondary to lumbar disc herniation (LDH). This new surgical approach was recognized as potentially even less invasive compared with the microscope-assisted transcanal technique. However, the development of the posterolateral extracanal approach has witnessed a slow and complicated technique and equipment evolution. PURPOSE: To report the surgical outcome, complications and technique of decompressing radiculopathy secondary to noncontained intracanal LDH using percutaneous extracanal access, the transforaminal endoscopic approach. STUDY DESIGN/SETTING: Consecutive cases of LDHs from L3-S1 who had at least 1-year postoperative follow-up were included in this retrospective review. PATIENT SAMPLE: Two hundred nineteen patients met inclusion criteria. There were 136 (62.1%) male patients, average age 41.5 years, and 83 (37.9%) female patients, average age 42.5 years. The age range was 17 to 71 years. METHODS: Two outcome measures were used. The first part was a surgeon-performed assessment. The second used a patient-based outcome questionnaire. OUTCOME MEASURES: The surgeon's retrospective assessment of excellent, good, fair and poor is a modified MacNab classification. The same terminology is used in the patient-based outcome questionnaire. Poor outcome resulting from technique failure is identified. RESULTS: Two hundred nineteen patients met the inclusion criteria. One hundred ninety-three patients also send back their completed questionnaire. The surgeon graded 88% percent of the 219 patients had a good or excellent result and the questionnaire subgroup 91.2%. The fair results were 5% of the 219 patients, 3.6% for the questionnaire patients. The poor results were 6.8% of the 219 patients and 5.2% for the questionnaire subgroup. The overall complication rate was 2.7% and missed fragment rate 0.9%. CONCLUSIONS: Noncontained intracanal LDH fragments are accessible using the transforaminal endoscopic technique and equipment described. Retrospective outcome reviews of our clinical material showed results comparable to the reported findings in the literature for both the endoscopic and open transcanal decompression techniques.

Adolescent↗

PubMed2003

Neuroendoscopic surgery for intracerebral haemorrhage--comparison with traditional therapies.

Endoscopy is a new therapeutic option for hypertensive intracerebral haemorrhage. Although it has the advantages of being less invasive than craniotomy and more effective than conservative treatment, not all patients are candidates for it. Since it is important to clarify which characteristics of patients are indications for this operation, we retrospectively evaluated the role of endoscopic surgery in comparison with traditional treatments for hypertensive intracerebral haemorrhage. Seven patients were treated with endoscopic surgery in our institution between January 2000 and November 2001. Two had thalamic haemorrhage, 4 putaminal haemorrhage, and 1 intracerebral haemorrhage. The average age of patients was 55 years. Endoscopic operation was mainly selected for haematomas more than 20 ml and less than 40 ml in volume. Generally, endoscopy yielded good outcomes with GR in 50 % of patients. Adequate indications for endoscopic operation may be the following; 1) Putaminal haematoma of small-intermediate size, 2) Haematoma situated deep in the brain, e. g., thalamic haemorrhage, 3) Intraventricular haematoma, 4) High-risk patients who cannot tolerate general anaesthesia.

Adult↗

PubMed2004

Blood biochemistry following endoscopic third ventriculostomy.

BACKGROUND: Endoscopic third ventriculostomy (ETV) is now an accepted treatment for obstructive hydrocephalus. Anandh et al. have reported postoperative hyperkalemia following ETV. However, due to small sample size (20 patients), the authors could not confirm their hypothesis (8). Therefore, we have conducted the present study in order to investigate postoperative blood chemistry following ETV. PATIENTS AND METHODS: The computerized database and the medical records of 50 patients who underwent ETV under general anesthesia were studied. Blood chemistry for all patients was done preoperatively as well as for three consecutive days postoperatively. Preoperative and peak postoperative serum blood chemistry variables were compared by using Student's t-test for paired samples. A p value of < 0.05 was considered significant. RESULTS: Preoperative serum K+ concentration mean value was 4.8 +/- 0.7 mmol/l. In the consecutive two postoperative days serum K+ levels mean values were 4.4 +/- 0.8 and 4.3 +/- 0.8 mmol/l with significantly lower levels compared to preoperative values (p < 0.05). CONCLUSIONS: Although significantly lower K+ values have occurred in our series postoperatively, they were of no clinical significance. Moreover, our results were in contrast to Anandh et al. who used lactated Ringer's (LR) as irrigation fluid which led to postoperative hyperkalemia. We recommend the use of normal saline as irrigation fluid instead of LR.

Child↗

PubMed2003

Endoscopic endonasal management of invasive skull base mucocele: report of two cases.

Two cases of massive erosive skull base sphenoid mucocele are reported. Even if intra-sphenoid mucoceles are an ENT pathology, when extensive they become of neurosurgical interest. An endoscopic minimally invasive procedure was performed in both cases with an excellent outcome. Patient 1 presented with several years of retro-orbital bilateral pain and several months of purulent pharyngeal leak. CT scan and MRI imaging showed an extensive erosive intra-sphenoid mass, with peripheral contrast enhancement. Patient 2 was referred because of several months of frontal headache and decreased left visual acuity. A wide intra-sphenoid mass was evident at CT scan and MRI. This mass included an anterior compartment, hyperintense on both T (1)- and T (2)-weighted images, and a posterior part, hypointense on T (1)- and hyperintense on T (2)-weighted images. A pure endoscopic endonasal one nostril pure procedure was performed in both cases. Endoscopic technique has been shown to be an easy and minimally invasive procedure. It should be the treatment of choice in case of invasive skull base mucocele in order to avoid blind damage of vasculo-nervous structures which are not protected by the bone, extensively eroded by the lesion.

Adult↗

PubMed2003

Overdrainage after endoscopic third ventriculostomy: an unusual case of chronic subdural hematoma--case report and review of the literature.

Endoscopic third ventriculostomy is considered a safe technique for the treatment of obstructive hydrocephalus. However, the literature contains several reports of complications related to this procedure. We describe a case of chronic subdural hematoma (CSDH) after ETV, which required surgical evacuation, in a 69-year-old male patient completely asymptomatic up to the control MRI four weeks after the operation. We believe this unusual complication could result from the ICP changes caused by ETV. In our opinion, successful ETV gives a boost to CSF absorption, and overdrainage may evolve also in endoscopic treatment of obstructive hydrocephalus. This situation could be the starting point of the subdural collection. We review the literature and discuss the causes that may lead to CSDH after ETV procedure.

Aged↗

PubMed2003

Endoscopic removal of thalamic hematoma: a technical note.

OBJECT: To minimize invasiveness, an endoscopic surgical technique under stereotactic guidance is described for removal of thalamic hematoma. SURGICAL TECHNIQUE: A burr hole is placed at a point 3 cm above the glabella and 3 cm lateral from the midline. A transcortical transventricular puncture is performed with a stainless steel tube under stereotactic guidance. The tube is mounted to a metal holder. Through this tube, a rod-lens working channel endoscope and surgical instruments are inserted for visualization of the thalamus and evacuation of the hematoma. Compared with the endoscopic approach through the shortest distance of viable brain tissue, this technique allows removal of the hematoma in the ventricular space and thalamus simultaneously. The case of one patient with thalamic hemorrhage and obstructive hydrocephalus, caused by an intraventricular blood clot, is reported for surgical demonstration. CONCLUSION: An endoscopic technique for removal of thalamic hematoma with the aid of stereotactic guidance, which allows precise targeting of the lesion, is reported.

Aged↗

PubMed2003

Chronic subdural haematoma treatment with a rigid endoscope.

Surgical treatment is the method of choice in cases of chronic subdural haematoma--as a rule: trephination, drainage with lavage, or repeated drainage (drain reinsertion where the haematoma has been evacuated insufficiently). A poorly manageable but non-negligible group is made up of patients (about 5-12 % of all cases) where the less invasive methods of choice keep failing. The equally mini-invasive endoscopic technique appears to be one of the suitable therapeutical approaches before resorting to open-surgery revision. The adapted technique of rigid endoscope insertion permitting sufficient revision and treatment of the subdural space concerned is presented. The method is demonstrated on three case reports where routine trephination with lavage, drainage and repeated drain insertion failed. A very good improvement in clinical condition and graphic findings was achieved in two patients. In the remaining one, the neurological lesion improved ad integrum despite a tiny residual haematoma as visualized by CT. Two weeks later, a clinical relapse had developed and the patient was treated with new trephination and drain reinsertion. The technical aspects of the modification of the endoscopic technique are discussed: stressing the advantages or low-degree invasiveness, scope for keeping intact the inner membrane of the haematoma and avoiding direct invasion of the cerebral tissue. The limits of the method are discussed as well. The authors regard this method as a useful addition to the surgical armamentarium, especially in cases of chronic subdural haematomas resisting conventional approaches.

Aged↗

PubMed2004

A simplified endoscopic third ventriculostomy under local anesthesia.

The aim of this study is the analysis of our experience with awake endoscopic third ventriculostomy (ETVS) in hydrocephalic patients. From September 1994 to December 2001, 24 neuroendoscopic procedures were performed under local anesthesia. Local infiltration was administered using a bupivacaine and lidocaine mixture. Analgesics were titrated to the effect. A free-hand technique with a flexible endoscope was adopted in 24 patients with primitive and secondary (neoplastic) hydrocephalus. ETVS was performed successfully in all cases. No procedure needed to be discontinued due to seizures, bleeding or agitation. Dural incision/coagulation and Fogarty dilatation proved to be the most painful maneuvers requiring, sometimes, supplemental analgesic administration. No intraoperative complications were observed; however, two asymptomatic trajectory hematomas were incidentally discovered two and three days after the operation, respectively. Awake ETVS is a valuable alternative procedure that can be adopted in adult cooperative patients, provided that the procedure is done in an essential and fast way with the free-hand technique, by means of a flexible endoscope, and with the assistance of an anesthesiologist.

Adult↗

PubMed2004

Trapped fourth ventricle treated with shunt placement in the fourth ventricle by direct visualization with flexible neuroendoscope.

Shunt placement was the most common procedure used for ventricular dilatation, but in many neurosurgical centers it has been substituted by flexible neuroendoscope; however, none of them had solved the problem of the trapped and dilated fourth ventricle. The combination of the ventricle-peritoneal catheter placement in the center of the fourth ventricle by direct visualization with a flexible neuroendoscope using a single coronal burr-hole has solved this problem. Eleven patients with a trapped fourth ventricle, with previous third ventriculostomy and aqueductal plasty, were treated with this procedure; all patients were evaluated clinically and with computed tomography 8 to 24 months (mean, 18 months) later. Here, we describe the technical procedure.

Adolescent↗

PubMed2004

A newly designed disposable introducer sheath for a ventricular fiberscope.

We have developed a disposable plastic introducer sheath for use with a flexible endoscope during intraventricular procedures. The sheath is composed of a thin polypropylene tube passing through the center of a plastic stopper. The tube serves as a sheath through which the fiberscope is introduced into the ventricle. The stopper seats in the burr hole and prevents downward and lateral movement of the tube. The sheath can be placed safely in the ventricle with a drainage catheter used as an introducing guide. We used this sheath system in 10 patients and found it very useful. Manipulation of the fiberscope was not hindered, copious irrigation was allowed, and the sheath remained stable on the skull. This new introducer sheath may contribute to the increased use of a flexible endoscope in neuroendoscopic procedures.

Cerebral Ventricles↗

PubMed2004

Third ventriculostomy in communicating hydrocephalus in adult patients -- the role of lumbar and cranial cerebrospinal fluid outflow measurement.

OBJECTIVE: To evaluate the value of CSF outflow resistance testing as a criterion for endscopic treatment in case of communicating hydrocephalus. METHODS: 12 patients with communicating hydrocephalus were integrated in a prospective study from 1999 - 2001. Under the assumption of different hydromechanical properties of both spinal and cerebral CSF compartment the resorption capacity was measured. V.-p. shunting, ventriculostomy or conservative treatment were performed dependent on the results and clinical outcome was evaluated. RESULTS: Six patients with pathological lumbar testing underwent primary ventriculo-peritoneal shunting. In 6 of the 12 cases the lumbar CSF resorption capacity was found to be normal and cerebral testing was accomplished. Two patients with normal spinal and cerebral resorption capacity were not operated. In the remaining 4 patients cerebral testing was found to be pathological and ventriculostomy was performed. An improvement of clinical symptoms was observed in patients operated with a v.-p. shunt and in the VCS group as well. CONCLUSIONS: This study demonstrates that there is a subgroup of patients with morphological communicating hydrocephalus that is characterized by a functional dissociation of hydromechanical properties of intracranial and spinal CSF compartment. In cases of regular CSF resorption but restricted CSF outflow from the ventricular system to the subarachnoid space ventriculo-peritoneal shunting may be an efficient therapy, but VCS was proved to be an efficient alternative.

Aged↗

PubMed2004

A neuroendoscopic approach to the aqueduct via the fourth ventricle combined with suboccipital craniectomy.

OBJECTIVES: We have tried to approach the aqueduct less invasively with the endoscope in combination with a small suboccipital craniectomy, especially for lesions of the aqueduct close to the fourth ventricle. METHODS: The patient is placed in the prone position and a small suboccipital craniectomy is performed. After elevating the bilateral tonsils with retractors, the sheath of the endoscope is inserted from a small skin incision made on the posterior midline of the neck, far from the craniectomy site. The skin incision for endoscopic insertion is planned on the linear extension connecting the aqueduct and the foramen of Magendi on the craniocervical MRI. A rigid endoscope is inserted through the fourth ventricle to the aqueduct for exploration and surgical manipulation. RESULTS: Two cases with hydrocephalus due to aqueductal stenosis, with gait disturbance were operated. After exploration of the aqueduct via the fourth ventricle, endoscopic aqueductal plasty was performed. The postoperative courses were uneventful. The patients' symptoms disappeared. CONCLUSIONS: This approach can be applied for less invasive endoscopic exploration and surgery around the aqueduct close to the fourth ventricle with a rigid endoscope, without overflexion of the neck, or a large craniectomy, or overretraction of the tonsils, or incision of the inferior vermis.

Cerebral Aqueduct↗