Clinical Neuroendoscopy by Venkataramanaa

1

With wide experience of neurosurgeons across the globe and encouraging results, the endoscopic treatment of hydro-cephalus has made a mark of universal acceptance. From what was considered as treatment option for hydrocepha-lus due to aqueductal stenosis only, it has had ramifi cations in all types of hydrocephalus. Most of the educated patients ask for the option of endoscopic treatments. Even those who have had insertion of ventriculoperitoneal (VP) shunt pre-viously often come to explore the possibility of removal of shunt and substituted treatment with endoscope.

The additional advantage of endoscope has been a bet-ter understanding of ventricular anatomy, the response of ependyma to foreign body, and perhaps improved knowl-edge of cerebrospinal fl uid (CSF) dynamics.

The VP shunt has done a remarkable service to the patient of hydrocephalus for the last seven decades. However, popu-larity of shunt has been severely dented by endoscope and endoscopy may completely replace shunt over a decade time at some of the centers. VP shunt may perhaps have a role left over in the treatment of failed endoscopic third ventriculos-tomy (ETV).

The current indications, success, and complications are changing every 5 years. The present understanding has been summarized here for the benefi ts of the students.

HistoryBozzinni (1806) is credited for visualization of internal organs using candle lights. Original eff orts to see inside brain was made by Lespinasse in 1910 using cystoscope.1 Dandy, the father of neuroendoscopy, attempted endoscopic fulgu-ration of choroid plexus with 80% mortality.2 Mixter (1923) did fi rst third ventriculocisternotomy.3 The major revolu-tion in neuroendoscopy was the development of Hopkins solid rod system in 1960. Since then several modifi cations of endoscope are being introduced in the market. Another advancement in endoscopy had been the development of 3 chip CCD camera (above 800 horizontal lines) and high-resolution monitor for better image quality. Large screen monitor results in image pixilation. For better image, the resolution of monitor shall not exceed that of camera. Cur-rently, the evolution of three-dimensional (3D) endoscope may provide a superior orientation ability and optics. Xenon light is superior to halogen for neuroendoscopy.

Types of Endoscopic Procedures Used in Hydrocephalus

Endoscopic Third VentriculostomyThe most commonly used procedure which is currently per-formed for all types of hydrocephalus. The opening is made in the fl oor of third ventricle and after opening of second (Lilliquest) or third membrane communication is estab-lished between third ventricle and prepontine/interpedun-cular cisterns.

The site of burr hole and site of ETV is best calculated on mid-sagittal T1 sequence of magnetic resonance imaging (MRI). We select our burr hole in such a manner that it forms a straight line with point of perforation of the third ventricle. The burr hole site may have to be modifi ed if ETV is to be combined with aqueductoplasty. Virtual 3D MR reconstruc-tion may be helpful for the beginners.4

Perforation of the fl oor is done with blunt tip of cautery without pressing the paddle. Further enlargement of fl oor is done with 3F Fogarty single balloon catheter. Sometime, double balloon catheter or angioplasty catheter with cylin-drical balloon can also be used.

It is mandatory to examine second or third membrane which needs to be opened for the success of ETV. To and fro movements of the margins of the ostomy are not necessary indicator of adequate ETV. Sometime, second membrane can be present as low as mid-basilar point.

The clinical success of ETV after a satisfactory anatomi-cal communication is dependent on normal absorption of CSF in the brain. There are no noninvasive tests available to document the adequacy of normal CSF absorption; hence, the success of ETV cannot be entirely predicted in all cases.

The clinical betterment following ETV is determined by several factors, the age of the patient remains the most important.5–13 In most of the published literature, the age of more than 1 year has been found to be associated with better outcome. This perhaps is related to well-developed absorp-tion ability of the CSF by the brain.

Fulguration of choroid plexus: Choroid plexuses are believed to be the only site of CSF formation and hence are targeted in fulguration.14 There are reports of bulky choroid plexus in acute phase of tubercular meningi-tis as additional source of overproduction.15 Generally,

Daljit Singh

Hydrocephalus: Role of Endoscopic Third Ventriculostomy1

Clinical Neuroendoscopy_Ch01_p001-006.indd 1Clinical Neuroendoscopy_Ch01_p001-006.indd 1 11/16/13 11:30 AM11/16/13 11:30 AM

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Clinical Neuroendoscopy2

niation with ETV. It is important to review the mid-sagittal MRI in tumor cases so as to assess the prepontine cistern and displaced basilar artery in such cases.

Enlarged cistern magna, Dandy–Walker cyst and fourth ventricular outlet obstruction have shown to be benefi ted with ETV.37–39

Certain Special Conditions for Endoscopic Third VentriculostomySurplus fl oor: In some cases, the fl oor of the third ventricle is too steep with large third ventricle. In such cases, it may be diffi cult to puncture the fl oor. Moreover, routine ETV in such cases leads to overhanging margins on ostomy site which can result in ostomy closure. Coagulation of lateral sides ETV can prevent such complications.

Small space for ETV: Sometime, fl oor of ETV is very small and it may not be possible to puncture the fl oor directly. In such situations, it is advisable to open the fl oor over the bony landmark of clivus/dorsum sella and to expand the opening laterally.

Thick Floor of Third VentricleIn patient with postinfection hydrocephalus (PIH) or with shunt infection, the fl oor may be thick to perforate. It can be opened with gentle pressure of the cautery without pressing the paddle or with minimal current.

PIH: What was believed to be a relative contraindica-tion, PIH is added indication for ETV in several series from South Asia. The leading cause of PIH being tuberculosis has had special attentions by several authors. The success of ETV in such cases is dependent on the stage of tubercular men-ingitis (TBM), clinical grade of TBM, age of the patient, and adequacy of ETV.40–45 The pyogenic infections produce more scarring 30 and loculations.46

The posttubercular hydrocephalus can be of both obstructive and communicating types. Although ETV releases obstruction at aqueduct of Sylvius or at outlet lev-els, its role in communicating hydrocephalus is debated even now. Proponent of ETV in TBM believe that it washes away the exudates, allows the CSF fl ow in previously inac-cessible area, and decreases transventricular pressure gra-dient as mechanisms for improvements. Overall, success rate in TBMH ranges from 70 to 82%. Some authors practice repeated lumbar puncture in failures.

Hydrocephalus in Neural Tube Defects and Chiari MalformationThe exact mode by which ETV work in this indication is still unclear. ETV is more benefi cial in association with aqueductal stenosis. The overall success is 50 to 60% with some authors

it is done on one side; however, it can be done bilater-ally in cases of absent septum pellucidum. Sometime, ETV can be combined with fulguration for additional benefi ts. Fulguration has been recommended in neo-natal hydrocephalus and in Chiari malformations.

Monroplasty: The foramen of Monro is opened in asymmetrical ventriculomegaly wherein one of the lateral ventricles is larger than others. Such asym-metry is seen in conditions such as shunt infections, neurocysticercosis (NCC), and postmeningitis.

Aqueductoplasty: The procedure is done to open the membrane present in the fi rst part of aqueduct. The short-segment stenosis yield better results than long-segment obstruction. It requires extensive experience of handling the fl exible endoscope. Aqueductoplasty can be supplemented with stent placement.16 The out-come is dependent on the patency of fourth ventricle outlets and absorption of CSF as in ETV.

Magendo Luschcoplasty/Magendostomy Luschcostomy: After performing aqueductoplasty, the fourth ventricle outlet can be opened with fl exible scopes. There are no published series of such procedure as of now.

Septoplasty: Multisegment hydrocephalus can be aff ectively treated with endoscope. The idea behind is to combine the various or most of the loculated fl uid-fi lled area as one chamber following which they can be drained by a shunt tube or ETV. The exact etiology of multiloculated hydrocephalus is not clear. It may be the result of infection, ventriculitis, ependymitis, or poor embryological development.

IndicationsThe most consistent reports have been on the good outcome of ETV in aqueductal stenosis with success rate ranging from 70 to 90%.17–19 It can be productive in both primary as well as secondary aqueductal stenoses. Most authors have reported inferior outcome in infants which could be related to poor absorption ability of infants and younger kids.20–27

Good outcome has been shown with triventriculomegaly, presence of periventricular ooze, and good size ostomy.28,29

Radiological recovery takes longer period than clini-cal improovment.30–32 After ETV, some patients may remain symptomatic for 10 days. This period referred as adaptation period is a time for CSF dynamics to adjust via new open-ing. Some centers recommend repeated lumbar drainage for about a week time to cover adaptation period. We, however, feel that lumbar puncture (LP) drainage may further alter the CSF pressure and may actually be harmful for the fl ow of CSF via new ETV site.

ETV in posterior fossa tumors and brain stem tumors have yielded good results leading to prevention of shunt place-ment.33–36 Unlike VP shunt, there is no risk of reverse her-


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3Hydrocephalus: Role of Endoscopic Third Ventriculostomy

in selected cases and re-ETV shows similar results as pri-mary ETV. Results of re-ETV are better than primary ETV in children.

Rescue Endoscopic Third VentriculostomyGoyal et al66 reported a situation wherein repeated shunt failure of 13 times had no suitable site in abdomen to allow a fresh insertion. ETV was the only remedy in such case with good follow-up of 3 years. Such situations can be seen some-time in busy neurosurgical centers.

Complications of Endoscopic Third VentriculostomyAlthough a safe procedure, complication following ETV in a large series was around 8 to 10%. The fatal complications are usually rare but can happen with rupture of basilar artery or its branches.67–72

Complications can be broadly classifi ed as intraopera-tive and postoperative. Intraoperative complications include severe hemodynamic changes during perforation of fl oor and irrigation of cavity. Although bradycardia is reported by many, the tachycardia preceding bradycardia has been observed by Ganjoo et al.73 The hemodynamic changes are temporary but need to be observed diligently. In our center putting an arterial line is obligatory so as to have continuous monitoring of pulse and BP. In the event of any remarkable deviation from the baseline, surgeon is immediately warned by the anesthetist so as to modify or withhold the step being performed.

Minor bleeding during the procedure can be controlled by continuous irrigation and at time occluding the outfl ow channel of irrigation fl uid. This produces a tamponade eff ect within ventricle and stops the bleeding. This step has to be monitored for any hemodynamic changes.

Coagulation of bleeding sources can be obtained by cau-terization. Major bleed, however, is diffi cult to manage and may require placement of external drain and continuous irrigation to avoid blockage of tubings.

Damage to fornix, thalamus, septal, and thalamostriate vein can result during surgery and may cause moderate to severe neurological defi cits.

Postoperative complications are often the results of improper selection of case. Patients with large ventricle and age less than 1 year form subdural hygroma. There is no way to prevent as it is due to sudden load of fl uid in the brain from one to another compartment. It may require repeated tapping or placement of subdural drain. The CSF leak from the incision site occurs in such cases. Such leak in most cases can be managed with additional sutures. There is risk of meningitis; hence, prophylactic antimeningitic is recommended.

reporting a higher success (78%) when ETV is combined with choroid plexus fulguration.47–51 It may be imperative to suggest that in these cases, there may be over production of CSF as well. Chiari malformations of both types, that is, types 1 and II, have shown improvement following ETV with later have better results (94%).

Hydrocephalus due to HemorrhageWith limited visibility in patient with hemorrhage of any etiology, the ETV has not been very popular. The eff ect of the bleed in technical hindrance in performing ETV can be improved by thorough washing of ventricular cavity with ringer lactate at body temperature.

The subependymal hemorrhage associated with prema-ture baby gives tiger skin appearance in ventricular wall. There are associated defective arachnoid villi in such cases leading to poor absorption and failures.52–55 The success rate is further compromised due to small age of the patients. In subarachnoid hemorrhage due to aneurysm rupture, there can be limited short-term advantages and may avoid place-ment of external drain.

Endoscopic Third Ventriculostomy in Shunt DysfunctionOne of the newly added indications of ETV has been shunt failures. Although it provides an opportunity for freedom from shunt, the factors for the success of ETV in such cases is same as that in primary ETV in nonshunted cases.56–61 Although success rate has been reported from 63 to 80%, the freedom from shunt has not been widely reported. It has been suggested by some that shunt should not be blindly removed after performing ETV. They showed neovasculari-zation of tube from surrounding ependyma which can be a source of potential life-threatening bleed while removing shunt tube.

Ostomy Closure and Repeat Endoscopic Third VentriculostomyFailure of ETV occurs in 8 to 60%. Early failures are due to wrong selection or inadequate ETV. Late failures are due to true restenosis. Re-ETV can be performed in the same way as primary ETV. The success of re-ETV in early and late failures is 50 and 78%, respectively.62–65 The pro-cedure involves careful scrutiny of cases and cine MRI is helpful to document adequacy of stoma. The stoma closure involves a complex procedure wherein exudative response is converted in fi brous reaction and intraoperative bleed-ing, overhanging margins of ETV and presence of shunt tube are predisposing factors for ostomy closure. Failure to open second membrane, poor size ostomy, and infection results in failure of ETV. The procedure can be repeated


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tectal plate gliomas. Neurosurgery 2002;51(1):63–67, discussion 67–68

18. Singh D, Gupta V, Goyal A, et al. Endoscopic third ventriculostomy in obstructed hydrocephalus. Neurol India 2003;51(1):39–42

19. Feng H, Huang G, Liao X, et al. Endoscopic third ventriculostomy in the management of obstructive hydrocephalus: an outcome analy-sis. J Neurosurg 2004;100(4):626–633

20. Ray P, Jallo GI, Kim RY, et al. Endoscopic third ventriculostomy for tumor-related hydrocephalus in a pediatric population. Neurosurg Focus 2005;19(6):E8

21. Amini A, Schmidt RH. Endoscopic third ventriculostomy in a series of 36 adult patients. Neurosurg Focus 2005;19(6):E9

22. Garg A, Suri A, Chandra PS, Kumar R, Sharma BS, Mahapatra AK. Endoscopic third ventriculostomy: 5 years’ experience at the All India Institute of Medical Sciences. Pediatr Neurosurg 2009;45(1):1–5

23. Roopesh Kumar SV, Mohanty A, Santosh V, et al. Endoscopic options in management of posterior third ventricular tumors. Childs Nerv Syst 2007;23(10):1135–1145

24. Dusick JR, McArthur DL, Bergsneider M. Success and complication rates of endoscopic third ventriculostomy for adult hydrocephalus: a series of 108 patients. Surg Neurol 2008;69(1):5–15

25. Gangemi M, Mascari C, Maiuri F, Godano U, Donati P, Lon-gatti PL. Long-term outcome of endoscopic third ventriculos-tomy in obstructive hydrocephalus. Minim Invasive Neurosurg 2007;50(5):265–269

26. Jenkinson MD, Hayhurst C, Al-Jumaily M, Kandasamy J, Clark S, Mallucci CL. The role of endoscopic third ventriculostomy in adult patients with hydrocephalus. J Neurosurg 2009;110(5):861–866

27. Sacko O, Boetto S, Lauwers-Cances V, Dupuy M, Roux FE. Endo-scopic third ventriculostomy: outcome analysis in 368 procedures. J Neurosurg Pediatr 2010;5(1):68–74

28. Fritsch MJ, Kienke S, Ankermann T, Padoin M, Mehdorn HM. Endo-scopic third ventriculostomy in infants. J Neurosurg 2005;103(1, Suppl):50–53

29. Elgamal EA, El-Dawlatly AA, Murshid WR, El-Watidy SM, Jamjoom ZA. Endoscopic third ventriculostomy for hydrocephalus in children younger than 1 year of age. Childs Nerv Syst 2011;27(1):111–116

30. Santamarta D, Martin-Vallejo J. Evolution of intracranial pres-sure during the immediate postoperative period after endoscopic third ventriculostomy. Acta Neurochir Suppl (Wien) 2005;95:213–217

31. Nishiyama K, Mori H, Tanaka R. Changes in cerebrospinal fl uid hydrodynamics following endoscopic third ventriculostomy for shunt-dependent noncommunicating hydrocephalus. J Neurosurg 2003;98(5):1027–1031

32. Cinalli G, Spennato P, Ruggiero C, et al. Intracranial pressure monitor-ing and lumbar puncture after endoscopic third ventriculostomy in children. Neurosurgery 2006;58(1):126–136, discussion 126–136

33. El-Ghandour NM. Endoscopic third ventriculostomy versus ven-triculoperitoneal shunt in the treatment of obstructive hydroceph-alus due to posterior fossa tumors in children. Childs Nerv Syst 2011;27(1):117–126

34. Tamburrini G, Pettorini BL, Massimi L, Caldarelli M, Di Rocco C. Endoscopic third ventriculostomy: the best option in the treatment of persistent hydrocephalus after posterior cranial fossa tumour removal? Childs Nerv Syst 2008;24(12):1405–1412

35. Fritsch MJ, Doerner L, Kienke S, Mehdorn HM. Hydrocephalus in children with posterior fossa tumors: role of endoscopic third ven-triculostomy. J Neurosurg 2005;103(1, Suppl):40–42

Hypothermia, fever, and other hypothalamic dysfunction have also been reported following ETV. There can be foreign body reaction to shunt which can lead to adhesion formation and bleeding.74

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5Hydrocephalus: Role of Endoscopic Third Ventriculostomy

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Clinical Neuroendoscopy by Venkataramanaa

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