Limitations of Neuroendoscopic Treatment for Pediatric Hydrocephalus and Considerations from Future Perspectives

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.

The Role of Ventriculocisternostomy in the Management of Hydrocephalus in Mali and the Democratic Republic of the Congo

BACKGROUND

 Hydrocephalus continues to pose significant clinical challenges in neurosurgery. The primary goal of this study is to assess the feasibility of ventriculocisternostomy (VCS) within the provincial city of Kinshasa and Mali to optimize the management of patients afflicted with hydrocephalus.

METHODS

 This investigation was hosted at two major urban healthcare facilities: the Initiative Plus Hospital Center, positioned in the bustling metropolis of Kinshasa, Democratic Republic of the Congo (DRC), and the Bamako Hospital, Republic of Mali. A prospective, analytical cohort study was executed from December 2022 to June 2023.

RESULTS

In the Mali group, seven patients underwent VCS, four patients were treated with VCS and spinal surgery, and one case was treated with VCS and biopsy. Similarly, in the Kinshasa group, 25 patients underwent VCS, whereas four patients were treated with VCS and spinal surgery. The median hospital stay was eight and 10 days for the Mali and the Kinshasa groups, respectively.

CONCLUSION

VCS emerges as a formidable alternative for hydrocephalus management in Mali and DRC, showcasing the potential to markedly ameliorate patient outcomes, economize healthcare expenditures, and fortify the local neurosurgical capacity.

Addressing hydrocephalus in Africa: Challenges and way forward

Hydrocephalus occurs when the cerebrospinal fluid (CSF) accumulates in the cerebral ventricles. This is due to either obstruction in the CSF flow, decreasing its absorption by the arachnoid villus to the Dural venous sinuses, or increasing production of the CSF. The most disproportionately and severely affected by the disease consequences are African children. This is because of the high incidence of postinfectious hydrocephalus and spinal dysraphism compared with other world children. The health care system in Africa has access to 488 neurosurgeons which represents less than 1% of the global neurosurgeons, thus pediatric hydrocephalus is considered an emerging public health problem in Africa because of the difficulty of the patient's access to proper care. Numerous studies conducted in Africa have revealed a significant imbalance in the distribution of neurosurgical resources across the continent. Specifically, South Africa and North Africa collectively account for 86% of the total practicing neurosurgeons, indicating a pronounced concentration of these specialized medical professionals in these regions. Having an abundance of case studies regarding hydrocephalus is vital to increase our awareness and understanding. Hydrocephalus should gain more priority by current policymakers as an important health concern. This may be achieved by proper resource allocation to ensure better quality means of diagnosis, intervention, and rehabilitation.

Biomechanics of brain tissue damage caused by fiber endoscope penetration in third ventriculostomy surgery

Third ventriculostomy is the preferred treatment for obstructive hydrocephalus, but the biomechanics of brain tissue damage caused by fiber endoscopes remains unclear. In this study, brain tissue material parameters were tested based on the Ogden model to simulate needle puncture mechanics, and replicated the entire fiber endoscope advancement process during third ventriculostomy. It was found that a smaller diameter fiber endoscope, a perpendicular puncture angle, and a faster puncture speed would decrease the damage of brain tissue caused by the fiber endoscope. This study provides valuable insights for optimizing the instrumentation and surgical process of third ventriculostomy.

Hydrocephalus associated to congenital Zika syndrome: does shunting improve clinical features?

PURPOSE

Congenital Zika syndrome (CZS) is a new entity with little information about its course and natural history. It is known that prenatal infection by Zika virus is associated to disrupted nervous system development, leading to typical neurological disabilities and deformities. Some children present progressive ventriculomegaly and hydrocephalus associated to aggravation of seizures and neurological impairment. The aim of this study is to evaluate the development of hydrocephalus and the impact of ventriculoperitoneal shunt insertion in the clinical condition of these children.

METHODS

Data was obtained from chart review, direct interviews with patients' parents, direct neurological examination, and analysis of pre- and postoperative neuroimages.

RESULTS

A group of 115 patients had CZS diagnosis from November 2015 to July 2017. Among them, 21 (18.3%) patients had ventricular enlargement noted on follow-up CT scans. Six children (28.6%) underwent a ventriculoperitoneal shunt and all had some improvement after surgery concerning either waking time during the day and better interaction. Overall improvement was also noted in seizures. Spasticity decrease and more cervical control were also achieved. In two out of six cases, a slight increase in parenchymal length could be noted on the CT scans.

CONCLUSION

This series points out the possibility of hypertensive hydrocephalus development in CZS patients. Affected children may benefit from VP shunt insertion. These findings suggest a dual pathology association: fetal brain disruption and primary cortical malformation by the virus itself and hypertensive hydrocephalus. This is already seen in some cases of congenital rubella, toxoplasmosis, or cytomegalovirus-associated hydrocephalus.

Endoscopic third ventriculostomy and repeat endoscopic third ventriculostomy in pediatric patients: the Dutch experience

OBJECTIVE After endoscopic third ventriculostomy (ETV), some patients develop recurrent symptoms of hydrocephalus. The optimal treatment for these patients is not clear: repeat ETV (re-ETV) or CSF shunting. The goals of the study were to assess the effectiveness of re-ETV relative to initial ETV in pediatric patients and validate the ETV success score (ETVSS) for re-ETV. METHODS Retrospective data of 624 ETV and 93 re-ETV procedures were collected from 6 neurosurgical centers in the Netherlands (1998-2015). Multivariable Cox proportional hazards modeling was used to provide an adjusted estimate of the hazard ratio for re-ETV failure relative to ETV failure. The correlation coefficient between ETVSS and the chance of re-ETV success was calculated using Kendall's tau coefficient. Model discrimination was quantified using the c-statistic. The effects of intraoperative findings and management on re-ETV success were also analyzed. RESULTS The hazard ratio for re-ETV failure relative to ETV failure was 1.23 (95% CI 0.90-1.69; p = 0.20). At 6 months, the success rates for both ETV and re-ETV were 68%. ETVSS was significantly related to the chances of re-ETV success (τ = 0.37; 95% bias corrected and accelerated CI 0.21-0.52; p < 0.001). The c-statistic was 0.74 (95% CI 0.64-0.85). The presence of prepontine arachnoid membranes and use of an external ventricular drain (EVD) were negatively associated with treatment success, with ORs of 4.0 (95% CI 1.5-10.5) and 9.7 (95% CI 3.4-27.8), respectively. CONCLUSIONS Re-ETV seems to be as safe and effective as initial ETV. ETVSS adequately predicts the chance of successful re-ETV. The presence of prepontine arachnoid membranes and the use of EVD negatively influence the chance of success.