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Issa M, Younsi A, Paggetti F, Miotk N, Seitz A, Bendszus M, Wisoff JH, Unterberg A, El Damaty A. Heidelberg ETV score to assess success of ETV in patients with occlusive hydrocephalus: a retrospective single-center study. Neurosurg Rev 2023; 46:214. [PMID: 37644240 PMCID: PMC10465657 DOI: 10.1007/s10143-023-02122-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 08/13/2023] [Accepted: 08/15/2023] [Indexed: 08/31/2023]
Abstract
In aqueduct stenosis, pressure difference below and above level of obstruction leads to bulging of third ventricular floor (TVF) and lamina terminalis (LT). Endoscopic third ventriculocisternostomy (ETV) is the standard treatment in these patients. We tried to assess success of ETV depending on those two radiological changes in aqueduct stenosis. We implemented "Heidelberg ETV score" retrospectively to assess the state of TVF as well as LT in same manner in midsagittal MR image. Every patient had a preoperative, direct, 3-months and one-year postoperative score from -2 to + 2. We correlated the scores to clinical course to decide whether the score is reliable in defining success of ETV. Between 2017-2021, 67 (mean age 25.6 ± 23.9y) patients treated with ETV were included. Success rate of primary and Re-ETVs was 91% over 46.8 ± 19.0 months. A marked shift of score to the left after surgery in success group was noticed through the distribution of score immediate postoperative, 3-months later; 70.2% showed (+ 2) before surgery, 38.9% scored (0) after surgery and 50.9% showed further score drop to (-1) 3 months later, p < 0.001. In cases of failure, there was initial decrease after surgery followed by increase with ETV-failure (mean time to failure: 7.2 ± 5.7 months) in 100%. Significant difference was noticed in Heidelberg score at postoperative 1-year- and failure-MRI follow-up between two groups, p < 0.001. Heidelberg score describes anatomical changes in third ventricle after ETV and can serve in assessment of MR images to define success of the procedure in patients with aqueduct stenosis.
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Affiliation(s)
- Mohammed Issa
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Alexander Younsi
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Filippo Paggetti
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Nikolai Miotk
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Angelika Seitz
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Martin Bendszus
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Jeffrey H Wisoff
- Department of Neurosurgery, Division of Pediatric Neurosurgery, The Hassenfeld Children's Hospital at NYU Langone Health, New York City, NY, USA
| | - Andreas Unterberg
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Ahmed El Damaty
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.
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Gillespie CS, Fang WYS, Lee KS, Clynch AL, Alam AM, McMahon CJ. Long-Standing Overt Ventriculomegaly in Adults: A Systematic Review and Meta-Analysis of Endoscopic Third Ventriculostomy Versus Ventriculoperitoneal Shunt as First-Line Treatment. World Neurosurg 2023; 174:213-220.e2. [PMID: 36958719 DOI: 10.1016/j.wneu.2023.03.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 03/14/2023] [Accepted: 03/15/2023] [Indexed: 03/25/2023]
Abstract
BACKGROUND Long-standing overt ventriculomegaly in adults (LOVA) is a heterogeneous term describing forms of adult hydrocephalus. LOVA incidence is increasing, yet the optimal treatment strategy for symptomatic cases remains unclear. We compared success rates and complication rates between endoscopic third ventriculostomy (ETV) and ventriculoperitoneal shunt (VPS) as first-line treatment for LOVA. METHODS A systematic review and meta-analysis was conducted in accordance with PRISMA guidelines. Three databases were searched, and articles published from 2000 to October 2022 were included (last search date October 24, 2022). Success rates and complications of both ETV and VPS were compared using random-effects models. RESULTS Of 895 articles identified, 22 studies were included in the analysis (556 patients: 346 in ETV group, 210 in VPS group). Mean age was 44.8 years. The most common presenting symptoms were gait disturbance (n = 178), headache (n = 156), and cognitive decline (n = 134). Combined success rates were 81.8% (n = 283/346) in the ETV group and 86.7% (n = 182/210) in the VPS group (median follow-up 41 months). There was no difference in success rates between ETV and VPS groups (odds ratio 0.94, 95% confidence interval 0.86-1.03, I2 = 0%). Combined complication rates were 4.6% (n = 16/346) in the ETV group and 27.1% (n = 57/210) in the VPS group. ETV had a lower rate of postoperative complications (odds ratio 0.22, 95% confidence interval 0.11-0.33, I2 = 0%). CONCLUSIONS Symptomatic LOVA can be successfully managed with surgical intervention. ETV and VPS have similar success rates when used as first-line treatment. VPS has a higher complication rate.
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Affiliation(s)
- Conor S Gillespie
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom.
| | - Wen Yung Stephanie Fang
- Department of Clinical Neurosciences, St George's, University of London, London, United Kingdom
| | - Keng Siang Lee
- Department of Neurosurgery, King's College Hospital, London, United Kingdom; Department of Basic and Clinical Neurosciences, Maurice Wohl Clinical Neuroscience Institute, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
| | - Abigail L Clynch
- Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, United Kingdom; Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, United Kingdom
| | - Ali M Alam
- Institution of Infection, Veterinary and Ecological Science, University of Liverpool, Liverpool, United Kingdom
| | - Catherine J McMahon
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, United Kingdom
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Kumar S, Sahana D, Rathore L, Jain A, Tawari M, Singh D, Sahu R, Madhariya SN. Extra-axial endoscopic third ventriculostomy: preliminary experience with a technique to circumvent conventional endoscopic third ventriculostomy complications. J Neurosurg 2023; 138:503-513. [PMID: 35901703 DOI: 10.3171/2022.5.jns22589] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Accepted: 05/16/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Endoscopic third ventriculostomy (ETV) is mostly safe but may have serious complications. Most of the complications are inherent to the procedure's intra-axial nature. This study aimed to explore an alternative route to overcome inherent issues with conventional ETV. The authors performed supraorbital, subfrontal extra-axial ETV (EAETV) via the lamina terminalis. METHODS This prospective study began in October 2021 and included patients with obstructive triventricular hydrocephalus with a Glasgow Coma Scale score of 8 or more and a minimum follow-up of 3 months. Patients with multiloculated hydrocephalus and those younger than 1 year of age were excluded. The preoperative parameters etiology, symptoms, Evans' Index, frontal occipital horn ratio (FOHR), and third ventricle index were recorded. The surgical procedure is described. Postoperative evaluation included clinical (modified Rankin Scale [mRS]) and radiological assessment with CT and cine phase-contrast MRI. Preoperative and postoperative parameters were compared statistically. RESULTS Ten patients were included in this study. Six patients had acute hydrocephalus, and 4 had chronic hydrocephalus. After EAETV, all patients showed clinical improvement. An mRS score of 0 or 1 was achieved in 9 patients, but the mRS score remained at 4 in a patient with tectal tuberculoma. There was a significant reduction in Evans' Index, FOHR, and third ventricle index after EAETV (p < 0.05). The mean percent reduction in Evans' Index was 20.80% ± 13.89%, the mean percent reduction in FOHR was 20.79% ± 12.98%, and the mean percent reduction in the third ventricle index was 37.45% ± 14.74%. CSF flow voids were seen in all cases. The results of CSF flow quantification parameters were as follows: mean peak velocity 3.82 ± 0.93 cm/sec, mean average velocity 0.10 ± 0.05 cm/sec, mean average flow rate 46.60 ± 28.58 μL/sec, mean forward volume 39.90 ± 23.29 μL, mean reverse volume 34.10 ± 15.98 μL, mean overall flow amplitude 74.00 ± 27.61 μL, and mean stroke volume 37.00 ± 13.80 μL. One patient developed a minor frontal lobe contusion. The frontal air sinus was breached in 5 patients, but none had CSF rhinorrhea. Transient supraorbital hypesthesia was seen in 3 patients. No patient had electrolyte disturbance or change in thirst or fluid intake habits. CONCLUSIONS EAETV is a feasible, safe, and effective surgical alternative to conventional ETV.
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Affiliation(s)
- Sanjeev Kumar
- 1Department of Neurosurgery, DKS Post Graduate Institute and Research Center, Raipur Chhattisgarh
| | - Debabrata Sahana
- 1Department of Neurosurgery, DKS Post Graduate Institute and Research Center, Raipur Chhattisgarh
| | - Lavlesh Rathore
- 1Department of Neurosurgery, DKS Post Graduate Institute and Research Center, Raipur Chhattisgarh
| | - Amit Jain
- 1Department of Neurosurgery, DKS Post Graduate Institute and Research Center, Raipur Chhattisgarh
| | - Manish Tawari
- 1Department of Neurosurgery, DKS Post Graduate Institute and Research Center, Raipur Chhattisgarh
| | - Deepak Singh
- 2Department of Neuro-anesthesia, DKS Post Graduate Institute and Research Center, Raipur Chhattisgarh; and
| | - Rajiv Sahu
- 1Department of Neurosurgery, DKS Post Graduate Institute and Research Center, Raipur Chhattisgarh
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Yang C, Li Y. Review of the prevention and treatment of hydrocephalus after aneurysmal subarachnoid hemorrhage. World Neurosurg 2022; 168:134-138. [PMID: 36041720 DOI: 10.1016/j.wneu.2022.08.089] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Accepted: 08/20/2022] [Indexed: 11/16/2022]
Abstract
Hydrocephalus following a ruptured aneurysm portends a poor prognosis. Patients have to face the risk of infection and shunt obstruction after shunt surgery, which may require a second procedure and greatly reduce the quality of life for survivors. It is crucial to minimize the incidence of hydrocephalus and reduce cerebrospinal fluid shunt dependency. This article reviews current interventions before and after hydrocephalus formation after aneurysmal subarachnoid hemorrhage, focusing on the relationships between treatment options and the incidence of postoperative hydrocephalus, management of cerebrospinal fluid drainage and shunt dependent hydrocephalus, and advocates the combination of prevention and treatment to develop individualized treatment plans for patients.
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Affiliation(s)
- Cheng Yang
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Yuhong Li
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China.
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Hersh DS, Martin JE, Bristol RE, Browd SR, Grant G, Gupta N, Hankinson TC, Jackson EM, Kestle JRW, Krieger MD, Kulkarni AV, Madura CJ, Pindrik J, Pollack IF, Raskin JS, Riva-Cambrin J, Rozzelle CJ, Smith JL, Wellons JC. Hydrocephalus surveillance following CSF diversion: a modified Delphi study. J Neurosurg Pediatr 2022; 30:177-187. [PMID: 35901763 DOI: 10.3171/2022.5.peds22116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Accepted: 05/16/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Long-term follow-up is often recommended for patients with hydrocephalus, but the frequency of clinical follow-up, timing and modality of imaging, and duration of surveillance have not been clearly defined. Here, the authors used the modified Delphi method to identify areas of consensus regarding the modality, frequency, and duration of hydrocephalus surveillance following surgical treatment. METHODS Pediatric neurosurgeons serving as institutional liaisons to the Hydrocephalus Clinical Research Network (HCRN), or its implementation/quality improvement arm (HCRNq), were invited to participate in this modified Delphi study. Thirty-seven consensus statements were generated and distributed via an anonymous electronic survey, with responses structured as a 4-point Likert scale (strongly agree, agree, disagree, strongly disagree). A subsequent, virtual meeting offered the opportunity for open discussion and modification of the statements in an effort to reach consensus (defined as ≥ 80% agreement or disagreement). RESULTS Nineteen pediatric neurosurgeons participated in the first round, after which 15 statements reached consensus. During the second round, 14 participants met virtually for review and discussion. Some statements were modified and 2 statements were combined, resulting in a total of 36 statements. At the conclusion of the session, consensus was achieved for 17 statements regarding the following: 1) the role of standardization; 2) preferred imaging modalities; 3) postoperative follow-up after shunt surgery (subdivided into immediate postoperative imaging, delayed postoperative imaging, routine clinical surveillance, and routine radiological surveillance); and 4) postoperative follow-up after an endoscopic third ventriculostomy. Consensus could not be achieved for 19 statements. CONCLUSIONS Using the modified Delphi method, 17 consensus statements were developed with respect to both clinical and radiological follow-up after a shunt or endoscopic third ventriculostomy. The frequency, modality, and duration of surveillance were addressed, highlighting areas in which no clear data exist to guide clinical practice. Although further studies are needed to evaluate the clinical utility and cost-effectiveness of hydrocephalus surveillance, the current study provides a framework to guide future efforts to develop standardized clinical protocols for the postoperative surveillance of patients with hydrocephalus. Ultimately, the standardization of hydrocephalus surveillance has the potential to improve patient care as well as optimize the use of healthcare resources.
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Affiliation(s)
- David S Hersh
- 1Division of Neurosurgery, Connecticut Children's, Hartford
- 2Department of Surgery, UConn School of Medicine, Farmington, Connecticut
| | - Jonathan E Martin
- 1Division of Neurosurgery, Connecticut Children's, Hartford
- 2Department of Surgery, UConn School of Medicine, Farmington, Connecticut
| | - Ruth E Bristol
- 3Division of Pediatric Neurosurgery, Department of Surgery, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, Arizona
| | - Samuel R Browd
- 4Department of Neurosurgery, University of Washington, Seattle Children's Hospital, Seattle, Washington
| | - Gerald Grant
- 5Department of Neurosurgery, Duke University, Durham, North Carolina
| | - Nalin Gupta
- 6Departments of Neurological Surgery and Pediatrics, University of California, San Francisco, California
| | - Todd C Hankinson
- 7Departments of Neurosurgery and Pediatrics, University of Colorado School of Medicine/Children's Hospital Colorado, Aurora, Colorado
| | - Eric M Jackson
- 8Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - John R W Kestle
- 9Division of Pediatric Neurosurgery, Primary Children's Hospital, Salt Lake City
- 10Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Mark D Krieger
- 11Division of Neurological Surgery, Department of Surgery, Children's Hospital Los Angeles
- 12Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Abhaya V Kulkarni
- 13Division of Neurosurgery, Hospital for Sick Children, University of Toronto, Ontario, Canada
| | - Casey J Madura
- 14Section of Neurosurgery, Division of Pediatric Neurosciences, Helen DeVos Children's Hospital, Grand Rapids, Michigan
| | - Jonathan Pindrik
- 15Division of Pediatric Neurosurgery, Nationwide Children's Hospital, Columbus
- 16Department of Neurological Surgery, The Ohio State University College of Medicine, Columbus, Ohio
| | - Ian F Pollack
- 17Department of Neurosurgery, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Jeffrey S Raskin
- 18Division of Pediatric Neurosurgery, Ann and Robert H. Lurie Children's Hospital, Chicago
- 19Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jay Riva-Cambrin
- 20Department of Clinical Neurosciences, University of Calgary, Alberta, Canada
| | - Curtis J Rozzelle
- 21Division of Pediatric Neurosurgery, Children's of Alabama, Birmingham
- 22Department of Neurosurgery, Heersink School of Medicine, University of Alabama at Birmingham, Alabama
| | - Jodi L Smith
- 23Goodman Campbell Brain and Spine, Peyton Manning Children's Hospital at St. Vincent Ascension, Indianapolis, Indiana; and
| | - John C Wellons
- 24Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee
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Juhler M, Hansen TS, Novrup HVG, MacAulay N, Munch TN. Hydrocephalus Study Design: Testing New Hypotheses in Clinical Studies and Bench-to-Bedside Research. World Neurosurg 2022; 161:424-431. [PMID: 35505563 DOI: 10.1016/j.wneu.2021.12.100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 12/23/2021] [Accepted: 12/24/2021] [Indexed: 10/18/2022]
Abstract
In this article, we aimed to describe some of the currently most challenging problems in neurosurgical management of hydrocephalus and how these can be reasons for inspiration for and development of research. We chose 4 areas of focus: 2 dedicated to improvement of current treatments (shunt implant surgery and endoscopic hydrocephalus surgery) and 2 dedicated to emerging future treatment principles (molecular mechanisms of cerebrospinal fluid secretion and hydrocephalus genetics).
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Affiliation(s)
- Marianne Juhler
- Department of Neurosurgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Department of Neurosurgery, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
| | | | - Hans V G Novrup
- Department of Neurosurgery, Aarhus University Hospital, Aarhus, Denmark
| | - Nanna MacAulay
- Department of Neuroscience, University of Copenhagen, Copenhagen, Denmark
| | - Tina Nørgaard Munch
- Department of Neurosurgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark; Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark
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Vemula RCV, Prasad BCM, Kumar K. Endoscopic Third Ventriculostomy: Our Experience of Consecutive 50 Cases at a Tertiary Care Center. INDIAN JOURNAL OF NEUROSURGERY 2022. [DOI: 10.1055/s-0041-1724466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
Abstract
Objective The aim of this study was to do a retrospective analysis of the various neurosurgical pathologies where endoscopic third ventriculostomy (ETV) was used and to evaluate the outcome and prognosis.
Methods The retrospective data collection was done for the patients who underwent ETV with or without other adjunct procedures; the results were prepared for clinical presentation, diagnosis, surgical approach, and surgical goal; and success rate and prognosis were analyzed and compared with other studies.
Results A total of 50 patients were included in the study, with overall success rate of ETV as 88%; aqueductal stenosis was the most common indication where ETV was used; headache and vomiting were the most common presenting complaints followed by ataxia and visual blurring; and ETV provided flexibility in its use with biopsy, abscess drainage, temporary external ventricular drain placement, etc.
Conclusion ETV being superior to ventriculo-peritoneal shunt for obstructive hydrocephalus provides flexibility in its use and possibly is a useful adjunct to prevent postoperative hydrocephalus after endoscopic intraventricular surgery; proper case selection in accordance to ETV success score yields a better success rate. In experienced hands with proper precautions, perioperative complications can be kept at minimum. Wherever possible, in cases of obstructive hydrocephalus, especially in patients >1 year of age, ETV should be the treatment of choice. We recommend a proper case selection, including preoperative detailed reading of sagittal magnetic resonance imaging scan, to improve the success rate with less complication.
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Affiliation(s)
| | - BCM Prasad
- Department of Neurosurgery, Sri Venkateswara Institute of Medical Sciences (SVIMS), Tirupati, Andhra Pradesh, India
| | - Kunal Kumar
- Department of Neurosurgery, Sri Venkateswara Institute of Medical Sciences (SVIMS), Tirupati, Andhra Pradesh, India
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Gillespie CS, Richardson GE, Mustafa MA, Evans D, George AM, Islim AI, Mallucci C, Jenkinson MD, McMahon CJ. How should we treat long-standing overt ventriculomegaly in adults (LOVA)? A retrospective cohort study. Neurosurg Rev 2022; 45:3193-3200. [PMID: 35688957 PMCID: PMC9492616 DOI: 10.1007/s10143-022-01812-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Revised: 04/16/2022] [Accepted: 05/10/2022] [Indexed: 02/03/2023]
Abstract
Long-standing overt ventriculomegaly in adults (LOVA) is a heterogenous group of conditions with differing presentations. Few studies have evaluated success rates of available surgical treatments, or ascertained the natural history. There is a need to assess the efficacy of both endoscopic third ventriculostomy (ETV) and ventriculoperitoneal shunt (VPS) as first-line treatments. We conducted a retrospective, single-centre study of adults with LOVA at a tertiary neurosurgery centre in England, UK, aiming to identify presentation, management strategy, and outcome following treatment. A total of 127 patients were included (mean age 48.1 years, 61/127 male). Most patients were symptomatic (73.2%, n = 93/127, median symptom duration 10 months). The most common symptoms were gait ataxia, headache, and cognitive decline (52.8%, 50.4%, and 33.9%, respectively). Fourteen patients had papilloedema. Ninety-one patients (71.7%) underwent surgery (84 ETV, 7 VPS). Over a median follow-up of 33.0 months (interquartile range [IQR] 19.0-65.7), 82.4% had a clinical improvement after surgery, and 81.3% had radiological improvement. Clinical improvement rates were similar between ETV and VP shunt groups (82.1% vs 85.7%, p = 0.812). Surgical complication rates were significantly lower in the ETV group than the VP shunt group (4.8% vs 42.9%, p < 0.001). Of the patients treated surgically, 20 (22.0%) underwent further surgery, with 14 patients improving. This study demonstrates the efficacy of ETV as a first-line treatment for LOVA.
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Affiliation(s)
- Conor S. Gillespie
- Institute of Systems, Molecular and Integrative Biology, School of Medicine, University of Liverpool, Cedar House, Ashton Street, Liverpool, L69 3GE UK ,Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - George E. Richardson
- Institute of Systems, Molecular and Integrative Biology, School of Medicine, University of Liverpool, Cedar House, Ashton Street, Liverpool, L69 3GE UK ,Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Mohammad A. Mustafa
- Institute of Systems, Molecular and Integrative Biology, School of Medicine, University of Liverpool, Cedar House, Ashton Street, Liverpool, L69 3GE UK ,Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Daisy Evans
- School of Medicine, Keele University, Staffordshire, UK
| | - Alan M. George
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK ,School of Medicine, University of Birmingham, Birmingham, UK
| | - Abdurrahman I. Islim
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Conor Mallucci
- Department of Neurosurgery, Alder Hey Children’s NHS Foundation Trust, Liverpool, UK
| | - Michael D. Jenkinson
- Institute of Systems, Molecular and Integrative Biology, School of Medicine, University of Liverpool, Cedar House, Ashton Street, Liverpool, L69 3GE UK ,Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Catherine J. McMahon
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
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Zwimpfer TJ, Salterio N, Williams MA, Holubkov R, Katzen H, Luciano MG, Moghekar A, Nagel SJ, Wisoff JH, Golomb J, McKhann GM, Edwards RJ, Hamilton MG. Cognitive and gait outcomes after primary endoscopic third ventriculostomy in adults with chronic obstructive hydrocephalus. J Neurosurg 2021; 136:887-894. [PMID: 34534954 DOI: 10.3171/2021.3.jns203424] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 03/10/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The object of this study was to determine the short- and long-term efficacy of primary endoscopic third ventriculostomy (ETV) on cognition and gait in adults with chronic obstructive hydrocephalus. METHODS Patients were prospectively accrued through the Adult Hydrocephalus Clinical Research Network patient registry. Patients with previously untreated congenital or acquired obstructive hydrocephalus were included in this study. Gait velocity was assessed using a 10-m walk test. Global cognition was assessed with the Montreal Cognitive Assessment (MoCA). Only patients with documented pre- and post-ETV gait analysis and/or pre- and post-ETV MoCA were included. RESULTS A total of 74 patients had undergone primary ETV, 42 of whom were analyzed. The remaining 32 patients were excluded, as they could not complete both pre- and post-ETV assessments. The mean age of the 42 patients, 19 (45.2%) of whom were female, was 51.9 ± 17.1 years (range 19-79 years). Most patients were White (37 [88.1%]), and the remainder were Asian. Surgical complications were minor. Congenital etiologies occurred in 31 patients (73.8%), with aqueductal stenosis in 23 of those patients (54.8%). The remaining 11 patients (26.2%) had acquired cases. The gait short-term follow-up cohort (mean 4.7 ± 4.1 months, 35 patients) had a baseline median gait velocity of 0.9 m/sec (IQR 0.7-1.3 m/sec) and a post-ETV median velocity of 1.3 m/sec (IQR 1.1-1.4 m/sec). Gait velocity significantly improved post-ETV with a median within-patient change of 0.3 m/sec (IQR 0.0-0.6 m/sec, p < 0.001). Gait velocity improvements were sustained in the long term (mean 14 ± 2.8 months, 12 patients) with a baseline median velocity of 0.7 m/sec (IQR 0.6-1.3 m/sec), post-ETV median of 1.3 m/sec (IQR 1.1-1.7 m/sec), and median within-patient change of 0.4 m/sec (IQR 0.2-0.6 m/sec, p < 0.001). The cognitive short-term follow-up cohort (mean 4.6 ± 4.0 months, 38 patients) had a baseline median MoCA total score (MoCA TS) of 24/30 (IQR 23-27) that improved to 26/30 (IQR 24-28) post-ETV. The median within-patient change was +1 point (IQR 0-2 points, p < 0.001). However, this change is not clinically significant. The cognitive long-term follow-up cohort (mean 14 ± 3.1 months, 15 patients) had a baseline median MoCA TS of 23/30 (IQR 22-27), which improved to 26/30 (IQR 25-28) post-ETV. The median within-patient change was +2 points (IQR 1-3 points, p = 0.007), which is both statistically and clinically significant. CONCLUSIONS Primary ETV can safely improve symptoms of gait and cognitive dysfunction in adults with chronic obstructive hydrocephalus. Gait velocity and global cognition were significantly improved, and the worsening of either was rare following ETV.
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Affiliation(s)
- Thomas J Zwimpfer
- 1Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Nicholas Salterio
- 1Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Michael A Williams
- 2Departments of Neurology and Neurological Surgery, University of Washington, Seattle, Washington
| | - Richard Holubkov
- 3Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Heather Katzen
- 4Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida
| | | | - Abhay Moghekar
- 6Neurology, Johns Hopkins University, Baltimore, Maryland
| | - Sean J Nagel
- 7Department of Neurosurgery, Center for Neurological Restoration, Cleveland Clinic, Cleveland, Ohio
| | | | - James Golomb
- 9Neurology, New York University School of Medicine, New York, New York
| | - Guy M McKhann
- 10Department of Neurological Surgery, Columbia University Irving Medical Center, New York, New York
| | - Richard J Edwards
- 11Department of Neurosurgery, Southmead Hospital, Bristol, United Kingdom; and
| | - Mark G Hamilton
- 12Department of Clinical Neurosciences, Division of Neurosurgery, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
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Jenkinson MD, Mills S, Mallucci CL, Santarius T. Management of pineal and colloid cysts. Pract Neurol 2021; 21:practneurol-2020-002838. [PMID: 34039752 PMCID: PMC8327315 DOI: 10.1136/practneurol-2020-002838] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2021] [Indexed: 11/15/2022]
Abstract
The widespread use of MRI has led to the increasingly frequent diagnosis of pineal and colloid cysts. While most are small and incidental, do not require long-term monitoring and will never need treatment, they are a cause of patient anxiety and clinician uncertainty regarding the optimal management-particularly for larger cysts or those with an atypical appearance. Occasionally pineal cysts, and more commonly colloid cysts, cause hydrocephalus that requires urgent neurosurgical treatment. More recently the non-hydrocephalic symptomatic pineal cyst has been described in the neurosurgical literature but there is controversy over this entity and its management. This review addresses the difficulties in managing pineal and colloid cysts and provides a pragmatic framework for the practising clinician.
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Affiliation(s)
- Michael D Jenkinson
- Clinical and Molecular Cancer, University of Liverpool, Liverpool, Merseyside, UK
- Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, Liverpool, UK
| | - Samantha Mills
- Neuroradiology, The Walton Centre NHS Foundation Trust, Liverpool, Liverpool, UK
| | - Conor L Mallucci
- Paediatric Neurosurgery, Alder Hey Children's NHS Foundation Trust, Liverpool, Merseyside, UK
| | - Thomas Santarius
- Clinical and Academic Neuroscience, Addenbrooke's Hospital, Cambridge, Cambridgeshire, UK
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11
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Hersh DS, Kumar R, Klimo P, Bookland M, Martin JE. Hydrocephalus surveillance following shunt placement or endoscopic third ventriculostomy: a survey of surgeons in the Hydrocephalus Clinical Research Networks. J Neurosurg Pediatr 2021; 28:139-146. [PMID: 34020413 DOI: 10.3171/2020.12.peds20830] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 12/21/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Late failure is a well-documented complication of cerebrospinal fluid shunt placement and, less commonly, endoscopic third ventriculostomy (ETV). However, standards regarding the frequency of clinical and radiological follow-up in these patients have not been defined. Here, the authors report on their survey of surgeons at sites for the Hydrocephalus Clinical Research Network (HCRN) or its implementation/quality improvement arm (HCRNq) to provide a cross-sectional overview of practice patterns. METHODS A 24-question survey was developed using the Research Electronic Data Capture (REDCap) platform and was distributed to the 138 pediatric neurosurgeons across 39 centers who participate in the HCRN or HCRNq. Survey questions were organized into three sections: 1) Demographics (5 questions), 2) Shunt Surveillance (12 questions), and 3) ETV Surveillance (7 questions). RESULTS A total of 122 complete responses were obtained, for an overall response rate of 88%. The majority of respondents have been in practice for more than 10 years (58%) and exclusively treat pediatric patients (79%). Most respondents consider hydrocephalus to have stabilized 1 month (21%) or 3 months (39%) after shunt surgery, and once stability is achieved, 72% then ask patients to return for routine clinical follow-up annually. Overall, 83% recommend lifelong clinical follow-up after shunt placement. Additionally, 75% obtain routine imaging studies in asymptomatic patients, although the specific imaging modality and frequency of imaging vary. The management of an asymptomatic increase in ventricle size or an asymptomatic catheter fracture also varies widely. Many respondents believe that hydrocephalus takes longer to stabilize after ETV than after shunt placement, reporting that they consider hydrocephalus to have stabilized 3 (28%), 6 (33%), or 12 (28%) months after an ETV. Although 68% of respondents have patients return annually for routine clinical follow-up after an ETV, only 56% recommend lifelong follow-up. The proportion of respondents who perform lifelong follow-up increases with greater practice experience (p = 0.01). Overall, 67% of respondents obtain routine imaging studies in asymptomatic patients after an ETV, with "rapid" MRI the study of choice for most respondents. CONCLUSIONS While there is a general consensus among pediatric neurosurgeons across North America that hydrocephalus patients should have long-term follow-up after shunt placement, radiological surveillance is characterized by considerable variety, as is follow-up after an ETV. Future work should focus on evaluating whether any one of these surveillance protocols is associated with improved outcomes.
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Affiliation(s)
- David S Hersh
- 1Division of Neurosurgery, Connecticut Children's, Hartford
- 2Department of Surgery, UConn School of Medicine, Farmington, Connecticut
| | | | - Paul Klimo
- 4Department of Neurosurgery, University of Tennessee Health Science Center, Memphis
- 5Le Bonheur Children's Hospital, Memphis; and
- 6Semmes-Murphey, Memphis, Tennessee
| | - Markus Bookland
- 1Division of Neurosurgery, Connecticut Children's, Hartford
- 2Department of Surgery, UConn School of Medicine, Farmington, Connecticut
| | - Jonathan E Martin
- 1Division of Neurosurgery, Connecticut Children's, Hartford
- 2Department of Surgery, UConn School of Medicine, Farmington, Connecticut
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12
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Oertel JMK, Huelser MJM. Benefits and obstacles of telemetric ICP monitoring. Acta Neurochir (Wien) 2021; 163:1083-1085. [PMID: 33550517 PMCID: PMC7966137 DOI: 10.1007/s00701-021-04730-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 01/21/2021] [Indexed: 12/16/2022]
Affiliation(s)
- Joachim M K Oertel
- Department of Neurosurgery, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Saarland, Germany.
| | - Matthias J M Huelser
- Department of Neurosurgery, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Saarland, Germany
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13
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The Third Eye Sees Double: Cohort Study of Clinical Presentation, Histology, Surgical Approaches, and Ophthalmic Outcomes in Pineal Region Germ Cell Tumors. World Neurosurg 2021; 150:e482-e490. [PMID: 33722723 DOI: 10.1016/j.wneu.2021.03.030] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 03/07/2021] [Accepted: 03/07/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Intracranial germ cell tumors (GCTs) predominantly occur in the adolescent and young adult population and are most frequently located at the pineal gland. Tumor masses in the pineal region may cause ophthalmic symptoms due to compression to the midbrain, frequently presenting with Parinaud syndrome and hydrocephalus due to aqueductal compression. METHODS We conducted a single-institution cohort study of primary, pineal region GCTs to characterize the clinical presentation, as well as associated ophthalmic and hydrocephalus outcomes. RESULTS Fifty-six primary pineal GCTs were identified. Among the 40 isolated pineal region GCTs, 15 were germinomas while 25 were nongerminomatous GCTs. Among 43 cases of hydrocephalus, endoscopic third ventriculostomy was the primary treatment in 27 cases, which was successful in 23 but failed and required additional treatment for the rest. Pineal tumor mass was significantly larger in cases with hydrocephalus compared with those without, and the 20-mm diameter of the tumor was the crucial point for obstructive hydrocephalus. Ophthalmic symptoms were commonly observed at presentation, which included diplopia (74.3%), upward-gaze palsy (69.7%), and Argyll Robertson pupil (40%). These symptoms tended to remain, and the existence of these symptoms at presentation predicted the remaining symptoms in the follow-up. CONCLUSIONS Intracranial GCTs presenting with ophthalmic abnormalities appear to be at increased risk of residual posttreatment symptoms, while second-look surgery presents a significant risk factor for the development of new deficits. Hydrocephalus often accompanies pineal region GCTs, and in most cases both cerebrospinal fluid diversion and tissue diagnosis can be successfully achieved via endoscopic third ventriculostomy.
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14
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Gürbüz MS, Dağçınar A, Bayri Y, Şeker A, Güçlü H. Anterior third ventricular height and infundibulochiasmatic angle: two novel measurements to predict clinical success of endoscopic third ventriculostomy in the early postoperative period. J Neurosurg 2020; 132:1764-1772. [DOI: 10.3171/2019.1.jns181330] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 01/29/2019] [Indexed: 12/24/2022]
Abstract
OBJECTIVEThe authors sought to develop a set of parameters that reliably predict the clinical success of endoscopic third ventriculostomy (ETV) when assessed before and after the operation, and to establish a plan for MRI follow-up after this procedure.METHODSThis retrospective study involved 77 patients who had undergone 78 ETV procedures for obstructive hydrocephalus between 2010 and 2015. Constructive interference in steady-state (CISS) MRI evaluations before and after ETV were reviewed, and 4 parameters were measured. Two well-known standard parameters, fronto-occipital horn ratio (FOHR) and third ventricular index (TVI), and 2 newly defined parameters, infundibulochiasmatic (IC) angle and anterior third ventricular height (TVH), were measured in this study. Associations between preoperative measurements of and postoperative changes in the 4 variables and the clinical success of ETV were analyzed.RESULTSOf the 78 ETV procedures, 70 (89.7%) were successful and 8 (10.3%) failed. On the preoperative MR images, the mean IC angle and anterior TVH were significantly larger in the successful procedures. On the 24-hour postoperative MR images of the successful procedures, the mean IC angle declined significantly from 114.2° to 94.6° (p < 0.05) and the mean anterior TVH declined significantly from 15 to 11.2 mm (p < 0.05). The mean percentage reduction of the IC angle was 17.1%, and that of the anterior TVH was 25.5% (both p < 0.05). On the 1-month MR images of the successful procedures, the mean IC angle declined significantly from 94.6° to 84.2° (p < 0.05) and the mean anterior TVH declined significantly from 11.2 to 9.3 mm (p < 0.05). The mean percentage reductions in IC angle (11%) and anterior TVH (16.9%) remained significant at this time point but were smaller than those observed at 24 hours. The 6-month and 1-year postoperative MR images of the successful group showed no significant changes in mean IC angle or mean anterior TVH. Regarding the unsuccessful procedures, there were no significant changes observed in IC angle or anterior TVH at any of the time points studied. Reduction of IC angle and reduction of anterior TVH on 24-hour postoperative MR images were significantly associated with successful ETV. However, no clinically significant association was found between FOHR, TVI, and ETV success.CONCLUSIONSAssessing the IC angle and anterior TVH on preoperative and 24-hour postoperative MR images is useful for predicting the clinical success of ETV. These 2 measurements could also be valuable as radiological follow-up parameters.
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Affiliation(s)
- Mehmet Sabri Gürbüz
- Department of Neurosurgery, School of Medicine, İstanbul Medeniyet University
| | - Adnan Dağçınar
- Department of Neurosurgery, School of Medicine, Marmara University; and
| | - Yaşar Bayri
- Department of Neurosurgery, School of Medicine, Marmara University; and
| | - Aşkın Şeker
- Department of Neurosurgery, School of Medicine, Marmara University; and
| | - Hasan Güçlü
- Department of Biostatistics and Medical Informatics, School of Medicine, İstanbul Medeniyet University, İstanbul, Turkey
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15
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Bruscella S, Solari D, Somma T, Barbato M, Gangemi M, Cavallo LM. Predicting endoscopic third ventriculostomy success in adult hydrocephalus: preliminary assessment of a modified ETV success score for adults (ETVSS-A) in a series of 47 patients. J Neurosurg Sci 2019; 66:33-39. [PMID: 31565904 DOI: 10.23736/s0390-5616.19.04712-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Endoscopic third ventriculostomy is an established treatment for noncommunicating hydrocephalus. In carefully selected patients, it can be adopted for the management of communicating variant; however controversy exists in regards to the definition of the appropriate candidates. Predictive score of Endoscopic Third Ventriculostomy Success (ETVSS) has been reported for pediatric and mixed populations only. Our purpose was to define a ETV success score for adult population (ETVSS-A), measuring the strength of correlation between preoperative score retrospectively evaluated and the success rates achieved in a class of adult patients. METHODS A retrospective analysis of 47 cases which received ETV procedure at our Institution between 2015 and 2018 was run. Demographic data,clinical history,preoperative and postoperative signs were reviewed and ETVSS-A was calculated. Thereafter ETVSS-A results were compared with the actual success rates. RESULTS 29 patients(61,7%) presented unchanged or improvedclinical status with a mean ETVSS-A of 54.5%;18 patients(38,3%) worsened with mean ETVSS-A of 37,7%. We found that age,type of hydrocephalus and symptoms of admission are each apart important factors in predicting ETV success:older patients and those with non-obstructive hydrocephalus had the lowest predicted ETV success. In patients in whom ETV was actually successful, the pre-operative ETVSS-A was significantly higher as compared to those patients in whom we observed a poor surgical outcome. CONCLUSIONS From the results of this series, though small and retrospectively analyzed, it seems that ETVSS-A can be considered as a useful instrument to help neurosurgeon in predicting the ETV success and though define a more accurate surgical strategy in cases of hydrocephalus. Wider series and prospective studies are attended to validate these preliminary results.
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Affiliation(s)
- Sara Bruscella
- Division of Neurosurgery, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Domenico Solari
- Division of Neurosurgery, Università degli Studi di Napoli "Federico II", Naples, Italy -
| | - Teresa Somma
- Division of Neurosurgery, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Marcello Barbato
- Division of Neurosurgery, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Michelangelo Gangemi
- Division of Neurosurgery, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Luigi M Cavallo
- Division of Neurosurgery, Università degli Studi di Napoli "Federico II", Naples, Italy
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Endoscopic Third Ventriculostomy in Cases of Ventriculoperitoneal Shunt Malfunction: Does Shunt Duration Play a Role? World Neurosurg 2019; 127:e799-e808. [DOI: 10.1016/j.wneu.2019.03.268] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Revised: 03/26/2019] [Accepted: 03/27/2019] [Indexed: 11/23/2022]
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17
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Filis AK, Aghayev K, Vrionis FD. Cerebrospinal Fluid and Hydrocephalus: Physiology, Diagnosis, and Treatment. Cancer Control 2017; 24:6-8. [PMID: 28178707 DOI: 10.1177/107327481702400102] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Cerebrospinal fluid (CSF) is found around and inside the brain and vertebral column. CSF plays a crucial role in the protection and homeostasis of neural tissue. METHODS Key points on the physiology of CSF as well as the diagnostic and treatment options for hydrocephalus are discussed. RESULTS Understanding the fundamentals of the production, absorption, dynamics, and pathophysiology of CSF is crucial for addressing hydrocephalus. Shunts and endoscopic third ventriculostomy have changed the therapeutic landscape of hydrocephalus. CONCLUSIONS The treatment of hydrocephalus in adults and children represents a large part of everyday practice for the neurologist, both in benign cases and cancer-related diagnoses.
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Affiliation(s)
| | - Kamran Aghayev
- Department of Neuro-Oncology, Moffitt Cancer Center and the University of South Florida Morsani College of Medicine, Tampa, FL
| | - Frank D Vrionis
- Marcus Neuroscience Institute, Boca Raton Regional Hospital and the Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL.
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18
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Shimoda Y, Murakami K, Narita N, Tominaga T. Fourth Ventricle Outlet Obstruction with Expanding Space on the Surface of Cerebellum. World Neurosurg 2017; 100:711.e1-711.e5. [PMID: 28153613 DOI: 10.1016/j.wneu.2017.01.088] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Revised: 01/19/2017] [Accepted: 01/23/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND Hydrocephalus is classified as noncommunicating and communicating based on whether all ventricular and subarachnoid spaces are communicating. Although the diagnosis between the two different states is crucial, it is difficult in certain conditions. In particular, communicating hydrocephalus and noncommunicating hydrocephalus owing to fourth ventricle outlet obstruction are highly misdiagnosed. We describe a case of fourth ventricle outlet obstruction of unknown origin that was initially misdiagnosed as communicating hydrocephalus. CASE DESCRIPTION A 66-year-old woman with gait disturbance and incontinence caused by hydrocephalus underwent ventriculoperitoneal shunt surgery. After 9 months, her fourth ventricle became enlarged and could not be controlled by lowering the shunt pressure. Magnetic resonance imaging (MRI) demonstrated obstruction at the foramen of Magendie, foramina of Luschka, and the cerebral aqueduct. Endoscopic surgery for aqueduct plasty with third ventriculostomy was planned. Because the aqueduct was observed to open spontaneously, only the standard third ventriculostomy was performed. When MRI findings were reviewed retrospectively, an unnatural space was observed between the lower cranial nerves and cerebellar hemisphere that grew along with the fourth ventricular enlargement. This space was determined by MRI cisternography to be the cystic membrane ballooning out from the foramen of Luschka. The primary hydrocephalus likely resulted from fourth ventricle outlet obstruction. CONCLUSIONS Enlargement of the whole ventricular system with an expanded space between the lower cranial nerves and cerebellar hemisphere can be caused by fourth ventricle outlet obstruction. In such cases, preoperative evaluation of anatomic architecture and cerebrospinal fluid obstruction using MRI cisternography is essential and leads to a successful endoscopic strategy.
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Affiliation(s)
- Yoshiteru Shimoda
- Department of Neurosurgery, Kesen-numa City Hospital, Miyagi, Japan; Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan.
| | - Kensuke Murakami
- Department of Neurosurgery, Sendai Medical Center, Sendai, Japan
| | - Norio Narita
- Department of Neurosurgery, Kesen-numa City Hospital, Miyagi, Japan
| | - Teiji Tominaga
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
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