A Novel Approach Using Electromagnetic Neuronavigation and a Flexible Neuroendoscope for Placement of Ommaya Reservoirs

Ommaya reservoir placement using ultrasound guidance via anterior fontanelle combined with frameless electromagnetic neuronavigation in patients with mucopolysaccharidosis type 2: Case reports and review of the literature

Mucopolysaccharidosis type II (MPS II) results from the genetic deficiency of a lysosomal enzyme and is associated with central nervous system (CNS) dysfunction. In Japan, in addition to intravenous enzyme administration, intracerebroventricular enzyme delivery through the Ommaya reservoir has recently gained approval. Nevertheless, the ideal approach for safely implanting the reservoir into the narrow ventricles of infantile MPS II patients remains uncertain. In this report, we present two cases of successful reservoir placement in infantile MPS II patients using ultrasound guidance via the anterior fontanelle, coupled with flameless electromagnetic neuronavigation.

Advances in the treatment of Adamantinomatous craniopharyngioma: How to balance tumor control and quality of life in the current environment: a narrative review

Adamantinomatous craniopharyngioma (ACP) presents a significant challenge to neurosurgeons despite its benign histology due to its aggressive behavior and unique growth patterns. This narrative review explores the evolving landscape of ACP treatments and their efficacy, highlighting the continuous development in therapeutic approaches in recent years. Traditionally, complete resection was the primary treatment for ACP, but surgical -related morbidity have led to a shift. The invasive nature of the finger-like protrusions in the histological structure results in a higher recurrence rate for ACP compared to papillary craniopharyngioma (PCP), even after complete macroscopic resection. Given this, combining subtotal resection with adjuvant radiotherapy has shown potential for achieving similar tumor control rates and potentially positive endocrine effects. Simultaneously, adjuvant treatments (such as radiotherapy, intracystic treatment, and catheter implantation) following limited surgery offer alternative approaches for sustained disease control while minimizing morbidity and alleviating clinical symptoms. Additionally, advances in understanding the molecular pathways of ACP have paved the way for targeted drugs, showing promise for therapy. There is a diversity of treatment models for ACP, and determining the optimal approach remains a subject of ongoing debate in the present context. In order to achieve a good-term quality of life (QOL), the main goal of the cyst disappearance or reduction of surgical treatment is still the main. Additionally, there should be a greater emphasis on personalized treatment at this particular stage and the consideration of ACP as a potentially chronic neurosurgical condition. This review navigates the evolving landscape of ACP therapies, fostering ongoing discussions in this complex field.

Neuroendoscopic surgery combined with Ommaya reservoir placement for cystic craniopharyngiomas: 11 years of experience in a single institution

INTRODUCTION

Total resection of cystic craniopharyngiomas is challenging, especially for some large cystic tumors, because it is often associated with high recurrence and morbidity rates. Minimally invasive cyst decompression and continuous drainage are appropriate to manage clinical symptoms. We reviewed our experience of the past 11 years to determine the long-term effects of neuroendoscopic surgery (NES) combined with Ommaya reservoir (OR) for the treatment of cystic craniopharyngiomas.

METHODS

We retrospectively analyzed the data of 15 adult patients with cystic craniopharyngiomas at a single institution with the primary goal to evaluate the treatment mode with initial adequate decompression of the cyst under visualization and continuous drainage. The study endpoints were functional outcome, cyst volume changes, and tumor progression.

RESULTS

The median follow up was 77 (20-136) months. Clinical symptoms, e.g. increased intracranial pressure and visual impairment, could be rapidly improved after NES. The postoperative reduction in cyst volume (p < 0.001) and improvement in Karnofsky performance status (p < 0.001) were significant, and long-term tumor control was achieved in 10 patients (67%). Aspiration from the OR after progression of the tumor's cystic portion remains a major option, with only few patients requiring repeat NES procedures. No patient developed acute or severe clinical symptoms during follow up.

CONCLUSIONS

NES could decompress the craniopharyngioma cyst under visualization and enable faster clinical-symptom improvement. The minimally invasive NES combined with OR allowed long-term symptom control in most patients without surgery-related injury. This palliative treatment strategy could be an alternative modality for cystic craniopharyngioma treatment.

Neuroendoscopic treatment of giant cystic craniopharyngioma in the foramen magnum: report of two cases

Pediatric craniopharyngioma is typically characterized by cystic changes and calcifications. It can grow from the suprasellar area to the posterior fossa (4%). This work reports that it is very rare for craniopharyngioma to grow from the suprasellar area to or beyond the level of the foramen magnum. Twelve patients with this disease have undergone one or several microsurgeries, and the microsurgical approaches are different. Among them, two cases died, and most of the remaining patients had certain complications such as endocrine dysfunction, nerve palsy, and subdural effusion. We treated two patients whose tumors had grown to the level of the foramen magnum, one of which reached C2 levels. Both cases were treated with a neuroendoscopy. There were no deaths and no complications. Our cases are the longest follow-up of this type of craniopharyngioma.

THE SAFETY AND EFFICACY OF ROBOT-ASSISTED STEREOTACTIC BIOPSY FOR BRAIN GLIOMA: EARLIEST INSTITUTIONAL EXPERIENCES AND EVALUATION OF LITERATURE

Robot-assisted brain tumor biopsy is becoming one of the most important innovative technologies in neurosurgical practice. The idea behind its engagement is to advance the safety and efficacy of the biopsy procedure, which is much in demand when planning the management of endocranial tumor pathology. Herein, we provide our earliest institutional experiences in utilizing this mesmerizing technology. Cranial robotic device was employed for stereotactic robot-assisted brain glioma biopsy in three consecutive patients from our series: an anaplastic isocitrate dehydrogenase (IDH) negative astrocytoma (WHO grade III) located in the right trigone region of the periventricular white matter; a low grade diffuse astrocytoma (WHO grade II) of bilateral thalamic region spreading into the right mesencephalic area; and an IDH-wildtype glioblastoma (WHO grade IV) of the right frontal lobe producing a contralateral midline shifting. Robot-assisted tumor biopsy was successfully performed to get tissue samples for histopathologic and immunohistochemical analysis. The adjacent tissue iatrogenic damage of the eloquent cortical areas was minimal, while the immediate postoperative recovery was satisfactory in all patients. In conclusion, considering the preliminary results of our early experiences, robot-assisted tumor biopsy was proven to be a feasible and accurate procedure when surgery for brain glioma was not an option. It may increase safety and precision, without expanding surgical time, being similarly effective when compared to standard stereotactic and manual biopsy. Using this method to provide accurate sampling for histopathologic and immunohistochemical analysis is a safe and easy way to determine management strategies and outcome of different types of brain glioma.

[Use of Ommaya Reservoirs to Deliver Pemetrexed in Leptomeningeal Metastasis from Non-small Cell Lung Cancer: A Case Report and Review of the Literature]

软脑膜转移（leptomeningeal metastasis, LM）是非小细胞肺癌（non-small cell lung cancer, NSCLC）最严重的并发症之一。随着靶向药物的发展，LM发病率逐年上升，目前缺乏标准有效的治疗方案。鞘内化疗是治疗LM的一种重要方法，但对于NSCLC伴LM，现有的经鞘内途径给化疗药物治疗效果有限，最佳的药物、给药途径、给药模式和剂量仍不清楚。本文报道1例NSCLC伴LM患者，经奥希替尼治疗病情进展后，予培美曲塞经Ommaya囊脑室内化疗，颅内病灶得到较好控制，脑脊液（cerebrospinal fluid, CSF）细胞学转为阴性，同时患者耐受良好，生活质量明显改善，病情长时间内维持稳定，从确诊LM后随访至今已17个月。本文报道了国内外第一例关于经Ommaya囊鞘内注射培美曲塞治疗NSCLC患者LM的临床案例，并结合相关文献总结了鞘内化疗的安全性及有效性，为临床提供了一种LM局部治疗的新策略。

Placement of Ommaya Reservoirs Using Electromagnetic Neuronavigation and Neuroendoscopy: A Retrospective Study with Cost-Benefit Analysis

BACKGROUND

Placement of intraventricular catheters in oncology patients is associated with high complication rates. Placing Ommaya reservoirs with the zero-error precision protocol (ZEPP), a combination of neuronavigation (AxiEM stereotactic navigation) and direct verification of catheter tip placement with a flexible neuroendoscope, is associated with decreased complication rates as a result of increased catheter placement accuracy. However, the ZEPP costs more than traditional methods of catheter placement, and the question of whether this increased accuracy with the ZEPP is cost-effective is unknown.

METHODS

We performed a single-center retrospective chart review of 50 consecutive ommaya reservoir patient placements between 2010 and 2017. Twenty-five ventricular catheters were placed using the ZEPP protocol, and 25 ventricular catheters were placed using only AxiEM stealth navigation. Postoperative catheter accuracy and complication rates were assessed. A cost-benefit analysis was then conducted to determine if the overall cost for placing Ommaya reservoirs with the ZEPP was effective compared with the alternative method of using neuronavigation alone.

RESULTS

In the non-ZEPP cohort, 10 of 25 catheters were placed within the optimal location compared with 25 of 25 catheters placed in the ZEPP cohort. Three complications occurred in the non-ZEPP cohort: 2 malpositioned catheters required surgical revision and 1 catheter-related hemorrhage resulted in a prolonged stay in the intensive care unit. No complications occurred in the ZEPP cohort. A cost-benefit analysis showed $4784 savings per patient with ZEPP utilization because of the high complication-associated costs.

CONCLUSIONS

Implementation of the ZEPP for verifying ventricular catheter placement in Ommaya reservoirs improved catheter tip accuracy, resulted in lower complication rates, and was more cost-effective when compared with the non-ZEPP cohort, which used only neuronavigation. The ZEPP can be used for ventricular shunt catheter placement to decrease complications and verify catheter tip accuracy in Ommaya or standard ventriculoperitoneal shunts.

The Barrow Innovation Center Case Series: A Novel 3-Dimensional-Printed Retractor for Use with Electromagnetic Neuronavigation Systems

OBJECTIVE

The Barrow Innovation Center consists of an educational program that promotes interdisciplinary collaboration among neurosurgery, legal, and engineering professionals to foster the development of new medical devices. This report describes a common issue faced during the placement of ventricular shunts for the treatment of hydrocephalus and the solution to this problem that was developed through the Barrow Innovation Center.

METHODS

Neurosurgery residents involved in the Barrow Innovation Center presented the problem of ferromagnetic retractors interfering with pinless image-guidance systems at a monthly meeting. Potential solutions were openly discussed by an interdisciplinary committee of neurosurgeons, patent lawyers, and biomedical engineers. The committee decided to pursue development of a novel self-retaining retractor made of nonferromagnetic material as a solution to the problem.

RESULTS

Each retractor design was tested in the cadaver laboratory for size and functionality. A final design was chosen and used in a surgical case requiring ventriculoperitoneal shunt placement. The new retractor successfully retracted the scalp without interfering with the electromagnetic image-guidance system.

CONCLUSIONS

Through the interdisciplinary Barrow Innovation Center program, a newly designed, 3-dimensional-printed skin and soft-tissue retractor was created, along with an innovative universal shunt retainer. Through this integrated program dedicated to surgical innovation (i.e., the Barrow Innovation Center), the process of developing and implementing new technology at our institution has been streamlined, creating a culture of innovation within the neurosurgery training program.

The use of a smartphone-assisted ventricle catheter guide for Ommaya reservoir placement-experience of a retrospective bi-center study

BACKGROUND

For intraventricular chemotherapy (IVC) as part of many oncological treatment protocols, Ommaya reservoir is enabling repeated access to the cerebro-spinal fluid (CSF). The correct placement of the catheter in the ventricle is essential for correct application of drugs, which is enabled by sophisticated techniques such as neuronavigation.

OBJECTIVE

In a bi-center retrospective study, we reviewed our experience using a smartphone-assisted ventricle catheter guide as simple solution for correct Ommaya reservoir placement.

METHODS

Sixty Ommaya reservoirs have been placed in 60 patients between 2011 and 2017 with the smartphone-assisted ventricular catheter guidance technique. Patient characteristics, preoperative frontal and occipital horn ratio (FOHR), postoperative catheter position, and complications were assessed.

RESULTS

The majority of our patients (71.6%) have got narrow or slit-like ventricles (FOHR ≤ 0.4). All Ommaya reservoirs were placed successfully. Fifty-eight ventricular catheters (97%) were inserted at the first and 2 (3%) at the second attempt using the same technique. No immediate perioperative complications were observed. All catheters (100%) could be used for IVC. Postoperative imaging was available in 52 patients. Thirty-two (61.5%) of ventricular catheters were rated as grade I, 20 (38.5%) as grade II, and none (0%) as grade III. Four patients (6.7%) showed postoperative complications during a median follow-up of 8.5 months (hydrocephalus, n = 1; infection, n = 1; parenchymal cyst around catheter, n = 1; shunt revision, n = 1).

CONCLUSIONS

The smartphone-assisted guide offers decent accuracy of ventricle catheter placement with ease and simplicity for a small surgical intervention. We propose this technique as routine tool for Ommaya reservoir placement independent of lateral ventricular size to decrease the rate of ventricle catheter malposition as reasonable alternative to a neuronavigation system.