Endoscopic third ventriculostomy

Therapy management and outcome of acute hydrocephalus secondary to intraventricular hemorrhage in adults

BACKGROUND

Intraventricular hemorrhage (IVH) refers to bleeding within the brain's ventricular system, and hydrocephalus is a life-threatening complication of IVH characterized by increased cerebrospinal fluid accumulation in the ventricles resulting in elevated intracranial pressure. IVH poses significant challenges for healthcare providers due to the complexity of the underlying pathophysiology and lack of standardized treatment guidelines. Herein, we performed a systematic review of the treatment strategies for hydrocephalus secondary to IVH.

METHODS

This systematic review was prospectively registered with PROSPERO (CRD42023450786). The search was conducted in PubMed, Cochrane Library, and Web of Science on July 15, 2023. We included original studies containing valid information on therapy management and outcome of hydrocephalus secondary to primary, spontaneous, and subarachnoid or intracranial hemorrhage following IVH in adults that were published between 2000 and 2023. Glasgow Outcome Scale (GOS) or modified Ranking Scale (mRS) scores during follow-up were extracted as primary outcomes. The risk of bias was assessed using the Newcastle-Ottawa Scale for Cohort Studies or Cochrane Risk of Bias 2.0 Tool.

RESULTS

Two hundred and seven patients from nine published papers, including two randomized controlled trials, were included in the analysis. The GOS was used in five studies, while the mRS was used in four. Seven interventions were applied, including craniotomy for removal of hematoma, endoscopic removal of hematoma with/without endoscopic third ventriculostomy (ETV), traditional external ventricular drainage (EVD), and various combinations of EVD, lumbar drainage (LD), and intraventricular fibrinolysis (IVF). Endoscopic removal of hematoma was performed in five of nine studies. Traditional EVD had no obvious benefit compared with new management strategies. Three different combinations of EVD, LD, and IVF demonstrated satisfactory outcomes, although more studies are required to confirm their reliability. Removal of hematoma through craniotomy generated reliable result. Generally, endoscopic removal of hematoma with ETV, removal of hematoma through craniotomy, EVD with IVF, and EVD with early continuous LD were useful.

CONCLUSION

EVD is still crucial for the management of IVH and hydrocephalus. Despite a more reliable result from the removal of hematoma through craniotomy, a trend toward endoscopic approach was observed due to a less invasive profile.

Endoscopic Ventriculocysternostomy, Magendie Foraminoplasty, and Plexusectomy With Craniovertebral Shunt Placement in a Pediatric Patient With Hydrocephalus and VACTERL Association: A Novel Treatment Option

Endoscopic third ventriculocysternostomy (ETV) is a minimally invasive neurosurgical technique with good results in the treatment of obstructive hydrocephalus. The VACTERL (vertebrae, anorectal, cardiovascular, tracheal, esophageal, renal, limb defects) association, or VATER syndrome, is defined as congenital malformations, mostly derived from the mesoderm, affecting specific areas. It is diagnosed by the presence of at least three of the seven characteristic malformations that describe it. The association of this pathology and obstructive hydrocephalus in pediatric age is not common, making management and conventional neurosurgical procedures difficult due to the number of underlying pathologies. In this study, we report the management of hydrocephalus and VACTERL association with multiple congenital malformations in a 30-day-old premature neonate (birth at 29 weeks). Operations performed prior to admission to our service included: coloesophagoplasty and placement of esophagostoma in the left anterior cervical region, perineal anorectoplasty, gastrostomy and placement of sigmoidostomy in the left anterior abdominal wall, relaparotomy, gastric suture, sanitation, and abdominal drainage. Upon admission, the patient showed a Grade 3 intraventricular hemorrhage and internal occlusive hydrocephalus due to circulatory blockage of the cerebrospinal fluid (CSF) at the level of the outlet of the fourth ventricle. This was accompanied by intracranial hypertension and refractory cervical syringomyelia. We performed endoscopic ventriculocysternostomy plus plexusectomy plus Magendie foraminoplasty with craniovertebral shunt placement, achieving excellent results after two interventions. This is the first case described in the literature placing a craniovertebral shunt using a lateral-ventricle-to-the-subarachnoid-spinal-space-stenting technique in a patient with VACTERL association, which represents an innovation in the field of minimally invasive pediatric neurosurgery.

Endoscopic third ventriculostomy in hydrocephalus patients with functioning ventriculoperitoneal shunts: challenging the dictum that shunts treat all types of hydrocephalus. Patient series

BACKGROUND

Although ventriculoperitoneal shunting is standard for hydrocephalus, shunting may not be ideal for aqueductal stenosis. A cohort of patients with aqueductal stenosis displayed symptoms of over- and underdrainage, despite a patent ventriculoperitoneal shunt (VPS) and optimized valve settings. Endoscopic third ventriculostomies (ETVs) were performed in a subset of these patients with successful treatment of their underlying hydrocephalus, despite a functioning shunt.

OBSERVATIONS

All patients who had undergone ETV with a history of ventriculoperitoneal shunting were retrospectively reviewed. Patients experiencing over- or underdrainage symptoms despite a patent shunt were included. Cerebral aqueduct anatomy and third ventricle bowing were reviewed on preoperative imaging. Seven patients met the study criteria. All showed cerebral aqueductal stenosis and third ventricle bowing. After ETV, all patients demonstrated decreased third ventricle bowing and clinical improvement without the need for secondary cerebrospinal fluid (CSF) diversion.

LESSONS

Despite a functioning VPS, patients with aqueductal stenosis may not be adequately treated. The underlying reasons are not clearly understood but suggest abnormal CSF dynamics due to aberrant parenchymal compliance. The authors theorize that ETV can more effectively treat these patients. ETV can be considered a viable treatment option in aqueductal stenosis despite a patent VPS, challenging the traditional teaching that shunts ideally treat all types of hydrocephalus.

Pediatric and adult meningeal, parenchymal, and spinal tuberculosis: A neuroimaging review

Neurotuberculosis is defined as a tuberculous infection of the meninges, brain parenchyma, vessels, cranial and spinal nerves, spinal cord, skull, and spine that can occur either in a localized or in a diffuse form. It is a heterogeneous disease characterized by many imaging appearances and it has been defined as "the great mimicker" due to similarities with many other conditions. The diagnosis of central nervous system (CNS) tuberculosis (TB) is based on clinical presentation, neuroimaging findings, laboratory and microbiological findings, and comprehensive evaluation of the response to anti-TB drug treatment. However, the absence of specific symptoms, the wide spectrum of neurological manifestations, the myriad of imaging findings, possible inconclusive laboratory results, and the paradoxical reaction to treatment make the diagnosis often challenging and difficult, potentially delaying adequate treatment with possible devastating short-term and long-term neurologic sequelae. Familiarity with the imaging characteristics helps in accurate diagnosis and may prevent or limit significantly morbidity and mortality. The goal of this review is to provide a comprehensive up-to-date overview of the conventional and advanced imaging features of CNS TB for radiologists, neuroradiologists, and pediatric radiologists. We discuss the most typical neurotuberculosis imaging findings and their differential diagnosis in children and adults with the goal to provide a global overview of this entity.

Dorsum Sellae as Key Landmark in ETV With Disminished Prepontine Cistern: Technical Note and Case Series

BACKGROUND AND OBJECTIVES

One of the key aspects in the surgical technique of endoscopic third ventriculostomy (ETV) is the perforation of the floor of the third ventricle because of the high risk of injuring vital structures located in that region. According to the standard technique, this perforation should be performed in the midline halfway between mammillary bodies and the infundibular recess to avoid damage to the structures. This can be performed without excessive complications when the diameter of the prepontine cistern is wide. However, in situations where the diameter is reduced (defined in the literature as having a prepontine interval [PPI] ≤1 mm), the probability of complications increases exponentially.In this article, we propose using dorsum sellae as a key point to safely perform ETV in patients with a decreased PPI, guiding the trajectory and its marking using neuronavigation.

METHODS

A review was conducted on the latest 100 ETV procedures performed by our team in the past 5 years. The measurement of the PPI was conducted using archived preoperative MRI imaging studies, specifically between the dorsum sellae and the basilar artery. In cases where the PPI was ≤1 mm and, therefore, the use of the dorsum sellae was applied as a reference point, the technical results and procedural functions were documented.

RESULTS

In the cohort, 7 patients with a PPI ≤1 mm were identified. In all 7 cases, fenestration of the tuber cinereum was successfully performed without causing vascular damage or associated complications. ETV was successful in 6 patients, with only one experiencing ETV failure necessitating the placement of a ventriculoperitoneal shunt.

CONCLUSION

The utilization of the dorsum sellae as a reference point to perform ETV in reduced PPI constitutes a safe alternative to the classical technique.

Dandy-Walker Syndrome: Delayed Acute Presentation With Unusual Symptoms

Dandy-Walker syndrome (DWS) is a rare congenital brain malformation defined by the presence of an expanded posterior fossa, full or partial absence of the cerebellar vermis, and a cystic expansion of the fourth ventricle. We report an 18-month-old girl with DWS presenting with atypical clinical manifestations and unusual symptoms. She initially presented with persistent vomiting and abdominal pain for four days, not responding to antiemetic medication. In addition, she was found to have abnormal postural arching of the back, extension of the lower limbs, and neck extension. MRI and CT head suggested Dandy-Walker syndrome with hydrocephalus (the lateral ventricle, third ventricle, and fourth ventricle are all significantly dilated with evidence of trans-ependymal cerebrospinal fluid permeation, severe compression anterior displacement of the brain stem). The patient underwent urgent, lifesaving right sub-occipital craniotomy, evacuation, and decompression of the posterior fossa cyst and external ventricular drain (EVD) insertion along with left supra-tentorial EVD insertion. A series of brain magnetic imaging and CT brain post-procedure studies showed a significant reduction in the size of the ventricular system and mass effect on the brain stem.

Ventricular CSF proteomic profiles and predictors of surgical treatment outcome in chronic hydrocephalus

BACKGROUND

By applying an unbiased proteomic approach, we aimed to search for cerebrospinal fluid (CSF) protein biomarkers distinguishing between obstructive and communicating hydrocephalus in order to improve appropriate surgical selection for endoscopic third ventriculostomy vs. shunt implants. Our second study purpose was to look for potential CSF biomarkers distinguishing between patients with adult chronic hydrocephalus benefitting from surgery (responders) vs. those who did not (non-responders).

METHODS

Ventricular CSF samples were collected from 62 patients with communicating hydrocephalus and 28 patients with obstructive hydrocephalus. CSF was collected in relation to the patients' surgical treatment. As a control group, CSF was collected from ten patients with unruptured aneurysm undergoing preventive surgery (vascular clipping).

RESULTS

Mass spectrometry-based proteomic analysis of the samples identified 1251 unique proteins. No proteins differed significantly between the communicating hydrocephalus group and the obstructive hydrocephalus group. Four proteins were found to be significantly less abundant in CSF from communicating hydrocephalus patients compared to control subjects. A PCA plot revealed similar proteomic CSF profiles of obstructive and communicating hydrocephalus and control samples. For obstructive hydrocephalus, ten proteins were found to predict responders from non-responders.

CONCLUSION

Here, we show that the proteomic profile of ventricular CSF from patients with hydrocephalus differs slightly from control subjects. Furthermore, we find ten predictors of response to surgical outcome (endoscopic third ventriculostomy or ventriculo-peritoneal shunt) in patients with obstructive hydrocephalus.

The Neuro-Ophthalmology of Tuberculosis

Tuberculosis (TB) is a global health concern and central nervous system (CNS) TB leads to high mortality and morbidity. CNS TB can manifest as tubercular meningitis, tuberculoma, myelitis, and arachnoiditis. Neuro-ophthalmological involvement by TB can lead to permanent blindness, ocular nerve palsies and gaze restriction. Visual impairment is a dreaded complication of tubercular meningitis (TBM), which can result from visual pathway involvement at different levels with varying pathogenesis. Efferent pathway involvement includes cranial nerve palsies and disorders of gaze. The purpose of this review is to outline the various neuro-ophthalmological manifestations of TB along with a description of their unique pathogenesis and management. Optochiasmatic arachnoiditis and tuberculomas are the most common causes of vision loss followed by chronic papilloedema. Abducens nerve palsy is the most commonly seen ocular nerve palsy in TBM. Gaze palsies with deficits in saccades and pursuits can occur due to brainstem tuberculomas. Corticosteroids are the cornerstone in the management of paradoxical reactions, but other immunomodulators such as thalidomide and infliximab are being explored. Toxic optic neuropathy caused by ethambutol necessitates careful monitoring and immediate drug discontinuation. Cerebrospinal fluid diversion through ventriculo-peritoneal shunting may be required in patients with hydrocephalus in stage I and II of TBM to prevent visual impairment. Early diagnosis and prompt management are crucial to prevent permanent disability. Prevention strategies, public health initiatives, regular follow-up and timely intervention are essential in reducing the burden of CNS TB and its neuro-ophthalmological complications.

Posttraumatic hydrocephalus: Recent advances and new therapeutic strategies

Background

Hydrocephalus or ventriculomegaly is a condition brought on by an overabundance of cerebrospinal fluid (CSF) in the ventricular system. The major contributor to posttraumatic hydrocephalus (PTH) is traumatic brain injuries (TBIs), especially in individuals with occupations set in industrial settings. A variety of criteria have been employed for the diagnosis of PTH, including the combination of neurological symptoms like nerve deficits and headache, as well as an initial improvement followed by a worsened relapse of altered consciousness and neurological deterioration, which is detected by computed tomography-brain imaging that reveals gradual ventriculomegaly.

Aim

In this article, we discuss and summarize briefly the current understandings and advancements in the management of PTH.

Methods

The available literature for this review was searched on various bibliographic databases using an individually verified, prespecified approach. The level of evidence of the included studies was considered as per the Centre for Evidence-Based Medicine recommendations.

Results

The commonly practiced current treatment modality involves shunting CSF but is often associated with complications and recurrence. The lack of a definitive management strategy for PTH warrants the utilization of novel and innovative modalities such as stem cell transplantations and antioxidative stress therapies.

Conclusion

One of the worst complications of a TBI is PTH, which has a high morbidity and mortality rate. Even though there hasn't been a successful method in stopping PTH from happening, hemorrhage-derived blood, and its metabolic by-products, like iron, hemoglobin, free radicals, thrombin, and red blood cells, may be potential targets for PTH hindrance and management. Also, using stem cell transplantations in animal models and antioxidative stress therapies in future studies can lower PTH occurrence and improve its outcome. Moreover, the integration of clinical trials and theoretical knowledge should be encouraged in future research projects to establish effective and updated management guidelines for PTH.

The Efficacy of Endoscopic Third Ventriculostomy for Idiopathic Normal Pressure Hydrocephalus

Recently, intervention with endoscopic third ventriculostomy (ETV) for patients with idiopathic normal pressure hydrocephalus (iNPH) has emerged as a potential minimally invasive alternative to traditional treatments (ventriculoperitoneal shunting). The clinical response to these interventions is variable and unclear. The objective of this review was to assess the efficacy of endoscopic third ventriculostomy in treating patients with iNPH. A systematic review of PubMed, Web of Science, and Google Scholar was conducted using search terms relevant to ETV and iNPH. Included studies met consistent, predetermined diagnostic criteria for iNPH, implemented ETV in subjects greater than 40 years of age, and assessed all 3 components of Hakim's triad (gait impairment, dementia, and incontinence). Data extraction included dichotomization of successful ETV clinical outcomes and a subgroup meta-analysis of ETV success rates across binarized age groups. Meta-analysis was conducted using a Mantel-Haenszel fixed-effects model. The outcomes presented include generalized ETV success rates across all 12 studies. Age-specific individual data was measured with odds ratios, with a pooled statistic measured using the Mantel-Haenszel test. Overall, 2294 studies were identified in this search, of which 12 were selected for inclusion in this systematic review. Of these, 3 studies were utilized for age-specific meta-analyses. Preliminary synthesis of ETV clinical outcomes across all 12 studies revealed a success rate of 60.2%. Additionally, meta-analysis revealed that iNPH patients younger than or equal to 65 years of age were significantly more likely to respond successfully to ETV intervention. Heterogeneity was inconsequential in this analysis.

Robot-assisted endoscopic third ventriculostomy under intraoperative CT imaging guidance

BACKGROUND

The robot-assisted neurosurgical procedures have recently benefited of the evolution of intraoperative imaging, including mobile CT unit available in the operating room. This facilitated use paved the way to perform more neurosurgical procedures under robotic assistance. Endoscopic third ventriculocisternostomy requires both a safe transcortical trajectory and a smooth manipulation.

METHOD

We describe our technique of robot-assisted endoscopic third ventriculocisternostomy combining robotic assistance and intraoperative CT imaging.

CONCLUSION

Robot-assisted endoscopic third ventriculocisternostomy using modern intraoperative neuroimaging can be easily implemented and prevented erroneous trajectory and abrupt endoscopic movements, reducing surgically induced brain damages.

Right Transcephalic Ventriculo-Subclavian Shunt in the Surgical Treatment of Hydrocephalus-An Original Procedure for Drainage of Cerebrospinal Fluid into the Venous System

The objectives of this article are to present an original surgical procedure for the temporary or definitive resolution of hydrocephalus, in the case of repeated failure of standard treatment techniques, and to present a case that was resolved using this surgical technique.

MATERIALS AND METHODS

We present the case of a 20-year-old male patient with congenital hydrocephalus who underwent a number of 39 shunt revisions, given the repetitive dysfunctions of various techniques (ventriculo-peritoneal shunt, ventriculo-cardiac shunt). The patient was evaluated with the ventricular catheter externalized at the distal end and it was necessary to find an emergency surgical solution, considering the imminent risk of meningitis. The patient was also associated with the diagnosis of acute lithiasic cholecystitis.

RESULTS AND DISCUSSIONS

The final chosen solution, right ventriculo-venous drainage using the cephalic vein, was a temporary surgical solution, but there are signs that this procedure can provide long-term ventricular drainage.

CONCLUSIONS

Transcephalic ventriculo-subclavian drainage represents an alternative technical option, which can be used when established options become ineffective.

Endoscopic third ventriculostomy for management of hydrocephalus associated with Chiari malformation type II in children

BACKGROUND

Hydrocephalus is commonly associated with Chiari malformation (CM) particularly CM type II. The traditional treatment of hydrocephalus in these patients has been cerebrospinal fluid diversion by shunts. Endoscopic third ventriculostomy (ETV) has emerged as an alternative procedure in these patients.

PURPOSE

Assessment of the clinical and radiological outcomes of ETV in the management of hydrocephalus in children with CM II.

METHODS

This is a prospective study conducted on 18 patients with CM II associated with hydrocephalus admitted to Cairo University hospitals between January 2020 and June 2021. These patients had been managed surgically by ETV. Clinical outcome was assessed based on improvement of manifestations of increased intracranial pressure while radiological outcome was based on the findings of postoperative computed tomography. In cases with early failure, serial lumbar puncture (LP) was performed for 2 days.

RESULTS

ETV was performed as a secondary procedure in 4 cases. The overall success rate of the procedure was 72%, and its success rate as a secondary procedure was 100%. Serial LP was effective in decreasing early failure in 44.4% of cases. Radiological regression of hydrocephalic changes was detected in 50% of the cases.

CONCLUSION

ETV is an efficient and safe procedure in the treatment of hydrocephalus in children with Chiari malformation II, particularly when performed as a secondary procedure. Serial LP following the procedure increases the success rate in patients with early failure.

Endoscopic Third Ventriculostomy in a 12-Year-Old With Recurrent Failure of Ventriculoperitoneal Shunts

With a success rate of about 80%, ventriculoperitoneal (VP) shunts are widely used for the treatment of hydrocephalus. Whether congenital or acquired, hydrocephalus is not a single disease entity. It can be caused by abnormal cerebrospinal fluid (CSF) reabsorption, obstruction along the ventricular pathways, or, very rarely, increased production of CSF itself. This case presents a patient with a history of congenital hydrocephalus with multiple failed VP shunts. Through various clinical examinations and diagnostic measures, an endoscopic third ventriculostomy was eventually performed. This case highlights the rare complications, yet a large possibility, that can lead to failure of VP shunts in more than one way and when it is appropriate for shunt reversal versus removal.

Hydrocephalus: A neuropsychological and theoretical primer

Hydrocephalus is a common neurological condition, the hallmark feature of which is an excess in production, or accumulation, of cerebrospinal fluid in the ventricles. Although it is associated with diffuse damage to paraventricular brain areas, patients are broadly typified by a particular pattern of cognitive impairments that include deficits in working memory, attention, and spatial abilities. There have, however, been relatively few neuropsychological accounts of the condition. Moreover, theories of the relationship between aetiology and impairment appear to have emerged in isolation of each other, and proffer fundamentally different accounts. In this primer, we aim to provide a comprehensive and contemporary overview of hydrocephalus for the neuropsychologist, covering cognitive sequelae and theoretical interpretations of their origins. We review clinical and neuropsychological assays of cognitive profiles, along with the few studies that have addressed more integrative behaviours. In particular, we explore the distinction between congenital or early-onset hydrocephalus with a normal-pressure variant that can be acquired later in life. The relationship between these two populations is a singularly interesting one in neuropsychology since it can allow for the examination of typical and atypical developmental trajectories, and their interaction with chronic and acute impairment, within the same broad neurological condition. We reflect on the ramifications of this for our subject and suggest avenues for future research.

Outcomes of Endoscopic Third Ventriculostomy in Pediatric Patients With Hydrocephalus

Background

Endoscopic third ventriculostomy (ETV) is used to treat patients with obstructive hydrocephalus in infants. This study evaluated the postoperative outcomes of ETV among pediatric patients.

Methodology

A retrospective study was undertaken at the Mardan Medical Complex between June 2018 and June 2021. All pediatric patients who underwent the procedure of ETV in both the absence and presence of choroid plexus cauterization (CPC) at our center were included in the study. Using medical history data, a comprehensive survey questionnaire was designed. The findings and effects were evaluated either as a success or failure.

Results

A total of 90 cases were reviewed during the study. The rate of in-hospital mortality was 1.1% while the most commonly identified causes of hydrocephalus were myelomeningocele and aqueductal stenosis. A total of 39 (43.33%) patients had a successful surgery. In patients where hydrocephalus was secondary to aqueductal stenosis, the success rate was the highest, while the success rate was quite low for post-infectious hydrocephalus and intraventricular hemorrhage (p < 0.0001). The postoperative complication rate was 55.56% in our study. The rate of in-hospital mortality was 1.1%.

Conclusions

We found that the success rate of ETV was dependent upon factors such as the cause of hydrocephalus, type of hydrocephalus, and the age of the patient. Therefore, ETV is not suitable for all patients, and vigilance must be undertaken in selecting patients for the procedure. The rate of postoperative infections in our institution was alarmingly high which is a concerning matter for the institution.

Hydrocephalus-Associated Hyponatremia: A Review

Hydrocephalus is the pathological accumulation of cerebrospinal fluid within the ventricles of the brain. Hydrocephalus may be broadly divided into three categories: congenital, acquired, or other. Hyponatremia, serum sodium level <135 meq/ml, may be caused by dilution (e.g. syndrome of inappropriate antidiuretic hormone (SIADH)), depletion (e.g. cerebral salt wasting (CSW)), or delusion (e.g. psychogenic water intake) etiologies. This review discusses “hydrocephalus-associated hyponatremia” as a clinical entity, distinct from SIADH and CSW.

Some experts believe that in hydrocephalus patients, increased pressure on the hypothalamus leads to the release of antidiuretic hormone (ADH), which in turn causes hyponatremia. The true etiology of hyponatremia is critical to diagnose, as it will determine the treatment. So while both SIADH and CSW may result in hyponatremia, the former is treated with fluid restriction, while the latter requires fluid repletion; treating SIADH as CSW, and vice versa, will exacerbate the hyponatremia.

The etiology and severity of hyponatremia will determine the management. For hydrocephalus-associated hyponatremia, treating the underlying problem (i.e. hydrocephalus) is the mainstay of therapy. Theoretically, treatment of hydrocephalus-related hyponatremia with CSF-diversion procedures should relieve the pressure on the hypothalamus, mitigating ADH production, which in turn will decrease sodium excretion and ameliorate the hyponatremia.

Management of ventriculomegaly in pediatric patients with syndromic craniosynostosis: a single center experience

INTRODUCTION

Management of ventriculomegaly in pediatric patients with syndromic craniosynostosis (SC) requires understanding the underlying mechanisms that cause increased intracranial pressure (ICP) and the role of cerebrospinal fluid (CSF) in cranial vault expansion in order to select the best treatment option for each individual patient.

METHODS

A total of 33 pediatric patients with SC requiring craniofacial surgery were retrospectively evaluated. Cases of nonsyndromic craniosynostosis and shunt-induced craniosynostosis were excluded. Six syndrome-based categories were distinguished: Crouzon syndrome, Pfeiffer syndrome, Apert syndrome, cloverleaf skull syndrome, and others (Muenke syndrome, Sensenbrenner syndrome, unclassified). All of the patients were treated surgically for their cranial deformity between 2010 and 2016. The presence of ventriculomegaly and ventriculoperitoneal (VP) shunt requirement with its impact in cranial vault expansion were analyzed. Clinical and neuroimaging studies covering the time from presentation through the follow-up period were revised. The mean postoperative follow-up was 6 years and 3 months. A systematic review of the literature was conducted through a PubMed search.

RESULTS

Of the total of 33 patients with SC, 18 (54.5%) developed ventriculomegaly and 13 (39.4%) required ventriculoperitoneal (VP) shunt placement. Six patients (18.2%) required shunt placement previous to craniofacial surgery. Seven patients (21.2%) required a shunt after craniofacial surgery. Seven fixed pressure ventriculoperitoneal shunts and six programmable valves were placed as first choice. All patients improved their clinical symptoms after shunt placement. Aesthetic results seemed to be better in patients with programmable shunts.

CONCLUSIONS

Unless clear criteria for overt hydrocephalus are present, it is recommended to perform craniofacial surgery as a first step in the management of patients with SC in order to preserve the expansive effect of CSF for cranial vault expansion. In our experience, the use of externally programmable valves allows for the treatment of hydrocephalus while maintaining the expansive effect of CSF for the remodeling of the cranial vault. Prospective evaluations are needed to determine causality.

Advanced Magnetic Resonance Imaging of the Skull Base

Magnetic resonance (MR) imaging is a crucial tool for evaluation of the skull base, enabling characterization of complex anatomy by utilizing multiple image contrasts. Recent technical MR advances have greatly enhanced radiologists' capability to diagnose skull base pathology and help direct management. In this paper, we will summarize cutting-edge clinical and emerging research MR techniques for the skull base, including high-resolution, phase-contrast, diffusion, perfusion, vascular, zero echo-time, elastography, spectroscopy, chemical exchange saturation transfer, PET/MR, ultra-high-field, and 3D visualization. For each imaging technique, we provide a high-level summary of underlying technical principles accompanied by relevant literature review and clinical imaging examples.

The role of the Liliequist membrane in the third ventriculostomy

Endoscopic third ventriculostomy (ETV) is a hydrocephalus treatment procedure that involves opening the Liliequist membrane (LM). However, LM anatomy has not been well-studied neuroendoscopically, because approach angles differ between descriptive and microsurgical anatomical explorations. Discrepancies in ETV efficacy, especially among children age 2 and younger, may be due to incomplete LM opening. The objective of this study was to characterize the LM anatomically from a neuroendoscopic perspective to better understand the impact of anatomical features during LM ostomy and the ETV success rate. Additionally, the ETV success score was tested to predict patient outcome after the intraoperatively difficult opening of LM. Fifty-four patients who underwent ETV were prospectively analyzed with a mean follow-up of 53.1 months (1-90 months). The ETV technical parameters of difficulty were validated by seven expert neurosurgeons. The pediatric population (44) of this study represents the majority of patients (81.4%). The overall ETV success rate was 68.5%. Anomalies on the IIIVT floor resulted in an increased rate of ETV failure. The IIIVT was anomalous, and LM was thick in 33.3% of cases. Fenestration of LM was difficult in 39% of cases, and the LM and TC were opened separately in 55.6% of cases. The endoscopic third ventriculostomy success score (ETVSS) accurately predicted the level of difficulty opening the LM (p = 0.012), and the group with easy opening presented greater durability in ETV success. Neurosurgeons should be aware of the difficulty level of the overture of LM during ETV and its impact on long-term ETV effectiveness.

Frameless radiosurgical third ventriculostomy: Technical report

Background:

We describe the technical report and results of the first image-guided, linear accelerator, frameless radiosurgical third ventriculostomy.

Methods:

We report a 20 years old man, with diplopia, balance disturbances, and limitation for gaze supraversion. Magnetic resonance imaging resonance imaging of the brain and cranial computed tomography showed showed a left thalamic-midbrain lesion that caused partial compression of the Silvio aqueduct and mild ventricular dilatation. The biopsy revealed the diagnosis of pleomorphic xanthoastrocytoma. Before radical treatment of the tumor with fractionated stereotactic radiotherapy, the patient underwent to frameless radiosurgical third ventriculostomy, on the TrueBeam STX® platform with the ExacTrac localization system. The target used was the one defined on the floor of the third ventricle, at the midpoint between the mammillary bodies and the infundibular recess. The prescription dose was 120 Gy, given using a monoisocentric technique of multiple noncoplanar circular arches. The geometric arrangement of the plan consisted of 15 arches, with a 4 mm cone, distributed over a 110° table.

Results:

There was symptomatic and image improvement two days after radiosurgery. On CT, a reduction in ventricular dilation was observed with a reduction in the Evans index from 0.39 (initial CT) to 0.29 (CT at 15 days). In 3.0T magnetic resonance image at 3 months, we showed the third ventriculostomy. There have been no treatment failures or complications.

Conclusion:

It is possible to effectively perform the frameless radiosurgical third ventriculostomy without associated morbidity in the short term.

A Review of Common Endoscopic Intracranial Approaches

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

The Current State of Clinical Trials Studying Hydrocephalus: An Analysis of ClinicalTrials.gov

Introduction

Hydrocephalus is a significant public health concern estimated to affect 380,000 new individuals annually. In addition, it exhibits an increasingly high financial burden for the healthcare industry. Clinical trials are the gold standard for evaluating preventative and therapeutic strategies to bring potential treatments to the forefront of clinical practice.

Methods

A study of the ClinicalTrials.gov was conducted in April 2019 to examine all current and previously reported clinical trials studying hydrocephalus. Studies were reviewed to extrapolate information to characterize the current state of research being conducted for hydrocephalus.

Results

In total, 80 clinical trials met inclusion criteria and were analyzed: 48.8% were observation and 51.2% were interventional. Of those, 55% have been completed while 30.0% are still recruiting, and 15.0% are not yet recruiting. The United States has the most clinical trials (42.0%) and a plurality of trials has a sample size of 0-50 participants. The majority of studies included only adults (53.8%). Of those studies, 54.0% were cohort and the majority were prospective (74.0%). Of the different types of hydrocephalus, normal pressure hydrocephalus and pediatric hydrocephalus have generated the most interest for research comprising a majority of the clinical trial registry. While 44 of the trials are complete, only 20 have published results in peer-reviewed literature highlighting the need for improvement in publishing study results even if the results of the trials are null.

Conclusion

Most clinical trials to date have pertained to the treatment of normal pressure hydrocephalus and pediatric hydrocephalus. While great advancements have been made for the treatment of hydrocephalus, there remains much room for improvements in therapeutic interventional modalities as well as ensuring the reporting of all undertaken clinical trials.

Obstructive hydrocephalus due to aqueductal stenosis from developmental venous anomaly draining bilateral medial thalami: a case report

Hydrocephalus is a pathological buildup of cerebrospinal fluid within the ventricles leading to ventricular enlargement out of proportion to sulci and subarachnoid spaces. Developmental venous anomaly is a common benign and usually asymptomatic congenital cerebrovascular malformation. Hydrocephalus caused by aqueductal developmental venous anomaly is extremely rare. We describe a case of a 47-year-old man who presents with short-term memory impairment who was found to have a developmental venous anomaly draining bilateral medial thalami through a common collector vein that causes aqueductal stenosis and obstructive hydrocephalus.

The Scanty Knowledge of Endoscopic Third Ventriculostomy in Infants

Introduction:

Hydrocephalus (HCP) remains one of the commonest pathologies treated in developing countries. Endoscopic third ventriculostomy (ETV) has become the alternative to shunt-divergen procedures in the treatment of many pathologies of the cerebral fluid in the brain. Age has been considered a limitation to perform the procedure, we started to perform ETV In younger patients earlier than many other units. Objectives: In this study, we demonstrate the overall efficacy of ETV in infants younger than 1-year of age and to subsequently report the outcome of this procedure.

Methods:

From 2000 till 2016 we have performed a total of 386 cases of ETV of all ages. 71-cases were infants (below 1-year of age). Our study was undertaken to evaluate these cases. Patients were divided into two subgroups according to the cause of hydrocephalus; obstructive HCP, communicating HCP.

Results:

Mean time for follow up was 52 months. Mean age at surgery was 137days (7- 351days). The population included 31-females and 40-males, while10 infants were premature. Success rates were; 91.6%, 63.6% correspond to each sub-group with an overall success rate of 73.24%.

Conclusion:

ETV in infants is feasible, technically more demanding. Success rate justifies the procedure to be performed in such age group of patients. ETV can be used, attentively, in cases of hydrocephalus associated with MMC, morbidity and mortality does not differ from the general population.

Neurosarcoidosis Presenting with Obstructive Hydrocephalus Successfully Treated with Endoscopic Third Ventriculostomy

A 58-year-old Japanese woman complained of unstable gait and dizziness lasting for a month. She had been diagnosed histologically with pulmonary and cutaneous sarcoidosis and attended outpatient clinics for routine checkups. Head computed tomography and magnetic resonance imaging (MRI) indicated obstructive hydrocephalus caused by a contrast-enhanced lesion in the cerebral aqueduct. The patient underwent endoscopic third ventriculostomy and a biopsy of the lesion, leading to the diagnosis of neurosarcoidosis. This was a rare case of neurosarcoidosis presenting with obstructive hydrocephalus that was treated with endoscopic third ventriculostomy and diagnosed histologically via an intraoperative biopsy.

Natural History of Endoscopic Third Ventriculostomy in Adults: Serial Evaluation with High-Resolution CISS

BACKGROUND AND PURPOSE

Endoscopic third ventriculostomy is a well-accepted treatment choice for hydrocephalus and is used most frequently with a known impediment to CSF flow between the third ventricle and basal cisterns. However, there are scarce data on the imaging evolution of the defect in the floor of the third ventricle and how this affects patency rates and clinical outcomes. The purpose of this study was to assess whether, and how, the endoscopic third ventriculostomy defect changes in size with time.

MATERIALS AND METHODS

All high-resolution endoscopic third ventriculostomy protocol MRIs performed between 2009 through 2014 were retrospectively identified. Two fellowship-trained neuroradiologists, blinded to clinical information, independently reviewed all retrospective cases.

RESULTS

A total of 98 imaging studies were included from 34 patients. The average change in the area throughout the studied period was 0.02 mm²/day (7.5 mm²/year), with a higher increase in size noted in the first 3 postsurgical months, with a gradual decrease in the degree of defect-size change. Use of the NICO Myriad device was correlated with the area of the endoscopic third ventriculostomy defect on the last follow-up, demonstrating a larger final defect size in patients in whom the surgical technique included debridement of the endoscopic third ventriculostomy defect walls with the NICO Myriad device (28.21 versus 11.25 mm, P < .05).

CONCLUSIONS

High-resolution MR imaging with sagittal CISS images is useful in the postoperative evaluation of endoscopic third ventriculostomies. Such findings may prove useful in determining the optimal duration of follow-up with MR imaging of patients who have undergone endoscopic third ventriculostomy.

Neuroendoscopy for post-infective hydrocephalus in children

The treatment of hydrocephalus has changed in recent years with better imaging and introduction of endoscopic procedures as well as enhanced shunts. Indications of endoscopic third ventriculostomy (ETV) are now more refined with better quantification of outcome. This article reviews the current state of neuroendoscopy for infective hydrocephalus in children. The roles of third ventriculostomy as a primary procedure or after shunt malfunction, endoscopic interventions in multiloculated hydrocephalus and introduction of intraventricular lavage to salvage severely infected children are evaluated.

Endoscopic third ventriculostomy (ETV) and ventriculoperitoneal shunt (VPS) in non-communicating hydrocephalus (NCH): comparison of outcome profiles in Nigerian children

BACKGROUND

Endoscopic third ventriculostomy (ETV) and ventriculo-peritoneal shunt (VPS) although recognized surgical options for non-communicating hydrocephalus have debatable applications.

OBJECTIVE

We analysed a prospective cohort of age-matched children with non-tumor, non-communicating hydrocephalus treated with the two surgical modalities using clinically measurable parameters.

METHODS

A single institution analysis of age-matched patients with non-communicating hydrocephalus treated with VPS or ETV over a 3-year period. Occipitofrontal circumference (OFC), milestone, shunt independence as well as complication profiles of patients were recorded and analysed. Mean follow-up period was 1.27 ± 0.19 years 95%CI). Data analysis were performed using SPSS version 15, Chicago, IL. Statistical tests were set at 95% significance level.

RESULTS

Fifty-five patients were enrolled, 25 patients had ETV, while 30 had VPS. Mean age was 2.3 ± 0.7 years (95% CI) with a range of 3 months to 4.5 years. Aqueductal stenosis was the most common indication. OFC profile decline was significant among the VPS group when compared with ETV group at 3 months follow-up (χ² = 7.59, df = 1, p < 0.05). There was no difference among the two treatment groups χ² = 2.47, df = 1, p > 0.05) in milestone profile. Thirteen percent of VPS, compared to (4%) ETV patients, had sepsis (χ² = 4.59, df = 1 p < 0.05). Ninety-two percent of ETV patients remained shunt free, while 80% of shunted patients achieved ETV independence. Two patients died among the VPS group compared to one patient in the ETV group.

CONCLUSION

VPS compared to ETV is associated with an earlier milestone and OFC response. ETV is associated with lower rates of sepsis and mortality.

Management of hydrocephalus in patients with leptomeningeal metastases: an ethical approach to decision-making

PURPOSE

Leptomeningeal metastases (LM) are a rare, but often debilitating complication of advanced cancer that can severely impact a patient's quality-of-life. LM can result in hydrocephalus (HC) and lead to a range of neurologic sequelae, including weakness, headaches, and altered mental status. Given that patients with LM generally have quite poor prognoses, the decision of how to manage this HC remains unclear and is not only a medical, but also an ethical one.

METHODS

We first provide a brief overview of management options for hydrocephalus secondary to LM. We then apply general ethical principles to decision making in LM-associated hydrocephalus that can help guide physicians and patients.

RESULTS

Management options for LM-associated hydrocephalus include shunt placement, repeated lumbar punctures, intraventricular reservoir placement, endoscopic third ventriculostomy, or pain management alone without intervention. While these options may offer symptomatic relief in the short-term, each is also associated with risks to the patient. Moreover, data on survival and quality-of-life following intervention is sparse. We propose that the pros and cons of each option should be evaluated not only from a clinical standpoint, but also within a larger framework that incorporates ethical principles and individual patient values.

CONCLUSIONS

The decision of how to manage LM-associated hydrocephalus is complex and requires close collaboration amongst the physician, patient, and/or patient's family/friends/community leaders. Ultimately, the decision should be rooted in the patients' values and should aim to optimize a patient's quality-of-life.

Management of Arachnoid Cysts: A Comprehensive Review

Arachnoid cysts are non-neoplastic, intracranial cerebrospinal fluid (CSF)-filled spaces lined with arachnoid membranes. Large arachnoid cysts are often symptomatic because they compress surrounding structures; therefore, they must be treated surgically. As several surgical management options exist, we explore the best approach according to each major type of arachnoid cyst: middle cranial fossa cyst, suprasellar cyst, intrahemispheric cyst, and quadrigeminal cyst.

Indigenous Inexpensive Practice Models for Skill Development in Neuroendoscopy

Introduction:

Neurosurgery is a branch having a tough learning curve. Residents generally get very less hands-on exposure for advanced procedures like neuroendoscopy. With the limited number of cadavers available and ethical issues associated with animal models, practice models, and simulators are becoming the able alternative. Most of these simulators are very costly. We tried to build indigenous inexpensive practice models that can help in developing most of the skills of neuroendoscopy.

Materials and Methods:

Models were built for learning hand-eye coordination, dexterity, instrument manipulation, cutting, fine dissection, keyhole concept, drilling, and simulation of laminectomy and ligamentum flavum resection. These were shown in the neuroendoscopic fellowship program conducted in authors' institute, and trainees' responses were recorded.

Results:

Both novice and experienced neuroendoscopic surgeons validated the models. There was no significant difference between their responses (P = 0.791).

Conclusion:

Indigenous innovative models can be used to learn and teach neuroendoscopic skills. The presented models were reliable, valid, eco-friendly, highly cost-effective, portable, easily made and can be kept in one's chamber for practicing.

Endoscopic-Assisted Median Aperture Approach for Resection of Fourth Ventricular Tumor and Confirmation of Patency of Cerebral Aqueduct Using an Adjustable-Angle Endoscope: Technical Case Report

BACKGROUND AND IMPORTANCE: Open microsurgical approaches to the roof of the fourth ventricle via a telovelar approach typically require cerebellar retraction and/or splitting of the vermis and may be associated with postoperative neurological morbidities. In this case report and technical note, we describe the use of an adjustable-angle endoscope inserted into the median aperture via suboccipital craniotomy, resulting in enhanced visualization of the roof of the fourth ventricle and cerebral aqueduct and maximal safe tumor resection.

CLINICAL PRESENTATION: A 49-yr-old woman with obstructive hydrocephalus and a fourth ventricular mass that was not fully visible with the use of an operative microscope.

CONCLUSION: Direct visualization of the roof of the fourth ventricle, including the superior medullary velum and cerebral aqueduct, can be facilitated with an adjustable angle endoscope inserted into the median aperture via suboccipital craniotomy to minimize the degree of telovelar dissection and vermis splitting.

Keyhole approach in the neuroendoscopic treatment for hydrocephalus

The aim of the study was to explore keyhole approach and dura suture in the neuroendoscopic treatment for hydrocephalus.Twelve cases of hydrocephalus patients who were treated with neuroendoscope by this approach were analyzed retrospectively from April 2015 to April 2016 in our department. The basic steps of this procedure was using drill and milling cutter to form a small bone flap instead of burr hole, and then making a cruciate incision on the dura. After endoscopic third ventriculostomy or endoscopic third ventriculostomy + ventriculocystostomy finished, dura was sutured and the bone flap was reset.All 12 patients could suture dura effectively, and no cerebrospinal fluid leak and subcutaneous cerebrospinal fluid collection happened; symptoms of hydrocephalus were also improved. Moreover, during the operation, we found this approach could suspend dura, and avoid the cerebral sulcus and cortical coarse vein effectively, which could reduce the risk of intracranial hemorrhage. In addition, we found this approach could increase the reachable range of the neuroendoscope significantly.Keyhole approach can suture dura and avoid the cerebral sulcus and cortical coarse vein effectively, increase the indications, and reduce complications of neuroendoscope. So, this approach has clinical values and can be used in hydrocephalus.

Learning neuroendoscopy with an exoscope system (video telescopic operating monitor): Early clinical results

CONTEXT

Steep learning curve is found initially in pure endoscopic procedures. Video telescopic operating monitor (VITOM) is an advance in rigid-lens telescope systems provides an alternative method for learning basics of neuroendoscopy with the help of the familiar principle of microneurosurgery.

AIMS

The aim was to evaluate the clinical utility of VITOM as a learning tool for neuroendoscopy.

MATERIALS AND METHODS

Video telescopic operating monitor was used 39 cranial and spinal procedures and its utility as a tool for minimally invasive neurosurgery and neuroendoscopy for initial learning curve was studied.

RESULTS

Video telescopic operating monitor was used in 25 cranial and 14 spinal procedures. Image quality is comparable to endoscope and microscope. Surgeons comfort improved with VITOM. Frequent repositioning of scope holder and lack of stereopsis is initial limiting factor was compensated for with repeated procedures.

CONCLUSIONS

Video telescopic operating monitor is found useful to reduce initial learning curve of neuroendoscopy.

The efficacy analysis of endoscopic third ventriculostomy in infantile hydrocephalus

Objective

To investigate the efficacy of endoscopic third ventriculostomy (ETV) for infantile hydrocephalus.

Methods

Retrospectively reviewed the 17 infantile hydrocephalus cases who were treated with ETV between July 2009 and June 2013. The study includes 17 patients (4 Han and 13 Hui) between the ages of 51 and 337 days. Five cases with encephalitis history and 2 cases with cerebral hemorrhage, with the remaining 10 cases congenital hydrocephalus. ETVs were performed for all patients with 1 case failing because the severe ventricle inflammatory adhesion, excessive exudation, and vague basilar artery.

Results

Among the 16 successful cases 7 cases improved remarkably : heads and ventricles reduced and cerebral cortexes thickening morphologically. The ventricles of the remaining cases were unchanged.

Conclusion

The ethnic minority account for the majority of the patients in this study. ETV is effective for infantile obstructive hydrocephalus.

Endoscopic third ventriculostomy in the management of hydrocephalus: Outcome analysis of 168 consecutive procedures

BACKGROUND

Endoscopic third ventriculostomy (ETV) is the treatment of choice for obstructive hydrocephalus, but the outcome is still controversial in terms of age and aetiology.

METHODS

Between 1998 and 2011, 168 consecutive procedures were performed in 164 patients, primarily children (56%<18 years of age and 35%<2 years of age). The causes of obstructive hydrocephalus included tumoural pathology, Chiari malformation, congenital obstruction of the aqueduct, post-infectious and post-haemorrhagic membranes, and ventriculo-peritoneal shunt (VPS) malfunctions. Successful ETV was defined by the resolution of symptoms and the avoidance of a shunt.

RESULTS

ETV was successful in 75.6% of patients, but 19% of the patients required VPS in the first month after ETV, and 5.4% required a VPS more than one month after ETV. Four patients were ultimately submitted for second ETVs. In this series, no major permanent morbidity or mortality was observed.

CONCLUSIONS

ETV is a safe procedure and an effective treatment for obstructive hydrocephalus even following the dysfunction of previous VPSs and in children younger than two years.

ETV as a last resort

INTRODUCTION

The field of neuroendoscopy is rapidly expanding with increasing indications for endoscopic third ventriculostomy (ETV).

DISCUSSION

As a treatment for hydrocephalus, ETV has the advantage of providing a more physiological cerebrospinal fluid diversion without shunt hardware which reduces the risk of recurrent infection and malfunction. The success rate of ETV has been increasing with decreasing morbidity and mortality.

CONCLUSION

Originally, ETV was indicated for cases of obstructive hydrocephalus, however the indications are expanding. To highlight this, we present a small series of cases were ETV is not traditionally indicated and was a treatment of last choice.

An operative technique combining endoscopic third ventriculostomy and long-term ICP monitoring

Neuroendoscopy has been well established in the treatment of many neurological and neurosurgical diseases. Especially its application in occlusive hydrocephalus to restore a physiological cerebrospinal fluid circulation has been extensively examined in the past. Although such procedures are believed to be safe and effective, complication as well as failure rates up to 20% have been described pointing to the importance of long-term postoperative care. Therefore, different and partly invasive procedures as ventricular drain insertions or complex cranial imaging methods have been proposed; however, associated pitfalls and restrictions often limited their prognostic value and long-term benefit. An operative technique combining endoscopic third ventriculostomy and telemetric increased intracranial pressure monitoring has now been developed to optimize the postoperative care management. The main intention is to provide sufficient brain pressure data for long-term observation and early recognition of endoscopy failures and complications. The new operative technique was applied in a series with 24 patients suffering from occlusive hydrocephalus. Surgical technique and future perspectives are presented.

A morphologic study of the transcallosal-interventricular foramen approach in endoscopic third ventriculostomy with magnetic resonance imaging

There is a very wide range of applications in neurosurgery for the treatment of obstructive hydrocephalus by third ventriculostomy. To facilitate the operation, we measured the related data of transcallosal-interventricular foramen approach in endoscopic third ventriculostomy with the magnetic resonance images of the third ventricle from 103 healthy adults. We calculated the mean and standard deviation as well as the 95% confidence interval for the mean value of the measured data, which conformed to normal distribution. We used median and interquartile range to show its concentration and the level of variation when it does not.

The ventricular system of the brain: a comprehensive review of its history, anatomy, histology, embryology, and surgical considerations

INTRODUCTION

The cerebral ventricles have been recognized since ancient medical history. Their true function started to be realized more than a thousand years later. Their anatomy and function are extremely important in the neurosurgical panorama.

METHODS

The literature was searched for articles and textbooks of different topics related to the history, anatomy, physiology, histology, embryology and surgical considerations of the brain ventricles.

CONCLUSION

Herein, we summarize the literature about the cerebral ventricular system.