Intraoperative Hemorrhage in Ventriculoscopic Surgery: Experience of a Single Chinese Neurosurgery Center

Combined intra- and extra-endoscopic techniques for endoscopic intraventricular surgery with a new mini-tubular port

Objective

Intraoperative hemorrhage represents a major risk during endoscopic intraventricular surgery. There are very few publications describing the maintenance of hemostasis during conventional endoscopic intraventricular surgery. Here, we designed a new mini-tubular port to combine intra- and extra-endoscopic techniques for endoscopic intraventricular surgery. With this new methodology, complicated techniques can be performed more efficiently with improved bleeding control.

Methods

The new mini-tubular port consists of an outer sheath and an obturator. The sheath is a thin-walled transparent cylinder that is 0.35 mm thick, 10 mm in diameter, and 90 mm in length. In this report, we describe the use of the mini-tubular port on 36 patients receiving endoscopic intraventricular surgery.

Results

The study enrolled 36 patients, with a median age of 45 years (range: 0–72 years), of which 19 were male and 17 were female. Pure ETV (endoscopic third ventriculostomy) was performed in 20 patients and pure biopsy was performed in 2. ETV and biopsy were performed in five patients, ETV and the removal of cysticerci were performed in five, cyst fenestration was performed in one, ETV and cyst fenestration were performed in two, and ETV and shunt removal were performed in one patient. Two patients received microscopic surgery following endoscopic surgery during the same operation. A total of 17 patients (47%) underwent extra-endoscopic techniques. The median Karnofsky Performance Status (KPS) score of the patients prior to surgery was 50, while the median KPS score of the patients after one month of surgery was 80; these scores were significantly different (P < 0.05), as determined by Wilcoxon's test. In total, 27 patients had a KPS score ≥70% and 75% of patients had a favorable prognosis one month after surgery. None of the patients experienced seizure.

Conclusion

The new mini-tubular port can conveniently combine intra- and extra-endoscopic techniques for endoscopic intraventricular surgery. The application of these techniques can efficiently control bleeding during surgery, help improve the confidence of the surgeons involved, and provide a highly efficient approach for performing complicated procedures.

Endoscopic surgery for intraventricular hemorrhage: A comparative study and single center surgical experience

BACKGROUND

Intraventricular hemorrhage is a neurosurgical emergency, and a dangerous condition associated with high morbidity and mortality. Previously, hematoma evacuation is generally executed by external intracranial drainage (EVD) or surgical evacuation. Nowadays, endoscopic evacuation is emerging as a good alternative because it brings relatively less invasion and injury. However, successful endoscopic evacuation requires skilled manipulation of endoscopic devices and the evidence supporting its efficacy differs in different reports.

AIM

To improve the technique usage and provide more evidence of endoscopic evacuation efficacy, we summarize our surgical experience and compared the outcomes of the endoscopic evacuation with EVD using real-world data.

METHODS

We retrospectively studied 96 consecutive patients with intraventricular hemorrhage who underwent either endoscopic surgery (n = 43) or non-endoscopic surgery (n = 53) for hemorrhage evacuation between November 2013 and September 2019 in our center. Patients’ conditions prior to and after the operation were evaluated and analyzed to assess the efficacy of the operation. The consciousness status improvement and perioperative in-hospital parameters in the two types of operation groups were assessed and compared.

RESULTS

Patients in the endoscopic and non-endoscopic groups presented with a similar state of consciousness, with a comparable Glasgow Coma Scale (GCS) index. The average operation time of the endoscopic group was longer than that of the non-endoscopic group (median 2.42 h vs 1.08 h, P < 0.001). Although the endoscopic group was older and had a baseline Graeb score that indicated more severe hemorrhage than the non-endoscopic group (Graeb median: Endoscopic group = 9 vs non-endoscopic group = 8, P = 0.023), the clearance rate of hematoma was as high as 60.5%. Both the endoscopic and non-endoscopic groups showed an improved GCS index after surgery. However, this improvement was more marked in patients in the endoscopic group (median improvement of GCS index: Endoscope group = 4 vs non-endoscopic group = 1, P < 0.001). Additionally, the endoscopic group had a lower Graeb score than the non-endoscopic group after the operation. The intensive care unit stay of the endoscopic group was significantly shorter than that of the non-endoscopic group (median: endoscopic group = 6 d vs non-endoscope group = 7 d, P = 0.017).

CONCLUSION

Endoscopic evacuation of intraventricular hemorrhage was generally an effective and efficient way for hemorrhage evacuation, and contributed remarkably to the improvement of consciousness in patients with intraventricular hemorrhage.

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.

Pineal region tumors: Long-term results of endoscopic third ventriculostomy and concurrent tumor biopsy with a single entry approach in a series of 64 cases

OBJECTIVES

Endoscopic third ventriculostomy and concurrent biopsy is increasingly used in management of the pineal region tumors. Our objective was to assess the results of single entry approach to surgically manage the tumors of the pineal region.

PATIENTS AND METHODS

A retrospective study was designed, and a series of 64 consecutive patients (31 male, 33 female) with pineal region tumor undergoing endoscopic third ventriculostomy and concurrent biopsy of the tumor was undertaken.

RESULTS

A total of 64 patients underwent simultaneous endoscopic third ventriculostomy and biopsy of the pineal tumors with a single entry approach. A positive initial diagnosis was established in 97% of patients. 5 patients (7%) required the insertion of an external ventricular drain which was removed in all patients after 72 h but in one case (1%) undergoing permanent VP shunt insertion. The postoperative complications were divided into two transient and permanent complications. The transient complications included intraventricular hemorrhage (18%), seizure (1 to two episodes of seizure) (5%), diabetes insipidus (3%) and meningitis (3%) all were successfully managed. The only permanent complication was memory deficits occurred in one patient (1%). There was no mortality rate in current study.

CONCLUSION

The results of this study support the safety and efficacy of endoscopic third ventriculostomy and concurrent biopsy of the pineal region tumors as a less invasive surgical method associated with low morbidity and mortality rate. Our data demonstrated how simultaneous endoscopic third ventriculostomy and biopsy of the pineal region tumors with a single entry approach can produce favorable results.

Visual-Controlled Endoscopic Biopsy of Paraventricular Intraparenchymal Tumors

OBJECTIVE

Frame-based stereotaxy represents the gold standard for biopsy of deep-seated lesions. Visual control of possible bleeding in these lesions is not possible. Neuroendoscopic biopsy represents an alternative procedure for tissue sampling in deep-seated intraventricular lesions. The authors present a technique for transventricular-navigated endoscopic biopsy of lesions that are located in the paraventricular region.

METHODS

Biopsy of paraventricular pathologies was performed in 6 male and 6 female patients between March 2013 and September 2018. The patient age ranged from 18 to 82 years. All patients underwent a pure endoscopic procedure over a burr hole trepanation supported by frameless navigation of the sedan probe.

RESULTS

Histologic diagnoses were established in all biopsies. In all patients, a direct control of the biopsy area was feasible, and hemostasis could be obtained. In 5 patients, endoscopic third ventriculostomy was performed first due to obstructive hydrocephalus. In 1 patient suffering from obstructive hydrocephalus, a pellucidotomy was performed. In 9 cases, the initial postoperative course was uneventful. Three patients suffered from persistent hydrocephalus and had to be treated with ventriculoperitoneal shunt insertion.

CONCLUSIONS

Endoscopically conducted biopsies with the aid of navigated tracking of the probe represent a possible additional technique in selected paraventricular intraparenchymal pathologies. The endoscopic approach enables the direct visualization of the intraventricular surface and its vessels. In contrast to standard stereotactic biopsy, direct visual control of hemostasis can be obtained even in paraventricular tumors.

The subependymal microvascular network revealed by endoscopic fluorescence angiography

BACKGROUND

The subependymal vascularization of the cerebral ventricles has been described in anatomical studies on human specimens. Its identification in vivo during neuroendoscopic navigation could have anatomical interest and may lead to a safer ventricular navigation, also avoiding unexpected bleeding. The traditional endoscopic visualization allows the certain identification of only the main vessels. In this study we describe the features of the subependymal vascular network (SEVN) enhanced by sodium fluorescein (SF) angiography. We compare these findings with the vascular patterns visible under white light to evaluate the sensitivity of this technique in unveiling the most distant branches of the SEVN.

METHODS

We reviewed the video records of 39 fluorescein-assisted neuroendoscopic procedures. Steerable fiberscopes equipped with a dual observation mode for both white light and fluorescence were used. After preliminary inspection of the ventricular cavities, the camera was switched to the blue light fluorescent mode. Identical portion of ventricular walls observed in both modalities were compared and analyzed to enhance potential differences of the vascular features.

RESULTS

The main veins were positive (fluorescein enhanced) in 10 patients (25.6%), vessels of smaller diameter visible also under white light presented a detectable fluorescence in 27 patients (69.2%), the micro SEVN, not visible under with light, was revealed by SF in 21 patients (53.8%).

CONCLUSIONS

Fluorescein-guided neuroendoscopy deserves closer investigation since it allows detection of small vessels, not otherwise visible, in the ventricle walls. This method could be applied to ameliorate the knowledge of the environment the surgeon is working on, leading as a result to a safer navigation, also by avoiding minor bleedings.