The importance of extent of choroid plexus cauterization in addition to endoscopic third ventriculostomy for infantile hydrocephalus: a retrospective North American observational study using propensity score-adjusted analysis

Neuroendoscopic Lavage and Third Ventriculostomy for the Treatment of Intraventricular Hemorrhage and Hydrocephalus in Neonates. A Prospective Study with 18 Months of Follow-Up

BACKGROUND

 Neonatal intraventricular hemorrhage (IVH) may evolve into posthemorrhagic hydrocephalus and cause neurodevelopmental impairment, becoming a common complication of premature infants, occurring in up to 40% of preterm infants weighing less than 1,500 g at birth. Around 10 to 15% of preterm infants develop severe (grades III-IV) IVH. These infants are at high risk of developing posthemorrhagic hydrocephalus. Neuroendoscopic lavage (NEL) is a suitable alternative for the management of this pathology. In this study, an endoscopic surgical approach directed toward the removal of intraventricular hematoma was evaluated for its safety and efficacy.

METHODS

 Between August 2016 and December 2019 (29 months), 14 neonates with posthemorrhagic hydrocephalus underwent NEL for removal of intraventricular blood by a single senior neurosurgeon. Complications such as reintervention and ventriculoperitoneal (VP) shunt placement were evaluated prospectively with an 18-month follow-up on average.

RESULTS

 In total, 14 neonates with IVH grades III and IV were prospectively recruited. Of these, six neonates did not need a VP shunt in the follow-up after neuroendoscopy (group 1), whereas eight neonates underwent a VP shunt placement (group 2). Nonsignificant difference between the groups was found concerning days after neuroendoscopy, clot extraction, third ventriculostomy, lamina terminalis fenestration, and septum pellucidum fenestration. In group 2, there was shunt dysfunction in five cases with shunt replacement in four cases.

CONCLUSION

 NEL is a feasible technique to remove intraventricular blood degradation products and residual hematoma in neonates suffering from posthemorrhagic hydrocephalus. In our series, endoscopic third ventriculostomy (ETV) + NEL could be effective in avoiding hydrocephalus after hemorrhage (no control group studied). Furthermore, patients without the necessity of VP-shunt had a better GMFCS in comparison with shunted patients.

Choroid plexus epithelium and its role in neurological diseases

Choroid plexus epithelial cells can secrete cerebrospinal fluid into the ventricles, serving as the major structural basis of the selective barrier between the neurological system and blood in the brain. In fact, choroid plexus epithelial cells release the majority of cerebrospinal fluid, which is connected with particular ion channels in choroid plexus epithelial cells. Choroid plexus epithelial cells also produce and secrete a number of essential growth factors and peptides that help the injured cerebrovascular system heal. The pathophysiology of major neurodegenerative disorders like Alzheimer's disease, Parkinson's disease, as well as minor brain damage diseases like hydrocephalus and stroke is still unknown. Few studies have previously connected choroid plexus epithelial cells to the etiology of these serious brain disorders. Therefore, in the hopes of discovering novel treatment options for linked conditions, this review extensively analyzes the association between choroid plexus epithelial cells and the etiology of neurological diseases such as Alzheimer's disease and hydrocephalus. Finally, we review CPE based immunotherapy, choroid plexus cauterization, choroid plexus transplantation, and gene therapy.

Repeat endoscopic third ventriculostomy combined with choroid plexus cauterization as salvage surgery for failed endoscopic third ventriculostomy

PURPOSE

Although the endoscopic third ventriculostomy (ETV) is an effective treatment for hydrocephalus, failures do on occasion occur. In such cases, a repeat ETV or shunt insertion is usually performed. However, there is, as of yet, no clear consensus on the best measure to take in the event of a failed ETV. We herein examined the outcomes of a repeat ETV combined with choroid plexus cauterization for ETV failure.

METHODS

All patients who underwent an ETV at the Department of Neurosurgery at Tokyo Metropolitan Children's Medical Center between April 2013 and March 2019 were retrospectively analyzed.

RESULTS

In total, 36 patients received an ETV. Six patients experienced ETV failure; three of these underwent a repeat ETV combined with choroid plexus cauterization. Three of the six patients who experienced early ETV failure received a ventriculoperitoneal shunt. During the median follow-up period of 42 months (range: 32-73 months), all repeat ETVs were successful.

CONCLUSION

A repeat ETV combined with choroid plexus cauterization can be an effective salvage therapy in the event of ETV failure.

Choroid Plexectomy for Hydrocephalus Management in a Pediatric Patient with a Pilocytic Astrocytoma

Choroid plexectomy is a debated surgical intervention for the treatment of hydranencephaly and chronic infected hydrocephalus. We present a case of a 2-year-old with multiple shunt revisions and hydrocephalus secondary to a pilocytic astrocytoma. He presented with new somnolence, vomiting, and abdominal distension 5 months post subtotal tumor resection, with a history of shunt revisions and infections related to his chemotherapy-induced low white blood cell count. He underwent choroid plexus coagulation and resection. Three years post choroid plexectomy, the patient continues to meet neurodevelopmental milestones and is shunt independent. While ventricular shunt placement is the most common course of treatment, choroid plexectomy should be considered as an alternative treatment of hydrocephalus secondary to other neurological disorders, especially when the patient is immunocompromised, to avoid the recurrent infections seen with shunt placement.

Ventriculomegaly in children: nocturnal ICP dynamics identify pressure-compensated but active paediatric hydrocephalus

INTRODUCTION

Paediatric ventriculomegaly without obvious signs or symptoms of raised intracranial pressure (ICP) is often interpreted as resulting from either relative brain atrophy, arrested "benign" hydrocephalus, or "successful" endoscopic third ventriculostomy (ETV). We hypothesise that the typical ICP "signature" found in symptomatic hydrocephalus can be present in asymptomatic or oligosymptomatic children, indicating pressure-compensated, but active hydrocephalus.

METHODS

A total of 37 children fulfilling the mentioned criteria underwent computerised ICP overnight monitoring (ONM). Fifteen children had previous hydrocephalus treatment. ICP was analysed for nocturnal dynamics of ICP, ICP amplitudes (AMP), magnitude of slow waves (SLOW), and ICP/AMP correlation index RAP. Depending on the ONM results, children were either treated or observed. The ventricular width was determined at the time of ONM and at 1-year follow-up.

RESULTS

The recordings of 14 children (group A) were considered normal. In the 23 children with pathologic recordings (group B), all ICP values and dependent variables (AMP, SLOW) were significantly higher, except for RAP. In group B, 12 of 15 children had received a pre-treatment and 11 of 22 without previous treatment. All group B children received treatment for hydrocephalus and showed a significant reduction of frontal-occipital horn ratio at 1 year. During follow-up, a positive neurological development was seen in 74% of children of group A and 100% of group B.

CONCLUSION

Ventriculomegaly in the absence of signs and symptoms of raised ICP was associated in 62% of cases to pathological ICP dynamics. In 80% of pre-treated cases, ETV or shunt failure was found. Treating children with abnormal ICP dynamics resulted in an outcome at least as favourable as in the group with normal ICP dynamics. Thus, asymptomatic ventriculomegaly in children deserves further investigation and, if associated with abnormal ICP dynamics, should be treated in order to provide a normalised intracranial physiology as basis for best possible long-term outcome.

Technical Nuances in Neuroendoscopic Lavage for Germinal Matrix Hemorrhage in Preterm Infants: Twenty Tips and Pearls after More than One Hundred Procedures

INTRODUCTION

Posthemorrhagic hydrocephalus in preterm infants is a serious entity related to high mortality and morbidity. Neuroendoscopic lavage (NEL) is a suitable alternative for the management of this pathology. However, as with every endoscopic technique, it requires some experience and several cases to master.

METHODS

We present a descriptive study of some technical nuances, tips, and tricks that have been learned in the last 8 years with over a hundred NELs performed in preterm infants. These variations are classified into 3 categories according to their temporal relationship with the surgical procedure: preoperative stage, intraoperative stage, and postoperative stage. We include a brief description of each one and the reasons why they are included in our current clinical practice.

RESULTS

Twenty tips and pearls were described in detail and are reported here. Preoperative, intraoperative, and postoperative variations were exposed and related to the most frequent complications of this procedure: infection, cerebrospinal fluid leak, and rebleeding.

CONCLUSIONS

NEL is a useful technique for the management of germinal matrix hemorrhage in preterm infants. These technical nuances have improved the results of our technique and helped us to prevent complications related to the procedure.

Selective Neuroendoscopic Resection of the Choroid Plexus as an Alternative Technique for Optimizing the Standard Endoscopic Approach to Hydrocephalus

In the past four decades, enormous advances have been made in the neuroendoscopic techniques, along with improvement of illumination, and the development of effective instruments. As a result, endoscopic third ventriculostomy (ETV) and choroid plexus cauterization (CPC) have become consolidated techniques for the treatment of hydrocephalus. In particular, endoscopic cauterization of the choroid plexus has increased the effectiveness of hydrocephalus treatment in combination with ETV. In the past decade, the use of flexible endoscopes has enabled surgeons to resect even the temporal segment of the choroid plexus at the lateral ventricles, which has increased the success of treatment. In this technical note, we describe CPC with the use of a rigid endoscope, which we used to selectively disconnect the glomus of the choroid plexus, in addition to choroid plexus coagulation, as an alternative way to facilitate ETV. This new procedure optimized the visualization of the choroid plexus and the temporal horn and prevented additional difficulties in coagulation of this mobile region of the choroid plexus in selected patients. To achieve the best outcome, avoid bleeding, and optimize the standard technique, it was important to recognize both the classical anatomic structure of the choroid plexus and some variations, and previous expertise in ETV and CPC were necessary. We demonstrate that resection of the glomus of the choroid plexus in selected patients is safe and feasible.

A Review of Common Endoscopic Intracranial Approaches

With the evolution of surgical techniques, endoscopy has emerged as a suitable alternative to many instances of more invasive methods. In this review article, we aim to discuss the endoscopic advancements, procedural details, indications, and outcomes of the most commonly practiced neuroendoscopic procedures. We have also summarized the uses, techniques, and challenges of neuroendoscopy in select neurosurgical pathologies.

The ventriculo-cholecystic shunt: does CSF volume matter?

INTRODUCTION

The management of hydrocephalus in paediatric patients where the peritoneum has failed can be challenging. One option is to perform a ventriculo-cholecystic shunt. However, little is known about the capacity of the gall bladder to accommodate cerebrospinal fluid (CSF).

METHODS

A retrospective case series was performed to include all paediatric patients who received a ventriculo-cholecystic shunt at a single centre, Sheffield Children's Hospital.

RESULTS

We identified three patients who had a ventriculo-cholecystic shunt inserted. The shunt survived past 1 year in two patients, who had pre-operative external ventricular drain (EVD) outputs of 8 and 10 ml/h respectively. One patient shunt failed at day four post-op due to distal dysfunction, his pre-operative EVD was over 30 ml/h.

CONCLUSIONS

When considering a patient for a ventriculo-cholecystic shunt, caution should be taken if a high CSF output is known, for example, as per an EVD measurement.