Fenestration of intraventricular cysts using a flexible, steerable endoscope

Multiloculated hydrocephalus with multiple intraventricular septae due to meningitis associated with ventriculitis and other CSF containing intraventricular cysts can be treated by endoscopic fenestration. Seven patients with various CSF containing intraventricular cysts were treated using a flexible steerable endoscope and the argon laser. The experience using several currently available steerable endoscopes for treatment of this neurosurgical problem is reviewed. Emphasis is placed on the use of the laser for cyst fenestration. Successful decompression of the ventricular cyst(s) was accomplished in five cases with the endoscope alone. Craniotomy was required in two patients in order to complete cyst fenestration. It is the author's impression that laser assisted ventriculoscopy with steerable flexible endoscopes is an alternative and oftentimes superior method of treating CSF containing cysts within the lateral ventricles of hydrocephalic patients. Steerable flexible endoscopes designed specifically for neurosurgical use are needed.

Application of superfine fiberscope for endovasculoscopy, ventriculoscopy, and myeloscopy

In the past three years, we have used a superfine fiberscope for endovasculoscopy, ventriculoscopy, and myeloscopy. Flexible superfine fiberscope, 0.75 mm in outer diameter, could visualize various intravascular findings. In in-vivo canine experiment, sequential changes of thrombus produced by endothelial abrasion by needle or balloon in the canine carotid artery can be clearly seen. And thrombolysis by focal arterial injection of tissue plasminogen activator was sequentially observed. In the clinical study, we could evaluate the stenotic lesions of the subclavian and vertebral arteries before and after balloon angioplasty. During ventriculoscopy, a 2 mm of mini-caliber fiberscope was introduced under ultrasound monitoring, and provided clear visualization of intraventricular tumours. In myeloscopy, draining veins of arteriovenous malformations and nerve roots of the cauda equina could be clearly seen by flexible fiberscope. From these results, it can be said that the superfine fiberscope provides clear and useful visualizations of the interior of vessels, ventricles, and the intrathecal area of the spinal canal. The new applications of this superfine fiberscope for minimally invasive neurosurgery may bring about a marked improvement of therapeutic results.

The history of ventriculoscopy: where do we go from here?

With the availability of better endoscopes, improved lighting and increased instrumentation, the use of ventriculoscopy and ventriculostomy in the management of hydrocephalus is becoming increasingly more common. Neurosurgeons recognized the potential for endoscopic surgery early in this century, but were frustrated in many of their attempts at treatment due to the poor quality of the instruments available. Nevertheless, much progress has been made, and the stage was set for better results with modern instrument design. This paper reviews the history of endoscopes in neurosurgery and ponders the direction these instruments will take us in the near future.

Removal of adherent ventricular catheter

The technique for freeing adherent ventricular catheters is described in which a Bugbee wire, insulated except for the tip, is used to deliver a monopolar coagulating current to the tissue adherent to the drainage holes of the catheter. This may have some advantage over the use of an uninsulated metal cannula for delivery of a unipolar diathermy cutting current. The technique described has permitted effective and safe removal of adherent ventricular catheters.

Therapeutic risks of anti-siphon devices

Anti-Siphon devices need a siphon length of about 25 cm H2O to activate them. SCD and ASD show a dependence on the prepressure. The subcutaneous pressure can obstruct Anti-Siphon devices.

Nursing care of the child with external ventricular drainage

External ventricular drainage (EVD) is used in children who have hydrocephalus, usually for shunt infection. Several complications, including increased intracranial pressure, hemorrhage, brain injury and infection, can occur in children with EVD. Nursing care for these children involves interventions to prevent complications and promote the well-being of children and their families.

Testing the hydrocephalus shunt valve: long-term bench test results of various new and explanted valves. The need for model for testing valves under physiological conditions

13 new and 19 explanted hydrocephalus shunt valves were tested under perfusion for two weeks, using a modified ASTM test. Some manufacturers seem to have problems with quality control. Our results show large deviations in pressure-flow-characteristics in different valves, in some cases leading to an extremely high pre-shunt pressure. Test results almost corresponding to manufacturer's specifications were found in diaphragm valves and in some ball and spring valves. Results from slit valves usually varied widely, some being good, but others bad (much too high a pressure) or dangerous with even possibly fatal characteristics. Whilst laboratory performance may not correlate with clinical results, due to different impact of cerebrospinal fluid (CSF) pressure and flow on hydrocephalus shunting systems, manufacturers should provide devices that meet their supposed specifications. We developed an apparatus allowing simulation of different CSF production rates, CSF outflow resistances, CSF pressure waves caused by arterial and venous pulsation, breathing and coughing, and hydrostatic differential pressure caused by body position changes. This model enables testing of shunt valves under almost physiological conditions, thus closing the gap between conventional bench test results and clinical performance of hydrocephalus shunt valves.

Rapid bedside technique for percutaneous ventricular drainage in patients with severe subarachnoid haemorrhage. Technical note

Using immediate ventricular drainage and aggressive postoperative therapy, poor-grade patients suffering ruptured cerebral aneurysms could have a greater opportunity for meaningful recovery. This treatment protocol is facilitated by percutaneous ventricular drainage at the bedside. A simple and less invasive technique reported here is particularly useful for neurosurgeons responsible for the treatment of severe subarachnoid haemorrhage on an emergency basis.

Management of head injury. Intracranial pressure monitoring

The role of intracranial pressure monitoring as an adjunct to the clinical examination, CT scanning, and other diagnostic modalities has become increasingly recognized. This article presents a brief overview of the present status of this technique and touches on prospects for further developments.

External ventricular drainage in the new-born. Technical note

A new method for external ventricular drainage using an introducer and a plastic-covered catheter is described. The advantages of the system are discussed.

Endoscopic procedures in stereotactic neurosurgery

A new prototype of an endoscope for stereotactic interventions is described. This endoscope is adapted to the Mundinger-Birg stereotactic system. Stereotactic endoscopic procedures are carried out for brain-tumour-biopsy as well as for evacuation of haematomas, brain-cysts and abscesses. Ventriculoscopy is performed on hydrocephalus and biopsy of ventricle-relating tumours. One-year experience with stereotactic endoscopy is reviewed.

Broviac ventriculostomy for long-term external ventricular drainage

A closed external ventricular drainage system that incorporates a Broviac catheter, with its dacron cuff, is described and its use is detailed. This device has been placed in 17 patients who have undergone 19 procedures. Indications for prolonged cerebrospinal fluid (CSF) drainage were: CSF leak (1 child) and shunt infection (16 children). Drainage was maintained for an average of 19 days, with a range of 6-47 days. The child with the CSF leak had resolution of this problem after 15 days, whereupon the system was removed. Thirteen of the 16 patients with shunt infections eventually underwent shunt placement. Two of the children in this group developed a shunt infection unrelated to their original septic episode that required placement of a second Broviac ventriculostomy. Two of the 3 children who did not undergo permanent shunt placement expired from other causes. Both of these children had clinically functioning Broviac ventriculostomies and culture-proven sterile CSF at the time of death. The remaining child with an infected shunt died of overwhelming sepsis. Complications included: ventricular catheter revision (4 cases), irrigation of the system (4 cases), and secondary CSF infection (1 case). The infection attack rate was 1 in 361 patient-catheter days, or 2.77/1,000 patient-catheter days. The advantages of the Broviac ventriculostomy are two. First, this system is highly resistant to infection. Second, the device is difficult to dislodge.

Anatomic evaluation of cisternal puncture

Cisternal puncture, although less frequently used since the advent of computed tomography and magnetic resonance imaging, is an important tool in the neurodiagnostic armamentarium. An anatomic study of cisternal puncture was conducted on fresh cadavers by direct visualization and fluoroscopic guidance of cisternal puncture. Anatomic and radiographic analyses demonstrated a dramatic dynamic anatomy of the cisternal space during cisternal puncture and indicated that "tenting" of the dura mater over the needle occurs reliably during cisternal puncture. Lateral fluoroscopy may decrease the risk of cisternal puncture by allowing visualization of needle depth in the cisternal space.

Management of posthemorrhagic hydrocephalus in the low-birth-weight preterm neonate

Over a period of 34 months from 1987 to 1990 we inserted ventricular catheter reservoirs (VCR) into 20 premature low-birth-weight infants who had developed progressive, symptomatic posthemorrhagic hydrocephalus following grade III or IV intraventricular hemorrhages. The mean estimated gestational age was 27.7 +/- 5.3 weeks and mean birth weight was 1,041 +/- 699 g. The ventricular catheter reservoirs were placed on day of life 30.7 +/- 29.7 and tapped for a total of 3-34 days at varying frequencies and for varying volumes. Of the 20 patients, 4 died on days of life 25, 76, 88, and 187. There were two reservoir infections, both occurring in infants who eventually died. The 16 survivors have been followed from 2 to 24 months (adjusted age). Four (25%) remain shunt-free and 3 have undergone VCR removal. There have been two shunt infections in the 12 shunted patients; ten shunt revisions have been performed overall. At the time of last follow-up, 14 patients were old enough to undergo neurodevelopmental evaluation. Five patients (36%) were 'normal' on gross neurological screening examination, 5 (36%) had 'mild developmental delay' and 4 (28%) had 'significant developmental delay'. We feel these data support the continued use of ventricular catheter reservoirs in the management of posthemorrhagic hydrocephalus and offer hope that some of these patients might remain shunt-free and most will have a normal or mildly delayed neurodevelopmental outcome.

Diagnostic-therapeutic ventriculocystostomy

Simple diagnostic-therapeutic ventriculocystostomy is described. Arachnoid, intracerebral, or intraventricular cysts are permanently connected with the ventricles by a Kifa red catheter with spirally situated holes. The pressure balance and the connection with a physiological space for resorption is maintained in this simple way. Twenty patients have been operated on over a 2-year period with good results.