Stereotactically guided endoscopic port surgery for intraventricular tumor and colloid cyst resection

Effect comparison of neuroendoscopy versus microsurgery in the treatment of lateral ventricular tumors

PURPOSE

We sought to reveal the clinical characteristics of lateral ventricle tumors and to evaluate the superior surgical procedure available.

METHODS

There involved a total of of 49 adult patients harboring lateral ventricle tumors in neurosurgery department of our hospital from January 2016 to March 2022. The patients enrolled were retrospectively analyzed, so are their clinical manifestations, pathological characteristics and surgical strategies. The patients were allocated into neuroendoscope group (11 cases) and microsurgery group (38 cases) according to the operation method. The two groups underwent a detailed evaluation of operation effectiveness and safety profile (operation time, intraoperative bleeding, surgical resection rate, postoperative complications) and economic indicators (postoperative hospital stay, hospital costs).

RESULTS

The neuroendoscope group demonstrated a markedly shorter operation time than the microsurgery group (p<0.05), with the amount of bleeding significantly less than the microsurgery group (p<0.01). However, there was no significant difference in the resection rate and postoperative complications between the two groups (p>0.05). Significant difference was found in the economic indicators (postoperative hospital stay and hospital costs) of the patients in the neuroendoscope group (p<0.05).

CONCLUSION

Surgery intervention is regarded as the core treatment option for lateral ventricle tumors. Both microsurgery and neuroendoscopy are effective with safety profile. In the selected lateral ventricle tumor surgery, the application of neuroendoscopic surgery showed promising results, in terms of less intraoperative bleeding, and shorter operation time, postoperative hospital stays, and hospital costs. The selection of surgical approach and methods for lateral ventricle tumors is principally depended on the experience of neurosurgeon concerning the surgical approach and related neuroanatomy.

Neurosurgical Approaches to Brain Tissue Harvesting for the Establishment of Cell Cultures in Neural Experimental Cell Models

In recent decades, cell biology has made rapid progress. Cell isolation and cultivation techniques, supported by modern laboratory procedures and experimental capabilities, provide a wide range of opportunities for in vitro research to study physiological and pathophysiological processes in health and disease. They can also be used very efficiently for the analysis of biomaterials. Before a new biomaterial is ready for implantation into tissues and widespread use in clinical practice, it must be extensively tested. Experimental cell models, which are a suitable testing ground and the first line of empirical exploration of new biomaterials, must contain suitable cells that form the basis of biomaterial testing. To isolate a stable and suitable cell culture, many steps are required. The first and one of the most important steps is the collection of donor tissue, usually during a surgical procedure. Thus, the collection is the foundation for the success of cell isolation. This article explains the sources and neurosurgical procedures for obtaining brain tissue samples for cell isolation techniques, which are essential for biomaterial testing procedures.

Current trends in the management of subependymal giant cell astrocytomas in tuberous sclerosis

INTRODUCTION

The management of subependymal giant cells astrocytomas (SEGAs) has been traditionally represented by surgical treatment through an open craniotomic approach. Though open surgery still represents a major option in the management of this kind of tumors, the introduction of mTOR inhibitors in the clinical practice, technological advances in neuroendoscopy and the more recent use of laser interstitial therapy have significantly enlarged the range of available management opportunities.

METHODS

A thorough review of the literature has been performed. Accordingly, current views in open surgical treatment, medical therapy, endoscopic tumor removal and new trends (such as laser interstitial thermal therapy) are discussed.

RESULTS

The risk of significant neurological morbidity (5-50%) complicating open surgery has been for a long time representing a main drawback in the management of SEGAs. More recent series report a significant reduction of morbidity and mortality. The mTOR inhibitors have demonstrated efficacy in both warranting a tumor reduction by up to 60% of the tumor size and helping the control of seizures. However, the reported rate of side effects is as high as 30% and tumor recurrence is a documented occurrence at the time of mTOR inhibitor discontinuation. Endoscopic tumor removal has been more extensively considered an option due to the acquisition of new tools. Limits are still represented by tumor size (< 3 cm) and broad attachment of the tumor to the basal ganglia. Laser interstitial thermal therapy (LITT) is the more recently considered option. Though promising, only short follow-up is available so far, while data on medium- and long-term results of this treatment are completely lacking to date.

CONCLUSIONS

Surgical treatment remains a mainstay of the management of SEGAs. The indication for an open craniotomic approach should be balanced with an endoscopic tumor removal or LITT according to patient conditions, presence or not of an active hydrocephalus and extension of the attachment of the tumor to the basal ganglia. The mTOR inhibitors do have a definite role both as primary and as adjuvant treatment, but consistent limitations are represented up to now by a not negligible rate of complications and the uncertainties related to the possibility of tumor recurrence once the medical treatment is discontinued.

A multiport MR-compatible neuroendoscope: spanning the gap between rigid and flexible scopes

OBJECTIVE Rigid endoscopes enable minimally invasive access to the ventricular system; however, the operative field is limited to the instrument tip, necessitating rotation of the entire instrument and causing consequent tissue compression while reaching around corners. Although flexible endoscopes offer tip steerability to address this limitation, they are more difficult to control and provide fewer and smaller working channels. A middle ground between these instruments-a rigid endoscope that possesses multiple instrument ports (for example, one at the tip and one on the side)-is proposed in this article, and a prototype device is evaluated in the context of a third ventricular colloid cyst resection combined with septostomy. METHODS A prototype neuroendoscope was designed and fabricated to include 2 optical ports, one located at the instrument tip and one located laterally. Each optical port includes its own complementary metal-oxide semiconductor (CMOS) chip camera, light-emitting diode (LED) illumination, and working channels. The tip port incorporates a clear silicone optical window that provides 2 additional features. First, for enhanced safety during tool insertion, instruments can be initially seen inside the window before they extend from the scope tip. Second, the compliant tip can be pressed against tissue to enable visualization even in a blood-filled field. These capabilities were tested in fresh porcine brains. The image quality of the multiport endoscope was evaluated using test targets positioned at clinically relevant distances from each imaging port, comparing it with those of clinical rigid and flexible neuroendoscopes. Human cadaver testing was used to demonstrate third ventricular colloid cyst phantom resection through the tip port and a septostomy performed through the lateral port. To extend its utility in the treatment of periventricular tumors using MR-guided laser therapy, the device was designed to be MR compatible. Its functionality and compatibility inside a 3-T clinical scanner were also tested in a brain from a freshly euthanized female pig. RESULTS Testing in porcine brains confirmed the multiport endoscope's ability to visualize tissue in a blood-filled field and to operate inside a 3-T MRI scanner. Cadaver testing confirmed the device's utility in operating through both of its ports and performing combined third ventricular colloid cyst resection and septostomy with an endoscope rotation of less than 5°. CONCLUSIONS The proposed design provides freedom in selecting both the number and orientation of imaging and instrument ports, which can be customized for each ventricular pathological entity. The lightweight, easily manipulated device can provide added steerability while reducing the potential for the serious brain distortion that happens with rigid endoscope navigation. This capability would be particularly valuable in treating hydrocephalus, both primary and secondary (due to tumors, cysts, and so forth). Magnetic resonance compatibility can aid in endoscope-assisted ventricular aqueductal plasty and stenting, the management of multiloculated complex hydrocephalus, and postinflammatory hydrocephalus in which scarring obscures the ventricular anatomy.

Endoscope Holders in Cranial Neurosurgery: Part I-Technology, Trends, and Implications

OBJECTIVE

Cranial neuroendoscopy is becoming increasingly popular. Endoscopes may be used free-hand or with endoscope holders (EH). The aim of this paper is to summarize the evolution of EH and attempt an overview of currently available devices, features, and usage, identifying weaknesses and focusing on feasibility.

METHODS

A systematic review was conducted on Pubmed, OvidSP, Ebsco, and Google Scholar. Targeted search through cross-references was also implemented, followed by personal contacts, interviews, company websites, and operating manuals. A pilot survey was performed to acquire an impression of the current state of usage. This was conducted by approaching surgeons from several countries via e-mail and online through a neurosurgical exchange forum. A more extensive survey will follow as Part II.

RESULTS

EH may be divided into manual and pneumatic. The use of micromanipulators is sometimes implemented. Different characteristics have been described, such as pneumatic, mechanical, friction, micromanipulator, robotic, hybrid, air-locking, and voice-control. Twenty eight surgeons responded. The majority (75%) do not routinely use EH. The rest use EH mainly for intraventricular rather than skull base procedures. Nearly all surgeons (96%) stated using a second surgeon regularly. Reported weaknesses included crude movements, downward drift, loss of depth perception, lack of flexibility, iatrogenic injury, cost, and bulky construction.

CONCLUSIONS

Although EH have a role in neuroendoscopy, their use seems to be limited and their features regarded as suboptimal. There are no clear indications regarding the procedures that should be performed using EH. Many factors affect the implication of EH, including safety, type of surgery, surgeon's preference, and mechanical properties.

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.

Intraventricular Meningioma: Technical Nuances in Surgical Management

OBJECTIVE

Intraventricular meningiomas (IVMs) are rare tumors compared with intracranial meningiomas. Optimal surgical management of IVMs is controversial. The objective of this article was to review the outcomes and complications of meningiomas treated with various surgical approaches.

METHODS

We performed a retrospective review of 18 patients with IVMs who received different treatment strategies during the period 2000-2014. Of 18 patients, 17 underwent microsurgical resection, and 1 patient received Gamma Knife radiosurgery. The literature was reviewed to compare the present cohort with previously published series.

RESULTS

In our series, 12 (70%) patients underwent parieto-occipital craniotomy and a superior parietal gyrus approach, which was similar to procedures used in various series (74.4%) in the existing literature. Preoperatively, patients commonly presented with headache (65%) and neurologic deficits (70%). After surgical management, there was a significant reduction in symptoms, including headache (preoperative 65% vs. postoperative 6%, P = 0.0001), and neurologic deficits (preoperative 70% vs. postoperative 5.5%). Preoperatively, 2 patients experienced visual impairment, which was completely resolved after surgery. The Karnofsky performance scale was significantly improved after resection compared with before treatment (89 vs. 76, P = 0.003). In 4 patients with World Health Organization grade II tumor, redo surgery was required because of recurrence of tumor.

CONCLUSIONS

Based on a literature review and our experience, surgical approaches for patients with IVM vary according to size, location, and laterality of the meningioma. In addition, the growth pattern of the tumor (transependymal extension), vascular supply of the tumor, and brain function (particularly visual function) can affect surgical treatment and should be identified preoperatively.

Combination of Neuroendoscopic and Stereotactic Procedures for Total Resection of Colloid Cysts with Favorable Neurological and Cognitive Outcomes

BACKGROUND

Despite a wide range of surgical procedures, an unresolved debate remains regarding which attempt is optimal for the treatment of colloid cysts in the third ventricle. In this article, we present a new combination of stereotactic and endoscopic techniques.

METHODS

This prospective study includes 27 consecutive patients with symptomatic primary and recurrent colloid cysts. All cysts were removed via a neuroendoscope through a rostral transfrontal, transforaminal approach. The endoscope was supported by an additional cannula fixed in the stereotactic frame. Both tools were inserted into one lateral ventricle through two separate burr holes using stereotactic guidance.

RESULTS

The median operating time was 135 minutes. All cysts were removed completely, and no mortality or permanent complications related to surgery occurred. The mean time of observation was 43.5 months (range, 3-78 months), and no clinical or radiologic recurrences were observed. One patient with a history of an infected ventriculoperitoneal shunt did not improve after cyst removal, but improved after subsequent reimplantation of the shunt. In all other cases, symptoms resolved (67%) or decreased (30%). Cognitive functions improved or remained unchanged in all 10 elective cases examined neuropsychologically before and after surgery.

CONCLUSIONS

The techniques we describe for removal of colloid cysts are safe and effective, even for recurrent cases, and they provide 100% total resection, favorable cognitive outcomes, low risk of recurrence, and low risk of morbidity. The disadvantages of this method are a longer time for surgery and the need for more complex instrumentation compared with conventional endoscopic resection.

Intraoperative Conversion from Endoscopic to Open Transcortical-Transventricular Removal of Colloid Cysts as a Salvage Procedure

OBJECTIVE

 To describe the transcortical-transventricular as an intraoperative salvage procedure and its effect of operative time and outcome.

METHODS

 Thirty-three patients were included in the study. Twenty patients had an endoscopic operation, five had a transcortical-transventricular approach, and eight underwent an interhemispheric approach for resection. Based on common cyst location in the roof of the third ventricle, we propose a simple classification of surgical operative zones based on relationships defined by the anterior column of the fornix, the septal vein, and the medial atrial vein.

RESULTS

 Complete capsule removal was achieved in 35% of endoscopic operations, 100% of transcortical-transventricular operations, and 63% of the interhemispheric operations. Operative time was 176 minutes for endoscopic operations, whereas the operative time for cases that converted to the transcortical-transventricular approach was 190 minutes (p=0.39).

CONCLUSION

 A surgical-based classification of zones within the roof of the third ventricle that can be accessed with microsurgical techniques is proposed. Both endoscopic and microsurgical cyst aspiration and excision remain options. We believe that younger patients, patients with large cysts that fill the third ventricle, or those with recurrence after prior treatment would benefit from open transcortical excision as a safe and effective operative approach using modern image-guided systems. Consent was formally obtained or waived for all subjects present within this study.

Predictive Value of Somatosensory Evoked Potential Monitoring during Resection of Intraparenchymal and Intraventricular Tumors Using an Endoscopic Port

BACKGROUND AND PURPOSE

Intraoperative neurophysiological monitoring (IONM) using upper and lower somatosensory evoked potentials (SSEPs) is an established technique used to predict and prevent neurologic injury during intracranial tumor resections. Endoscopic port surgery (EPS) is a minimally-invasive approach to deep intraparenchymal and intraventricular brain tumors. The authors intended to evaluate the predictive value of SSEP monitoring during resection of intracranial brain tumors using a parallel endoscopic technique.

METHODS

A retrospective review was conducted of patients operated on from 2007-2010 utilizing IONM in whom endoscopic ports were used to remove either intraparenchymal or intraventricular tumors. Cases were eligible for review if an endoscopic port was used to resect an intracranial tumor and the electronic chart included all intraoperative monitoring data as well as pre- and post-operative neurologic exams.

RESULTS

139 EPS cases met criteria for inclusion. Eighty five patients (61%) had intraparenchymal and fifty four (39%) had intraventricular tumors or colloid cysts. SSEP changes were seen in eleven cases (7.9%), being irreversible in three (2.2%) and reversible in eight cases (5.8%). Seven patients (5.0%) with intraparenchymal tumors had SSEP changes which met our criterea for significant changes while there were four (2.9%) with intraventricular (p-value=0.25). Five patients suffered post operative deficits, two reversible and two irreversible SSEP changes. Only one case exhibited post operative hemiparesis with no SSEP changes. The positive predictive value of SSEP was 45.4% and the negative predictive value was 99.2%.

CONCLUSIONS

Based on the high negative and low positive predictive values, the utility of SSEP monitoring for cylindrical port resections may be limited. However, the use of SSEP monitoring can be helpful in reducing the impact of endoscopic port manipulation when the tumor is closer to the somatosensory pathway.

Combined awake craniotomy with endoscopic port surgery for resection of a deep-seated temporal lobe glioma: a case report

The authors describe the combination of awake craniotomy and minimally invasive endoscopic port surgery to resect a high-grade glioma located near eloquent structures of the temporal lobe. Combined minimally invasive techniques such as these may facilitate deep tumor resection within eloquent regions of the brain, allowing minimum white matter dissection. Technical aspects of this procedure, a case outcome involving this technique, and the direction of further investigations for the utility of these techniques are discussed.

Side-cutting aspiration device for endoscopic and microscopic tumor removal

The authors present a unique side-cutting instrument (NICO Myriad, Indianapolis, IN) with variable aspiration designed specifically for tumor resection. The study included retrospective review of data collected from 10/2009 to 01/2011. We detail the use of the Myriad in 31 patients with the following pathologies: meningioma (n=16), chordoma (n = 3), schwannoma (n = 3), pituitary adenoma (n = 2), metastasis (n = 3), hemangioblastoma (n = 1), craniopharyngioma (n = 1), and nasopharyngeal tumors (n = 2). Surgical approaches included expanded endonasal approach (n = 19), endoscopic brain port (n = 3), supraorbital "eyebrow" craniotomy (n = 3), retrosigmoid suboccipital craniotomy (n = 3), pterional craniotomy (n = 1), extreme far lateral (n = 1), and laminectomy (n = 1). Successful tumor resection was achieved in 30 cases. Instrument failure was noted in only one extremely fibrous meningioma. The design of this instrument facilitated maneuvering through narrow corridors while providing direct visualization of the suction aperture during tumor resection. These features allowed for tumor removal without injury to adjacent neurovascular structures. The side-cutting aspiration device allows safe and effective tumor removal. Its low profile, variable aspiration, and lack of thermal heat energy are particularly useful in tumor resection through narrow corridors, such as endonasal, port, and keyhole approaches. The multifunctional nature of the instrument (suction, scissors, and dissectors) minimizes multiple exchanges, facilitating tumor resection through these minimal access corridors.