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PubMed2005

Endoscopic surgery for intraventricular brain tumors in patients without hydrocephalus.

OBJECTIVE: Endoscopy usually is avoided in patients without hydrocephalus because of presumed difficulties with ventricular cannulation and intraventricular navigation. The feasibility of endoscopic tumor management in patients without hydrocephalus was assessed on the basis of achieving the surgical objective and assessing procedure-related morbidity. METHODS: Eighty patients who underwent endoscopic management for an intraventricular brain tumor were identified from a prospective database. Of these patients, 15 had an intraventricular tumor without concomitant hydrocephalus and underwent primary endoscopic surgery for biopsy or resection. The surgical technique, the success rate, and patient outcome were assessed and then compared with 65 hydrocephalic patients who underwent similar procedures. RESULTS: Tumors were located in the third ventricle in 11 patients and the lateral ventricle in 4 patients. The ventricular compartment was cannulated successfully and the intended goal was accomplished in all patients (100%); 12 had successful diagnostic sampling and 3 had complete colloid cyst resection. There were no operative complications related to the endoscopic procedure, and no patient required subsequent intervention for hydrocephalus. The results in this group of patients did not differ with the success and morbidity after endoscopic tumor surgery in patients with hydrocephalus. CONCLUSION: Endoscopic biopsy or resection of intraventricular brain tumors in patients without hydrocephalus is feasible. The described procedure uniformly satisfied the intended surgical goal. The absence of ventriculomegaly in patients with an intraventricular brain tumor should not serve as a contraindication to endoscopic tumor biopsy or resection.

Adolescent↗
PubMed2006

Intracranial pressure monitoring and lumbar puncture after endoscopic third ventriculostomy in children.

OBJECTIVE: The aim of this study is to analyze changes in intracranial pressure (ICP) after endoscopic third ventriculostomy (ETV) performed in children affected by noncommunicating hydrocephalus. METHODS: ICP was continuously recorded for an average of 7 days in 64 children who underwent 68 ETVs for obstructive triventricular hydrocephalus of various etiology. In the first group (44 children), ETV was performed as the primary treatment; in the second group (20 children), the patients presented with shunt malfunction and underwent ETV and shunt removal. Three of the patients in the second group were reoperated for obstruction of the stoma: two were reoperated once and one was reoperated twice. RESULTS: ICP changes after ETV were not homogeneous and varied according to etiology: the highest values were observed in patients affected by posterior fossa tumors and the lowest values were seen in patients operated on during shunt malfunction and who had their shunt removed. After 31 procedures (45.6%), ICP remained normal (< 20 mmHg) for the entire duration of the monitoring. After 37 procedures (54.5%), ICP was persistently high on Day 1 (mean, 29.7) and decreased very slowly in the subsequent days, remaining high for 2-9 days (mean, 4.5). After 20 of the 37 procedures with high postoperative ICP, patients presented symptoms of intracranial hypertension that resolved, in most of the cases, with one or two lumbar punctures. Lumbar puncture was noted to be effective in bringing about fast normalization of the ICP and resolution of the symptoms. In 13 patients (19.1%), ETV failed and a ventriculoperitoneal shunt was implanted. After four procedures, the stoma obstructed and the patients were treated, reopening the stoma. Postoperative ICP was not statistically significant higher in the patients in whom ETV failed. CONCLUSION: The high ICP observed in a group of patients in the early postoperative days is probably related to the slow permeation of the subarachnoid spaces by the cerebrospinal fluid flowing out of the third ventriculostomy. Management of intracranial hypertension after ETV remains a matter of controversy. The role of the lumbar puncture in the faster normalization of the ICP is examined in this article. By increasing the compliance and the buffering capacities of the spinal subarachnoid spaces, it probably decreases the cerebrospinal fluid outflow resistance from the ventricular system, facilitating the decrease of the ventricular volume and allowing faster permeation of the intracranial subarachnoid spaces. High postoperative ICP can account for persistent symptoms of intracranial hypertension and ventricular dilatation on computed tomographic scans after third ventriculostomy. A cycle of one to three lumbar punctures should always be performed in patients who remain symptomatic and who show increasing ventricular dilatation after ETV, before ETV is assumed to have failed and an extracranial cerebrospinal fluid shunt is implanted.

Cerebrospinal Fluid Shunts↗
PubMed2006

Endoscopic transsphenoidal surgery: stone-in-the-pond effect.

THE TRANSSPHENOIDAL MIDLINE route represents the standard approach to the pituitary and sellar area and is used for more than 95% of surgical indications in this region. It is the least traumatic route to the sella turcica, it avoids brain retraction, and it provides excellent visualization of the pituitary gland and lesions related to that structure. The technique has essentially replaced craniotomy and has been used by every pituitary neurosurgeon, representing the "gold standard" of the transsphenoidal approach to the sellar region for more than 30 years. The introduction of endoscopic techniques has produced a "stone-in-the-pond" effect, influencing the relatively peaceful neurosurgical environment. The brilliant increased vision of the surgical target offered by the endoscope can allow more effective removal of the lesion, followed by superior clinical results and a reduction in the incidence of complications. Endoscopy contributes to better and more contemporary knowledge of the possibilities of the transsphenoidal approach, thus increasing the extended approaches, not only for the pituitary area. Whether or not the transsphenoidal approach should be performed with the use of the microscope or the endoscope is finally discussed.

Humans↗
PubMed2006

Endoscopic third ventriculostomy for occlusive hydrocephalus caused by cerebellar infarction.

OBJECTIVE: The surgical management of occlusive hydrocephalus caused by massive cerebellar infarction remains controversial. The procedures that are more commonly used to avoid progressive neurological deterioration are based on transient external ventricular drainage or the placement of permanent shunt systems. To our knowledge, this is the first report regarding using endoscopic third ventriculostomy (ETV) in patients with an occlusive hydrocephalus caused by cerebellar ischemic stroke. We report our experience of 10 reviewed cases. METHODS: Between 1997 and 2004, 10 patients with a resulting hydrocephalus caused by a space-occupying cerebellar infarction were managed with ETV. Glasgow Coma Scale score on admission, cause of stroke, and computed tomographic signs, including the ischemic vascular territory involved and brain edema, were noted. Clinical outcome was evaluated using the Glasgow Outcome Scale. RESULTS: In all patients, there was a mean interval of 4 days from the onset of deterioration of consciousness to operation. Mean Glasgow Coma Scale score on admission was 11.2. In nine patients, ETV was the initial procedure of ventricular drainage. One patient was primarily treated with an external ventricular drainage, but the device dislocated and ETV was performed. In one patient, an external ventricular drainage became necessary 7 days after the initial ETV because of a malfunction of the stoma. One patient showed a progressive brain edema 2 days after ETV, and suboccipital decompression was performed. Eight successfully treated patients demonstrated an improvement in the level of consciousness after ETV. Mean Glasgow Outcome Scale score on discharge of all patients was 3.4. CONCLUSION: Occlusive hydrocephalus caused by cerebellar infarction is infrequent. When occlusive hydrocephalus is observed, ETV can be used successfully with minimal risks, especially with avoidance of a higher rate of infectious complications caused by external drainage systems.

Adult↗
PubMed2007

Extended endoscopic endonasal transsphenoidal approach for the removal of suprasellar tumors: Part 2.

OBJECTIVE: The widespread use of the endoscope in transsphenoidal pituitary surgery has recently contributed to the extension of the approach beyond the tuberculum sellae and planum sphenoidale for the management of lesions located in the suprasellar area, either with an endoscope-assisted or purely endoscopic technique. Based on our previous experience with more than 450 standard endoscopic transsphenoidal operations, we have retrospectively evaluated the effectiveness of the extended endoscopic endonasal transsphenoidal approach in the management of lesions mainly located in the suprasellar area. METHODS: Between January 2004 and December 2005, 20 consecutive patients underwent extended endoscopic endonasal transsphenoidal surgery for a total of 21 procedures. The series consisted of seven pituitary adenomas, seven craniopharyngiomas, three suprasellar Rathke's cleft cysts, two tuberculum sellae meningiomas, and one pilocytic astrocytoma of the chiasm. RESULTS: Tumor removal, as assessed by postoperative magnetic resonance imaging, revealed complete removal of the lesion in four out of seven pituitary adenomas, five out of seven craniopharyngiomas, three out of three Rathke's cleft cysts, and two out of two tuberculum sellae meningiomas. One patient (5%) with craniopharyngioma had a postoperative cerebrospinal fluid leak that required reoperation. The same patient experienced a sphenoid mycosis, which was treated with medical therapy. Some specific conditions associated with the anatomy of the surgical route, as well as to the morphology of the lesion, have resulted to condition the feasibility of the approach. CONCLUSION: Small and medium sized suprasellar lesions located in the midline, with or without a limited parasellar extension and without involvement of vascular structures, seem amenable to be resected through such extended endoscopic transsphenoidal approach. Improvements in closure techniques and the use of new materials and surgical glues seem to significantly reduce the postoperative cerebrospinal fluid leak rate and meningitis.

Adult↗
PubMed2005

Newly developed endoscopic instruments for the removal of intracerebral hematoma.

Ultra-early surgical treatment in which associated brain injury is minimized and maximal volume of hematoma is removed shortly after onset with secure hemostasis is expected to be established. We developed a transparent guiding sheath and other surgical instruments for endoscopic surgery and established a novel, ultra-early stage surgical procedure using those instruments. This procedure has the following characteristics: (a) burr hole opening under local anesthesia is possible; (b) a transparent sheath improves the visualization of the surgical field in the parenchyma and the hematoma; (c) free-hand surgery without fixing an endoscope and a sheath to a frame facilitates three-dimensional operation; (d) secure hemostasis by electric coagulation is possible; (e) relatively simple surgical instruments are easy to prepare. We have performed this procedure in 82 patients with intracerebral or intraventricular hemorrhage (44 with putaminal hemorrhage, 12 with thalamic hemorrhage, 8 with subcortical hemorrhage, 8 with cerebellar hemorrhage, 10 with intraventricular hemorrhage). Twenty-four of those patients received our treatment in the ultra-early stage (within 3 hours after onset). The mean duration of surgery was 63 minutes, the mean hematoma reduction rate was 96%, and no peri-operative hemorrhage with deterioration of symptoms and/or signs occurred. Therefore, we believe that endoscopic hematoma evacuation with our surgical procedure is a promising ultra-early stage treatment for intracerebral hemorrhage and that it may improve the long-term prognosis in patents with intracerebral hemorrhage.

Equipment Design↗
PubMed2004

Tension pneumocephalus after a neuroendoscopic procedure--case report.

A 60-year-old female presented with gait disturbance, urinary incontinence, and recent memory disturbance. Computed tomography and magnetic resonance imaging revealed a partially calcified mass lesion without enhancement in the left caudate head and mild ventriculomegaly. She underwent endoscopic tumor biopsy. The histological diagnosis was astrocytoma grade 2. After the endoscopic procedure she presented with prolonged consciousness disturbance caused by tension pneumocephalus. Tension pneumocephalus is one of the potential complications of neuroendoscopic procedures.

Astrocytoma↗
PubMed2004

Neuroendoscopic transventricular surgery for suprasellar cystic mass lesions such as cystic craniopharyngioma and Rathke cleft cyst.

Cystic mass lesions in the suprasellar cistern are often associated with neurological deficits, cognitive disorders, and endocrinological impairments. Many surgical approaches are available to treat these mass lesions, but are technically difficult and cannot remove the lesion completely without risking damage to neurological and endocrinological functions due to the proximity to the surrounding structures. Neuroendoscopic transventricular surgery was performed using a ventricular fiberscope for three patients with craniopharyngiomas and two patients with Rathke cleft cysts, with gamma knife radiosurgery for craniopharyngiomas. The endoscopic transventricular approach is safe and minimally invasive for congenital benign suprasellar cystic lesions, especially arachnoid cysts.

Aged↗
PubMed2004

Pulsed holmium:yttrium-aluminum-garnet laser-induced liquid jet as a novel dissection device in neuroendoscopic surgery.

OBJECT: A pressure-driven continuous jet of water has been reported to be a feasible tool for neuroendoscopic dissection owing to its superiority at selective tissue dissection in the absence of thermal effects. With respect to a safe, accurate dissection, however, continuous water flow may not be suitable for intraventricular use. The authors performed experiments aimed at solving problems associated with continuous flow by using a pulsed holmium:yttrium-aluminum-garnet (Ho:YAG) laser-induced liquid jet (LILJ). They present this candidate neuroendoscopic LILJ dissection system, having examined its mechanical characteristics and evaluated its controllability both in a tissue phantom and in a rabbit cadaveric ventricle wall. METHODS: The LILJ generator was incorporated into the tip of a No. 4 French catheter so that the LILJ could be delivered via a neuroendoscope. Briefly, the LILJ was generated by irradiating an internally supplied column of physiological saline with a pulsed Ho:YAG laser (pulse duration time 350 microsec; laser energy 250-700 mJ/pulse) within a No. 4 French catheter (internal diameter 1 mm) and ejecting it from a metal nozzle (internal diameter 100 microm). The Ho:YAG laser energy pulses were conveyed by an optical fiber (core diameter 400 microm) at 3 Hz, whereas physiological saline (4 degrees C) was supplied at a rate of 40 ml/hour. The mechanical characteristics of the pulsed LILJ were investigated using high-speed photography and pressure measurements; thermal effects and controllability were analyzed using an artificial tissue model (10% gelatin of 1 mm thickness). Finally, the ventricle wall of a rabbit cadaver was dissected using the LILJ. Jet pressure increased in accordance with laser energy from 0.1 to 2 bar; this translated into a penetration depth of 0.08 to 0.9 mm per shot in the ventricle wall of the rabbit cadaver. The gelatin phantom could be cut into the desired shape without significant thermal effects and in the intended manner, with a good surgical view. CONCLUSIONS: The present results show that the pulsed LILJ has the potential to become a safe and reliable dissecting method for endoscopic procedures.

Animals↗
PubMed2004

Endoscope-assisted microsurgical resection of epidermoid tumors of the cerebellopontine angle.

OBJECT: Epidermoid tumors located in the cerebellopontine angle (CPA) are challenging lesions because they grow along the subarachnoid spaces around delicate neurovascular structures and often extend into the middle cranial fossa. The purpose of this study was to determine the value of endoscopic assistance in the microsurgical resection of these lesions, in which total removal is the therapy of choice. METHODS: Eight patients harboring an epidermoid tumor of the CPA were treated using an endoscope-assisted microsurgical technique. A retrosigmoid suboccipital approach was used in five patients and a pterional transsylvian approach was chosen in the other three. In four patients the lesion was resected microsurgically and the endoscope was used repeatedly to verify complete tumor removal, whereas most of the tumor mass was removed with the aid of an operating microscope in the other four. Tumor parts extending into other cranial compartments that were not visible through the microscope were removed under endoscopic view by using rigid rod-lens scopes with 30 and 70 degrees angles of view. All epidermoids were completely evacuated and the membranes were widely resected. Large tumors occupying both the middle and posterior cranial fossa were removed through a single small opening without enlarging the craniotomy. Permanent hearing loss and permanent hypacusis were observed in one patient each. One patient with facial and one with abducent nerve palsy recovered within 6 and 4 months, respectively. A transient weakness of the chewing muscles was encountered in one patient. Postoperative magnetic resonance imaging revealed no residual tumor in any patient. To date no recurrences have been-observed (follow up range 12-98 months). CONCLUSIONS: The endoscope-assisted microsurgical technique enables safe removal even when tumor parts are not visible in a straight line. Tumor extensions into adjacent cranial compartments can be removed with the same approach without retracting neurovascular structures or enlarging the craniotomy.

Adult↗
PubMed2004

Transradial approach for neuroendovascular surgery of intracranial vascular lesions.

OBJECT: The authors present their experience in performing a transradial approach for neuroendovascular surgery of intracranial vascular lesions when a transfemoral approach was unfavorable. METHODS: Eight patients ranging in age from 52 to 88 years underwent a total of nine neuroendovascular procedures for intracranial vascular lesions. A transradial approach was used in all patients. The patients had previously undergone a transfemoral approach for the endovascular intervention, but that procedure was unsuccessful. Five patients had intracranial basilar artery (BA) aneurysms, one patient had symptomatic BA stenosis, one patient had a dural arteriovenous fistula in the posterior fossa, and one patient had a high-flow arteriovenous malformation in the frontal lobe. In each case, a transradial approach achieved a stable platform that allowed intracranial microcatheterization for neuroendovascular intervention. None of the patients experienced complications attributed to the transradial artery approach. CONCLUSIONS: During neuroendovascular surgery for the treatment of intracranial lesions, the transradial approach is a viable alternative if the transfemoral approach is unfavorable. This series represents the first known description of neuroendovascular surgery for intracranial lesions via a transradial approach.

Aged↗
PubMed2004

Endoscopic anatomy of the chordae willisii in the superior sagittal sinus.

OBJECT: Chordae willisii are structures located in the lumen of the superior sagittal sinus (SSS). It is thought that they act as flow-improving structures within the sinuses. There are few anatomical descriptions of chordae willisii, and all previous observations were performed through standard anatomical dissections. The purpose of this study was to visualize and describe structural and topographical features of the chordae willisii with the aid of rigid endoscopy. METHODS: Twenty-five SSSs obtained from fresh human cadavers during autopsies were the material for this study. Specimens were flushed with tap water to remove clots. Bridging veins emptying into the sinus were ligated, and continuous flow of a saline solution through the sinus in a physiological direction was achieved by connecting the sinus to an irrigating system. Rigid endoscopes of different diameters (2.7-4.5 mm) and optic (0 and 30 degrees) were inserted into the lumen of the sinus. The endoscope was connected to a digital camera and a video system to allow for recording of the observed structures. Finally, the sinuses were opened and the chordae willisii were dissected using standard anatomical methods. The chordae willisii were observed in all examined specimens. Three different types of the cords were found: lamellar, trabecular, and valvelike types. The most common type was the valvelike (mixed) one, which comprised 45.1% of all cords. The chordae willisii were most commonly observed in the parietooccipital region of the SSS. CONCLUSIONS: Witout disturbing any structural relationships, the use of endoscopy allowed visualization and description of intraluminal structures as they behaved physiologically.

Adult↗
PubMed2006

Comparison between the microscope and endoscope in the direct endonasal extended transsphenoidal approach: anatomical study.

OBJECT: The authors compare the views afforded by the operating microscope and the endoscope in the direct endonasal extended transsphenoidal approach to the sellar, suprasellar, and parasellar regions. METHODS: Five formalin-fixed, silicone-injected adult cadaveric heads were studied. A direct endonasal transsphenoidal approach was performed via the right nostril, pushing aside the nasal septum. The approach was performed with the microscope first, then with the endoscope. For each step (sellar, suprasellar, and clival), the exposure afforded by direct microscopic view was measured and then compared with that obtained using the endoscope. The direct endonasal approach provides a slightly off-midline view. Although the microscope provides an adequate view of the midline structures and part of the contralateral parasellar areas, the addition of the endoscope allows for a more panoramic view and permits widening of the approach in all directions. CONCLUSIONS: An adequate exposure of the sellar, suprasellar, and infrasellar/upper clival regions can be achieved via a simple, direct endonasal approach. From a direct endonasal route, there is a preferential visualization of the structures contralateral to the approach. The endoscope affords a more panoramic view that extends the area covered by the operating microscope.

Cadaver↗
PubMed2006

Bruns syndrome caused by intraventricular neurocysticercosis treated using flexible endoscopy.

OBJECT: Neurocysticercosis is the most frequent cause of hydrocephalus in adults in regions where the disease is endemic, including Latin America. The prognosis for intraventricular neurocysticercosis is worse than that for the intraparenchymal form of the disease, making treatment especially important. Although active and viable intraventricular cysts produce no reaction in the host, they can cause noncommunicating hydrocephalus, whose onset is frequently abrupt. Sometimes the increasing intracranial pressure due to obstruction of the cerebral aqueduct (ball-valve mechanism) is intermittent, producing relapsing/remitting symptoms; this life-threatening phenomenon is called "Bruns syndrome." METHODS: Between 1996 and 2004, among a group of 285 patients with neurocysticercosis and Bruns syndrome caused by cysticercal cysts of the third ventricle was diagnosed in seven patients by using magnetic resonance imaging. An endoscopic procedure with a flexible cerebral endoscope was performed, intact parasitic cysts were removed, and a complete exploration was undertaken to look for more cysticercal cysts in the whole ventricular system and the subarachnoid basal cisterns. There were no deaths or complications. All seven patients were asymptomatic during a follow-up period ranging from 1 to 5 years. CONCLUSIONS: Flexible cerebral endoscopy allows one, in a minimally invasive manner, to approach the ventricular system and subarachnoid basal cisterns and to remove intraventricular neurocysticercal cysts. Flexible endoscopy is an alternative treatment for Bruns syndrome caused by neurocysticercosis of the third ventricle.

Adolescent↗
PubMed2004

Neuroendoscopic findings in patients with intracranial germinomas correlating with diabetes insipidus.

OBJECT: Intracranial germinomas commonly occur in the pineal region, the floor of the third ventricle (hypothalamus), or both, and they are often associated with diabetes insipidus (DI). The authors conducted a study to correlate preoperative DI with the endoscopic and magnetic resonance (MR) imaging evidence of tumor on the third ventricle floor. METHODS: The authors reviewed hospital records, office charts, and MR imaging studies obtained in patients in whom a biopsy sampling procedure was performed with or without endoscopic third ventriculostomy (ETV) at Children's Hospital, Birmingham, Alabama between May 1998 and July 2002. Ten patients with the pathological diagnosis of pure germinoma were identified. Preoperative MR imaging findings and presenting symptoms were correlated with intraoperative neuroendoscopic findings. Seven patients presented with symptomatic hydrocephalus and underwent concomitant ETV. Six patients presented with DI and MR imaging evidence of involvement of the third ventricle floor. Two patients presented with DI and no initial MR imaging evidence of neoplastic involvement of the third ventricle floor; in both there was endoscopic evidence of neoplastic involvement of the floor of the third ventricle. In two children without DI, neither MR imaging nor endoscopic evidence of involvement of the third ventricle floor was observed. CONCLUSIONS: In the authors' experience with intracranial germinoma, endoscopic tumor biopsy sampling, and ETV provide an effective, safe, and minimally invasive means of obtaining diagnostic tissue and treating any concomitant hydrocephalus. The authors found that preoperative DI is an absolute predictor of neoplastic involvement of the hypothalamus regardless of MR imaging findings. Therefore, in the setting of DI and intracranial germinoma without neuroimaging evidence of hypothalamic involvement, germinomatous involvement of the hypothalamus should be assumed present, if not confirmed endoscopically at the time of biopsy sampling or third ventriculostomy, when devising adjuvant treatment plans for such patients.

Adolescent↗
PubMed2005

Endoscopic cerebral aqueductoplasty: a trans-fourth ventricle approach.

OBJECT: Advances in endoscopic technology have afforded the neurosurgeon new avenues in the treatment of hydrocephalus, rendering many patients independent of shunts, thus averting shunt complications and failure. Cerebral aqueductoplasty has gained popularity as an effective treatment for membranous and short-segment stenoses of the sylvian aqueduct. Traditionally, this procedure has been performed via a coronal approach, passing through the lateral ventricle, foramen of Monro, and third ventricle into the aqueduct. The authors report on the success of a novel technique for this operation, in which they use a suboccipital foramen magnum trans-fourth ventricle approach. METHODS: A retrospective chart review was performed to document the success of cerebral aqueductoplasty procedures via the foramen magnum trans-fourth ventricle approach in patients who had membranous or short-segment stenosis of the cerebral aqueduct. Nine patients underwent 11 cerebral aqueductoplasty procedures. At a mean of 21 months of postoperative follow up, all patients demonstrated resolution of their preoperative symptoms. The only surgical complication was transient vertical diplopia or upgaze weakness in two patients. There was no permanent morbidity. Recurrent aqueductal stenosis developed in one patient twice, requiring the placement of an aqueductal stent via the same approach. CONCLUSIONS: The authors state that in their experience, performing cerebral aqueductoplasty via the foramen magnum trans-fourth ventricle approach is both effective and safe. They advocate the use of this technique, if performed by an experienced neuroendoscopist, for select cases involving membranous or short-segment stenosis of the cerebral aqueduct, a trapped fourth ventricle, or aqueductal stent placement.

Adolescent↗