Indications for intracranial reservoirs: A six-year study

Intratumoral catheter placement in pediatric patients with diffuse midline gliomas

INTRODUCTION

Diffuse midline brainstem gliomas have a poor prognosis and are generally not amenable to surgical resection. Occasionally, palliative surgical procedures can be performed to improve the quality of life of these patients. We describe three patients with solid-cystic brainstem gliomas in whom an Ommaya reservoir catheter was placed to reduce mass effect.

OBJECTIVES

To describe the characteristics, indications for, and operative technique of Ommaya reservoir catheter placement in patients with solid-cystic diffuse midline glioma.

MATERIALS AND METHODS

A review was conducted of the medical records of pediatric patients with solid-cystic diffuse midline glioma H3 K27-altered, treated with an Ommaya reservoir at Hospital J.P. Garrahan between 2014 and 2021 together with a search of the literature.

RESULTS

Three cases of stereotaxic Ommaya placement in solid-cystic diffuse midline gliomas, H3 K27M-altered were identified. After the procedure, clinical improvement and reduction of the size of the tumor cyst size was achieved. No associated complications were seen. At the time of the study, one patient died, and the remaining two patients continued in follow-up at our hospital.

CONCLUSION

We believe that the placement of an intratumoral Ommaya reservoir catheter may be considered a therapeutic option to improve symptoms and quality of life of selected patients with solid-cystic diffuse midline glioma.

Neuroendoscopic Transventricular Approach for Cystic Craniopharyngioma

The literature is rich with many studies reporting different treatment modalities and approaches for cystic craniopharyngioma (CC), including microsurgery, neuroendoscopic transventricular approach, endoscopic transnasal surgery, stereotactic drainage, and Ommaya reservoir insertion. The goals of this manuscript are to report the successful treatment of an atypical case of CC using the neuroendoscopic transventricular approach (NTVA) as well as discuss the different surgical modalities for these tumors following a comprehensive review of the literature. Our patient is a nine-year-old female with a large CC who was managed using the NTVA. No complications or recurrence occurred over two years of follow-up. Results of our literature review showed lower recurrence and complication rates of the NTVA compared to other surgical modalities.The NTVA is potentially efficient, reliable, and safe for managing CC and cystic-dominant craniopharyngiomas, with low recurrence and complication rates compared to microsurgery and Ommaya reservoir insertion. Future randomized clinical studies comparing the various treatment modalities of CC are needed to solidify these conclusions.

Malignant Intracranial High Grade Glioma and Current Treatment Strategy

Malignant high-grade glioma (HGG) is the most common and extremely fatal type of primary intracranial tumor. These tumors recurred within 2 to 3 cm of the primary region of tumor resection in the majority of cases. Furthermore, the blood-brain barrier significantly limited the access of many systemically administered chemotherapeutics to the tumor, pointing towards a stringent need for new therapeutic patterns. Therefore, targeting therapy using local drug delivery for HGG becomes a priority for the development of novel therapeutic strategies. The main objectives to the effective use of chemotherapy for HGG include the drug delivery to the tumor region and the infusion of chemotherapeutic agents into the vascular supply of a tumor directly, which could improve the pharmacokinetic profile by enhancing drug delivery to the neoplasm tissue. Herein, we reviewed clinical and molecular features, different methods of chemotherapy application in HGGs, especially the existing and promising targeting therapies using local drug delivery for HGG which could effectively inhibit tumor invasion, proliferation and recurrence of HGG to combat the deadly disease. Undoubtedly, novel chemical medicines targeting these HGG may represent one of the most important directions in the Neuro-oncology.

The usefulness of fibrin glue as a support in the dissection of malignant cystic brain tumors

BACKGROUND

If the complete microsurgical resection of a brain tumor is a logical oncologic goal, the surgical strategy for the cystic component remains controversial secondary to the risk of morbidity. The objective of this study was to analyze the interest of using fibrin glue in the resection of malignant cystic brain tumors (MCBT).

METHODS

Seven patients (median: 60-years-old (range [52-72]/sex ratio M/F: 2.5) were analyzed prospectively in the Neurosurgery Department at Strasbourg University Hospital, from October 2014 to November 2016. The surgical technique consisted of injecting fibrin glue into the tumor cyst after partial drainage. After the solidification of the glue, the cysts walls were removal by following the dissection plan around the fibrin glue. The primary objective was to evaluate the quality of surgical resection on brain MRI scans postoperatively with the use of ITK-SNAP software for precise measurements of tumor volume.

RESULTS

Four metastases and 3 glial lesions were operated on with this technique. An average reduction in cystic volume of 64.6% (P=0.016) and 82.1% (P=0.016) for contrast enhancement volume were observed. If two cases (#2 and #7) were excluded, the average contrast enhancement reduction was respectively 94% and 72% for the cystic volume. In addition, there were no complications, tumor recurrence or difference between gliomas and metastases and the Karnofsky score increased by at least 10% in all patients.

CONCLUSION

This procedure allowed to extend the resection to the cystic component of MCBT without increasing the risk of morbidity related to injury on the underlying parenchyma.

Microsurgical removal of craniopharyngioma: endoscopic and transcranial techniques for complication avoidance

Craniopharyngioma remains a challenging entity for neurosurgeons because of its midline, deep seated location and intimate relationship with critical neurovascular structures. Although gross total resection is ideal, the need to reduce surgical morbidity and preserve quality of life has led to a number of neurosurgical approaches which have attained this goal. Here we discuss the commonly used approaches for surgical resection and highlight technical considerations to reduce the potential of complications. We also discuss the mutually exclusive underlying genetic lesions in different histopathological subtypes that will likely lead to future treatment options for these tumors.

Safety profile of long-term intraventricular access devices in pediatric patients receiving radioimmunotherapy for central nervous system malignancies

BACKGROUND

The use of Ommaya catheters or ventriculoperitoneal shunts with programmable valves (pVP-shunts) for intraventricular drug administration is increasingly more common.

PROCEDURE

We reviewed the safety and complication rate associated with ventricular access devices in patients receiving compartmental intraventricular radioimmunotherapy (cRIT).

RESULTS

One hundred fifty one patients with recurrent primary or metastatic central nervous system (CNS) tumors (1-34 years) had a ventricular access device (143 Ommaya reservoirs, 8 VP shunts with programmable valves) placed for drug administration and cerebrospinal fluid acquisition. Patients received 2-5 serial injections (124) I- or (131) I- labeled monoclonal antibody 3F8 or 8H9. For each injection, catheters remained accessed for pharmacokinetic studies up to 48 hours or were individually accessed 3-6×/injection. Thereafter catheters were accessed for periodic routine cytology. Six patients (4%) had complications including three with catheter migration in the newly-placed setting requiring surgical revision. Two patients had pericatheter cyst formation (with cyst formation before radioimmunotherapy administration in one patient) resulting in elective removal and endoscopic cystoventriculostomy in both patients. There were no catheter-related infections, hemorrhages, seizures, focal deficits, or valve malfunctioning. Four patients later required Ommaya conversion to VP shunts because of hydrocephalus secondary to disease progression.

CONCLUSIONS

We report a long-term safety profile of ventricular access devices in patients receiving cRIT. Minimal acute complications are observed despite the frequency of cerebrospinal fluid acquisition; long-term complications are rare. Programmable VP shunts appear to be a safe and effective alternative to Ommaya catheters.