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PubMed1996

Complications of endoscopic neurosurgery.

Neuroendoscopy is rapidly becoming an essential part of the neurosurgeon's repertoire. Currently, very few studies have identified the complications of this new technique, yet many have warned of the steep learning curve associated with its practice. We have reviewed the last 173 neuroendoscopic procedures performed by one surgeon and identified two distinct groups of complications: those that have clinically significant sequelae and those that cause concern intraoperatively but no overt clinical problems. The 173 procedures were performed on 152 patients. Of these patients, 11 suffered significant complications (7%). Twenty-two of the procedures were complicated by intraoperative problems (13%). The incidence of insignificant complications appeared to decrease with experience, whereas that of the significant ones did not. These complications occurred in association with a wide variety of operations over a 2-year period. We conclude that neuroendoscopy is a relatively safe technique with an overall 7% complication rate and a steep learning curve, and that, with a few simple guidelines, it can be employed by all neurosurgeons for the betterment of their patients.

Adolescent↗

PubMed2003

Endoscopic adjuncts to intraventricular surgery.

Recently, endoscopic intraventricular surgery has been performed successfully in several clinical series. Although the therapeutic results must be compared with conventional surgery, neuroendoscopy seems to be a safe surgical technique when performed by surgeons with appropriate experience and refined endoscopic tools. Rigid or flexible endoscopes equipped with various-sized working channels should be selected depending on the nature of the pathologic findings. The well-proven tenets of microsurgery must not be sacrificed for the sake of more rapid surgical time and noninvasiveness; thus, endoscopic surgery must adhere to the principles of microsurgery. The improved visualization and lower morbidity have established neuroendoscopy in the management of specific disease processes, such as obstructive hydrocephalus. Its further use in the management of intraventricular cysts and tumors is dependent on long-term follow-up and the development of even better instrumentation.

Cerebral Ventricles↗

PubMed2003

Application of endoscopy for a midbrain tumor.

OBJECTIVE AND IMPORTANCE: It has been difficult to obtain a biopsy of a midbrain lesion. In addition, proper cerebrospinal fluid diversion should be secured because progressing tumor in the midbrain causes obstructive hydrocephalus. We report on the superiority of flexible neuroendoscopy to treat progressing midbrain tumor. CLINICAL PRESENTATION: A 64-year-old man presented with an occasional double vision. A magnetic resonance imaging scan disclosed an enhancing lesion in the midbrain. INTERVENTION: We performed a neuroendoscopic biopsy of the tumor and third ventriculostomy. Neuroendoscopy confirmed a bulging of the posterior commissure, which caused stenosis of the entrance of the aqueduct. Histological examination of the specimen obtained disclosed a diffuse astrocytoma. No permanent postoperative complications occurred although the patient felt slight double vision for 2 days after the operation. Conventional radiation therapy was supplemented. CONCLUSION: Flexible neuroendoscopic biopsy with third ventriculostomy was a less-invasive and safer alternative for the progressing midbrain tumor bulging into the ventricles.

Astrocytoma↗

PubMed2000

Neuroendoscopic procedures: anesthetic considerations for a growing trend: a review.

The recent trend in neurosurgery is shifting toward further reduction in invasiveness to minimize trauma to the brain. Endoscopy holds the promise of shortened hospital stay with improved postoperative outcome. An important minimally invasive technique is neuroendoscopy. The ventricular system and subarachnoid space of the brain provide suitable conditions for the use of an endoscope. The currently available literature focuses only on recent advances in neuroendoscopy from the surgical perspective. To date, there is paucity of anesthetic literature emphasizing the implications for this growing trend. The surgical technique, instrumentation, anesthetic requirements, potential pitfalls and complications of this technique must be completely understood to ensure a successful outcome. The purpose of this review is to provide knowledge of indications, instrumentation, and anesthetic considerations in anticipation of complications steming from this procedure.

Anesthesia↗

PubMed1999

Experiences with cranial neuronavigation in pediatric neurosurgery.

Frameless, infrared-based neuronavigation (Surgical Microscope Navigator and Surgical Tool Navigator) was applied to intracranial neurosurgery in 22 children and infants (age range 7 months to 16 years). Predominant diagnoses were tumor and hydrocephalus (including multiloculated forms); the surgical procedures were open microneurosurgery in 10 cases and neuroendoscopy in 12 patients. There were no principal technical problems even in very young infants. Surgical and clinical results were satisfying in all cases. Neuronavigation proved to be particularly helpful in targeting deep-seated processes and in guiding neuroendoscopy in cases of multiloculated hydrocephalus or small ventricles.

Adolescent↗

PubMed2001

Frameless neuronavigation in intracranial endoscopic neurosurgery.

OBJECT: Frameless computerized neuronavigation has been increasingly used in intracranial endoscopic neurosurgery. However, clear indications for the application of neuronavigation in neuroendoscopy have not yet been defined. The purpose of this study was to determine in which intracranial neuroendoscopic procedures frameless neuronavigation is necessary and really beneficial compared with a free-hand endoscopic approach. METHODS: A frameless infrared-based computerized neuronavigation system was used in 44 patients who underwent intracranial endoscopic procedures, including 13 third ventriculostomies, nine aqueductoplasties, eight intraventricular tumor biopsy procedures or resections, six cystocistemostomies in arachnoid cysts, five colloid cyst removals, four septostomies in multiloculated hydrocephalus, four cystoventriculostomies in intraparenchymal cysts, two aqueductal stent placements, and fenestration of one pineal cyst and one cavum veli interpositi. All interventions were successfully accomplished. In all procedures, the navigational system guided the surgeons precisely to the target. Navigational tracking was helpful in entering small ventricles, in approaching the posterior third ventricle when the foramen of Monro was narrow, and in selecting the best approach to colloid cysts. Neuronavigation was essential in some cystic lesions lacking clear landmarks, such as intraparenchymal cysts or multiloculated hydrocephalus. Neuronavigation was not necessary in standard third ventriculostomies, tumor biopsy procedures, and large sylvian arachnoid cysts, or for approaching the posterior third ventricle when the foramen of Monro was enlarged. CONCLUSIONS: Frameless neuronavigation has proven to be accurate, reliable, and extremely useful in selected intracranial neuroendoscopic procedures. Image-guided neuroendoscopy improved the accuracy of the endoscopic approach and minimized brain trauma.

Adolescent↗

PubMed2001

Frameless navigation and endoscopy.

OBJECT: Frameless computerized neuronavigation has been increasingly used in intracranial endoscopic neurosurgery. However, clear indications for the application of neuronavigation in neuroendoscopy have not yet been defined. The purpose of this study was to determine in which intracranial neuroendoscopic procedures frameless neuronavigation is necessary and really beneficial compared with a free-hand endoscopic approach. METHODS: A frameless infrared-based computerized neuronavi- gation system was used in 44 patients who underwent intracranial endoscopic procedures, including 13 third ventriculostomies, nine aqueductoplasties. eight intraventricular tumor biopsy procedures or resections, six cystocisternostomies in arachnoid cysts, five colloid cyst removals, four septostomies in multiloculated hydrocephalus, four cystoventriculostomies in intraparenchymal cysts, two aqueductal stent placements, and fenestration of one pineal cyst and one cavum veli interpositi. All interventions were successfully accomplished. In all procedures, the navigational system guided the surgeons precisely to the target. Navigational tracking was helpful in entering small ventricles, in approaching the posterior third ventricle when the foramen of Monro was narrow, and in selecting the best approach to colloid cysts. Neuronavigation was essential in some cystic lesions lacking clear landmarks, such as intraparenchymal cysts or multiloculated hydrocephalus. Neuronavigation was not necessary in standard third ventriculostomies, tumor biopsy procedures, and large sylvian arachnoid cysts, or for approaching the posterior third ventricle when the foramen of Monro was enlarged. CONCLUSIONS: Frameless neuronavigation has proven to be accurate, reliable, and extremely useful in selected intracranial neuroendoscopic procedures. Image-guided neuroendoscopy improved the accuracy of the endoscopic approach and minimized brain trauma.

Biopsy↗

PubMed2001

History of ventriculostomy.

Ventriculoscopy and neuroendoscopy had their beginnings in the early part of the twentieth century, when neurosurgeons were motivated by a desire to control hydrocephalus. The development of endoscopy was initially hampered by significant complications. When extracranial shunting became commonplace, endoscopy was essentially discarded by neurosurgeons. It was because of the continuing problems with shunting that a renewed interest in neuroendoscopy developed. Specific indications for various procedures have now been developed, and increasing success is being realized by the use of endoscopic procedures.

Cerebrospinal Fluid Shunts↗

PubMed2003

Perspectives and limitations of image-guided neurosurgery in pediatric patients.

INTRODUCTION: Progress in image-guided neurosurgery, and specifically in computer-assisted frameless navigation techniques and the application of robotic systems, has brought about many changes in the way we approach and treat pathologies involving the adult and pediatric central nervous system (CNS). Nevertheless, children are a patient group with special demands, in whom image-guided surgical techniques have certain limitations. In this article we address the common problem of registration accuracy in image-guided neurosurgery and assess both the reliability and the potential of ultrasound-based neuronavigation and robot-assisted neuroendoscopy in pediatric patients. METHODS AND RESULTS: We present our experience with new referencing and tracking techniques adapted to the needs of the pediatric patient. In addition, advantages and limitations of a 3D real-time ultasonography-based navigation system are demonstrated. Finally, we describe our experience with robot-assisted neuroendocopy and discuss the possible implications of the technique for the future. CONCLUSION: Image-guided techniques in pediatric neurosurgery are valuable tools and may open up new perspectives in the future. From our point of view, these tools enhance both intellectual and manual surgical skills, which does not mean that they should be considered as a replacement for such skills.

Adolescent↗

PubMed2006

An optical evaluation of the phenomenon of red out in neuroendoscopic surgery: what is the physical background?

BACKGROUND: The loss of visualization in neuroendoscopy due to intraoperative bleeding is called "red out". Although red out is a well-known problem during endoscopy, clear physical descriptions of this phenomenon are lacking. OBJECTIVE: The aim of this study was to investigate the optical properties of red out. In particular, the attenuation coefficient, comprising scattering, and absorption, of various blood/Ringer solutions was quantified and measured spectrally resolved. Small amounts of blood virtually preclude neuroendoscopic visualization. In blood/Ringer solutions with a dilution of 1:101, it was not possible to distinguish characters (font size 10, Arial) at a distance of 5 mm. We have concluded, from our physical investigations, that the problem of red out is dominated by scattering rather than by absorption. Accordingly, technical developments aimed at increasing information acquisition under red out conditions should be based on optical measurement concepts for scattering media.

Blood↗

PubMed2004

Endoscopic third ventriculostomy for obstructive hydrocephalus.

The indications for neuroendoscopy are not only constantly increasing, but even the currently accepted indications are constantly being adjusted and tailored. This is also true for one of the most frequently used neuroendoscopic procedures, the endoscopic 3rd ventriculostomy (ETV) for obstructive hydrocephalus. ETV has gained popularity and widespread acceptance during the past few years, but little attention has been paid to the techniques of the procedure. After a short introduction describing the history of ETV, an overview is given of all the different techniques that have been and still are employed to open the floor of the 3rd ventricle. The spectrum of indications for ETV has been widely enlarged over the last years. Initially, the use of this procedure was restricted to patients older than 2 years, to patients with an obvious triventricular hydrocephalus, and to those with a bulging, translucent floor of the 3rd ventricle. Nowadays, indications include all kinds of obstructive hydrocephalus but also communicating forms of hydrocephalus. The results of endoscopic procedures in treating these pathologies are given under special consideration of shunt technologies. In summary, from the review of the publications since the first ETV performed by Mixter in 1923, this technique is the treatment of choice for obstructive hydrocephalus caused by different etiologies and is an alternative to cerebrospinal fluid shunt application.

Age Factors↗

PubMed2003

Minimal invasive neurosurgery of infiltrative tumours extending around the sellar region: advantage of combined methods.

Most of the infiltrative tumoural lesions located around the sellar region compromise the cavernous sinus, cranial nerves, vascular neighboured structures and the hypothalamus. Minimal invasive neurosurgery (MIN) employing microsurgery, neuroendoscopy, neuronavigation and intraoperative radioscopy are reported to increase gross total tumour resection reducing the operative trauma. We combined at least 3 of these techniques in 32 patients with solid and 8 patients with cystic tumours of this region. Thirty tumours were approached in a transphenoidal manner, ten were via a single burr hole craniotomy in a transcortico-ventricular approach. In 36 cases the tumours were adequately removed with only six cases suffering a transitory and one with a permanent deterioration of a preoperatively diagnosed neurological deficit. In our experience, the use of combined techniques, particularly in these patients, reduces the operative trauma and improves the accuracy in planning the access, angle and extension of tumour removal. It also protects the patient from secondary damage to neighboured structures.

Adult↗

PubMed2003

Neuroendoscopic biopsy for intraventricular tumors.

Neuroendoscopy has been shown to be an effective and minimally invasive method in the management of intraventricular tumors. Endoscopic tumor biopsy with or without additional endoscopic procedures such as third ventriculostomy and septostomy can be performed at the same session. Neuroendoscopic tumor biopsy was performed in 18 patients in our department. Their ages ranged from 2 to 65 years (median 12 years); only two of them were adult. Location of the tumors were as follows: pineal region in 7, hypothalamus and 3rd ventricle in 4, lateral ventricle in 4, thalamus in 2, and tectal in 1 patient. All procedures were performed under general anesthesia using rigid neuroendoscopes. Cerebrospinal fluid (CSF) was collected at the beginning of the procedure for cytological analysis and for pineal tumor markers. Biopsy forceps were used to obtain tissue from the lesion. The third ventriculostomy was performed in all patients with a pineal tumor, in addition to the tumor biopsy. The pathological examinations revealed a low-grade astrocytoma in 6 patients, anaplastic astrocytoma in 3, germinoma in 3, pineocytoma in 1, pineoblastoma in 2, glioblastoma multiforme in 1 and granulomatous lesion in 1. Subsequent mode of treatment such as radiation therapy, chemotherapy or radical surgery was determined on the basis of pathological diagnosis. Neuroendoscopic tumor biopsy is a less invasive method than open surgery and has some advantages such as treating the hydrocephalus at the same surgical session and the availability of CSF cytology. Neuroendoscopic techniques should be considered in selected patients.

Adolescent↗

PubMed2003

Endoscopic management of supratentorial ventricular neurocysticercosis: case series and review of the literature.

OBJECTIVE: Despite the increasing popularity of neuroendoscopy, scarce documentation exists in the literature regarding successes and failures of this treatment modality for ventricular cysticercosis. Since July 2000, we instituted a specific endoscopic strategy for select patients with supratentorial ventricular disease. The goals of the strategy were to 1) remove ventricular cysts; 2) employ internal CSF diversion procedures for hydrocephalus to avoid shunting, and; 3) elude open surgical procedures. METHODS: A retrospective analysis of the charts of 7 patients managed with an endoscope for symptomatic hydrocephalus and supratentorial ventricular cysts was performed. A description of our management plan is given. RESULTS: From July 2000 through July 2002, we successfully resected all supratentorial ventricular cysts in 7 patients with an endoscope and employed three septostomies and four third ventriculostomies in the same sitting. None of the seven patients required shunting or further surgery to date. No case of postoperative ventriculitis occurred despite an 86 % cyst rupture rate. One cyst adjacent to the left foramen of Monro, which was successfully resected, produced significant intraventricular bleeding during surgical dissection. This patient developed akinetic mutism postoperatively, which improved with bromocriptine. The follow-up period was 16 months (range, 10 - 24 months). CONCLUSIONS: The ease of performing septostomies and third ventriculostomies in conjunction with cyst removal makes these procedures appealing and practical for most cases of ventricular cysticercosis.

Adult↗

PubMed2004

Minimally invasive management of the third ventricle glioma in a patient without hydrocephalus: neurofiberscopic biopsy followed by gamma knife radiosurgery.

There is usually concern that ventricular enlargement is necessary for safe neuroendoscopic procedures. However, newly developed models of neurofiberscopes with a small outer diameter can be effectively used even in patients without ventriculomegaly. We present the case of a successful neurofiberscopic biopsy of a third ventricle anaplastic astrocytoma in a previously shunted patient without hydrocephalus. Subsequent gamma knife radiosurgery led to complete disappearance of the tumor. It seems that presence of collapsed ventricles, and even symptoms consistent with the slit ventricle syndrome, should not be considered as contraindications for neurofiberscopic surgery when brain compliance is sufficiently preserved. The latter should be considered as the key point of safe endoscopic manipulations. The combination of the neuroendoscopy and stereotactic radiosurgery provides wide possibilities for minimally invasive management of selected intracranial tumors.

Adolescent↗

PubMed2004

Neuroendoscopic management of intraventricular hemorrhage.

BACKGROUND AND PURPOSE: We reviewed our 7-year experience in neuroendoscopic management of severe intraventricular hemorrhage (IVH) to evaluate its safety, efficiency, and efficacy. METHODS: Thirteen patients with spontaneous primary or secondary tetraventricular IVH underwent neuroendoscopy. In all procedures, we used a flexible instrument. CT scans obtained before and after surgery were compared for Graeb score and ventriculocranial ratio. Glasgow Outcome Scale was assessed at 12 months. RESULTS: In all patients, the procedure resulted in a substantial removal of ventricular blood. Graeb score was reduced by 65%, and ventriculocranial ratio was reduced by 30% (P<0.002). The procedure was carried out safely even in the presence of a vascular malformation, and no rebleeding or delayed hydrocephalus was observed in any case. Mortality at 12 months was 30.7%. Favorable outcome (Glasgow Outcome Scale, 3 to 5) was observed in 61.5% of cases. CONCLUSIONS: Neuroendoscopic management of severe IVH in this cohort of patients was safe, efficiently reduced the amount of ventricular blood and ventricular dilatation, and effectively produced an outcome profile that compares very favorably with other more conventional treatments.

Adult↗

PubMed2005

Neuroendoscopic aspiration of hematocephalus totalis: technical note.

OBJECTIVE AND IMPORTANCE: Massive intraventricular hemorrhage requires aggressive and rapid management to decrease intracranial hypertension. The amount of intraventricular blood is a strong prognostic predictor, and its fast removal is a priority. Neuroendoscopy may offer some advantages over more traditional surgical approaches. We describe here the technical details and clinical outcomes of the neuroendoscopic management of massive tetraventricular hemorrhage in 25 consecutive patients, highlighting the potential pitfalls and the advantages of the technique. CLINICAL PRESENTATION: Twenty-five patients, aged 7 to 80 years, presenting with massive ventricular hemorrhage were admitted between January 1996 and May 2004 to our neurosurgery unit after an emergency computed tomographic scan. Severity of ventricular hemorrhage was graded according to the Graeb scale; the mean Graeb score was 9.8 +/- 2.9. Hemorrhages were secondary to vascular malformation in 12 cases. INTERVENTION: Endoscopy was performed on the first day in 17 cases, with a delay of 1 to 5 days in the remaining 8 cases. A flexible endoscope with "free-hand" technique was always preferred. The ventricular cleaning proceeded in three phases: lateral ventricle, third ventricle, and then aqueduct and fourth ventricle. In selected patients, a catheter, both for intracranial pressure monitoring and for drainage, was positioned. The procedure was successfully completed in all cases. There was no surgery-related mortality. The mean length of intensive care unit stay after the operation was 18 +/- 12 days. Short-term mortality (1 mo) was 12%, whereas long-term (> 6 mo) mortality was 24%. Complete recovery (Glasgow Outcome Scale score, 5) was achieved in 40% of cases. A ventriculoperitoneal shunt was necessary in 12% of patients. CONCLUSION: Intraventricular hemorrhage, analogously to other ventricular diseases, can be treated successfully with flexible endoscopes. Obviously, the limitation of this study lies in its observational nature; however, the encouraging results reported here should prompt a randomized study to evaluate the effectiveness and efficiency of the endoscopic approach in comparison to the more established semiconservative management offered by external derivation with fibrinolytic agents.

Adolescent↗

PubMed2002

Endoscopic removal of cisternal neurocysticercal cysts. Technical note.

The authors report the use of neuroendoscopy for the treatment of cisternal neurocysticercosis. The utilization of the endoscope is meant to provide a safe and minimally invasive procedure for the removal of symptomatic cysts, minimizing morbidity and mortality relating to the natural history of the disease, as well as possibly avoiding a more extensive standard open craniotomy. A retrospective review of three cases of cisternal cysticercosis was performed. The presenting signs and symptoms, neuroimaging findings, endoscopic treatment, and outcomes are presented. The technical aspect of the endoscopic resection is described, with visual support provided by intraoperative video. Cerebrospinal fluid shunt placement was avoided in one patient in whom complete resection of the cyst was required. In one patient there were extensive interhemispheric and premesencephalic cisternal cysts, some of which could not be removed because of their multiplicity and extensive adhesions. Despite the intraoperative rupture of cysts, there were no cases of arachnoiditis or ventriculitis postoperatively. The minimally invasive endoscopic resection of cisternal cysticercosis is possible and effective in selected patients. Although the most appropriate treatment of cisternal cysticercosis remains a controversial issue, endoscopic resection should be considered as a primary treatment in symptomatic patients in cases that are amenable to endoscopic intervention.

Adult↗