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Longatti P, Fiorindi A, Marton E, Sala F, Feletti A. Where the central canal begins: endoscopic in vivo description. J Neurosurg 2021; 136:895-904. [PMID: 34388726 DOI: 10.3171/2020.12.jns203649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 12/30/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Although evidence and descriptions of the central canal (CC) along the medulla oblongata and the spinal cord have been provided by several anatomical and radiological studies, a clear picture and assessment of the opening of the CC, or apertura canalis centralis (ACC), into the fourth ventricle is lacking, due to its submillimetric size and hidden position in the calamus scriptorius. METHODS The authors reviewed all of their cases in which patients underwent ventricular transaqueductal flexible endoscopic procedures and selected 44 cases in which an inspection of the region of the calamus scriptorius had been performed and was suitable for study inclusion. Patients were divided into different groups, based on the presence or absence of a chronic pathological process involving the fourth ventricle. In each case, the visual appearance of the opening of the CC of the ACC was classified as no evidence (A0), indirect evidence (A1), or clear evidence (A2). Morphometric measurements were inferred from surrounding structures and the size of surgical tools visible in the field. RESULTS The opening of the CC could be clearly observed in all cases (A1 4.5%, A2 95.5%). In normal cases, a lanceolate shape along the median sulcus was most frequently found, with an average size of 600 × 250 µm that became rounded and smaller in size in cases of hydrocephalus. The distance between the caudal margin of the ACC and the obex was about 1.8 mm in normal cases, 2.1 mm in cases of obstructive hydrocephalus, and 1 mm in cases of normal pressure hydrocephalus. The two wings of the area postrema, variable in size and shape, were sited just caudal to the opening. CONCLUSIONS A flexible scope inserted through the cerebral aqueduct can approach the hidden calamus scriptorius like a pen fits into an inkpot. With this privileged viewpoint, the authors provide for the first time, to their knowledge, a clear and novel vision of the opening of the CC in the fourth ventricle, along with the precise location of this tiny structure compared to other anatomical landmarks in the inferior triangle.
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Affiliation(s)
| | | | - Elisabetta Marton
- 3Neurosurgical Department, Treviso Regional Hospital-University of Padova, Treviso; and
| | - Francesco Sala
- 4Department of Neurosciences, Biomedicine, and Movement Sciences, Institute of Neurosurgery, University of Verona, Italy
| | - Alberto Feletti
- 4Department of Neurosciences, Biomedicine, and Movement Sciences, Institute of Neurosurgery, University of Verona, Italy
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Salem-Memou S, Amal T, Salihy SM, Soumare O, Najat B. Endoscopic Third Ventriculostomy in the Fourth Ventricle Outlet Obstruction Associated with Chiari Malformation Type I and Syringomyelia: Case Report. Asian J Neurosurg 2021; 16:170-173. [PMID: 34211888 PMCID: PMC8202361 DOI: 10.4103/ajns.ajns_67_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 05/05/2020] [Accepted: 08/04/2020] [Indexed: 11/06/2022] Open
Abstract
Hydrocephalus by the fourth ventricle outlet obstruction (FVOO) associated with a Chiari malformation type I and syringomyelia is a well-known entity but a rare situation in clinical practice. Although suboccipital craniectomy with the opening of the obstruction membrane appears to be the most physiological approach, by restoring the original pathway of cerebrospinal fluid flow, the endoscopic third ventriculostomy (ETV) represents an important minimally invasive alternative. We report the case of an adult patient with tetra ventricular hydrocephalus by FVOO associated with Chiari malformation and syringomyelia. The ETV alone completely resolved all symptoms, as well as neuroimaging abnormalities on the control magnetic resonance imaging. The ETV is a minimally invasive option for the treatment of hydrocephalus in patients with obstruction at the exit of the fourth ventricle, even in cases associated with Chiari malformation and syringomyelia.
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Affiliation(s)
- Sidi Salem-Memou
- Department of Neurosurgery, National Hospital Center, Nouakchott, Mauritania
| | - Tolba Amal
- Department of Neurosurgery, National Hospital Center, Nouakchott, Mauritania
| | - Sidi-Mohamed Salihy
- Department of Neurosurgery, National Hospital Center, Nouakchott, Mauritania
| | - Outouma Soumare
- Department of Neurosurgery, National Hospital Center, Nouakchott, Mauritania
| | - Boukhrissi Najat
- Department of Neurosurgery, National Hospital Center, Nouakchott, Mauritania
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Trapped fourth ventricle-treatment options and the role of open posterior fenestration in the surgical management. Acta Neurochir (Wien) 2020; 162:2441-2449. [PMID: 32337610 DOI: 10.1007/s00701-020-04352-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 04/14/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Trapped fourth ventricle (TFV) is a rare and difficult to treat condition. Most patients have a past inciting event (infection, IVH, trauma) and history of prior CSF diversion. The symptoms are due to the mass effect on brainstem and cerebellum. Rarely, TFV can also be associated with syrinx formation due to a dissociated craniospinal CSF flow near the fourth ventricle outlets. We present our experience and outcomes of open posterior fenestration in 11 cases, along with an overview of the surgical management of TFV. METHODS Between 2011 and 2018, 11 patients of TFV were operated by the posterior approach fenestration of the fourth ventricle outlets and arachnoid dissection. The clinical and radiological findings of the patients were retrieved from the hospital database. The surgical technique is described in detail. The patients' neurological status and imaging findings in the follow-up were recorded and compared. RESULTS The average age of the patients was 23.55 years. The most common presenting symptoms were headache (9/11) and gait imbalance (7), with TB meningitis being the commonest etiology. Ten patients had a history of prior CSF diversion with two presenting with shunt malfunction. Mean follow-up duration was 33.33 months. The improvement in neurological status was observed in 9/11 patients, 2 remained status quo. On follow-up imaging, 8/11 (72.72%) patients had a decrease in the size of TFV while syrinx improved in 3/5 (60%). CONCLUSION Multiple surgical approaches have been described for TFV. Endoscopic fourth ventriculostomy with aqueductoplasty is gaining popularity in the past two decades. However, an open posterior fenestration of the midline fourth ventricle outlet (magendieplasty) along with sharp arachnoid dissection (adhesiolysis) along the cerebello-medullary cisterns and paracervical gutters is relatively simple and provides physiological fourth ventricular CSF outflow. This is especially useful in TFV with syrinx as the craniospinal CSF circulation is established.
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Kawabata T, Takeuchi K, Nagata Y, Ishikawa T, Choo J, Wakabayashi T. Endoscopic Treatment Strategy for a Disproportionately Large Communicating Fourth Ventricle: Case Series and Literature Review. Neurol Med Chir (Tokyo) 2020; 60:351-359. [PMID: 32536656 PMCID: PMC7358780 DOI: 10.2176/nmc.oa.2019-0299] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
An isolated fourth ventricle (IFV) is characterized by fourth ventricular dilation due to obstruction of its inlet and outlet. A disproportionately large communicating fourth ventricle (DLCFV) is a rare subtype of IFV, characterized by dilation of the fourth ventricle, regardless of the size of the lateral ventricles, with no apparent obstruction of the cerebral aqueduct. To our knowledge, this is the first case series describing endoscopic diagnosis and treatment strategy for DLCFV. We retrospectively reviewed six cases of DLCFV in which endoscopic surgery was performed at our institution and affiliated facilities between June 2013 and March 2017. DLCFV was diagnosed using radiographic imaging and intraoperative endoscopy. We also conducted a PubMed search and included only original studies related to DLCFV treatment written in English in our review of the literature. Endoscopic third ventriculostomy (ETV) was performed in all patients. Additional endoscope-assisted placement of a fourth ventriculoperitoneal (VP) shunt was performed in two patients who could not be managed with ETV alone because of severe adhesion of the interpeduncular cistern due to subarachnoid hemorrhage (SAH). The patients' symptoms and the size of the fourth ventricle improved with surgical treatment, without complications. Endoscopic surgery for DLCFV appears to be a safe and effective treatment. Based on our treatment strategy, ETV is the first-line treatment for DLCFV. Endoscope-assisted placement of the fourth VP shunt can be treatment for severe adhesion of the interpeduncular cistern.
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Affiliation(s)
- Teppei Kawabata
- Department of Neurosurgery, Graduate School of Medicine, Nagoya University
| | - Kazuhito Takeuchi
- Department of Neurosurgery, Graduate School of Medicine, Nagoya University
| | - Yuichi Nagata
- Department of Neurosurgery, Graduate School of Medicine, Nagoya University
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Chowdhury FH, Haque MR, Rumi JUM, Arifin MS. Fourth Ventricular Outflow Obstruction in an Infant with Ileal Atresia and Laryngomalacia: Endoscopic Management. INDIAN JOURNAL OF NEUROSURGERY 2020. [DOI: 10.1055/s-0040-1710104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
AbstractFourth ventricle outflow obstruction (FVOO) is a rare cause of obstructive hydrocephalus. In this study, we described a case of idiopathic FVOO with ileal atresia and laryngomalacia which was managed with endoscopic third ventriculostomy (ETV) and re-endoscopy. We also described the techniques of fenestration of Liliequist membrane and partial removal of arachnoid membrane over dorsum sella (DS) to prevent closure of fenestration and recurrence of hydrocephalus. The patient was a 4-month-old infant presented with progressively increasing head size, feeding difficulty, respiratory distress, and tense fontanel. The infant had a history of laparotomy for ileal atresia. CT scan showed panventriculomegaly due to FVOO. ETV with fenestration of Liliequist membrane was done on emergency basis. After operation, the patient improved clinically and radiologically. Four weeks later, the patient returned with recurrent hydrocephalus. Endoscopic reoperation showed closure of fenestration in arachnoid membrane (Lilieqiest membrane). Endoscopic refenestration with partial excision of arachnoid on DS was done. The patient again recovered radiologically and clinically till last follow-up. In idiopathic FVOO, ETV with wide fenestration of Liliequist membrane, preferably with partial removal of arachnoid on DS, may be very useful in treating hydrocephalus (HCP) and preventing recurrent HCP even in infants.
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Affiliation(s)
- Forhad H. Chowdhury
- Department of Neurosurgery, National Institute of Neurosciences and Hospital, Dhaka, Bangladesh
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Orlando V, Spennato P, De Liso M, Trischitta V, Imperato A, Cinalli G. Fourth Ventricle Outlet Obstruction and Diverticular Enlargement of Luschka Foramina in a Child with Down Syndrome. Pediatr Neurosurg 2020; 55:359-362. [PMID: 33370726 DOI: 10.1159/000511088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 08/24/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Hydrocephalus is not usually part of Down syndrome (DS). Fourth ventricle outlet obstruction is a rare cause of obstructive hydrocephalus, difficult to diagnose, because tetraventricular dilatation may suggest a communicant/nonobstructive hydrocephalus. CASE PRESENTATION We describe the case of a 6-year-old boy with obstructive tetraventricular hydrocephalus, caused by Luschka and Magen-die foramina obstruction and diverticular enlargement of Luschka foramina (the so-called fourth ventricle outlet obstruction) associated with DS. He was treated with endoscopic third ventriculostomy (ETV) without complications, and a follow-up MRI revealed reduction of the ventricles, disappearance of the diverticula, and patency of the ventriculostomy. CONCLUSION Diverticular enlargement of Luschka foramina is an important radiological finding for obstructive tetraventricular hydrocephalus. ETV is a viable option in tetraventricular obstructive hydrocephalus in DS.
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Affiliation(s)
- Valentina Orlando
- Department of Neurosciences, Department of Neurosurgery, Santobono-Pausilipon Children's Hospital, Naples, Italy.,Department of Neurosciences, Reproductive and Odontostomatological Sciences, Division of Neurosurgery, University Federico II, Naples, Italy
| | - Pietro Spennato
- Department of Neurosciences, Department of Neurosurgery, Santobono-Pausilipon Children's Hospital, Naples, Italy,
| | - Maria De Liso
- Department of Neurosciences, Department of Neuroradiology, Santobono-Pausilipon Children's Hospital, Naples, Italy
| | - Vincenzo Trischitta
- Department of Neurosciences, Department of Neurosurgery, Santobono-Pausilipon Children's Hospital, Naples, Italy
| | - Alessia Imperato
- Department of Neurosciences, Department of Neurosurgery, Santobono-Pausilipon Children's Hospital, Naples, Italy
| | - Giuseppe Cinalli
- Department of Neurosciences, Department of Neurosurgery, Santobono-Pausilipon Children's Hospital, Naples, Italy
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Feletti A, Stanzani R, Alicandri-Ciufelli M, Giliberto G, Martinoni M, Pavesi G. Neuroendoscopic Aspiration of Blood Clots in the Cerebral Aqueduct and Third Ventricle During Posterior Fossa Surgery in the Prone Position. Oper Neurosurg (Hagerstown) 2019; 17:143-148. [PMID: 30496503 DOI: 10.1093/ons/opy324] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 09/22/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND During surgery in the posterior fossa in the prone position, blood can sometimes fill the surgical field, due both to the less efficient venous drainage compared to the sitting position and the horizontally positioned surgical field itself. In some cases, blood clots can wedge into the cerebral aqueduct and the third ventricle, and potentially cause acute hydrocephalus during the postoperative course. OBJECTIVE To illustrate a technique that can be used in these cases: the use of a flexible scope introduced through the opened roof of the fourth ventricle with a freehand technique allows the navigation of the fourth ventricle, the cerebral aqueduct, and the third ventricle in order to explore the cerebrospinal fluid pathways and eventually aspirate blood clots and surgical debris. METHODS We report on one patient affected by an ependymoma of the fourth ventricle, for whom we used a flexible neuroendoscope to explore and clear blood clots from the cerebral aqueduct and the third ventricle after the resection of the tumor in the prone position. Blood is aspirated with a syringe using the working channel of the scope as a sucker. RESULTS A large blood clot that was lying on the roof of the third ventricle was aspirated, setting the ventricle completely free. Other clots were aspirated from the right foramen of Monro and from the optic recess. CONCLUSION We describe this novel technique, which represents a safe and efficient way to clear the surgical field at the end of posterior fossa surgery in the prone position. The unusual endoscopic visual perspective and instrument maneuvers are easily handled with proper neuroendoscopic training.
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Affiliation(s)
- Alberto Feletti
- Department of Neurosciences, Neurosurgery Unit, Azienda Ospedaliero-Universitaria di Modena, Modena, Italy
| | - Riccardo Stanzani
- Department of Neurosciences, Neurosurgery Unit, Azienda Ospedaliero-Universitaria di Modena, Modena, Italy
| | - Matteo Alicandri-Ciufelli
- Department of Neurosciences, Neurosurgery Unit, Azienda Ospedaliero-Universitaria di Modena, Modena, Italy
| | - Giuliano Giliberto
- Department of Neurosciences, Neurosurgery Unit, Azienda Ospedaliero-Universitaria di Modena, Modena, Italy
| | - Matteo Martinoni
- IRCCS Institute of Neurological Sciences of Bologna, Division of Neurosurgery, Bellaria Hospital, Bologna, Italy
| | - Giacomo Pavesi
- Department of Neurosciences, Neurosurgery Unit, Azienda Ospedaliero-Universitaria di Modena, Modena, Italy
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Electromagnetic navigation-guided neuroendoscopic transfrontal transaqueductal fenestration of expansive posterior fossa arachnoid cyst with simultaneous endoscopic third ventriculostomy in an infant. Childs Nerv Syst 2018; 34:2309-2312. [PMID: 29846773 DOI: 10.1007/s00381-018-3847-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 05/21/2018] [Indexed: 10/16/2022]
Abstract
INTRODUCTION We present an infant with an expansive posterior fossa arachnoid cyst and severe clinical deterioration due to decompensated obstructive hydrocephalus. Given the dilated Sylvius aqueduct, we favoured the endoscopic transfrontal transaqueductal route to approach the cyst. CASE REPORT A 12-month-old boy was acutely admitted for severe symptoms of intracranial hypertension. Imaging revealed spacious cystic formation in the posterior fossa with expansive behaviour towards the brain stem, fourth ventricle and cerebellum associated with obstructive triventricular hydrocephalus. The patient underwent electromagnetically navigated transfrontal transaqueductal cyst fenestration with simultaneous ETV from two precoronal trajectories with a rigid endoscope. CONCLUSION A transaqueductal approach with a rigid endoscope is rarely published, and we were amazed by the impact on the child's clinical improvement after this minimally invasive endoscopic procedure. The case is well documented with imaging and perioperative neuroendoscopic views.
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Barany L, Baksa G, Patonay L, Racz G, Ganslandt O, Buchfelder M, Kurucz P. Primary Obstruction of the Foramen of Luschka: Anatomy, Histology, and Clinical Significance. World Neurosurg 2018; 112:e288-e297. [PMID: 29339320 DOI: 10.1016/j.wneu.2018.01.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Revised: 01/03/2018] [Accepted: 01/05/2018] [Indexed: 10/18/2022]
Abstract
BACKGROUND The foramen of Luschka is a natural aperture between the fourth ventricle and the subarachnoid space at the cerebellopontine angle. Membranous closure of this foramen is referred to as primary obstruction. Available information about this variant and its role in the development of the cysts of the posterior fossa is contradictory. METHODS The macroscopic and histologic features of the obstructed foramina were examined in 61 formalin-fixed human brains (122 foramina). Three rhomboid lips of various sizes with lateral recess were used for comparison. Five postoperative cases of diverticulum of the foramen of Luschka were included in this study, with 1 case presented in detail to illustrate anatomic and histologic findings. RESULTS Primary obstruction was present in 11 of 122 cases. In 1 case, an enlarged rigid pouch with a thick wall was found. The wall of the membrane in primary obstruction and the rhomboid lip were composed of an inner ependymal, a middle glial, and an outer leptomeningeal layer. CONCLUSIONS The rhomboid lip is a remnant of the roof of the fourth ventricle. Imperforation of the foramen of Luschka results in a pouch in the cerebellopontine angle that contains choroid plexus (Bochdalek's flower basket) and communicates with the fourth ventricle. This pouch has the potential to grow to a diverticulum and cause clinical symptoms. Based on our clinical observations, detailed radiologic and surgical-anatomic criteria were proposed to support the differential diagnosis of a diverticulum of the foramen of Luschka. Treatment strategies were also suggested.
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Affiliation(s)
- Laszlo Barany
- Laboratory for Applied and Clinical Anatomy, Department of Anatomy, Histology and Embryology, Semmelweis University, Budapest, Hungary.
| | - Gabor Baksa
- Laboratory for Applied and Clinical Anatomy, Department of Anatomy, Histology and Embryology, Semmelweis University, Budapest, Hungary
| | - Lajos Patonay
- Laboratory for Applied and Clinical Anatomy, Department of Anatomy, Histology and Embryology, Semmelweis University, Budapest, Hungary
| | - Gergely Racz
- 1(st) Department of Pathology and Experimental Cancer Research, Semmelweis University, Budapest, Hungary
| | - Oliver Ganslandt
- Department of Neurosurgery, Klinikum Stuttgart, Stuttgart, Germany
| | - Michael Buchfelder
- Department of Neurosurgery, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - Peter Kurucz
- Department of Neurosurgery, Klinikum Stuttgart, Stuttgart, Germany; Department of Neurosurgery, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
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Shimoda Y, Murakami K, Narita N, Tominaga T. Fourth Ventricle Outlet Obstruction with Expanding Space on the Surface of Cerebellum. World Neurosurg 2017; 100:711.e1-711.e5. [PMID: 28153613 DOI: 10.1016/j.wneu.2017.01.088] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Revised: 01/19/2017] [Accepted: 01/23/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND Hydrocephalus is classified as noncommunicating and communicating based on whether all ventricular and subarachnoid spaces are communicating. Although the diagnosis between the two different states is crucial, it is difficult in certain conditions. In particular, communicating hydrocephalus and noncommunicating hydrocephalus owing to fourth ventricle outlet obstruction are highly misdiagnosed. We describe a case of fourth ventricle outlet obstruction of unknown origin that was initially misdiagnosed as communicating hydrocephalus. CASE DESCRIPTION A 66-year-old woman with gait disturbance and incontinence caused by hydrocephalus underwent ventriculoperitoneal shunt surgery. After 9 months, her fourth ventricle became enlarged and could not be controlled by lowering the shunt pressure. Magnetic resonance imaging (MRI) demonstrated obstruction at the foramen of Magendie, foramina of Luschka, and the cerebral aqueduct. Endoscopic surgery for aqueduct plasty with third ventriculostomy was planned. Because the aqueduct was observed to open spontaneously, only the standard third ventriculostomy was performed. When MRI findings were reviewed retrospectively, an unnatural space was observed between the lower cranial nerves and cerebellar hemisphere that grew along with the fourth ventricular enlargement. This space was determined by MRI cisternography to be the cystic membrane ballooning out from the foramen of Luschka. The primary hydrocephalus likely resulted from fourth ventricle outlet obstruction. CONCLUSIONS Enlargement of the whole ventricular system with an expanded space between the lower cranial nerves and cerebellar hemisphere can be caused by fourth ventricle outlet obstruction. In such cases, preoperative evaluation of anatomic architecture and cerebrospinal fluid obstruction using MRI cisternography is essential and leads to a successful endoscopic strategy.
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Affiliation(s)
- Yoshiteru Shimoda
- Department of Neurosurgery, Kesen-numa City Hospital, Miyagi, Japan; Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan.
| | - Kensuke Murakami
- Department of Neurosurgery, Sendai Medical Center, Sendai, Japan
| | - Norio Narita
- Department of Neurosurgery, Kesen-numa City Hospital, Miyagi, Japan
| | - Teiji Tominaga
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
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Kent M, Glass EN, Haley AC, Shaikh LS, Sequel M, Blas-Machado U, Bishop TM, Holmes SP, Platt SR. Hydrocephalus secondary to obstruction of the lateral apertures in two dogs. Aust Vet J 2016; 94:415-422. [PMID: 27785804 DOI: 10.1111/avj.12510] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2015] [Revised: 01/24/2016] [Accepted: 01/27/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Traditionally, hydrocephalus is divided into communicating or non-communicating (obstructive) based on the identification of a blockage of cerebrospinal fluid (CSF) flow through the ventricular system. Hydrocephalus ex vacuo refers to ventricular enlargement as a consequence of neuroparenchymal loss. Hydrocephalus related to obstruction of the lateral apertures of the fourth ventricles has rarely been described. CASE REPORT The clinicopathologic findings in two dogs with hydrocephalus secondary to obstruction of the lateral apertures of the fourth ventricle are reported. Signs were associated with a caudal cervical spinal cord lesion in one dog and a caudal brain stem lesion in the other dog. Magnetic resonance imaging (MRI) disclosed dilation of the ventricular system, including the lateral recesses of the fourth ventricle. In one dog, postmortem ventriculography confirmed obstruction of the lateral apertures. Microscopic changes were identified in the choroid plexus in both dogs, yet a definitive cause of the obstructions was not identified. The MRI findings in both dogs are similar to membranous occlusion of the lateral and median apertures in human patients. CONCLUSION MRI detection of dilation of the entire ventricular system in the absence of an identifiable cause should prompt consideration of an obstruction of the lateral apertures. In future cases, therapeutic interventions aimed at re-establishing CSF flow or ventriculoperitoneal catheterisation should be considered.
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Affiliation(s)
- M Kent
- University of Georgia, Department of Small Animal Medicine and Surgery, Athens, Georgia, USA.
| | - E N Glass
- Red Bank Veterinary Hospital, Tinton Falls, New Jersey, USA
| | - A C Haley
- University of Georgia, Department of Small Animal Medicine and Surgery, Athens, Georgia, USA
| | - L S Shaikh
- University of Georgia, Veterinary Biosciences and Diagnostic imaging, Athens, GA, USA
| | - M Sequel
- University of Georgia, Department of Pathology, Athens, GA, USA
| | - U Blas-Machado
- Athens Veterinary Diagnostic Laboratory, University of Georgia, Athens, GA, USA
| | - T M Bishop
- Upstate Veterinary Specialists, Latham, New York, USA
| | - S P Holmes
- University of Georgia, Veterinary Biosciences and Diagnostic imaging, Athens, GA, USA
| | - S R Platt
- University of Georgia, Department of Small Animal Medicine and Surgery, Athens, Georgia, USA
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Feletti A, Alicandri-Ciufelli M, Pavesi G. If it can be done, it should be done,… or not? Response to Prof. Grotenhuis. Acta Neurochir (Wien) 2016; 158:1203-4. [PMID: 27107765 DOI: 10.1007/s00701-016-2814-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2016] [Accepted: 04/13/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Alberto Feletti
- Unit of Neurosurgery, Department of Neurosciences, NOCSAE Modena Hospital, Modena, Italy.
| | | | - Giacomo Pavesi
- Unit of Neurosurgery, Department of Neurosciences, NOCSAE Modena Hospital, Modena, Italy
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13
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Feletti A, Alicandri-Ciufelli M, Pavesi G. Transaqueductal trans-Magendie fenestration of arachnoid cyst in the posterior fossa. Acta Neurochir (Wien) 2016; 158:655-662. [PMID: 26883551 DOI: 10.1007/s00701-016-2734-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Accepted: 02/02/2016] [Indexed: 11/24/2022]
Abstract
BACKGROUND Neuroendoscopy is currently recommended as the first choice to treat posterior fossa arachnoid cysts. It has proven to be effective, providing improved outcome, and safe, having a low complication rate. Compared to craniotomy and shunt placement, it has lower surgical morbidity, minimizing or avoiding risks of subdural fluid collections, shunt infection, malfunction, overdrainage, and dependence. Usually, rigid scopes maneuvered through a suboccipital approach are used. When symptomatic obstructive hydrocephalus develops, CSF diversion is the first aim of surgery. METHODS In these patients, a flexible scope introduced through a frontal burr hole allows not only immediate and efficient management of hydrocephalus with endoscopic third-ventriculostomy, but in selected cases also direct cyst inspection and fenestration. Navigation of an enlarged cerebral aqueduct is actually safe when performed by experienced neurosurgeons. RESULTS We describe the cystocisternostomy of a cisterna magna arachnoid cyst using a transaqueductal trans-Magendie approach. CONCLUSIONS This minimally invasive technique gives the possibility of performing both endoscopic third-ventriculostomy and cyst fenestration, which alone may not be enough to efficiently treat hydrocephalus.
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Affiliation(s)
- Alberto Feletti
- Unit of Neurosurgery, Department of Neurosciences, NOCSAE Modena Hospital, Via Giardini 1355, 41126, Baggiovara (MO), Italy.
| | - Matteo Alicandri-Ciufelli
- Unit of Neurosurgery, Department of Neurosciences, NOCSAE Modena Hospital, Via Giardini 1355, 41126, Baggiovara (MO), Italy
| | - Giacomo Pavesi
- Unit of Neurosurgery, Department of Neurosciences, NOCSAE Modena Hospital, Via Giardini 1355, 41126, Baggiovara (MO), Italy
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Feletti A, Fiorindi A, Longatti P. Split cerebral aqueduct: a neuroendoscopic illustration. Childs Nerv Syst 2016; 32:199-203. [PMID: 26231565 DOI: 10.1007/s00381-015-2827-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Accepted: 07/09/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE Forking of the cerebral aqueduct is a developmental malformation that is infrequently encountered by neurosurgeons as a rare cause of hydrocephalus, sometimes with a delayed onset. The etiology of an apparently forked aqueduct might be different. However, neuroendoscopy can often be the optimal treatment. The purpose of this study was to review the literature by analyzing the anatomical, functional, diagnostic, and therapeutic features of this unusual condition and adding our personal cases. METHODS We present a case of forking of the cerebral aqueduct that was detected in vivo and treated with a flexible scope. A thorough review of the pertinent literature is also discussed. In the past years, diagnosis of forked aqueduct was possible only postmortem. RESULTS A forked aqueduct is occasionally encountered in patients when a delayed hydrocephalic decompensation occurs. CONCLUSIONS Flexible neuroendoscopy enables for a direct, in vivo diagnosis and immediate treatment through a third ventriculostomy.
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Affiliation(s)
- Alberto Feletti
- Neurosurgery Unit, Department of Neurosciences, NOCSAE Modena Hospital, Via Giardini 1355, 41126, Baggiovara, Modena, Italy.
| | - Alessandro Fiorindi
- Department of Neurosurgery, Treviso Hospital-University of Padova, Treviso, Italy
| | - Pierluigi Longatti
- Department of Neurosurgery, Treviso Hospital-University of Padova, Treviso, Italy
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Ishi Y, Asaoka K, Kobayashi H, Motegi H, Sugiyama T, Yokoyama Y, Echizenya S, Itamoto K. Idiopathic fourth ventricle outlet obstruction successfully treated by endoscopic third ventriculostomy: a case report. SPRINGERPLUS 2015; 4:565. [PMID: 26543700 PMCID: PMC4627988 DOI: 10.1186/s40064-015-1368-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Accepted: 09/22/2015] [Indexed: 11/30/2022]
Abstract
Introduction Fourth ventricle outlet obstruction (FVOO) is a rare cause of obstructive hydrocephalus. We describe a case of idiopathic FVOO that was successfully treated with endoscopic third ventriculostomy (ETV). Case report A 3-year old boy without any remarkable medical history presented with a headache and vomiting. Computed tomography (CT) images, which had incidentally been taken 2 years previously due to a minor head injury, showed no abnormality. Magnetic resonance imaging on admission showed tetra-ventricular hydrocephalus associated with the dilatation of the fourth ventricle outlets, without any obstructive lesions. However, CT ventriculography, involving contrast medium injection through a ventricular catheter, suggested mechanical obstruction of the cerebrospinal fluid (CSF) at the fourth ventricle outlets. Thus, the patient was diagnosed with FVOO and ETV was performed; the hydrocephalus was subsequently resolved. Although hydrocephalus recurred 1 year postoperatively, re-ETV for the highly stenosed fenestration successfully resolved this condition. Conclusions ETV should be considered for FVOO treatment, particularly in idiopathic cases without CSF malabsorption.
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Affiliation(s)
- Yukitomo Ishi
- Department of Neurosurgery, Teine Keijinkai Hospital, 1-40, Maeda 1-12, Teine-ku, Sapporo, 006-8555 Japan ; Department of Neurosurgery, Hokkaido University Graduate School of Medicine, North 15 West 7, Kita-ku, Sapporo, 060-8638 Japan
| | - Katsuyuki Asaoka
- Department of Neurosurgery, Teine Keijinkai Hospital, 1-40, Maeda 1-12, Teine-ku, Sapporo, 006-8555 Japan
| | - Hiroyuki Kobayashi
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, North 15 West 7, Kita-ku, Sapporo, 060-8638 Japan
| | - Hiroaki Motegi
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, North 15 West 7, Kita-ku, Sapporo, 060-8638 Japan
| | - Taku Sugiyama
- Department of Neurosurgery, Teine Keijinkai Hospital, 1-40, Maeda 1-12, Teine-ku, Sapporo, 006-8555 Japan
| | - Yuka Yokoyama
- Department of Neurosurgery, Teine Keijinkai Hospital, 1-40, Maeda 1-12, Teine-ku, Sapporo, 006-8555 Japan
| | - Sumire Echizenya
- Department of Neurosurgery, Teine Keijinkai Hospital, 1-40, Maeda 1-12, Teine-ku, Sapporo, 006-8555 Japan
| | - Koji Itamoto
- Department of Neurosurgery, Teine Keijinkai Hospital, 1-40, Maeda 1-12, Teine-ku, Sapporo, 006-8555 Japan
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Orakdogen M, Emon ST, Erdogan B, Somay H. Fourth Ventriculostomy in Occlusion of the Foramen of Magendie Associated with Chiari Malformation and Syringomyelia. NMC Case Rep J 2015; 2:72-75. [PMID: 28663969 PMCID: PMC5364914 DOI: 10.2176/nmccrj.2014-0245] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Accepted: 09/08/2014] [Indexed: 11/20/2022] Open
Abstract
We present four cases of hydrocephalus caused by occlusion of foramen of Magendie associated with Chiari Type I malformation and syringomyelia. The aim of this study is to evaluate the results of surgical treatment via fourth ventriculostomy with catheter from the fourth ventricle to the upper cervical subarachnoid space. Obstructive tetraventricular hydrocephalus due to occlusion of the foramina of Luschka and Magendie can be treated with cerebrospinal fluid shunting, opening the membranes with suboccipital craniotomy, placement of a catheter, endoscopic third ventriculostomy, and endoscopic fourth ventriculostomy. Our aim was to solve all the pathologies such as Chiari malformation, hydrocephalus, and syringomyelia in one approach. Thus, the treatment consisted of posterior fossa decompression and exploration. All the patients were treated with suboccipital craniectomy and C1 laminectomy with excision of the membrane obstructing the foramen of Magendie. Fourth ventriculostomy with cathetering from fourth ventricle to upper cervical subarachnoid space was performed. The postoperative period was uneventful in all the patients. Neurological status of all the patients improved. Tetraventricular hydrocephalus and syrinx were reduced in the control cranial magnetic resonance imaging. Complications such as infection and catheter migration were not observed during the follow-up period. Treatment with fourth ventriculostomy using a catheter from fourth ventricle to upper cervical subarachnoid space could be a treatment of choice in cases with hydrocephalus caused by occlusion of the foramina of Magendie, with associated Chiari Type I malformation and syringomyelia.
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Affiliation(s)
- Metin Orakdogen
- Department of Neurosurgery, Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey
| | - Selin Tural Emon
- Department of Neurosurgery, Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey
| | - Baris Erdogan
- Department of Neurosurgery, Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey
| | - Hakan Somay
- Department of Neurosurgery, Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey
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Longatti P, Porzionato A, Basaldella L, Fiorindi A, De Caro P, Feletti A. The human area postrema: clear-cut silhouette and variations shown in vivo. J Neurosurg 2015; 122:989-95. [PMID: 25594320 DOI: 10.3171/2014.11.jns14482] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECT The human area postrema (AP) is a circumventricular organ that has only been described in cadaveric specimens and animals. Because of its position in the calamus scriptorius and the absence of surface markers on the floor of the fourth ventricle, the AP cannot be clearly localized during surgical procedures. METHODS The authors intravenously administered 500 mg fluorescein sodium to 25 patients during neuroendoscopic procedures; in 12 of these patients they explored the fourth ventricle. A flexible endoscope equipped with dual observation modes for both white light and fluorescence was used. The intraoperative fluorescent images were reviewed and compared with anatomical specimens and 3D reconstructions. RESULTS Because the blood-brain barrier does not cover the AP, it was visualized in all cases after fluorescein sodium injection. The AP is seen as 2 coupled leaves on the floor of the fourth ventricle, diverging from the canalis centralis medullaris upward. Although the leaves normally appear short and thick, there can be different morphological patterns. Exploration using the endoscope's fluorescent mode allowed precise localization of the AP in all cases. CONCLUSIONS Fluorescence-enhanced inspection of the fourth ventricle accurately identifies the position of the AP, which is an important landmark during surgical procedures on the brainstem. A better understanding of the AP can also be valuable for neurologists, considering its functional role in the regulation of homeostasis, emesis, and cardiovascular and electrolyte balance. Despite the limited number of cases in this report, evidence indicates that the normal anatomical appearance of the AP is that of 2 short and thick leaves that are joined at the midline. However, there can be great variability in terms of the structure's shape and size.
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Orakdogen M, Emon ST, Erdogan B, Somay H. Fourth Ventriculostomy in Occlusion of the Foramen of Magendie Associated with Chiari Malformation and Syringomyelia. NMC Case Rep J 2015. [DOI: 10.2176/nmccrj.cr.2014-0245] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Torres-Corzo J, Sánchez-Rodríguez J, Cervantes D, Rodríguez-Della Vecchia R, Muruato-Araiza F, Hwang SW, Rangel-Castilla L. Endoscopic Transventricular Transaqueductal Magendie and Luschka Foraminoplasty for Hydrocephalus. Neurosurgery 2013; 74:426-35; discussion 436. [DOI: 10.1227/neu.0000000000000283] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
ABSTRACT
BACKGROUND:
Routinely, hydrocephalus related to fourth ventricular outlet obstruction (FVOO) has been managed with ventriculoperitoneal (VP) shunting or endoscopic third ventriculostomy (ETV). Few reports on Magendie foraminoplasty exist, and Luschka foraminoplasty has not been described.
OBJECTIVE:
To present an alternative technique in the management of FVOO via an endoscopic transventricular transaqueductal Magendie and Luschka foraminoplasty and to discuss the indications, technique, findings, and outcomes.
METHODS:
Between 1994 and 2011, all patients who underwent endoscopic Magendie and Luschka foraminoplasty were analyzed.
RESULTS:
A total of 33 Magendie (28) and/or Luschka (5) foraminoplasties were performed in 30 patients. Twenty-three were adult and 7 were pediatric patients. The etiology of the FVOO was divided into primary etiologies (congenital membrane in 5 and atresia in 2) and secondary causes (neurocysticercosis in 14 patients, bacterial meningitis in 9). Fifteen (50%) had previously failed procedures. Intraoperative findings that led to Magendie/Luschka foraminoplasty were ETV not feasible to perform, nonpatent basal subarachnoid space, or primary FVOO. Minor postoperative complications were seen in 3 patients. Only 26 patients had long-term follow-up; 17 (65.3%) of these had clinical improvement and did not require further procedures. Nine (34.7%) did not improve. Eight required another procedure (7 shunts, and 1 endoscopic procedure). One patient died.
CONCLUSION:
Flexible neuroendoscopic transventricular transforaminal Magendie and Luschka foraminoplasty is feasible and safe. These procedures may prove to be viable alternatives to standard ETV and VP shunt in appropriate patients. Adequate intraoperative assessment of ETV success is necessary to identify patients who will benefit.
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Affiliation(s)
- Jaime Torres-Corzo
- Department of Neurosurgery, Hospital Central, University of San Luis Potosi and School of Medicine, San Luis Potosi, Mexico
| | - Juan Sánchez-Rodríguez
- Department of Neurosurgery, Hospital Central, University of San Luis Potosi and School of Medicine, San Luis Potosi, Mexico
| | - Dominic Cervantes
- Department of Neurosurgery, Hospital Central, University of San Luis Potosi and School of Medicine, San Luis Potosi, Mexico
| | | | - Fernando Muruato-Araiza
- Department of Neurosurgery, Hospital Central, University of San Luis Potosi and School of Medicine, San Luis Potosi, Mexico
| | - Steven W. Hwang
- Department of Neurosurgery, Tufts Medical Center and Floating Hospital for Children, Boston, Massachusetts
| | - Leonardo Rangel-Castilla
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
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Matys T, Horsburgh A, Kirollos RW, Massoud TF. The aqueduct of Sylvius: applied 3-T magnetic resonance imaging anatomy and morphometry with neuroendoscopic relevance. Neurosurgery 2013; 73:ons132-40; discussion ons140. [PMID: 23615083 DOI: 10.1227/01.neu.0000430286.08552.ca] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The aqueduct of Sylvius (AqSylv) is a structure of increasing importance in neuroendoscopic procedures. However, there is currently no clear and adequate description of the normal anatomy of the AqSylv. OBJECTIVE To study in detail hitherto unavailable normal magnetic resonance imaging morphometry and anatomic variants of the AqSylv. METHODS We retrospectively studied normal midsagittal T1-weighted 3-T magnetic resonance images in 100 patients. We measured widths of the AqSylv pars anterior, ampulla, and pars posterior; its narrowest point; and its length. We recorded angulation of the AqSylv relative to the third ventricle as multiple deviations of the long axis of the AqSylv from the Talairach bicommissural line. We statistically determined age- and sex-related changes in AqSylv morphometry using the Pearson correlation coefficient. We measured angulation of the AqSylv relative to the fourth ventricle and correlated this to the cervicomedullary angle (a surrogate for head position). RESULTS Patients were 13 to 83 years of age (45% male, 55% female). Mean morphometrics were as follows: pars anterior width, 1.1 mm; ampulla width, 1.2 mm; pars posterior width, 1.4 mm; length, 14.1 mm; narrowest point, 0.9 mm; and angulation in relation to the third and fourth ventricles, 26° and 18°, respectively. Age correlated positively with width and negatively with length of the AqSylv. There was no correlation between AqSylv alignment relative to the foramen magnum and the cervicomedullary angle. CONCLUSION Normative dimensions of the AqSylv in vivo are at variance with published cadaveric morphometrics. The AqSylv widens and shortens with cerebral involution. Awareness of these normal morphometrics is highly useful when stent placement is an option during aqueductoplasty. Reported data are valuable in guiding neuroendoscopic management of hydrocephalus and aqueductal stenosis.
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Affiliation(s)
- Tomasz Matys
- *Section of Neuroradiology; and ‡Department of Neurosurgery, Addenbrooke's Hospital, Cambridge, United Kingdom; §Department of Radiology, University of Cambridge, Cambridge, United Kingdom
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Salma A, Yeremeyeva E, Baidya NB, Sayers MP, Ammirati M. An endoscopic, cadaveric analysis of the roof of the fourth ventricle. J Clin Neurosci 2013; 20:710-4. [PMID: 23507044 DOI: 10.1016/j.jocn.2012.05.051] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2012] [Revised: 05/06/2012] [Accepted: 05/12/2012] [Indexed: 10/27/2022]
Abstract
We performed endoscopic dissections of the roof of the fourth ventricle in eight fresh human cadaveric heads to characterize the endoscopic anatomy of the roof of the fourth ventricle and the anatomical configuration of the structures forming its roof. We also made three-dimensional (3D) silicone casts of the fourth ventricle in seven formalin-fixed specimens to evaluate the 3D configuration of the structures that create the roof of the fourth ventricle. The roof of the fourth ventricle can be divided into three zones. The upper zone is formed by the superior cerebellar peduncle and superior medullary velum and is associated with the lingula. The middle zone is formed by the inferior cerebellar peduncles and inferior medullary velum and is associated with the nodule in the midline and with the peduncle of the flocculus. The lower zone is formed by the tela choroidea and is associated with the tonsils. The 3D shape of the roof the fourth ventricle resembles that of a rhomboid-based pyramid; the edges of the base represent the borders of the ventricle, and the apex is the cerebellar fastigium. The lateral recess is shaped like a triangular-based pyramid, with its base connected to the cavity of the fourth ventricle and its tip opening into the lateral cerebellomedullary cistern through the foramen of Luschka. Our results may help in the endoscopic exploration of and microsurgical approaches to the fourth ventricle through its roof.
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Affiliation(s)
- Asem Salma
- Department of Neurological Surgery, The Ohio State University Medical Center, The Ohio State University, N1025 Doan Hall, 410 West 10th Avenue, Columbus, OH 43210, USA
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Neuroendoscopy in the Youngest Age Group. World Neurosurg 2013; 79:S23.e1-11. [DOI: 10.1016/j.wneu.2012.02.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2011] [Accepted: 02/02/2012] [Indexed: 12/13/2022]
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Ferrer E, de Notaris M. Third Ventriculostomy and Fourth Ventricle Outlets Obstruction. World Neurosurg 2013; 79:S20.e9-13. [DOI: 10.1016/j.wneu.2012.02.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2011] [Accepted: 02/02/2012] [Indexed: 10/14/2022]
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Longatti P, Basaldella L, Sammartino F, Boaro A, Fiorindi A. Fluorescein-Enhanced Characterization of Additional Anatomical Landmarks in Cerebral Ventricular Endoscopy. Neurosurgery 2013; 72:855-60. [DOI: 10.1227/neu.0b013e3182889e27] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Fluorescein enhancement to detect retinal disorder or differentiate cancer tissue in situ is a well-defined diagnostic procedure. It is a visible marker of where the blood-brain barrier is absent or disrupted. Little is reported in the contemporary literature on endoscopic fluorescein-enhanced visualization of the circumventricular organs, and the relevance of these structures as additional markers for safe ventricular endoscopic navigation remains an unexplored field.
OBJECTIVE:
To describe fluorescein sodium–enhanced visualization of circumventricular organs as additional anatomic landmarks during endoscopic ventricular surgery procedures.
METHODS:
We prospectively administered intravenously 500 mg fluorescein sodium in 12 consecutive endoscopic surgery patients. A flexible endoscope equipped with dual observation modes for both white light and fluorescence was used. During navigation from the lateral to the fourth ventricle, the endoscopic anatomic landmarks were first inspected under white light and then under the fluorescent mode.
RESULTS:
After a mean of 20 seconds in the fluorescent mode, the fluorescein enhanced visualization of the choroid plexus of the lateral ventricle, median eminence–tuber cinereum complex, organum vasculosum of the lamina terminalis, choroid plexus of the third and fourth ventricles, and area postrema.
CONCLUSION:
Fluorescein-enhanced visualization is a useful tool for helping neuroendoscopists recognize endoscopic anatomic landmarks. It could be adopted to guide orientation when the surgeon deems an endoscopic procedure unsafe or contraindicated because of unclear or subverted anatomic landmarks. Visualization of the circumventricular organs could add new insight into the functional anatomy of these structures, with possible implications for the site and safety of third ventriculostomy.
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Affiliation(s)
- Pierluigi Longatti
- Department of Neurosurgery, Treviso Regional Hospital, University of Padova, Treviso, Italy
| | - Luca Basaldella
- Department of Neurosurgery, Treviso Regional Hospital, University of Padova, Treviso, Italy
| | - Francesco Sammartino
- Department of Neurosurgery, Treviso Regional Hospital, University of Padova, Treviso, Italy
| | - Alessandro Boaro
- Department of Neurosurgery, Treviso Regional Hospital, University of Padova, Treviso, Italy
| | - Alessandro Fiorindi
- Department of Neurosurgery, Treviso Regional Hospital, University of Padova, Treviso, Italy
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Endoscopic septostomy through a standard precoronal ventricular access: feasibility and effectiveness. Acta Neurochir (Wien) 2012; 154:1517-22. [PMID: 22588340 DOI: 10.1007/s00701-012-1381-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2012] [Accepted: 05/01/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND Although endoscopic septostomy is widely adopted in the treatment of unilateral or specific types of hydrocephalus, there is no consensus on surgical indications, technical aspects and postoperative outcome. In particular, the choice of the ventricular access has been recently debated. We investigated the results of endoscopic septostomy performed through a standard precoronal ventricular access using a rigid endoscope. METHODS Patients who underwent an endoscopic septostomy at our Institution from March 2001 to March 2011 were retrospectively identified. Clinico-radiological data and video recordings of the endoscopic procedures were reviewed. RESULTS Sixty-three patients (50 children and 13 adults) were collected. In adults, the obstruction of the cerebrospinal fluid (CSF) pathway was exclusively secondary to a tumor (neoplastic or pseudoneoplastic lesion). In the pediatric group hydrocephalus was most commonly due to a neoplasm (33 out of 50 patients), post-hemorrhagic and/or post-infectious hydrocephalus affecting 11 children and malformative hydrocephalus the remaining six children. We were able to perform the septostomy in all but two patients, presenting with a scarred multilayered septum secondary to post-hemorrhagic hydrocephalus. In 37 cases, one or more other endoscopic procedures were performed contemporarily. The mean follow-up was 24 months (min-max: 5-96 months). Overall, all but one patient benefited clinically and radiologically from the endoscopic septostomy. Two patients harboring a pineal/mesencephalic tumor experienced a late obstruction of the stoma secondary to neoplastic infiltration of the septum. CONCLUSIONS Endoscopic septostomy can be safely performed through a standard burr-hole. The effectiveness of this approach is testified by an early success rate of more than 95% and a long term success rate of 92%.
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Neuronavigational neuroendoscopy--to be or not to be? An international pilot questionnaire-based study. World Neurosurg 2012; 79:S16.e15-21. [PMID: 22381837 DOI: 10.1016/j.wneu.2012.02.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2011] [Accepted: 02/03/2012] [Indexed: 11/23/2022]
Abstract
OBJECTIVE The almost age-old neuroendoscopy (NE) and neuronavigation (NN) in its twenties independently and indisputably have proved their high value as neurosurgical armamentarium and became even indispensable in some pathologies. However, nowadays the effectiveness of their simultaneous and combined application still is a matter of debate. The purpose of our pilot international, questionnaire-based survey was to assess the position of the opinion leaders in the field of neuroendoscopy worldwide toward the neuronavigational neuroendoscopy (NNNE). METHODS Within 3 months, a questionnaire with 17 questions was emailed repeatedly to 55 leading academic neuroendoscopic neurosurgeons from 50 institutions in 24 countries. The questionnaire covered aspects of personal and institutional experience in NE, NN, and NNNE, the most frequently treated pathologies by NNNE as well as inquiring the neurosurgeons' opinion for the importance and future of NNNE. RESULTS Forty-one questionnaires were returned (response rate = 74.6%). Six questionnaires were excluded because of incomplete or incorrect answers, leaving in the survey 35 respondents from 35 institutions in 18 countries. The less experienced neurosurgeons rely in higher degree on NNNE. Most frequently, NNNE is performed for hydrocephalus (procedures other than third ventriculostomy), transsphenoidal surgery, tumor biopsy, and cyst fenestration. Regardless their neurosurgical and NE experience, more than 75% of the respondents state that NNNE extends the range of neuroendoscopic procedures in their neurosurgical departments. CONCLUSION NNNE represents a valuable operative technique with excellent future prospects. NNNE extends the range of neuroendoscopic procedures, transforming some number of patients from "nonoperable" neuroendoscopically to suitable for neuroendoscopy.
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Rohde V, Behm T, Ludwig H, Wachter D. The role of neuronavigation in intracranial endoscopic procedures. Neurosurg Rev 2011; 35:351-8. [PMID: 22170178 PMCID: PMC3375008 DOI: 10.1007/s10143-011-0369-7] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2011] [Revised: 06/06/2011] [Accepted: 10/08/2011] [Indexed: 11/25/2022]
Abstract
In occlusive hydrocephalus, cysts and some ventricular tumours, neuroendoscopy has replaced shunt operations and microsurgery. There is an ongoing discussion if neuronavigation should routinely accompany neuroendoscopy or if its use should be limited to selected cases. In this prospective clinical series, the role of neuronavigation during intracranial endoscopic procedures was investigated. In 126 consecutive endoscopic procedures (endoscopic third ventriculostomy, ETV, n = 65; tumour biopsy/resection, n = 36; non-tumourous cyst fenestration, n = 23; abscess aspiration and hematoma removal, n = 1 each), performed in 121 patients, neuronavigation was made available. After operation and videotape review, the surgeon had to categorize the role of neuronavigation: not beneficial; beneficial, but not essential; essential. Overall, neuronavigation was of value in more than 50% of the operations, but its value depended on the type of the procedure. Neuronavigation was beneficial, but not essential in 16 ETVs (24.6%), 19 tumour biopsies/resections (52.7%) and 14 cyst fenestrations (60.9%). Neuronavigation was essential in 1 ETV (2%), 11 tumour biopsies/resections (30.6%) and 8 cyst fenestrations (34.8%). Neuronavigation was not needed/not used in 48 ETVs (73.9%), 6 endoscopic tumour operations (16.7%) and 1 cyst fenestration (4.3%). For ETV, neuronavigation mostly is not required. In the majority of the remaining endoscopic procedures, however, neuronavigation is at least beneficial. This finding suggests integrating neuronavigation into the operative routine in endoscopic tumour operations and cyst fenestrations.
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Affiliation(s)
- Veit Rohde
- Department of Neurosurgery, University of Aachen, Aachen, Germany.
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Giannetti AV, Malheiros JA, da Silva MC. Fourth ventriculostomy: an alternative treatment for hydrocephalus due to atresia of the Magendie and Luschka foramina. J Neurosurg Pediatr 2011; 7:152-6. [PMID: 21284460 DOI: 10.3171/2010.11.peds1080] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Atresia of the foramina of Magendie and Luschka is a rare cause of obstructive hydrocephalus. Although this condition has been classically treated by CSF shunting, recent treatments have also included endoscopic third ventriculostomy. In the present study, the authors present the case of a patient with hydrocephalus in whom an alternative method was used following a CSF shunt malfunction. A young female patient in whom a shunt was placed during the patient's 1st year of life was faring well until she was 8 years old. She was admitted to the emergency department 5 times with signs of CSF shunt malfunction. Each time, the CT scan showed a slight dilation of the lateral and third ventricles and a large increase in the size of the fourth ventricle. In comparison, ventricles were smaller in a previous imaging study obtained when the patient was asymptomatic. Magnetic resonance imaging showed the same slight dilation of all the ventricles and a significant increase in the fourth ventricle. There was no aqueductal stenosis. An important enlargement of both lateral recesses of the fourth ventricle suggested the possibility of an atresia of the foramina. The foramen of Monro and the width of the third ventricle would not allow the passage of an endoscope. The decision was made to open those foramina endoscopically through the fourth ventricle. After induction of general anesthesia, with the patient in the prone position, a bur hole was made in the left paramedian and suboccipital region. The endoscope was introduced underneath the cerebellar hemisphere. The authors were then able to distinguish the floor of the fourth ventricle and other anatomical landmarks. Navigation through the lateral recesses allowed them to see the fine membranes closing the foramina. These membranes were opened with a monopolar cautery as a blunt instrument. The orifice was then enlarged with a 3 Fr Fogarty catheter. The authors also opened a bulging thin membrane located at the foramen of Magendie. During the postoperative period, the authors observed a marked improvement in the state of the patient's alertness as well as a disappearance of her headaches and cessation of vomiting. In addition, the patient's gait ataxia improved slowly. Six-month postoperative MR imaging demonstrated an unequivocal reduction in the size of the fourth ventricle. The patient was still doing well 36 months after the surgery. Endoscopic fourth ventriculostomy, the opening of the 3 foramina of the fourth ventricle, may be an alternative treatment in cases in which these structures are congenitally closed.
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Guillaume DJ. Minimally invasive neurosurgery for cerebrospinal fluid disorders. Neurosurg Clin N Am 2010; 21:653-72, vii. [PMID: 20947034 DOI: 10.1016/j.nec.2010.07.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
This article focuses on minimally invasive approaches used to address disorders of cerebrospinal fluid (CSF) circulation. The author covers the primary CSF disorders that are amenable to minimally invasive treatment, including aqueductal stenosis, fourth ventricular outlet obstruction (including Chiari malformation), isolated lateral ventricle, isolated fourth ventricle, multiloculated hydrocephalus, arachnoid cysts, and tumors that block CSF flow. General approaches to evaluating disorders of CSF circulation, including detailed imaging studies, are discussed. Approaches to minimally invasive management of such disorders are described in general, and for each specific entity. For each procedure, indications, surgical technique, and known outcomes are detailed. Specific complications as well as strategies for their avoidance and management are addressed. Lastly, future directions and the need for structured outcome studies are discussed.
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Affiliation(s)
- Daniel J Guillaume
- Department of Neurosurgery, Oregon Health & Science University, Portland, OR 97239, USA.
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Cecchetto G, Feletti A, Montisci M, Fais P, Cecchetto A, Viel G. Fatal drowning accident and undiagnosed hydrocephalus. J Forensic Sci 2010; 55:826-9. [PMID: 20345777 DOI: 10.1111/j.1556-4029.2010.01355.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Bodies found in water present several diagnostic challenges for the forensic examiner, such as the identification of the time and mechanism of death, the postmortem submersion time, and above all the circumstances of drowning. We report the case of a 33-year-old security guard found dead in Venice, in the water of the lagoon, who at autopsy presented a previously undiagnosed hydrocephalus with macrocephaly. The victim remained asymptomatic until 2 months before death and had never undergone a neurological or radiological examination. In the article, we emphasize the need to perform a thorough autopsy in all suspected drownings, discuss the etiopathogenesis of the neurological disease and hypothesize a possible relationship between the hydrocephalus and the drowning accident. Finally, we discuss the major clinical and forensic implications of macrocephaly and hydrocephalus in adults.
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Affiliation(s)
- Giovanni Cecchetto
- Department of Environmental Medicine and Public Health, Legal Medicine, University of Padua, Via Falloppio 50, 35121 Padova, Italy
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Longatti P, Fiorindi A, Martinuzzi A, Feletti A. PRIMARY OBSTRUCTION OF THE FOURTH VENTRICLE OUTLETS. Neurosurgery 2009; 65:1078-85; discussion 1085-6. [PMID: 19934967 DOI: 10.1227/01.neu.0000360133.29217.44] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Abstract
OBJECTIVE
Primary obstruction of the foramina of Magendie and Luschka is an uncommon and still unclear cause of noncommunicating hydrocephalus. The aim of this work is the description, for the first time, of the inner aspect of these velar obstructions of the fourth ventricle outlets and the demonstration of the efficacy of neuroendoscopic treatment.
METHODS
Of 240 hydrocephalic patients treated in our institution with endoscopic third ventriculostomy, a subgroup of 10 cases with closure of the fourth ventricular outlets without associated Chiari malformation and syringomyelia was selected. In all of these cases, a transaqueductal endoscopic navigation of the fourth ventricle was performed, and the obstructed outlets were inspected. All of the clinical data and, in particular, the videotape records of endoscopic operations, as well as the cine-magnetic resonance imaging scans, were reviewed to evaluate their patency status.
RESULTS
Various degrees of stenosis were found endoscopically: restriction of the Magendie contour with thick and opaque membrane, transparent spider web-like membrane, and dense membrane with fissures acting as valves. Endoscopic third ventriculostomy was effective in almost all patients, although we noticed an unforeseen high incidence of closure of the stoma. The restored normal cerebrospinal fluid flux after ventriculocisternostomy and magendieplasty was demonstrated by comparative study of cerebrospinal fluid flow measurements by cine-magnetic resonance imaging.
CONCLUSION
This report demonstrates the effectiveness of neuroendoscopic third ventriculostomy as well as magendiestomy in cases of tetraventricular hydrocephalus attributable to primary obstruction of the outlets of the fourth ventricle and, for the first time, presents direct images of various types of outlet obstructive pathology.
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Affiliation(s)
- Pierluigi Longatti
- Department of Neurosurgery, Treviso Hospital, University of Padova, Padova, Italy
| | - Alessandro Fiorindi
- Department of Neurosurgery, Treviso Hospital, University of Padova, Padova, Italy
| | - Andrea Martinuzzi
- “E. Medea” Scientific Institute, Conegliano Research Centre, Conegliano, Italy
| | - Alberto Feletti
- Department of Neurosurgery, Treviso Hospital, University of Padova, Padova, Italy
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Dinçer A, Kohan S, Ozek MM. Is all "communicating" hydrocephalus really communicating? Prospective study on the value of 3D-constructive interference in steady state sequence at 3T. AJNR Am J Neuroradiol 2009; 30:1898-906. [PMID: 19643921 DOI: 10.3174/ajnr.a1726] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE 3D-constructive interference in steady state (3D-CISS) sequence has been used to assess the CSF pathways. The aim of this study was to investigate the additive value of 3D-CISS compared with conventional sequences in the diagnosis of obstructive membranes in hydrocephalus. MATERIALS AND METHODS A total of 134 patients with hydrocephalus underwent MR imaging examination with a 3T unit consisting of turbo spin-echo, 3D-CISS, and cine phase-contrast (cine PC) sequences. 3D-CISS was used to assess obstructive membranes in CSF pathways compared with other sequences. Cine PC, follow-up imaging, and surgical findings were used to confirm obstructive membranes. RESULTS Comparing the number of noncommunicating cases by using the conventional and 3D-CISS images, we found 26 new cases (19.4%) of 134 cases that were previously misdiagnosed as communicating hydrocephalus by conventional images. 3D-CISS sequence identified obstructive membranes invisible in other sequences, which facilitated selection of neuroendoscopy in the treatment of 31 patients (23.1%) in total who would have been otherwise treated with shunt insertion. These patients included 26 newly diagnosed noncommunicating cases after demonstration of intraventricular and/or fourth ventricular outlet membranes and 5 cases of communicating hydrocephalus with obstructing cisternal membranes. There were obstructions of the foramina of Luschka in 22 of 26 newly found noncommunicating cases. CONCLUSIONS Conventional sequences are insensitive to obstructive membranes in CSF pathways, especially in the fourth ventricular exit foramina and the basal cisterns. 3D-CISS sequence, revealing these obstructive membranes, can alter patient treatment and prognosis.
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Affiliation(s)
- A Dinçer
- Acibadem University, School of Medicine, Department of Radiology, Istanbul, Turkey.
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Mohanty A, Biswas A, Satish S, Vollmer DG. EFFICACY OF ENDOSCOPIC THIRD VENTRICULOSTOMY IN FOURTH VENTRICULAR OUTLET OBSTRUCTION. Neurosurgery 2008; 63:905-13; discussion 913-4. [PMID: 19005381 DOI: 10.1227/01.neu.0000333262.38548.e1] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Aaron Mohanty
- Division of Neurosurgery, University of Texas Medical Branch at Galveston, Galveston, Texas
| | - Arundhati Biswas
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Satyanarayana Satish
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Dennis G. Vollmer
- Department of Neurosurgery, University of Texas Health Sciences Center, Houston, Texas
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Abstract
OBJECTIVE This article demonstrates that a newly developed videoscope for use in neurosurgery is effective for patients with lesions in their ventricles, cisterns, and intraparenchyma. METHODS Neuroendoscopy was performed on 13 patients using a videoscope system with narrow-band imaging technology. RESULTS The results showed that the new videoscope was far superior to conventional fiberscopes in terms of visual quality and ease of manipulation. Observation of subependymal blood vessels, which had been difficult with fiberscopes, was possible with the videoscope. Furthermore, the videoscope was capable of producing enhanced images of capillary blood vessels under the ependymal layer space if used in conjunction with narrow-band imaging technology. CONCLUSION This videoscope will be effective in avoiding capillary vessel injuries during neuroendoscopic procedures. It will also contribute to the future development of neuroendoscopy.
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Affiliation(s)
- Kazunari Oka
- Department of Neurosurgery, Satte General Hospital, Saitama, Japan.
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Longatti P, Fiorindi A, Feletti A, D'Avella D, Martinuzzi A. Endoscopic anatomy of the fourth ventricle. J Neurosurg 2008; 109:530-5. [DOI: 10.3171/jns/2008/109/9/0530] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Microsurgical anatomy of the fourth ventricle has been comprehensively addressed by masterly reports providing classic descriptions of this complex region. Neuroendoscopy could offer a new, somewhat different perspective of the “inside” view of the fourth ventricle. The purpose of this study was to examine from the anatomical point of view the access to the fourth ventricle achieved by the endoscopic transaqueductal approach, to enumerate and describe the anatomically identifiable landmarks, and to compare them with those described during microsurgery.
Methods
The video recordings of 52 of 75 endoscopic explorations of the fourth ventricle performed at the authors' institution for different pathological conditions were reviewed and evaluated to identify and describe every anatomical landmark. According to the microsurgical anatomy, at least 23 superficial structures are clearly identifiable in the fourth ventricle, and they represent the comparative basis of parallel endoscopic anatomy of the structures found during the fourth ventricle navigation.
Results
The following anatomical structures were identified in all cases: median sulcus, superior and inferior vela medullare, choroid plexus, inferior fovea, hypoglossal and vagal triangles, area postrema, obex, canalis medullaris, lateral recess, and the foramina of Luschka and Magendie. The median eminence, facial colliculus, striae medullaris, auditory tubercle, and inferior fovea were seen in the majority of cases. The locus caevruleus could never be seen.
Conclusions
On the whole, 20 anatomical structures could consistently be identified by exploring the fourth ventricle with a fiberscope. Neuroendoscopy offers a quite different outlook on the anatomy of the fourth ventricle, and compared with the microsurgical descriptions it seems to provide a superior and detailed visualization, particularly of the structures located in the inferior triangle.
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Affiliation(s)
| | | | | | | | - Andrea Martinuzzi
- 3“E. Medea” Scientific Institute, Conegliano Research Centre, Conegliano, Italy
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