Secondary amenorrhea due to hydrocephalus treated with endoscopic ventriculocisternostomy. Case report

Non-communicating hydrocephalus with a primary empty sella presenting with growth hormone deficiency and delayed puberty successfully treated by endoscopic third ventriculocisternostomy

The authors present the unusual case of a 15-year-old boy with a primary empty sella caused by non-communicating hydrocephalus due to fourth ventricle outflow obstruction whose secondary symptoms of growth hormone deficiency and delayed puberty were successfully treated by endoscopic third ventriculocisternostomy (ETV). Hypopituitarism occurs only rarely in cases of hydrocephalus; rarer still are cases where hypopituitarism is the sole symptom of hydrocephalus. A primary empty sella may indicate elevated intracranial pressure; if the cause is non-communicating hydrocephalus, ETV is indicated as the preferred treatment modality.

Neuroendocrine mechanisms of reproduction

The neuroendocrinology of reproduction focuses on the neuromodulation of gonadotropin-releasing hormone (GnRH), the ontogeny of the hypothalamic-pituitary-gonadal axis, and common reproductive events and conditions, namely, puberty, the menstrual cycle, and disorders of reproductive function. The core concept underpinning the neuroendocrinology of reproduction is neuroregulation of hypothalamic GnRH drive. In both men and women, reproductive function requires that GnRH input elicit appropriate secretion of follicle-stimulating hormone and luteinizing hormone from the anterior pituitary and that the gonads respond to such input appropriately. Moreover, insufficient GnRH drive causes hypothalamic hypogonadism and secondary insufficiency of gonadal sex steroid hormone synthesis and release in both sexes. Alterations in GnRH drive also reflect gonadal conditions such as dysgenesis, hyperandrogenism, gonadotropin mutations, and aging and loss or absence of oocytes or Sertoli cells. The most common cause of insufficient GnRH drive is functional, that is, due to the endocrine effects of psychologic or behavioral variables. Rarely does reduced GnRH drive reflect organic or congenital causes such as developmental defects, brain tumors, or celiac disease. Despite a common neuropathogenesis the heterogeneity of behavioral variables associated with reduced GnRH drive has resulted in a variety of names, including functional hypothalamic amenorrhea, stress-induced anovulation, and psychogenic amenorrhea.

Amenorrhea after Endoscopic Third Ventriculostomy for a Failed Shunt in Spina Bifida: Case Report and Review of the Literature

BACKGROUND

Secondary endoscopic third ventriculostomy (ETV) for the management of shunt failure may be efficacious, though it may be followed by more frequent complications (including endocrinological impairment, e.g., amenorrhea) compared to primary ETV. These complications are usually underreported in the literature.

AIM

We report a case of secondary amenorrhea after ETV for the management of shunt failure in a young woman with hydrocephalus associated with myelomeningocele.

METHODS

A 25-year-old woman affected by hydrocephalus and myelomeningocele was admitted for secondary ETV for the management of shunt failure. The endoscopic procedure was preferred over shunt revision based on good results of secondary ETV, especially in patients with hydrocephalus associated with Chiari II malformation and spina bifida.

RESULTS

Despite the surgery being uneventful, the patient had early (postoperative seizure) and late (secondary amenorrhea) complications. In the early postoperative period, she received external ventricular drainage followed by VP shunt reimplantation 2 weeks later. There was no neurological morbidity, but 1 month after the ETV she reported secondary amenorrhea and weight gain. Laboratory investigations ruled out hyperprolactinemia, which had been treated with cabergoline administration with no efficacy since the patient was still without regular periods 1 year later.

CONCLUSION

ETV may be followed by endocrinological complications like amenorrhea that are rarely reported.

Neuroendocrine control of ovulation

Modern methods of diagnosis have made the distinction between hypothalamic failure and ovarian failure routine. Failure of the orderly progression of hypothalamic gonadotrophin-releasing hormone (GnRH) → pituitary gonadotrophins → ovarian steroids and inhibin → hypothalamus/pituitary results in anovulation/amenorrhea. The hypothalamic connections that regulate the pattern and amplitude of GnRH pulses are plastic and respond to external/psychological conditions and internal/metabolic factors that may affect the hypothalamic substrate on which estrogen levels can act. We trace the neuroendocrine regulation of the ovarian cycle, concentrating on hypothalamic connections that underlie negative and positive feedback control of GnRH and the complementary role of the adenohypophysis. The main hormone regulating this "central axis" and the development of the endometrium is estradiol which is exported from the developing ovarian follicles and thereby closes the feedback loop with follicle development. Progesterone and inhibin are also involved. Neuroendocrine responses to internal and external factors can cause anovulation and amenorrhea. Generally, these are accompanied by abnormal negative feedback between estradiol and the gonadotrophins; coexistence of low estradiol and luteinizing hormone/follicle-stimulating hormone. There are three main causes: (1) genetic diseases that interfere with the migration of GnRH cells into the brain or result in misfolding of GnRH; (2) input from the brain that interrupts normal feedback (e.g. stress and weight loss amenorrhea); and (3) the effect of agents which alter central neurotransmission and hypothalamic function (e.g. elevated prolactin and psychotropic medications). All types of hypothalamic insufficiency result in insufficient stimulation of the ovaries. In addition to amenorrhea, this central alteration also results in other complications (downstream disease) that make hypothalamic amenorrhea of greater consequence than simply reproductive failure. Thus, there may be more at stake in the diagnosis and treatment of hypothalamic failure than brings the patient to her caregiver.

Amenorrhea complicating endoscopic third ventriculostomy in the pediatric age group

Endoscopic third ventriculostomy (ETV) is an accepted option in the treatment of obstructive hydrocephalus in children and is considered by many pediatric neurosurgeons to be the treatment of choice in this population. The procedure involves perforation of the floor of the third ventricle, specifically, the tuber cinereum, which is part of the hypothalamic-pituitary axis of cerebral endocrine regulation. Endocrine dysfunction, such as amenorrhea, weight gain, and precocious puberty, which are recognized only months to years after the procedure, may be underreported because patients and physicians may not relate the endocrine sequelae to the ETV. Few detailed reports of endocrine-related complications following ETV exist to better understand these issues. In this study, the authors add to the literature with case descriptions of and correlative laboratory findings in 2 adolescent girls who underwent ETV for obstructive hydrocephalus and in whom amenorrhea subsequently developed.

Hypogonadotropic hypogonadism: a consequence of Chiari-I malformation

Chronic hydrocephalus, most commonly the result of aqueduct stenosis, is associated with both primary and secondary amenorrhea. Only six cases of secondary amenorrhea have been reported to date. We describe a women with cystic fibrosis who presented with secondary amenorrhea as a consequence of Chiari-I malformation and resultant hydrocephalus. The biochemical picture was characterized by hypogonadotropic hypogonadism. Resolution of the amenorrhea was observed to occur following 3rd ventriculostomy.

Changes in cerebral perfusion hormone profile and cerebrospinal fluid flow across the third ventriculostomy after endoscopic third ventriculostomy in patients with aqueductal stenosis: a prospective study. Clinical article

OBJECT

The object of the present study was 3-fold: 1) to study regional cerebral perfusion before and after endoscopic third ventriculostomy (ETV) in patients with obstructive hydrocephalus by using (99m)Tc ethyl cysteinate dimer SPECT: 2) to study any correlation between clinically successful third ventriculostomy and CSF flow across the third ventriculostomy; and 3) to determine any changes in hormone profile following ETV.

METHODS

The authors prospectively studied 15 patients with aqueductal stenosis who underwent ETV during the last 2 years. All the patients underwent pre- and postoperative MR imaging, brain (99m)Tc ethyl cysteinate dimer SPECT, and hormone profile studies.

RESULTS

Eight patients were infants. The mean follow-up duration was 17.6 months. Thirteen patients (86.7%) exhibited clinical improvement after surgery. In all patients with clinical improvement the studies documented CSF flow through the ventriculostomy site. Clinical progress could be correlated with SPECT changes in 14 cases (93.3%). In the 13 clinically successful cases, 12 were substantiated by improvement on SPECT scans, whereas in the 2 failed cases, SPECT images revealed no improvement of perfusion defects. Hormone analysis conducted in 14 patients revealed hyperprolactinemia in 8, low triiodothyronine values in 2 patients, and hypocortisolemia in 1, which was reversed after ETV.

CONCLUSIONS

Clinical improvement is not well correlated with a decrease in ventricular size following ETV. Brain SPECT is a valuable tool for the follow-up of patients with hydrocephalus after ETV, particularly in cases in which MR imaging findings are not clear. There are subtle hormonal changes in patients with hydrocephalus that may improve following ETV.

Reproductive implications of endoscopic third ventriculostomy for the treatment of hydrocephalus

OBJECTIVE

The objective of this study was to compare reproductive function after two neurosurgical procedures for treating non-neoplastic hydrocephalus; endoscopic third ventriculostomy (ETV) and ventriculo-peritoneal shunt (VP).

STUDY DESIGN

A cohort of 96 women who underwent neurosurgical procedures to treat non-neoplastic hydrocephalus at the Cleveland Clinic between January 1995 and January 2004 was identified. A follow up mailed survey was sent to all identified women between 15 and 45 years of age. In addition, phone interviews were performed to complete the required data. Clinical, laboratory and operative details were collected from 69 participants.

RESULTS

There was a two-fold significant increase in the menstrual irregularities after the procedure in the ETV group [5/52(10%)-10/52(19%), P=0.03] while those treated with VP shunt maintained the same menstrual pattern postoperatively. The rate of pregnancy was higher in the VP group compared to the ETV group, but did not reach statistical significance [8/17(47%) vs. 17/52(33%), P=0.462]. Similarly, the rate of term pregnancies was higher in the VP group compared to ETV group [8/8(100%) vs. 13/17(76%), P=0.269], which reflected a higher spontaneous miscarriage rate in ETV compared to VP group [4/17(33%) vs. 0/8(0%), P=0.269].

CONCLUSION

ETV appears to alter reproductive function postoperatively. In patients who establish a pregnancy, abortion rates seem to be higher in the ETV group; however, a prospective study will be required to validate these observations.

Endoneurosonography: technique and equipment, anatomy and imaging, and clinical application

OBJECTIVE

To evaluate the usefulness of transendoscopic ultrasound in neurosurgery, we studied two new sonoprobes measuring 6 and 8 French in diameter in 20 fresh specimens. The application and indication are discussed in the first clinical series of 75 patients.

METHODS

Sonocatheters (ALOKA, Meerbusch, Germany) 1.9 mm (6 French) and 2.4 mm (8 French) in diameter were introduced into the working channel of an endoscope. The preparations were done in nonfixed skulls in a surgical simulation-setting laboratory. Based on these experiences with imaging possibilities, intraoperative transendoscopic ultrasound was applied in 75 patients and a variety of lesions. It was used for imaging (41 patients), targeting (18 patients), and neuronavigation (16 patients) in neuroendoscopy.

RESULTS

The sonoprobe adds a transverse scan at the tip of the probe to the anterior endoscopic view. This axial scan to the longitudinal axis of the endoscope is geometrically comparable with radar scanning. Three probes working with 10, 15, and 20 MHz were used, resulting in a short penetration with a radius of 3 cm. The orthogonal scanning plane had limitations, which were documented. We observed precise imaging of well known anatomic structures and, moreover, achieved an additional dimension in endoscopy. The axial scan presents the anatomic landmarks like a map at the tip of the endoscope where the endoscope is represented as a spot. The real-time imaging and representation of the tip of the endoscope showed a capacity for navigation. This preclinical study rectified clinical application. The real-time imaging of this technique showed the ability of the navigation of endoscopes to detect more overall movements, such as blood flow or change of ventricle size during endoscopy. The primary benefit in this first clinical series was witnessed in difficult endoscopy cases and complex lesions, but benefit was also observed in cases in which vision through the endoscope alone was obscured. The main limitation was the result of little penetration depth and lack of anterior scanning.

CONCLUSION

Application of transendoscopic ultrasound is appropriate in neurosurgery. Training is necessary to understand the imaging and the geometry of scans because this technique does not scan along the axis of the endoscope. Further development to overcome the current limits of this technique and more clinical experience are needed.

Endocrine evaluation after endoscopic third ventriculostomy (ETV) in children

OBJECTIVE

Endoscopic third ventriculostomy (ETV) is a standard procedure for the treatment of obstructive hydrocephalus in children. Main part of the procedure is the perforation of the third ventricle floor (tuber cinereum). This structure is part of the hypothalamic-pituitary neuronal network of cerebral endocrine regulation. There are no systematic data available about the endocrine status after ETV in children.

MATERIALS AND METHODS

We examined 20 children who had undergone ETV. Examination included laboratory tests (adrenocorticotropic hormone, prolactin, insulin-like growth factor 1 [IGF-1], IGF-binding protein 3 [IGFBP-3], fT3, fT4, thyroid-stimulating hormone [TSH], serum osmolarity, electrolytes, glucose, urea, follicle-stimulating hormone [FSH] and luteinizing hormone [LH], and testosterone in selected patients), measurement of weight, height, and head circumference, and physical examination. The study was approved by the Ethics Committee of the Medical Faculty of Kiel University.

RESULTS

In seven patients, prolactin was moderately elevated. One patient demonstrated a significantly increased prolactin (56.3 ng/ml). In all eight patients, this was the only laboratory value that was out of the normal range; all other parameters were normal. Three other patients showed one abnormal parameter (decrease in FSH and LH, increase in TSH, decrease in IGF-1 and IGFBP-3). In nine patients, weight or height was not within the 3rd to 97th centiles for age.

DISCUSSION AND CONCLUSION

More patients than expected demonstrated endocrine laboratory abnormalities. However, there was no clinical relevance in any of the studied patients. It remains inconclusive whether ETV contributes to the abnormalities of prolactin levels or to other endocrine parameters in pediatric patients. Longitudinal studies are necessary to delineate the effect of ETV on endocrine regulation.

Complications of third ventriculostomy

As experience with ETV grows, the procedure will be performed by an increasing number of neurosurgeons. Although the technique has been greatly refined since its advent almost a century ago, today's neurosurgeon must never forget that this seemingly simple procedure holds the potential for a number of devastating complications. Appropriate training and experience are important to the success of ETV and for avoiding complications It is imperative that surgeons continue to report their experience with the complications of ETV so that the procedure can continue to be made as safe as possible.

Ventriculostomy in a tumor involving the third ventricular floor

Recently, endoscopic management has gotten preference over open surgical treatment in selected cases of intraventricular tumors. Endoscopic third ventriculostomy (ETV) appears unfeasible when tumors extend to the third ventricular floor region due to the risk of perforators and injury to the basilar artery. We report the case of a 12-year-old male with symptoms of acute, chronic, raised intracranial pressure. Computed tomography (CT) and magnetic resonance imaging (MRI) showed a posterior third ventricular tumor involving the aqueductal and floor regions. The ETV was done after clearing the floor by partial tumor resection, keeping the dorsum sellae as the major anatomical landmark. The patient improved satisfactorily and was given adjuvant radiotherapy, and the need for an external shunt was completely eliminated. We conclude that ETV appears worth trying, even in third ventricular tumors involving the floor region if they can be cleared from the tumor keeping the dorsum sellae as the major anatomical landmark.

Endo-neuro-sonography: first clinical series (52 cases)

OBJECTIVE

A sono catheter for transendoscopic imaging was applied in neurosurgery for the first time in 52 patients with a broad variety of lesions.

METHODS

A transendoscopic sono catheter (Aloka Deutschland GmbH, Düsseldorf, Germany) with a diameter of 1.9 mm (6F) was used and introduced into the working canal of an endoscope. The image produced by the probe is a 360 degrees scan ("brain radar") displayed on a monitor, on which some parameters can be varied to get the best view of the different anatomical structures.

RESULTS

In 39 patients intraoperative imaging was the main reason for investigation and in 13 patients neuronavigation was the focus of interest. In 18 cases of tumor resection control targeting a visualized remnant was necessary. There are limitations and artifacts, which should reveal themselves in laboratory and clinical experience.

CONCLUSION

In this small series, endo-neuro-sonography proved to make neuroendoscopy safer and easier by online and real-time imaging with high resolution.

Resumption of luteinizing hormone pulsatility and hypogonadotropic hypogonadism after endoscopic ventriculocisternostomy in a hydrocephalic patient

OBJECTIVE

To study gonadotropin pulsatility before and after surgical cure of hydrocephalus.

DESIGN

Case report.

SETTING

Department of Endocrinology and Centre d'Investigations Cliniques, Necker Hospital, Paris, France.

PATIENT(S)

A 29-year-old woman who presented with secondary amenorrhea.

INTERVENTION(S)

The patient underwent an endoscopic ventriculocisternostomy that led to restoration of normal menses and resolution of hypogonadism.

MAIN OUTCOME MEASURE(S)

A gonadotropin pulse study was performed before and 2 and 5 months after surgery.

RESULT(S)

No LH pulse was observed before surgery. Emergence of pulsatility was observed 2 months after surgery, and pulses became clearly individualized after 5 months.

CONCLUSION(S)

This observation strongly suggests that amenorrhea, in case of chronic hydrocephalus, is indeed due to a hypothalamic dysfunction of the GnRH pulse generator.

Successful neuroendoscopic third ventriculostomy for hydrocephalus and syringomyelia associated with fourth ventricle outlet obstruction. Case report

The authors report the use of neuroendoscopic third ventriculostomy to treat successfully both hydrocephalus and syringomyelia associated with fourth ventricle outlet obstruction. A 27-year-old woman presented with dizziness, headache, and nausea. Magnetic resonance (MR) imaging demonstrated dilation of all ventricles, downward displacement of the third ventricular floor, obliteration of the retrocerebellar cerebrospinal fluid (CSF) space, funnellike enlargement of the entrance of the central canal in the fourth ventricle, and syringomyelia involving mainly the cervical spinal cord. Cine-MR imaging indicated patency of the aqueduct and an absent CSF flow signal in the area of the cistema magna, which indicated obstruction of the outlets of the fourth ventricle. Although results of radioisotope cisternography indicated failure of CSF absorption, neuroendoscopic third ventriculostomy completely resolved all symptoms as well as the ventricular and spinal cord abnormalities evident on MR images. Neuroendoscopic third ventriculostomy is an important option for treating hydrocephalus in patients with fourth ventricle outlet obstruction.

Endoscopic third ventriculostomy: outcome analysis of 100 consecutive procedures

OBJECTIVE

Endoscopic third ventriculostomy (ETV) has been shown to be a sufficient alternative in the surgical treatment of occlusive hydrocephalus. To elucidate the ongoing discussion of timing, indication, and surgical technique, a retrospective analysis of 100 consecutive ETVs was conducted.

METHODS

One hundred ETVs were performed in 95 patients (43 female and 52 male patients). Their age ranged from 3 weeks to 77 years (mean age, 36 yr). Hydrocephalus was caused by aqueductal stenosis in 40 patients, space-occupying lesions in 42, and intraventricular or subarachnoid hemorrhage in 8. One patient had postinflammatory hydrocephalus, and four patients had occlusive hydrocephalus of unknown origin. In 33 cases, surgery was performed using stereotactic guidance.

RESULTS

ETV was accomplished in 98 of 100 cases. The overall success rate was 76%. Patients with benign space-occupying lesions and nontumorous aqueductal stenosis had the highest success rates, which were 95 and 83%, respectively. Complications were arterial bleeding in one case, venous bleeding in three cases, intracerebral bleeding in one case, and infection in one case. There were no permanent morbidities or mortalities.

CONCLUSION

ETV is most effective in treating uncomplicated occlusive hydrocephalus caused by aqueductal stenosis and space-occupying lesions. ETV is still effective in two-thirds of the patients with previous infections or intraventricular bleeding. Patients who have previously undergone shunting and who have occlusive hydrocephalus should undergo ETV at the time of shunt failure, with immediate ligation or removal of the shunt device. In selected cases of distorted anatomy or impaired visual conditions, stereotactic guidance is helpful.