Neuroendoscopic techniques in the treatment of arachnoid cysts in children and comparison with other operative methods

OBJECTIVE

The authors intended to evaluate the application of neuroendoscopic techniques for the treatment of arachnoid cysts in children and compare it with other operative methods.

METHODS

The analysis covered the results of treatment of 44 children with arachnoid cysts who were subjected to neuroendoscopic procedures and 62 patients who underwent other operations.

RESULTS

The neuroendoscopic treatment of arachnoid cysts was very effective because of low rate of reoperative treatment (six out of 44 patients), no need to change the operative method (40 effective out of total 44 operative procedures), and low rate of persistent worsening (none of 44 patients worsened).

CONCLUSIONS

Summing up all the mentioned aspects of neuroendoscopic techniques, the neuroendoscopic techniques were the most suitable operative procedures in the treatment of arachnoid cysts in the presented group of patients, providing that the connection between the lumen of the arachnoid cyst and the cerebrospinal fluid cisterns was of good quality.

Influence of neuroendoscopic third ventriculostomy on the size of ventricles in chronic hydrocephalus

Our intention was to compare the clinical outcome after surgical treatment of chronic hydrocephalus between patients who were subjected to neuroendoscopic third ventriculostomy and patients who underwent shunt implantation. At the Department of Neurosurgery of the Research Institute of Polish Mothers' Memorial Hospital from 1999 to 2001, 29 children, of an average age of 7 years (+/-7.1 years SD), underwent successful neuroendoscopic procedures, and from 1992 to 1994, 59 children, of an average age of 2 months (+/-1.9 months SD), underwent shunt implantation. The size of the ventricular system was described by the Frontal Horn Index and its change after operative procedures by the ratio of the final to the primary Frontal Horn Index. Head circumference was measured in percentiles according to the Kurniewicz-Witczakowa chart for Polish children. The reduction in head circumference after a neuroendoscopic procedure was, on average, significantly less than after a shunt implantation (0.39 percentiles +/-29.6 SD vs 17.93 percentiles +/-19.93 SD). Concerning the change in ventricular size after a neuroendoscopic procedure, it was noticed that the average ratio of the final to the primary Frontal Horn Index was 0.9. Meanwhile, the same parameter after a shunt implantation was 0.55. Based on the values of the Frontal Horn Indexes, it was observed that the ventricular system in infants after neuroendoscopic procedures was significantly larger than in other age groups (0.7 vs 0.5). After successful neuroendoscopic operations in a group of children suffering from Chiari II malformation, ventricular systems were slightly enlarged. The ratio of the final Frontal Index to the primary Frontal Horn Index was 1.31. In children suffering from chronic hydrocephalus, the average reduction in the size of the ventricular system and the rate of head circumference growth are lower after neuroendoscopic operations than after shunt implantations. Successful neuroendoscopic procedures are characterized by, on average, a higher rate of head circumference growth in infants than in neonates. In addition, the rate of head circumference growth after successful neuroendoscopic procedures could be higher than before the operation, which is clearly visible in children suffering from Chiari II malformation, but it does not mean a constant increase of that parameter during the postoperative period.

Effectiveness of neuroendoscopic procedures in the treatment of complex compartmentalized hydrocephalus in children

OBJECTIVE

The main object of the work is to assess the suitability of neuroendoscopic techniques for the treatment of complex compartmentalized hydrocephalus.

METHODS

For this purpose the authors compared two groups of children treated in the Research Institute of the Polish Mother's Memorial Hospital from March 1997 to January 2002. The first group of 47 children, treated using neuroendoscopic procedures, was compared with the second, which comprised 80 children treated conventionally by complicated shunt implantations.

RESULTS

The children treated neuroendoscopically needed on average 1.7660 procedures during the entire therapy, and 1.0232 operations a year. The same parameters in the conventionally-treated group were as follows: the total number of procedures was 7.050, and the rate of reoperation was 3.949 procedures a year. The proportion of patients who suffered from complications connected with operative treatment and who had a bad outcome was higher in the conventionally-treated group than in the neuroendoscopic one.

[A comparison of neuro-endoscopic techniques with other surgical procedures in the treatment of arachnoid cysts in children]

The aim of the study was to evaluate the use of neuroendoscopic techniques (in comparison with other surgical procedures) in the treatment for arachnoid cysts in children. The analysis was performed on results of treatment 22 children with arachnoid cysts submitted to neuroendoscopic procedures. The group consisted of 6 girls and 16 boys, aged from 1 day to 18 years (mean age 5.3 years, SD +/- 5.6). The control group treated with other, non-endoscopic surgical procedures consisted of 61 patients (20 girls and 41 boys aged from 10 days to 17 years, mean age 7 years, SD +/- 6). Criteria of success varied according to the type of surgical treatment. In the case of procedures other than shunt implantation, the treatment was regarded as effective, if there was no need to change the surgical method, while shunt implantation was considered effective, if shunt revision was not necessary. The operative treatment outcome was assessed using the Glasgow Outcome Scale. Post-treatment changes in the clinical state were graded as improvement, no change, or deterioration. In terms of the assumed criteria of success in the treatment for arachnoid cysts, neuroendoscopic procedures and microsurgical cyst excisions were among the most effective methods. As many as 90.9% of neuroendoscopically treated children needed no other operation, in comparison with 92.6% of patients submitted to microsurgical procedures, who needed no change in the operative treatment. In the group of neuroendoscopically treated patients the effectiveness of neuroendoscopic operations varied according to the type of procedure used. Cystocysternostomies or cystoventriculostomies were successful in 100%. The analysis of clinical outcome has shown that deterioration was observed only in 13% of the patients with shunt implantation. Analyzing each type of arachnoid cyst separately, a statistically significant relationship was found between improvement of the clinical state and the use of craniotomy in the surgical treatment for cysts localized in the posterior fossa. Improvement in the case of neuroendoscopically treated children was related to a larger reduction in the cyst size after surgery and to a lower intensity of intraoperative bleeding. Neuroendoscopic techniques allowed to reduce the average period of hospitalization. Neuroendoscopic cystocysternostomy and cystoventriculostomy were the most effective techniques, besides microsurgical excision of arachnoid cysts. Neuroendoscopic treatment efficacy depends on the type of procedure used. The application of neuroendoscopic techniques allows to reduce the period of hospitalization.

[Changes in head circumference and ventricular system size after neuro-endoscopic third ventriculostomy in children]

The aim of the study was to compare changes in the head circumference ventricular system size after neuroendoscopic third ventriculostomy with those following shunt implantation in children suffering from chronic hydrocephalus. The data were analysed to establish criteria of success of neuroendoscopic procedures. In the years 1999-2001 neuroendoscopic third ventriculostomy was performed in 59 children at the Neurosurgery Department of the Research Institute of Polish Mothers' Memorial Hospital. However, the sample analysed in the paper consists of 29 children (16 boys, 13 girls aged from 18 days to 18 years, mean age 7.03, SD = 7.11 years) with chronic hydrocephalus successfully treated with neuroendoscopic procedures. The control group consists of 59 children (31 boys, 28 girls) selected out of 80 patients who underwent primary shunt implantation at the same Neurosurgical Department in the years 1992-1994. The control children (aged from 2 weeks to 9 months, mean age 2 months, SD = 1.92 months) did not need shunt revision during the clinical observation period. The ventricular system size was assessed in terms of the Frontal Index, while postoperative changes in the system size were expressed by the ratio of the Final Frontal Index to the Baseline Frontal Index. If the ventricular system size remained the same, the ratio was 1; if its size decreased after surgery, the ratio was less than 1, while any increases in the system size were reflected by a ratio over 1. Moreover, the head circumference (HC) was measured before and after surgery only in infants and neonates with non-communicating hydrocephalus. HC was expressed in centiles using the centile chart developed by Kurniewicz-Witczakowa for various age and sex groups of Polish children. The analysis included also post-surgery changes in HC over the observation period, in terms of the difference between the baseline HC value and HC measurements in relation to the observation period duration. A positive sign of this index evidenced a decrease in the rate of HC enlargement, while a negative sign--an increased rate of HC growth. The mean HC at the end of the observation period was 72.96 centile in the neuroendoscopy group and 52.36 centile in children after shunt implantation. The reduction of head circumference following neuroendoscopic procedures was significantly smaller than that after shunt implantation, as the average decrease in HC after neuroendoscopy was only 0.4 centile as compared to about 18 centiles after shunt implantation. In the neuroendoscopy group a relationship was found between HC and age: in newborns HC was significantly smaller than that in infants (20.25 and 82.55 centiles, respectively). An analysis of HC changes (in centiles) in relation to the time since the surgery in all the children aged under 1 year, successfully treated with neuroendoscopic procedures, indicated no tendency to a steady increase in the rate of HC enlargement, even though in many cases the HC after surgery was larger than that prior to the surgery. As regards changes in the ventricular system size, the average ratio of Final to Baseline Frontal Index was 0.9 in the neuroendoscopy group and 0.5 in the group after shunt implantation. The ventricular system turned out to be significantly larger in infants after neuroendoscopy than in other age groups (the mean Frontal Index values were 0.65 vs. 0.53, respectively). No tendency to constant enlargement of the ventricular system size after neuroendoscopy was found. In children with non-communicating hydrocephalus due to Chiarii II malformation a mild enlargement of the ventricular system was seen after successful neuroscopy (the ratio of the Final to Baseline Frontal Index amounted to 1.3).

CONCLUSIONS

The rate of head circumference (HC) enlargement in infants after succeeded neuroendoscopic procedures did not continually increase during the postoperative period, although their HC expressed in centiles could be higher than that before surgery. The average reduction of the ventricular system size was much smaller after neuroendoscopic ventriculostomy than than after shunt implantations. In children with Chiarii II malformation and in infants the ventricle system size may be somewhat increased in comparison to pre-operative levels. However, no tendency to a steady enlargement with time was found either in the HC or in the ventricle system size.

[Neuro-endoscopic techniques in the treatment of complex hydrocephalus in children]

The aim of the paper was to evaluate effectiveness of neuroendoscopic procedures in comparison to complex shunt systems implantation in the treatment of complex compartmentalized hydrocephalus in children. Neuroendoscopic techniques were applied in 47 patients (23 boys, 24 girls aged from 25 days to 18 years, mean age 3 years SD = 4.9 years). The shunt implantation comparison group consisted of 80 patients (47 boys and 33 girls aged from 1 day to 16 years, mean age 0.8 year, SD = 2 years). Every endoscopic procedure was planned individually, in accordance with the patient's type of complex hydrocephalus and level of deformity of his/her ventricular system. In cases of multiloculated hydrocephalus septostomy was generally performed to restore communication between separated parts of the ventricular system. In uniloculated hydrocephalus resulting from the foramen of Monro obliteration, septostomy of pellucid septi was performed to connect the isolated lateral ventricles. In cases of isolated ventricle III the foramen of Monro patency was restored to connect the ventricle with the whole ventricular system. Neuroendoscopic techniques allowed to significantly reduce the number of necessary surgical procedures. Complex hydrocephalus patients treated with the traditional shunt implantation required on the average 7 operations during the whole therapy, as compared to about 2 in those treated by means of neuroendoscopic techniques. An analysis of the number of necessary surgical interventions per year of clinical observation also indicated superiority of neuroendoscopy techniques over shunt implantation (1 vs. 4 operations per year, respectively). Neuroendoscopy allowed to simplify shunt systems in 33 children, i.e. 70.2% of those treated with neuroendoscopic techniques, while in the group treated with traditional methods of shunt implantation only 16 children (16.3%) had a simple shunt system (a shunt with one intraventricular drain). The outcome assessed according to the Glasgow Outcome Scale (GOS 1, 2) in children treated only by shunt implantation was significantly inferior to that in the neuroendoscopy group, both in terms of mortality rate (22.5 and 4.3%, respectively) and postoperative complications present in 42 (52.5%) of shunt implantation cases and 9 (19.1%) of endoscopically treated patients.

CONCLUSIONS

Neuroendoscopic techniques allowed to reduce the number of necessary operative procedures, to simplify shunt systems, to improve clinical outcome, and to reduce the risk of complications in the early postoperative period.