Complications following endoscopic intracranial procedures in children

Purely Endoscopic Treatment for Arachnoid Cysts

Arachnoid cysts are benign, mostly congenital lesions that are asymptomatic in most patients. In some cases, due to their location or sheer size, they produce a mass effect or hydrocephalic obstruction of the cerebrospinal fluid (CSF) flow and thus might warrant surgical treatment. The goal of the surgery is usually to reduce pressure inside the cysts, to reduce the mass effect, or to restore the CSF pathway. Surgical treatment options are resection, fenestration, or shunting of the cyst. Over the past decades, treatment under sheer endoscopic control either through a tube or via craniotomy of arachnoid cysts has been studied thoroughly and replaced open microsurgical cyst surgery in the opinion of many neurosurgeons. Endoscopic treatment has proven to be a safe and feasible technique for both patients and surgeons. In the following chapter, the authors describe their indications for surgery and pre- and postoperative workup, where precautions should be taken, and discuss the different possibilities and techniques of endoscopic cyst fenestration. The aim is to give detailed instructions and present cases for ventriculocystostomy, cystocisternostomy, ventriculocystocisternostomy, and cystoventriculostomy and point out specifics deemed to be important to avoid complications and to ensure the best possible outcome for each patient.

Neuroendoscopic transventricular transchoroidal approach for access to the posterior zone of the third ventricle or pineal region

The endoscopic transventricular transchoroidal approach facilitates entry into the posterior part of the third ventricle, allowing a visualization field from the foramen of Monro to the pineal region through this anatomical corridor. Combined surgery to treat the target lesion and possible endoscopic third ventriculostomy (ETV) can be performed through a single burr hole. A detailed description of this surgical technique is given, and a series of cases from our center is presented. This retrospective study included patients with lesions in the pineal region or posterior zone of the third ventricle who underwent surgery between 2004 and 2022 in our center for tumor biopsy or endoscopic cyst fenestration. In nine cases, the transchoroidal approach was performed. Demographic and clinical variables were collected: sex, age at diagnosis, clinical presentation, characteristics of the lesion, pathological diagnosis, characteristics of the procedure, complications, subsequent treatments, evolution, follow-up time, and degree of success of the endoscopic procedure. The mean and range of the quantitative variables and frequency of the qualitative variables were analyzed, together with the statistical significance (p < 0.05). Surgical planning was carried out by performing a preoperative MRI, calculating the ideal entry point and trajectory for each case. The preoperative planning of the surgical technique is described in detail. Of our sample, 55.6% were women, with a mean age of 35 years (7-78). The most common clinical presentation was intracranial hypertension (55.6%), with or without a focus. Eight patients presented hydrocephalus at diagnosis. The most frequent procedure was endoscopic biopsy with ETV (66.7%). The pathological diagnosis varied widely. Procedure-related complications included one case of self-limited bleeding of the choroidal fissure at its opening and one intraventricular hemorrhage due to tumor bleeding in the postoperative period. Non-procedure-related complications comprised two ETV failures and one case of systemic infection, while late complications included one case of disease progression and one case of radionecrosis. Four patients died, one due to poor neurological evolution after post-surgical tumor bleeding and three due to causes unrelated to the procedure. The rest of the patients had a favorable evolution and were asymptomatic or stable. The transchoroidal approach through a single burr hole is a feasible and safe option for access to the posterior part of the third ventricle. Proper planning of each case is necessary to avoid complications.

Application of endoport-assisted neuroendoscopic techniques in lateral ventricular tumor surgery

Objective

The objective of this study was to investigate the clinical experience and therapeutic efficiency of Endoport-assisted neuroendoscopic surgery for resection of lateral ventricular tumors. The key points and application value of this surgical technique were additionally discussed.

Methods

A retrospective analysis was conducted on the clinical and follow-up data of 16 patients who underwent endoport-assisted neuroendoscopic surgery for lateral ventricular tumors at the Department of Neurosurgery, Nanjing Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medical School, between January 2018 and September 2020. The surgical procedures, complications and outcomes were analyzed.

Results

The study included a total of 16 patients (5 males and 11 females) with lateral ventricular tumors, with a mean age of 43.2 years (18-70 years old). The tumors were distributed as follows: 5 cases involved the body of the lateral ventricle, 3 involved the frontal horn and body, 3 involved the occipital horn, 2 involved the trigone, 2 involved the frontal horn, and 1 case involved the occipital horn and body. Perioperative complications were analyzed, revealing 1 case of intraoperative acute epidural hematoma intraoperative and 2 cases of postoperative obstructive hydrocephalus. All complications were promptly managed. Postoperative MRI revealed that 14 cases (88%) achieved total resection, while 2 cases (12%) achieved subtotal resection. During the follow-up of 6-38 months, no recurrence was observed. The patient diagnosed with glioblastoma died 16 months after surgery (GOS=1), while the remaining patients have successfully resumed to normal daily life with a GOS score of 5.

Conclusion

In conclusion, endoport-assisted neuroendoscopic surgery proved to be a minimally invasive and effective technique for resecting lateral ventricular tumors, with acceptable complications. It effectively utilizes the benefits of close observation, comprehensive exposure, and reduced tissue damage. Therefore, endoport-assisted neuroendoscopic surgery is suitable for the resection of lateral ventricular tumors.

A Subdural Hygroma Necessitating a Subdural-Peritoneal Shunt in a Pediatric Patient Following Total Cranial Vault Remodeling Surgery

Sagittal synostosis is a common non-syndromic synostosis treated with open or endoscopic cranial vault remodeling. Early intervention is recommended to avoid restricted brain growth, increased intracranial pressure, and resultant developmental delay. Common complications such as failure or reconstruction, cerebrospinal fluid leak, blood loss, and stroke are well-reported in the literature. Here, we present a rare case of the development of a subdural hygroma following cranial vault remodeling in a seven-month-old male, necessitating the insertion of a subdural-peritoneal shunt.

Dry Field Technique and Ultrasonic Aspirator in Endoscopic Removal of a Hemorrhagic Intraventricular Tumor in a 2-Year-Old Girl

Neuroendoscopic procedures inside the ventricular system always bear the risk for an unexpected intraoperative hemorrhage. Most hemorrhages can be managed by constant irrigation with low- and high-pressure washes. In the other rare cases, the dry field technique may be necessary.1-5 It requires the aspiration of the entire intraventricular cerebrospinal fluid with the aim of establishing a proper environment for hemostasis. Video 1 illustrates a step-by-step removal of an intraventricular tumor in a 2-year-old girl through an endoscopic technique where the dry field technique was undertaken because of its hemorrhagic nature. Postoperative magnetic resonance imaging showed complete removal of the left frontal tumor infiltration at the level of the left frontal ependyma. The small residual tumor on the left frontal horn was removed using microsurgical technique with another procedure and after achieving complete removal of all visible tumor, the patient was referred to radiotherapy.

Surgical indications in pediatric arachnoid cysts

INTRODUCTION

Arachnoid cysts are developmental lesions consisting of CSF collections within the subarachnoid space. There are many theories and hypotheses about their pathogenesis and histopathology and this may also explain the diversities seen in clinical behaviors of these cysts, their natural history and consequently their management where there is a great controversy about selecting patients for surgical intervention. The most common location in pediatrics is the Sylvian or middle cranial fossa and this made it gain more concern and greater debate about its management where its diagnosis is often accidently or associated with nonspecific symptoms.

AIM

Our aim in this article was to review the main surgical indications for pediatric arachnoid cysts in the literature.

CONCLUSION

We concluded that the decision for surgical intervention for pediatric arachnoid cysts is not a simple one and highly debatable and should be taken cautiously especially with sylvian arachnoid cysts that may reach a large size without symptoms. However, there is a consensus that the occurrence of symptoms definitely correlated to the presence of these cysts or their rupture with consequent subdural hematoma or hygroma are indications for surgical intervention. Large cysts in locations compressing CSF pathways causing hydrocephalus are also candidates for surgical fenestration. The surgical gain from prophylactic surgery is questionable particularly when asymptomatic.

Costs of pediatric hydrocephalus treatment for the Brazilian public health system in the Northeast of Brazil

PURPOSE

To estimate the costs of the surgical treatment of pediatric hydrocephalus, specifically ventriculoperitoneal shunt (VPS) and endoscopic third ventriculostomy (ETV), for the Brazilian public health system (SUS).

METHODS

Retrospective cohort study of health records of patients < 14 years of age with a diagnosis of hydrocephalus who underwent VPS or ETV between September 2009 and June 2016, regularly followed up for 24 months.

RESULTS

Seventy-six medical records were included. The groups of children who underwent VPS and ETV consisted of 60 and 16 patients, respectively. Complications during 2 years of follow-up were identified in 56% of the children undergoing VPS and in 18% of those undergoing ETV (p = 0.0103). The initial cost of VPS was lower than that of ETV up to approximately 1 year of post-surgical follow-up. After that, VPS generated higher expenses for the SUS due to higher rates of late post-surgical complications and repeated readmissions.

CONCLUSION

Higher public expenditures were observed in the group of children undergoing VPS due to higher rates of infectious and mechanical complications requiring repeated hospitalizations and prosthesis replacements. Public policies must be tailored to offer the best treatment to children with hydrocephalus and to make judicious use of public resources without compromising the quality of treatment.

Characteristic and management of pediatric arachnoid cysts: A case series

Background/Aim: Arachnoid cysts (ACs) are the collection of fluid, which is similar in composition to cerebrospinal fluid, within the congenitally duplicated arachnoid membrane. ACs are clinically silent lesions, but sometimes they can manifest themselves with headache, convulsion, focal neurological deficits, cognitive decline, torticollis, and macrocephaly. Although the appropriate surgical approach is less clear, there is a consensus on the need for surgical treatment in symptomatic ACs. This study aims to reveal the advantages and disadvantages of cystoperitoneal shunt and microsurgical fenestration techniques. Methods: One hundred ninety-one consecutive patients from 1 month to 15 years old with AC were evaluated for suitability. Sixteen patients who underwent surgery were included in the study. Medical records of the patients with AC managed at our institutions were retrospectively collected and analyzed. Sixteen of 191 patients underwent surgical treatment via craniotomy for microsurgical cyst fenestration (CF) and cysto-peritoneal shunting (CS). CF was performed with partial cyst wall excision in all patients. Results: Seizure was the most common presentation in the patients, followed by headache and trauma, respectively. In our series the most common indications of the surgery were increased intracranial pressure (IICP). CF was performed in nine patients, and CS was performed in seven as the primary treatment. CS-related complications, such as infection (n = 2), dysfunction (n = 2) and intraabdominal abscess (n = 1) were the most commonly observed complications. No infections were observed after CF, but subdural hematoma was observed in one child. Conclusions: Although the most common symptoms in cases with arachnoid cysts are headache, rare symptoms, such as torticollis, may exist. Due to this, clinicians should reveal the cyst-complaint relationship first. Given the increased complications of CS, in addition to shunt independency and being free from shunt-related complications, the microsurgical CF with wide excision of the membranes seems to be the more preferable surgical option.

Combined Neuroendoscopic Techniques in the Management of Pediatric Brain and Skull Base Tumors: A Single-Institutional Case Series

BACKGROUND

Central nervous system tumors encompass the leading cause of cancer-related death in the pediatric population. Neuroendoscopic techniques have been optimized over the years, becoming an important tool for the management of brain tumors. Our study aims to review the indications for neuroendoscopic procedures and the feasibility of combined interventions.

METHODS

This is a single-center, self-adjudicated, retrospective experience. Inclusion criteria consisted of pediatric patients (≤18 years old) who underwent management of brain tumor or related diseases with the employment of neuroendoscopy.

RESULTS

A total of 47 patients undergoing 51 procedures met inclusion criteria. The mean age was 9.8 ± 4.6 years, and the majority were female (55.3%). Common indications for endoscopic intervention were hydrocephalus management (n = 24; 16 endoscopic third ventriculostomies and 9 septostomies), tumor biopsy (n = 19), cyst fenestration (n = 16), and tumor resection (n = 9). In one third of the cases, combined interventions occurred during a single operative session. Hydrocephalus was successfully managed in 74.4% of cases; tumor biopsy confirmed the diagnosis in 95.8% of cases, and gross total resection was achieved in 88.9% of cases. Cyst fenestration required reintervention in 3 cases: one case associated with initial cyst enlargement and 2 cases with the development of new tumor cysts separated from the originally fenestrated cyst. The overall complication rate was 6.3%, with only one major safety event, which was successfully managed.

CONCLUSIONS

Neuroendoscopy is an important minimally invasive tool for diagnosing and treating pediatric patients with brain tumors, permitting to address multiple problems in a single surgery.

Analysis of complications in intraventricular neuroendoscopy in children: proposal for a standardization system

Although intraventricular neuroendoscopy is considered a minimally invasive technique with good results, there is nevertheless a risk of developing certain complications. As no agreement apparently exists concerning the classification of these complications, we aim to propose a form of classification based on the results of our series, comparing them with recent publications. We undertook a retrospective study of 170 children who underwent intraventricular neuroendoscopy between 2003 and September 2020 at our center. Data were recorded on demographic and clinical variables: age, gender, presenting symptoms, etiology, number of procedures, type of procedure, and complications. Complications were divided into two main groups, intraoperative and postoperative, and in subgroups. The intraoperative complications included one group of systemic alterations and another group of surgical problems. The postoperative complications were divided into six groups: systemic, neurologic, hormone, fluid, hemorrhagic and death. A total of 202 neuroendoscopic procedures were performed in 170 children. The mean age at first surgery was 71 months (22-122). The most common etiology of the hydrocephalus was intraventricular tumors (32.9%), followed by aqueductal stenosis (13.5%). The most usual presenting sign was intracranial hypertension. The procedure most used was third ventriculostomy (62.9%). During the procedures, we experienced 5 surgical intraoperative complications (2.47% per procedure). In the postoperative period, there were 23.7% systemic complications per procedure, 12.87% neurologic, 8.41% hormone, 10.9% fluid, 0.5% hemorrhagic, and 0.99% for postoperative death. The rate of complications associated with intraventricular neuroendoscopy was similar in our series to those already published. Comparative studies require standardization for the analysis of neuroendoscopic complications.

The utility of congenital cardiac status to predict endoscopic third ventriculostomy and ventriculoperitoneal shunt failure in hydrocephalic infants

OBJECTIVE

The effect of congenital cardiac status on endoscopic third ventriculostomy (ETV) and ventriculoperitoneal shunt (VPS) failure in hydrocephalic infants is unknown. Because cardiac status in infants can impact central venous pressure (CVP), it is possible that congenital heart disease (CHD) and congenital cardiac anomalies may render these cerebrospinal fluid diversion interventions more susceptible to failure. Correspondingly, the aim of this study was to determine how CHD and congenital cardiac anomalies may impact the failure of these initial interventions.

METHODS

A retrospective review of the Nationwide Inpatient Sample (NIS) database was conducted. Infants (aged < 1 year) with known congenital cardiac status managed with either ETV or VPS were included. Quantitative data were compared using either parametric or nonparametric methods, and failure rates were modeled using univariable and multivariable regression analyses.

RESULTS

A total of 18,763 infants treated with ETV or VPS for hydrocephalus were identified in our search, with ETV used to treat 7657 (41%) patients and VPS used to treat 11,106 (59%). There were 6722 (36%) patients who presented with CHD at admission, and a total of 25 unique congenital cardiac anomalies were detected across the cohort. Overall, the most common anomaly was patent ductus arteriosus (PDA) in 4990 (27%) patients, followed by atrial septal defect (ASD) in 2437 (13%) patients and pulmonary hypertension in 810 (4%) patients. With respect to initial intervention failure, 3869 (21%) patients required repeat surgical intervention during admission. This was significantly more common in the ETV group than the VPS group (36% vs 10%, p < 0.01). In both the ETV and VPS groups, CHD (p < 0.01), including all congenital cardiac anomalies, was an independent and significant predictor of failure. ASD (p < 0.01) and PDA (p < 0.01) both significantly predicted ETV failure, and PDA (p < 0.01) and pulmonary hypertension (p = 0.02) both significantly predicted VPS failure.

CONCLUSIONS

These results indicate that congenital cardiac status predicts ETV and VPS failure in patients with infantile hydrocephalus. The authors hypothesized that this finding was primarily due to changes in CVP; however, this may not be completely universal across both interventions and all congenital cardiac anomalies. Future studies about optimization of congenital cardiac status with ETV and VPS are required to understand the practical significance of these findings.

Management of severe intraoperative hemorrhage during intraventricular neuroendoscopic procedures: the dry field technique

OBJECTIVE

Neuroendoscopic procedures inside the ventricular system always bear the risk for an unexpected intraoperative hemorrhage with potentially devastating consequences. The authors present here their experience, and a stage-to-stage guide for the endoscopic management of intraoperative hemorrhages.

METHODS

A step-by-step guide for the management to gain control of and stop the bleeding is described including a grading system. More advanced techniques are presented in cases examples.

CONCLUSION

Most of intraoperative hemorrhages can be controlled by constant irrigation and coagulation. More advanced techniques can be applied quickly and easily to ensure control of the hemorrhages and avoid the need for a microsurgical conversion.

Endoscopic third ventriculostomy in the treatment of hydrocephalus: A 20-year retrospective analysis of 209 consecutive cases

Background

Endoscopic third ventriculostomy (ETV) has been shown to be a sufficient alternative to shunts in surgical treatment of obstructive hydrocephalus. Long-term failure, age limitations, and outcome by cause are some of the issues debated in literature. The objective of this article is to analyze the clinical success and failure of ETV and its main complications.

Methods

A total of 209 patients with hydrocephalus were submitted to ETV, including a mixed population of children and adults (from 0 to 59 years). Patients were divided into five groups: A - tumors, B - aqueductal stenosis, C - myelomeningocele, D - infection and hemorrhage, and E - arachnoid cyst. Variables were analyzed: age, ETV success rate, cerebrospinal fluid (CSF) fistula, mortality, and complications.

Results

The two main causes of hydrocephalus were tumors (44.9%) and aqueductal stenosis (25.3%). The overall success rate was of 82.8%, and patients in Group E had the highest rate 90.9%. Group A had a success rate of 89.3%, and Group B had a rate of 88.6%. The ETV success rate was significantly higher in patients older than 1 year (P < 0.001); the former also had a lower risk of CSF fistula (P < 0.0001). The overall mortality rate was 2.8%.

Conclusion

Better results were observed in the groups of patients with tumors, aqueductal stenosis, and arachnoid cysts, while those whose primary causes of hydrocephalus were myelomeningocele, infections, or bleeding had higher rates of failure after the procedure. This study demonstrated that age under 1 year and hydrocephalus caused by myelomeningocele, bleeding, and infection were considered independent risk factors of poor prognosis in ETV.

Surgical fenestration might not be the best option for very young patients with middle fossa arachnoid cysts

PURPOSE

Surgical fenestration is widely accepted as a primary treatment for middle fossa arachnoid cysts (MFACs) in pediatric patients. However, postoperative subdural effusion and/or hydrocephalus always affect treatment outcomes. In this study, we presented our experience of treating MFACs with surgical fenestration in pediatric patients and analyzed the cases complicated by postoperative subdural effusion and/or hydrocephalus, to give insight into the clinical characteristics predisposing the complications.

METHODS

We retrospectively analyzed 21 pediatric cases with MFACs treated by surgical fenestration suffering postoperative subdural effusion and/or hydrocephalus in our department from November 2011 to April 2019. We reviewed the clinical characteristics and treatment outcomes.

RESULTS

A total of 21 patients, among a total of 53 pediatric patients with MFACs treated by surgical fenestration, developed subdural effusion and/or hydrocephalus postoperatively. The mean age at the time of the initial surgery was 49 months. A total of 75% (6/8) of the patients under 2 years old and 13.3% (6/45) of the older patient group sustaining postoperative subdural effusion and/or hydrocephalus required further surgeries, respectively (Fisher's exact test, p = 0.001). Notably, among the 21 cases with postoperative subdural effusion and/or hydrocephalus, all the 6 patients under 2 years old needed additional surgeries, while of the other 15 older patients, only 40% (6/15) needed further surgical interventions (Fisher's exact test, p = 0.019).

CONCLUSION

The immature CSF absorption in MFAC patients younger than 2 years old might predispose them to the relatively serious postoperative subdural effusion and/or hydrocephalus. For very young patients with giant MFACs, surgical fenestration might not be the best option.

Effects of ETV and VPS on cognitive impairment in infants with congenital hydrocephalus: A retrospective study

This study aims to investigate the postoperative cognitive function changes of infants who underwent endoscopic third ventriculostomy (ETV) or ventriculoperitoneal shunt (VPS) for the treatment of congenital hydrocephalus. Data of 70 hydrocephalus infants and children were retrospectively analyzed. Among these patients, 20 patients underwent ETV, 27 patients underwent VPS, and 23 patients did not undergo any operation (controls). All patients were routinely cared after discharge. The Gecell Developmental Diagnostic Scale was filled for all patients at 2 weeks, 2 months, and 6 months after diagnosis. A total of 20 patients in the ETV group were followed up for 6 months. Among these patients, the clinical symptoms of 18 patients significantly improved. Results determined at 6 months after surgery in the ETV group was statistically significant, compared with the control group ( P < 0.05). Results determined at 2 and 6 months after surgery in the VPS group were statistically significant, compared with the control group ( P < 0.05). Developmental quotient (DQ) values in these two operation groups increased after the operation ( P < 0.01), and the differences were statistically significant. ETV and VPS can improve the cognitive function of infants with hydrocephalus. Improvement of cognitive function by VPS is more significant for infants.

Paediatric arachnoid cysts: Surgical outcomes from a Singapore children's hospital

Arachnoid cysts (AC) are reported to have a prevalence of up to 2.6% in children. Most AC remain indolent, but others may expand or rupture to cause life-threatening symptoms of raised intracranial pressure. Currently, there are 2 controversial topics with regards to the management of ACs: the indications for surgery and the choice of surgical procedure. We therein report our institution's neurosurgical experience for symptomatic AC over a 22-year period and corroborate our results with published literature. This is a single institution, retrospective study conducted at KK Women's and Children's Hospital from 01 January 1998 to 31 December 2019. A total of 38 patients with ACs that required surgery were recruited. The 3 most common anatomical locations were in the middle cranial fossa (40.5%), posterior fossa (24.3%) and interhemispheric (13.5%). Typical clinical presentations included symptoms of raised intracranial pressure (34.2%), obstructive hydrocephalus (28.9%) and AC rupture (21.1%). Surgical approaches included 17 craniotomy-based procedures, 7 endoscopic fenestrations, 11 cystoperitoneal shunts, 2 burrhole drainage operations and 1 excision of spinal AC. Thirteen patients (34.2%) underwent either another operation due to the lack of resolution of their AC-related symptoms or secondary to complications directly related to their initial surgery. Average length of followup from time of first operation was 84.1 months. Overall, our results demonstrate similarities in epidemiology, clinical presentation and surgical experience, in comparison to larger cohort studies. We advocate collaborative efforts to better understanding of the pathophysiology of paediatric ACs, particularly for deciding between the various surgical treatment modalities.

Pediatric posterior fossa tumors outcomes: Experience in a tertiary care center in the Middle East

BACKGROUND

Among all childhood cancers, brain tumors are second only to leukemia in incidence and are the most common solid pediatric tumors. More than 60 % of pediatric brain tumors are infra-tentorial. The first-line treatment for most infra-tentorial tumors in pediatric patients is surgical resection, with the goal of gross-total resection, relief of symptoms and hydrocephalus, and increased survival. The proximity to the fourth ventricle, and therefore, the cerebrospinal fluid (CSF) pathways, predisposes children with posterior fossa tumors to the development of obstructive hydrocephalus and multiple other co-morbidities pre and post-surgery.

OBJECTIVES

This study aims to present our series of pediatric posterior fossa tumor surgeries in the Neurosurgical Department at the American University of Beirut Medical Center(AUBMC) and perform internal quality control for our single-institution consecutive series as one of the largest referral and tertiary care centers in the region. The second purpose of this retrospective study is to weigh the risks of surgery against the presumed advantages and to have specific knowledge about the complication rates, especially those related to the CSF pathway, comparing our results to those in the literature.

METHODS

All pediatric patients (< 18 years of age), referred to our center from different regions in the middle east, and surgically treated for a posterior fossa tumor from June 2006 to June 2018 at the American University of Beirut Medical Center were included. A thorough review of all medical charts was performed to validate all the database records.

RESULTS

The patient sample consisted of 64 patients having a mean age of 6.19 ± 4.42 years and 59.37 % of whom were males. The most common tumor pathology was pilocytic astrocytoma (40.62 %) followed by medulloblastoma (35.93 %) and ependymoma. The most common type of tumor that was seen in patients that developed mutism postoperatively (n = 6, 9.37 %) was medulloblastoma (n = 4, 66.66 %). In this patient sample, 12.28 % (n = 7) of the patients developed hydrocephalus postoperatively.Midline tumors were more associated with the development of mutism(OR = 4.632, p = 0.306) and hydrocephalus (OR = 5.056, p = 0.135) postoperatively, albeit not statistically significantly.The presence of a preoperative shunt was shown to be protective against the development of CSF leak (OR = 0.636, p = 0.767), as none of the patients that came in with CSF diversion developed a CSF leak after their surgery.

CONCLUSION

This study from a single center experience accompanied by a thorough literature review sheds light on the complications frequently encountered after posterior fossa tumor surgery in children. These included transient cerebellar mutism, CSF leak, and hydrocephalus as seen in some of our patients. Our findings highlight the need for prospective studies with well-defined protocols directed at assessing novel ways and approaches to minimize the risk of these complications.

Management of severe intraoperative hemorrhage during intraventricular neuroendoscopic procedures: the dry field technique

OBJECTIVE

The unexpected intraoperative intraventricular hemorrhage is a rare but feared and life-threatening complication in neuroendoscopic procedures because of loss of endoscopic vision. The authors present their experience with the so-called "dry field technique" (DFT) for the management of intraventricular hemorrhages during purely endoscopic procedures. This technique requires the aspiration of the entire intraventricular CSF to achieve clear visualization of the bleeding source.

METHODS

More than 500 neuroendoscopic intraventricular procedures were retrospectively analyzed over the last 24 years for documented severe hemorrhages, which were treated by the application of the DFT.

RESULTS

The technique was required in 6 cases, including tumor resection/biopsy, cyst resection, and intraventricular lavage. Additionally, the technique was applied as part of the planned strategy in 3 cases of endoscopic tumor removal. The hemorrhage was stopped in all cases and no associated postoperative deficits occurred.

CONCLUSIONS

Although severe hemorrhages are rare, the neurosurgeon needs to be aware of them and has to establish strategies for their management. Most hemorrhages can be stopped by constant irrigation and coagulation. In the other rare cases, the DFT is a safe, reliable technique and can be easily incorporated into endoscopic surgery.

Treatment of multi-loculated hydrocephalus using endoscopic cyst fenestration and endoscopic guided VP shunt insertion

OBJECTIVE

To evaluate the role of endoscopic cyst fenestration and endoscopic guided VP shunt insertion in multi-loculated hydrocephalus in children.

METHOD

A retrospective analysis was performed on 20 patients with multi-loculated hydrocephalus who underwent endoscopic cyst fenestration (ECF) alone or in combination with VP shunt revision or insertion between August 2014 and December 2016 with the extended follow-up period to December 2017.

RESULTS

Thirty-one ECFs were performed: ECF alone, 10 operations in 8 cases, and 21 ECFs with shunt insertion in 12 cases. Eighteen of 20 patients required a VP shunt, 7 cases required multiple shunts. All patients with a previous shunt remained shunt dependent; and 6 cases with no prior shunt underwent endoscopic guided ventricular catheter insertion after ECF; only 2 cases did not require a shunt after ECF. The rate of repeated ECFs was 0.25 operations/year and the shunt revision rate was 0.11 operations/year. VP shunt or cystoperitoneal shunt without repeat ECF was used in 7 cases (35%). Mean duration between operations was 71 days in repeated ECF and 16 days in added-on shunt. The most common cause of re-operations was new formation of intraventricular fibrosis or compartmentalization causing ventricular catheter blockage.

CONCLUSION

Endoscopic cyst fenestration and endoscopic assisted VP shunt insertion minimize shunt complications in multi-loculated hydrocephalus. Shunt independence is unusual.

Subdural Hygroma Following Endoscopic Third Ventriculostomy: Understanding the Pathophysiology

BACKGROUND

Endoscopic third ventriculostomy (ETV) has overtaken the use of a ventriculoperitoneal shunt for the treatment of congenital hydrocephalus. Although ETV is relatively safe, several postoperative complications have been reported. One of the least described and understood complications is subdural hygroma following third ventriculostomy.

METHODS

In this series, we retrospectively analyzed patients who were managed for postventriculostomy subdural hygroma and analyzed the possible factors responsible for this condition.

RESULTS

A total of 248 patients who underwent ETV between 2014 and 2016 were included in this study. Twelve patients (4.8%) had developed subdural hygroma, including 6 patients with bilateral hygroma, 2 with contralateral hygroma, and 4 with ipsilateral subdural hygroma. Only 4 patients (1.6%) were symptomatic, with complains of pseudomeningocele, persistent vomiting, or headache. Significant mass effect was present in 2 patients with unilateral subdural hygroma, which improved after placement of a subduroperitoneal shunt. In 1 patient, the subdural hygroma decreased with persistent ventriculomegaly and improved after ventriculoperitoneal shunt implantation. One patient with posttraumatic hydrocephalus who had a bilateral subdural hygroma following ETV improved with conservative management. At a 12-month follow-up, all patients remained asymptomatic.

CONCLUSIONS

Post-ETV subdural hygroma may result from poor absorption of cerebrospinal fluid (CSF) in the subarachnoid space, dysfunction of the stoma with persistence of the ventriculosubdural fistula, or altered CSF cytology, such as hemorrhage. Most of these patients remain asymptomatic and improve with time. Symptomatic patients should be properly evaluated for the cause of the formation of subdural hygroma, which will guide the appropriate interventions.

Venous Air Embolism During Endoscopic Third Ventriculostomy

Neuroendoscopic procedures are increasingly performed nowadays due to the significant technological improvement of endoscopic instrumentation. It carries various advantages such as speed, simplicity, avoidance of implants, and no brain dissection or retraction. Although considered to be safe, it is associated with a host of complications. We hereby report a case of venous air embolism in an infant who was undergoing endoscopic third ventriculostomy. The complication occurred at the completion of surgery when surgeons were withdrawing the endoscope. The successful management of this uncommon event is being discussed.

Keyhole approach in the neuroendoscopic treatment for hydrocephalus

The aim of the study was to explore keyhole approach and dura suture in the neuroendoscopic treatment for hydrocephalus.Twelve cases of hydrocephalus patients who were treated with neuroendoscope by this approach were analyzed retrospectively from April 2015 to April 2016 in our department. The basic steps of this procedure was using drill and milling cutter to form a small bone flap instead of burr hole, and then making a cruciate incision on the dura. After endoscopic third ventriculostomy or endoscopic third ventriculostomy + ventriculocystostomy finished, dura was sutured and the bone flap was reset.All 12 patients could suture dura effectively, and no cerebrospinal fluid leak and subcutaneous cerebrospinal fluid collection happened; symptoms of hydrocephalus were also improved. Moreover, during the operation, we found this approach could suspend dura, and avoid the cerebral sulcus and cortical coarse vein effectively, which could reduce the risk of intracranial hemorrhage. In addition, we found this approach could increase the reachable range of the neuroendoscope significantly.Keyhole approach can suture dura and avoid the cerebral sulcus and cortical coarse vein effectively, increase the indications, and reduce complications of neuroendoscope. So, this approach has clinical values and can be used in hydrocephalus.

Pediatric intraventricular arachnoid cysts in the body of lateral ventricle: surgical outcome and its embryologic background

PURPOSE

The aim of this study is for the surgical treatment and outcome of the endoscopic fenestration of the arachnoid cyst located in the ventricular body to trigone in the pediatric population. Special concern was paid for the developmental origin of the intraventricular cysts estimated from the postoperative follow-up neuroimagings.

PATIENTS AND METHODS

Between July 2002 and June 2015, we performed endoscopic and partly CT/MRI navigated fenestrations of intraventricular arachnoid cysts located at the body to trigone of the lateral ventricle in ten pediatric patients aged 2 months to 5 years. Based on the long axis of the cyst, we have opted for two surgical approaches: anterior approach via burr hole at Kocher's point and posterior approach via burr hole at the posterior occipital region. Fenestration was performed based on the intraoperative findings, either ventriculocystostomy, ventriculocystoventriculostomy, or ventriculocystocisternostomy.

RESULTS

Intraventricular arachnoid cysts located in the body-trigone region showed a favorable outcome after endoscopic fenestration. All of the cysts shrank postoperatively. Follow-up neuroimagings taken between 6 and 126 months after surgery strongly suggested its relationship with the midline cisterns. Of our ten cases, eight were suggestive for originating from the velum interpositum cistern while two seemed to root from the quadrigeminal cistern.

CONCLUSION

In the present study, we found that endoscopic fenestration of intraventricular arachnoid cysts in the body to trigone is a safe procedure with a satisfactory outcome. In our limited experience, there are two anatomic backgrounds; velum interpositum cistern and quadrigeminal cistern. Differentiation can be possible by neuroimagings, especially those obtained after surgery.

The effectiveness of microsurgical fenestration for middle fossa arachnoid cysts in children

OBJECTIVE

Although middle fossa arachnoid cysts (MFACs) are common, the optimal surgical treatment for these lesions remains controversial. In this study, we present our experiences of treating MFACs by microsurgical fenestration and evaluate its effectiveness.

METHODS

We performed retrospective review of 28 patients who underwent microsurgical fenestration for MFACs between May 2003 and December 2014. We reviewed patient characteristics and treatment outcomes including age, sex, symptoms, complicating hydrocephalus, Gallasi classification, change in cyst size after surgery, complicating subdural hygroma, symptom resolution, regrowth of the cyst, and reoperation (including additional CSF diversion).

RESULTS

Twenty-eight MFACs in 28 patients were investigated. The average age at the time of surgery was 61.6 months. The average follow-up duration was 53.5 months. After surgery, 19 (90.5 %) of 21 patients with symptomatic MFACs experienced improvements. The cysts decreased in size in all cases (100 %, 28/28) and disappeared in three cases (11 %, 3/28). None of the cases experienced regrowth of the cyst. Subdural hygroma was identified in 23 cases (82.1 %) at the immediate postoperative period. Hygroma was asymptomatic in all cases but one. Hygroma disappeared in 19 cases (83 %) and decreased in size in three cases (13 %) in the long term. Only one case (4 %) required an additional subdural-peritoneal shunt. The rate of CSF diversion after the fenestration was significantly higher in patients with preoperative ventricular dilation (p = 0.0002).

CONCLUSION

Microsurgical fenestration for pediatric MFACs was considered to be safe and effective. Although subdural hygroma developed in significant number of patients at the immediate postoperative period, it was mostly asymptomatic and disappeared or decreased in size in the long term.

Resection of Intraventricular Tumors in Children by Purely Endoscopic Means

OBJECTIVE

Neuroendoscopy is increasingly being used in the management of intraventricular brain tumors. The role of endoscopy in diagnostic biopsy is well established. Expansion of these techniques may allow for definitive resection of intraventricular tumors. We report the feasibility and outcomes of endoscopic resection of select intraventricular tumors in children.

METHODS

The clinical characteristics of 11 children with solid intraventricular tumors who underwent tumor resection were reviewed. Twelve procedures were performed.

RESULTS

Gross-total resection was achieved in 11 of 12 cases (92%). Maximal tumor diameter ranged from 9 to 26 mm (mean, 16.6 mm). Pathologic results included subependymal giant cell astrocytomas, ependymomas, nongerminomatous germ cell tumors, and pilocytic astrocytomas. Mean follow-up was 35 months (range, 10-109 months). All patients returned to their neurologic baselines after surgery. Local tumor recurrence occurred in 1 patient and distant recurrence in another. In 1 patient, a transitory intraoperative increase of intracranial pressure without clinical implications occurred. There was no permanent morbidity or mortality in this series. Hydrocephalus was present preoperatively in 5 cases and was treated either with tumor removal alone or with an additional endoscopic third ventriculostomy. No patient required a ventriculoperitoneal shunt.

CONCLUSIONS

Neuroendoscopic gross-total resection of solid intraventricular tumors is a safe and efficacious procedure in carefully selected pediatric patients.

Comparison of Intracranial Neuroendoscopic Procedures in Children versus Adults

BACKGROUND

The emphasis regarding intracranial neuroendoscopy has been traditionally advocated and focused on the role in pediatric patients, although a significant usage has developed in adult patients. In this study, we examine and contrast the role of predominantly intracranial neuroendoscopy in both a pediatric and adult population with a minimum postprocedure follow-up of 5 years.

METHODS

A retrospective review was conducted for patients in the two hospitals that manage neurosurgical care for Southern Alberta, Canada, undergoing neuroendoscopic surgery between 1994 and 2008. The pediatric group was defined as age ≤17 years and the adult group as age ≥18 years.

RESULTS

A total of 273 patients who underwent a total of 330 procedures with a mean postprocedure follow-up of 12.9 years were identified. There were 161 adult and 112 pediatric patients, and both groups underwent surgery by the same surgeons. The most common procedure was endoscopic third ventriculostomy, accounting for 55% of procedures. One postoperative death occurred in an adult patient. Endoscopic third ventriculostomy success 1-year postprocedure was 81%, with only three late-term failures. Postoperative infection was the most common serious complication (two pediatric/four adult patients). Adult and pediatric patients had similar major complication rates (4.2% vs 5.7%, p=0.547).

CONCLUSIONS

Neuroendoscopy overall had a similar role in both pediatric and adult neurosurgical populations, with the most commonly associated complication being infection. Neuroendoscopy is an important therapeutic modality in the management of appropriate adult patients.

Stricter indications are recommended for fenestration surgery in intracranial arachnoid cysts of children

PURPOSE

The indication of surgical treatment for intracranial arachnoid cysts (ACs) is a controversial issue. In this study, we reviewed surgical outcomes of intracranial ACs that were treated with endoscopic fenestration or microscopic fenestration, which are currently standard practices for surgical treatment of AC. In addition, we also evaluated the validity of current surgical indications.

METHODS

We analyzed pediatric patients under 18 years of age who underwent surgical management for intracranial AC between January 2000 and December 2011. Patients with a follow-up period of less than 1 year were excluded. A total of 75 patients were enrolled in this study. These patients were assessed by subjective symptoms and by a clinician's objective evaluation. The radiological assessment of AC after surgery was also evaluated.

RESULTS

The median age of patients at the initial operation was 5 years. The median follow-up period was 38 months. The goal of surgery was achieved in 28% (21/75) of patients. The radiological alteration of AC after initial fenestration surgery was diverse. The results of the clinical and radiological assessments did not always coincide. A total of 35 complications occurred in 28 patients. Subdural fluid collection was the most common unexpected radiological complication.

CONCLUSIONS

Our study showed that the fenestration procedure for AC produced unsatisfactory clinical improvements compared to the relatively high complication rate. Therefore, surgical treatment for AC should be strictly limited to patients who have symptoms directly related to AC.

Ventricular endoscopy in the pediatric population: review of indications

INTRODUCTION

Neuroendoscopy has greatly impacted pediatric neurosurgery over the past few decades. Improved optics and microsurgical tools have allowed neuroendoscopes to be used for a multitude of neurosurgical procedures.

DISCUSSION

In this review article, we present the breadth of intraventricular neuroendoscopic procedures for the treatment of conditions ranging from hydrocephalus and brain tumors to congenital cysts and other pathologies. We critically discuss treatment indications and reported success rates for neuroendoscopic procedures. We also present novel approaches, technical nuances, and variations from recently published literature and as practiced in the authors' institution.

The small-chamber irrigation technique (SCIT): a simple maneuver for managing intraoperative hemorrhage during endoscopic intraventricular surgery

BACKGROUND

Acute intraoperative intraventricular hemorrhage is a feared event in endoscopic neurosurgical procedures.

OBJECTIVE

To describe the small-chamber irrigation technique (SCIT) for intraoperative endoscopic management of intraventricular hemorrhage.

METHODS

The SCIT was used in intraventricular surgery for hydrocephalus, intraventricular tumors requiring biopsy, arachnoid cysts, and colloid cysts.

RESULTS

Intraventricular hemorrhage was successfully managed endoscopically with a combination of the SCIT, routine irrigation, and coagulation, allowing for completion of the primary procedures.

CONCLUSION

The SCIT is a powerful tool that the neuroendoscopist can use for visualization to achieve hemostasis when performing intraventricular endoscopic surgery.

Pediatric intracranial arachnoid cysts: comparative effectiveness of surgical treatment options

PURPOSE

A variety of surgical approaches for the treatment of pediatric intracranial arachnoid cysts exist. In an effort to identify the optimal surgical treatment for this disorder, we developed a decision analytic model to evaluate outcomes of four surgical approaches in children. These included open craniotomy for cyst excision, open craniotomy for cyst fenestration, endoscopic cyst fenestration, and cystoperitoneal shunting.

METHODS

Pooled data were used to create evidence tables, from which we calculated incidence, relative risks, and summary outcomes in quality-adjusted life years (QALYs) for the four surgical treatments. Our study incorporated data up to 5 years postsurgery.

RESULTS

We analyzed 1,324 cases from 36 case series. There were no significant differences in outcome among the four surgical strategies. The QALYs (maximum of 5) for surgical approaches resulted in a range from 4.79 (for open craniotomy and excision) to 4.92 (for endoscopic fenestration).

CONCLUSIONS

Overall quality of life is comparable between patients undergoing open craniotomy for cyst excision or fenestration, endoscopic fenestration, and cystoperitoneal shunting up to 5 years after surgery. While each approach offers unique advantages and disadvantages, an individualized treatment strategy should be employed in the setting of surgical outcome equipoise.

Adult symptomatic and growing arachnoid cyst successfully treated by ventriculocystostomy: a new insight on adult arachnoid cyst history

BACKGROUND

Adult arachnoid cysts are known to be stable and asymptomatic but their history remains undefined.

CASE DESCRIPTION

The authors report the case of an 81-year-old woman with progressive hemiplegia and aphasia. CT scan revealed a voluminous left frontotemporal arachnoid cyst with a major mass effect on the midline and contralateral blocked hydrocephalus. Endoscopic ventriculocystostomy was performed with a spectacular neurological improvement.

DISCUSSION AND CONCLUSIONS

Symptomatic adult arachnoid cysts are extremely rare. To our knowledge, no similar clinical case of a growing arachnoid cyst in elderly patients has yet been reported in the literature. The mechanisms of cyst enlargement and decompensation still remain undefined and debated. The possibility of adult arachnoid cyst growth has to be considered in clinical practice. Endoscopic ventriculocystostomy is as effective as in paediatric cases.

The usefulness of electromagnetic neuronavigation in the pediatric neuroendoscopic surgery

OBJECTIVE

Neuroendoscopy is applied to various intracranial pathologic conditions. But this technique needs informations for the anatomy, critically. Neuronavigation makes the operation more safe, exact and lesser invasive procedures. But classical neuronavigation systems with rigid pinning fixations were difficult to apply to pediatric populations because of their thin and immature skull. Electromagnetic neuronavigation has used in the very young patients because it does not need rigid pinning fixations. The usefulness of electromagnetic neuronavigation is described through our experiences of neuroendoscopy for pediatric groups and reviews for several literatures.

METHODS

Between January 2007 and July 2011, nine pediatric patients were managed with endoscopic surgery using electromagnetic neuronavigation (AxiEM, Medtronics, USA). The patients were 4.0 years of mean age (4 months-12 years) and consisted of 8 boys and 1 girl. Totally, 11 endoscopic procedures were performed. The cases involving surgical outcomes were reviewed.

RESULTS

The goal of surgery was achieved successfully at the time of surgery, as confirmed by postoperative imaging. In 2 patients, each patient underwent re-operations due to the aggravation of the previous lesion. And one had transient mild third nerve palsy due to intraoperative manipulation and the others had no surgery related complication.

CONCLUSION

By using electromagnetic neuronavigation, neuroendoscopy was found to be a safe and effective technique. In conclusion, electromagnetic neuronavigation is a useful adjunct to neuroendoscopy in very young pediatric patients and an alternative to classical optical neuronavigation.

Use of the NeuroBalloon catheter for endoscopic third ventriculostomy

Endoscopic third ventriculostomy (ETV) has become the procedure of choice for treatment of obstructive hydrocephalus. While patient selection is the most critical factor in determining the success of an ETV procedure, the technical challenge lies in the proper site of fenestration and the successful creation of a patent stoma. Positioning of a single balloon catheter at the level or below the floor of the third ventricle to achieve an optimal ventriculostomy can at times be challenging. Here, the authors describe the use of a double-barrel balloon catheter (NeuroBalloon catheter), which facilitates positioning across, as well as dilation of, the floor of the third ventricle. The surgical technique and nuances of using the NeuroBalloon catheter and the experience in more than 1000 cases are described. The occurrence of vascular injury was less than 0.1%, and the risk of balloon rupture was less than 2%. The authors found that the placement and deployment of this balloon catheter facilitate the creation of an adequate ventriculostomy in a few simple steps.

Hydrocephalus in mucopolysaccharidosis type VI successfully treated with endoscopic third ventriculostomy

Mucopolysaccharidosis (MPS) Type VI, or Maroteaux-Lamy syndrome, is characterized by a deficiency of the enzyme arylsulfatase B (ASB). In patients with this disorder, craniocervical compression, carpal tunnel syndrome, and communicating hydrocephalus are common. Traditionally, hydrocephalus occurring in patients with MPS VI has been treated with shunt placements. Considering obstruction of the outlets from the fourth ventricle at the craniocervical transition, the authors decided to treat a female patient with MPS VI via endoscopic third ventriculostomy. She was 12 years old and had refractory headaches. This seems to be the first reported instance of the neuroendoscopic treatment of hydrocephalus in a patient with MPS VI. The pathophysiology is briefly discussed.

Fast-brain MRI in children is quick, without sedation, and radiation-free, but beware of limitations

Fast-brain MRI is a promising technique for young children who require anesthesia for conventional MRI; however, poor contrast resolution and the use of one type of pulse sequence only has limitations. We aimed to review and document pitfalls of fast-brain MRI in non-sedated children. Fifty fast-brain MRI studies (Fast Imaging Employing sTeady State Acquistion [FIESTA] protocol; 1.5-Tesla Signa Excite HD, GE HealthCare, Milwaukee, WI, USA) performed between January 2008 and August 2010 in 30 non-sedated patients aged 1 day to 5 years of age (mean: 18 months) were reviewed retrospectively and compared to the most recent MRI or CT scan. The indications were: ventriculoperitoneal (VP) shunt insertion or revision or follow-up (20/50, 40%), postoperative follow-up (9/50, 18%), macrocephaly, ventriculomegaly or congenital malformation (15/50, 30%), complications of prematurity (6/50, 12%). The VP shunt position and size of fluid-filled structures were satisfactorily assessed in all patients. Undetected findings in 7/50 studies (14%) were: venous sinus thrombosis (one patient), subdural hematoma (three), failure to differentiate blood products (two), and limited evaluation of extra-axial collections (one). FIESTA fast-brain MRI provides satisfactory assessment of shunt position and the size of fluid-filled structures, but radiologists should be aware of limitations for depiction of venous sinus thrombosis, and bleeding. Modification of fast-brain protocols appears to be indicated.

Ventriculoperitoneal shunt surgery outcome in adult transition patients with pediatric-onset hydrocephalus

BACKGROUND

Ventriculoperitoneal shunting remains the most widely used neurosurgical procedure for the management of hydrocephalus, albeit with many complications.

OBJECTIVE

To review and assess the long-term clinical outcome of ventriculoperitoneal shunt surgery in adult transition patients with pediatric-onset hydrocephalus.

METHODS

Patients 17 years or older who underwent ventriculoperitoneal shunt placement for hydrocephalus during their pediatric years (younger than 17 years) were included. Medical charts, operative reports, imaging studies, and clinical follow- up evaluations were reviewed and analyzed retrospectively.

RESULTS

A total of 105 adult patients with pediatric-onset hydrocephalus were included. The median age of the patients was 25.9 years. The median age at the time of the initial ventriculoperitoneal shunt placement was 1.0 year. The median follow-up time for all patients was 17.7 years. The incidence of shunt failure at 6 months was 15.2%, and the overall incidence of shunt failure was 82.9%. Single shunt revision occurred in 26.7% of the patients, and 56.2% had multiple shunt revisions. The cause of hydrocephalus was significantly associated with shunt survival for patients who had shunt failure before the age of 17 years. Being pediatric at first shunt revision, infection, proximal shunt complication, and other causes were independently associated with multiple shunt failures.

CONCLUSION

The findings of this retrospective study show that the long-term ventriculoperitoneal shunt survival remains low in adult transition patients with pediatric-onset hydrocephalus.

Success criteria in pediatric neuroendoscopic procedures. Proposal for classification of results after 67 operations

PURPOSE

Controversial issues exist concerning criteria for patient selection and long-term success in pediatric neuroendoscopic procedures. We designed a classification of success grades applicable to high-pressure and chronic hydrocephalus and also to those cases in which different endoscopic maneuvers are performed during the same procedure. We then evaluated the success rate and complications in our series.

METHODS

A total of 59 patients underwent 67 neuroendoscopic procedures between January 2003 and January 2011. A retrospective study was made of the preoperative history, operative reports, and postoperative imaging findings and medical records. A 5-grade scale was developed to assess the type of success depending on clinical and radiological data. Complications related to the surgical procedure were also recorded.

RESULTS

Two patients were excluded from the success analysis due to insufficient follow-up time. The final results for the first procedures in 57 patients were complete and permanent success (grade I) in 49.1%, complete but transitory success (grade II) in 10.5%, partial success (grade III) in 12.3%, doubtful success (grade IV) in 5.3%, and failure (grade V) in 22.8%. In eight cases a second procedure followed the failure of the first: grade I success was achieved in seven cases (87.5%) and grade V in one case (12.5%). The highest success rates were achieved in cases of hydrocephalus caused by tumors or arachnoid cysts and the lowest in slit ventricle syndrome.

CONCLUSIONS

A common classification of degrees of success, such as that proposed here, would aid the development of comparative and cooperative studies.

Success of pure neuroendoscopic technique in the treatment of Sylvian arachnoid cysts in children

INTRODUCTION

Neuroendoscopic approaches to Sylvian arachnoid cysts (SACs) constitute an alternative treatment option to craniotomy for fenestration and shunting procedures. In this study, the authors discuss their experience on pure neuroendoscopic technique in the treatment of SACs in children.

RESULTS

The results of treatment of 20 children (range of age, between 7 months and 17 years) with Galassi type II (n, 5) or III (n, 15) SACs who were subjected to pure neuroendoscopic fenestration procedure were presented. It was possible to perform the cystocisternostomy endoscopically in all children with several stomies. The site of the opening was between the optic nerve and the carotid artery in 19, between the carotid artery and the oculomotor nerve in 17, and below the oculomotor nerve in 7. The stomies were enlarged in all cases using the double balloon. Three of the cases required repetition of the operation and two cases required "cystoperitoneal shunt" implantation. There was one minor complication in a patient who had an asymptomatic postoperative subdural effusion, which resolved spontaneously. Of the 18 cases, in which the neuroendoscopic procedures succeeded, 10 showed a reduction in cyst size. The mean follow-up period was 53 months.

DISCUSSION

Our results suggest that "pure neuroendoscopic" approach can be used safely in the management of SACs in children. We recommend at least two fenestration sites for an effective marsupialization of the cyst within the basal cisterns. In pediatric cases, the use of a small diameter rigid endoscope allows to reach safely the planned target areas.

Fenestration methods for Sylvian arachnoid cysts--endoscopy or microsurgery

INTRODUCTION

Two different approaches to fenestration, endoscopic and microsurgical, are in use for Sylvian arachnoid cysts (SACs), the most frequent among intracranial arachnoid cysts. We presented the clinical data and compared our results, with regard to technique and clinical success, with either microsurgical or neuroendoscopic fenestration of SACs.

MATERIALS AND METHODS

Twenty-nine patients who subjected to cysto-cisternostomy by the same team, using either of the two methods, were studied retrospectively.

RESULTS

Thirteen patients underwent microsurgery, and 16 had endoscopic cysto-cisternostomy. No reoperation was needed in either of these groups, i.e., full clinical and radiological success was achieved in both. The complication rate was 23% in the microsurgery patients and 47% in the endoscopic surgery group, with no statistically significant difference.

CONCLUSIONS

No relevant differences between the two methods are seen either in the published data or in our results. Adding our results to the published data, both techniques were reviewed in a discussion of the one that allows a better controlled or safer fenestration. We conclude that endoscopic fenestration of SACs is not superior to microsurgical cyst fenestration, and the latter seems safer.

Factors predicting the need for cerebrospinal fluid diversion following posterior fossa tumor surgery in children

BACKGROUND

No consensus exists regarding the management of hydrocephalus in children with posterior fossa tumors before, during or after surgery. In the present study we analyze the factors that predispose to persistent hydrocephalus and the need for a postoperative cerebrospinal fluid (CSF) diversion procedure.

METHODS

Pediatric patients who underwent surgery for posterior fossa tumors with hydrocephalus at our hospital were reviewed to evaluate the need for a postoperative CSF diversion procedure. Patients having undergone CSF diversion preoperatively were excluded from the study group. The case records of 84 patients were reviewed. The factors evaluated included age at diagnosis, duration of symptoms, severity of preoperative hydrocephalus, tumor size, tumor location, tumor histology, extent of tumor resection and postoperative complications that could be related to CSF circulation disorders.

RESULTS

At the time of presentation, 80/84 (95.2%) patients had symptomatic hydrocephalus; 25/84 (29.8%) patients required a CSF diversion procedure in the postoperative period. Children presenting with symptom duration of less than 3 months had a significantly higher requirement for postoperative CSF diversion in comparison to those with longer symptomatology (p = 0.016). Evan's index and frontal and occipital horn ratio on preoperative imaging were found to correlate closely with the need for postoperative shunt (p = 0.001 and p < 0.001, respectively). The requirement for shunt was statistically higher in patients with midline tumors in comparison to laterally placed lesions (p = 0.04) and in children with medulloblastoma (p < 0.001) and ependymoma (p = 0.016) as the tumor subtypes. Children who underwent intraoperative external ventricular drainage (EVD) had a shunt insertion rate of 39.6% compared with 16.7% of those who did not have an EVD (p < 0.001). Patients with meningitis and pseudomeningocele in the postoperative period had a statistically significant higher risk of shunt requirement (p = 0.008 and p = 0.016, respectively). The mean age at diagnosis and the extent of tumor resection did not correlate with the need for CSF diversion.

CONCLUSION

The fact that less than one-third of patients require a CSF diversion after posterior fossa tumor resection refutes the role of prophylactic endoscopic third ventriculostomy. Awareness regarding the factors that can predict persistent postoperative hydrocephalus is essential for the surgeon during patient counseling and surgical planning, and also in deciding the intensity of postoperative clinical and radiological monitoring.

Evaluating the Children's Hospital of Alabama endoscopic third ventriculostomy experience using the Endoscopic Third Ventriculostomy Success Score: an external validation study

OBJECT

Endoscopic third ventriculostomy (ETV) success is dependent on patient characteristics including age, origin of hydrocephalus, and history of shunt therapy. Using these factors, an Endoscopic Third Ventriculostomy Success Score (ETVSS) model was constructed to predict success of therapy. This study reports a single-institution experience with ETV and explores the ETVSS model validity.

METHODS

A retrospective chart review identified 151 consecutive patients who underwent ETV at a pediatric hospital between August 1995 and December 2009. Of these 151, 136 patients had at least 6 months of clinical follow-up. Data concerning patient characteristics, operative characteristics, radiological findings, complications, and success of ETV were collected. The actual success rates were compared with those predicted by the ETVSS model.

RESULTS

The actual success rate of ETV at 6 months was 68.4% (93 of 136 patients), which compared well to the predicted ETVSS of 76.5% ± 12.5% (± SD). The C-statistic was 0.74 (95% CI 0.65-0.83), suggesting that the ability of the ETVSS to discriminate failures from successes was good. Secondary ETV was found to have a hazard ratio for failure of 4.2 (95% CI 2.4-7.2) compared with primary ETV (p < 0.001). The complication rate was 9.3% with no deaths. At the first radiological follow-up, the increased size of ventricles had a hazard ratio for failure of 3.0 (95% CI 1.5-6.0) compared with patients in whom ventricle size either remained stable or decreased (p = 0.002).

CONCLUSIONS

The ETVSS closely predicts the actual success of ETV, fitting the statistical model well. Shortcomings of the model were identified in overestimating success in patients with ETVSS ≤ 70, which may be attributable to the poor success of secondary ETVs in the authors' patient population.

Hydrocephalus and arachnoid cysts

AIM

The management of arachnoid cysts (AC) remains controversial. An additional problem derives from the management of hydrocephalus associated with an AC. In this work, we discuss existing procedures proposed in the current literature for their treatment.

METHODS

We reviewed selected reports on intracranial ACs placing special interest in those about the association of hydrocephalus and ACs. We also briefly surveyed data of our patients with this association.

RESULTS AND DISCUSSION

Hydrocephalus is often found in midline and posterior fossa ACs. Interhemispheric lesions may also evolve with ventriculomegaly, while middle fossa lesions rarely produce hydrocephalus. Patients' age, cyst location and size, and macrocephaly have all been related to the development of hydrocephalus. Some authors remark on the role played by hydrocephalus and hypothesize that some ACs would result from disturbed cerebrospinal fluid (CSF) dynamics. They also propose that ACs might represent a localized form of hydrocephalus. We also comment on hydrocephalus in relation to the diverse locations of ACs. Neuroendoscopic techniques have transformed previous ways of management as cystoperitoneal shunting and open fenestration.

CONCLUSIONS

ACs may be pathogenetically related with hydrocephalus, and conversely, ACs may cause hydrocephalus. In some patients, aberrant CSF dynamics seems to play a major role in the development of both cyst and hydrocephalus. Hydrocephalus and ACs may be treated exclusively with neuroendoscopic procedures, although some patients will still require CSF shunting. The ideal option seems to consist of choosing the method that offers the highest success with a single procedure for treating the hydrocephalus and the AC simultaneously.