Comparison of Intracranial Neuroendoscopic Procedures in Children versus Adults

Comparison of endoscopic third ventriculostomy versus cerebrospinal fluid shunt procedures for the treatment of pediatric hydrocephalus in Taiwan

PURPOSE

Pediatric hydrocephalus is the most common cause of surgically treatable neurological disease in children. Controversies exist whether endoscopic third ventriculostomy (ETV) or cerebrospinal fluid (CSF) shunt placement is the most appropriate treatment for pediatric hydrocephalus. This study aimed to compare the risk of re-operation and death between the two procedures.

METHODS

We performed a retrospective population-based cohort study and included patients younger than 20-years-old who underwent CSF shunt or ETV for hydrocephalus from the Taiwan National Health Insurance Research Database.

RESULTS

A total of 3,555 pediatric patients from 2004 to 2017 were selected, including 2,340 (65.8%) patients that received CSF shunt placement and 1215 (34.2%) patients that underwent ETV. The incidence of all-cause death was 3.31 per 100 person-year for CSF shunt group and 2.52 per 100 person-year for ETV group, with an adjusted hazard ratio (HR) of 0.79 (95% confidence interval [CI] = 0.66-0.94, p = 0.009). The cumulative incidence competing risk for reoperation was 31.2% for the CSF shunt group and 26.4% for the ETV group, with an adjusted subdistribution HR of 0.82 (95% CI = 0.70-0.96, p = 0.015). Subgroup analysis showed that ETV was beneficial for hydrocephalus coexisting with brain or spinal tumor, central nervous system infection, and intracranial hemorrhage.

CONCLUSION

Our data indicates ETV is a better operative procedure for pediatric hydrocephalus when advanced surgical techniques and instruments are available.

Tailored Concept for Accurate Neuroendoscopy: A Comparative Retrospective Single-Center Study on Image-Guided Neuroendoscopic Procedures

OBJECTIVE

Precise planning and execution is key for neuroendoscopic interventions, which can be based on different available aiding technologies. The aim of this retrospective study is to report a case-based use of guided neuroendoscopy and to develop a stratification algorithm for the available technologies.

METHODS

We reviewed consecutive neuroendoscopic cases performed at our center from 2016 to 2018. We distinguished between patients receiving a new burr hole (group A) and those with a preexisting burr hole (group B). Case-specific technical requirements for procedure planning and execution, complication rate, surgical outcome, and possible subsequent surgery were evaluated. From this experience, a stratification system was developed to tailor the available guiding technologies.

RESULTS

A total of 309 neuroendoscopic interventions in 243 patients were included in the present study. The cases included hydrocephalic (81.6%) and nonhydrocephalic (18.4%) conditions. The interventions were supported by coordinate-based (group A, n = 49; group B, n = 67), guide-based (group A, n = 42; group B, n = 0), ultrasound-guided (group A, n = 50; group B, n = 7), or navigated augmented reality-guided (group A, n = 85; group B, n = 9) techniques. The overall complication rate was 4.5%. Stratified by the surgical indication, fontanel status, entry point localization, presence of a preexisting burr hole, ventricular size, and number of targets, an approach toward image-guided neuroendoscopy is suggested.

CONCLUSIONS

Planning and technical guidance is essential in neuroendoscopic procedures. The stratified decision-making algorithm for different available technologies aims to achieve lower cost and time consumption, which was found to be safe and efficient. Further investigations are warranted to deliver solid data on procedure efficiency.

Outcome of Initial 3 Years of Cranial Endoscopy at DG Khan Medical College and Teaching Hospital, Dera Ghazi Khan

OBJECTIVE

With the evolution of surgical approaches, endoscopic skull base surgery has emerged as a suitable alternative to many other invasive methods. The aim of this study was to investigate the efficacy and outcome of cranial endoscopy in treating various neurosurgical intracranial pathologies in terms of procedural success and complications.

METHODS

This observational, prospective case series was conducted at the Department of Neurosurgery of DG Khan Medical College from November 2017 to October 2020. The study enrolled 74 patients with indications for cranial neuroendoscopy. Clinical examination was performed, and a detailed history of the disease was obtained. Follow-up was conducted in the outpatient department. The collected data were analyzed using statistical analysis software.

RESULTS

Of 77 procedures performed, endoscopic third ventriculostomy, arachnoid cyst fenestration, septostomy, colloid cyst excision, endoscopic assisted ventricular catheter placement, and intraventricular tumor biopsy were performed in 53.3%, 18.2%, 10.4%, 7.8%, 6.5%, and 3.9% of patients. Aqueductal stenosis was identified as the most common cause of obstructive hydrocephalus. Seizures and cerebrospinal fluid leaks were the most commonly reported complications (12% and 8.1%, respectively). The observed mortality rate was 2.7%.

CONCLUSIONS

Neuroendoscopic surgery has become safe and effective, as surgeon experience and learning have lowered the risk of complications, and offers a low-cost alternative intervention.

Colloid cysts of the third ventricle in children

OBJECTIVE

The rarity of colloid cysts in children makes it difficult to characterize this entity and offer meaningful advice on treatment. Infrequent case reports exist, but to date there has been no age-specific assessment. The purpose of this study was to define any differences between children and adults who are evaluated and treated for colloid cysts of the third ventricle.

METHODS

Patients with colloid cysts were reviewed and stratified by age. Individuals ≤ 18 years of age were defined as pediatric patients and those > 18 years of age as adults. Clinical and radiographic data, treatment, and postoperative outcomes were compared between both groups. Bivariate analysis was conducted using the Fisher exact test for categorical variables and Mann-Whitney U-test for continuous variables.

RESULTS

Of 132 endoscopic resections (121 primary, 10 secondary, and 1 tertiary) of a colloid cyst, 9 (6.8%) were performed in pediatric patients (mean age 14.1 years, range 9-18 years) and 123 (93.2%) were performed in adult patients (mean age 43.8 years, range 19-73 years). Cases were found incidentally more commonly in pediatric than adult patients (66.7% vs 37.4%, p > 0.05), and pediatric patients had lower rates of hydrocephalus than adult patients (11.1% vs 63.4%, p < 0.05). Acute decompensation at presentation was found in 8 adults (6.5%) but no children. Complete cyst removal (88.9% vs 90.2%, p > 0.05) and length of stay (1.6 days vs 2.9 days, p > 0.05) were not significantly different between the groups. Postoperative complications (6.5% in adults, 0% in children) and recurrence (2.4% in adults, 0% in children) were rare in both groups, and there were no treatment-related deaths. The mean postoperative radiological follow-up was longer in pediatric patients (45 months, range 4-89 months) than adults (44.1 months, range 1-171 months).

CONCLUSIONS

While differences exist between children and adults regarding colloid cyst presentation, these are in keeping with the predicted evolution of a slow-growing lesion. Consistent with this observation, children had lower rates of hydrocephalus and a smaller mean maximal cyst diameter. Contrary to the published literature, however, sudden deterioration was not observed in pediatric patients but occurred in adult patients. In this limited pediatric sample size, the authors have not recorded any postoperative complications or recurrences to date. These encouraging results with endoscopic removal may positively impact future decisions related to children given their protracted life expectancy and projected rates of progression.

Neurocognitive Complications after Ventricular Neuroendoscopy: A Systematic Review

In recent years, neuroendoscopic treatment of hydrocephalus and various ventricular pathologies has become increasingly popular. It is considered by many as the first-choice treatment for the majority of these cases. However, neurocognitive complications following ventricular neuroendoscopic procedures may occur leading mostly to amnesia, which might have a grave effect on the patient's quality of life. Studies assessing neurocognitive complications after ventricular neuroendoscopic procedures are sparse. Therefore, we conducted a systematic review assessing the available literature of neurocognitive complications and outcome after ventricular neuroendoscopy. Of 1216 articles screened, 46 were included in this systematic review. Transient and permanent neurocognitive complications in 2804 ventricular neuroendoscopic procedures occurred in 2.0% (n = 55) and 1.04% (n = 28) of the patients, respectively. Most complications described are memory impairment, followed by psychiatric symptoms (psychosyndrome), cognitive impairment not further specified, declined executive function, and confusion. However, only in 20% of the series describing neurocognitive complications or outcome (n = 40) was neurocognition assessed by a trained neuropsychologist in a systematic manner. While in most of these series only a part of the included patients underwent neuropsychological testing, neurocognitive assessment was seldom done pre- and postoperatively, long-term follow up was rare, and patient's cohorts were small. A paucity of studies analyzing neurocognitive complications and outcome, through systematic neuropsychological testing, and the correlation with intraoperative lesions of neuronal structures (e.g., fornix) exists in the literature. Therefore, the neurocognitive and emotional morbidity after ventricular neuroendoscopic procedures might be underestimated and warrants further research.