Endoscopic Treatment of an Adult with Tegmental Astrocytoma Accompanied by Cerebrospinal Fluid Dissemination

Midbrain gliomas are relatively rare neoplasms with a generally benign prognosis, with dissemination or metastasis not previously reported. We describe here a woman, in whom magnetic resonance imaging scans showed hydrocephalus and a tegmental lesion in the upper aqueduct. Endoscopic third ventriculostomy and biopsy were performed; during surgery, a second small lesion was observed in the infundibular recess. Histologically, the two lesions had the characteristics of low grade astrocytoma, suggesting that the midbrain astrocytoma may have been disseminated via the cerebral spinal fluid to the infundibular recess. Postoperatively this patient received radiotherapy for nearly one month. Although patients with these tumors are not usually administered adjunctive therapy, radiation and, combined modality therapy, including surgery, radiotherapy, and chemotherapy, may be beneficial in patients with midbrain gliomas with dissemination.

From Exoscope into the Next Generation

An exoscope, high-definition video telescope operating monitor system to perform microsurgery has recently been proposed an alternative to the operating microscope. It enables surgeons to complete the operation assistance by visualizing magnified images on a display. The strong points of exoscope are the wide field of view and deep focus. It minimized the need for repositioning and refocusing during the procedure. On the other hand, limitation of magnifying object was an emphasizing weak point. The procedures are performed under 2D motion images with a visual perception through dynamic cue and stereoscopically viewing corresponding to the motion parallax. Nevertheless, stereopsis is required to improve hand and eye coordination for high precision works. Consequently novel 3D high-definition operating scopes with various mechanical designs have been developed according to recent high-tech innovations in a digital surgical technology. It will set the stage for the next generation in digital image based neurosurgery.

Clinical Experience of Infantile Posthemorrhagic Hydrocephalus Treated with Ventriculo-Peritoneal Shunt / 대한신경손상학회지

OBJECTIVE: Infantile posthemorrhagic hydrocephalus (IPHH) is the most common cause of infantile acquired hydrocephalus. We present and discuss our experience of treatment of six IPHH patients treated by a ventriculo-peritoneal (VP) shunt. METHODS: Six preterm infants treated by a VP shunt due to germinal matrix hemorrhage and hydrocephalus were included in our study. External ventricular drainage (EVD) was performed in patients with symptomatic ventricular dilatation, and a VP shunt was placed in the case of no improvement of the ventricular index despite several rounds of EVD. Radiographic findings and surgical outcomes were analyzed retrospectively. RESULTS: Four patients were male and two were female. Mean gestational age was 25 weeks and mean weight at birth was 868.3 g. One patient had a Papile grade II (16.7%) hemorrhage, three had a grade III (50%) hemorrhage, and two had a grade IV (33.3%) hemorrhage. EVD complications (one case of ventriculitis and one case of a ventricular abscess) occurred in two patients. VP shunt complications occurred in two patients (33.3%). Three cases had an isolated 4th ventricle; two of these cases had a VP shunt placed whereas the other case had a VP shunt placed in addition to aqueductoplasty using a neuroendoscope. At the last follow-up, three of the six patients had severe neurodevelopmental delay, two had mild neurodevelopmental delay, and one had normal development status. CONCLUSION: In our study, although it is difficult to present the significant result for management of IPHH, we think that varied efforts are required to treat IPHH patients.

Combined application of neuroendoscope and laparoscope in ventriculo-peritoneal shunt for treatment of communicating hydrocephalus / 中华外科杂志

<p><b>OBJECTIVE</b>To summarize the clinical efficacy of ventriculo-peritoneal shunt (VPS) assisted by neuroendoscopy and laparoscopy for treatment of communicating hydrocephalus.</p><p><b>METHODS</b>From January 2010 to January 2014, 209 cases (male 93, female 116) who suffered communicating hydrocephalus performed VPS with neuroendoscopy and laparoscopy in Department of Neurosurgery of People's Liberation Army General Hospital. The age of the patients were from 7 months to 79 years (mean 38.1 years), average duration were 20 days to 4 years (mean (2.4 ± 0.7) months). Neuroendoscopy and laparoscopy were used to help respectively to place shunt catheter to better position, both in the ventricle and peritoneal cavity. The effect of subsequent shunt system survival was analyzed with Kaplan-Meier survival analysis.</p><p><b>RESULTS</b>There were 209 patients received 255 times of VPS. All operations were successfully completed. No craniotomy or open operation were needed for technical-related complications. Forty-six revisions were performed in all patients. After the operation, 203 patients with hydrocephalus improved at different level after surgery. Thirteen cases occurred intracranial hypotension syndrome and improved after the pressure adjusted. All patients were followed up for 1 month to 4 years, with a median follow-up time of 2.1 years, while the shunt system efficiencies were 91.0%, 86.7%, 83.9% and 82.0% respectively from the end of the 1st year to the end of the 4th year.</p><p><b>CONCLUSIONS</b>For VPS, neuroendoscopy and laparoscopy can respectively help to place shunt catheter to better position, both in the ventricle and peritoneal cavity. Hence, the combination of these two modalities can reduce the failure rate of shunt catheter insertion and has significant impact on shunt system survival.</p>

Choice of the surgical approach to petroclival tumor / 中华外科杂志

<p><b>OBJECTIVE</b>To discuss the reasonable choice of the surgical approach to petroclvial tumors.</p><p><b>METHODS</b>The clinical data of consecutive 53 patients with the petroclival tumors, treated from June 2002 to June 2004, were reviewed to compare the different surgical approaches to pertroclival region.</p><p><b>RESULT</b>Subtemporal transtentorial approach were used in 11 patients, suboccipital retrosigmoid approach in 12 patients, (transzygomatic or orbitozygomatic) frontotemporal (pterional) approach in 12 patients, presigmoid sinus approach in 2 patients, subtemporal and retrosigmoid sinus combined approach in 7 patients, subtemporal anterior petrosal extradural approach in 7 patients and extended transfrontal base extradural approach in 2 patients. Of all patients in this group, total tumor removal was achieved in 32 patients, subtotal in 9, largely partial in 12. The new cranial nerve deficit took place in 16 patients postoperatively, two patients died from coma and serious pneumonia.</p><p><b>CONCLUSIONS</b>Using perfect microsurgical technique, conventional surgical approaches on petroclival region such as suboccipital retrosigmoid approach, subtemporal transtentorial approach can be suitable for most petroclival tumor with the help of neuro-navigation and neuro-endoscopy. To the epidural tumor on petroclival region, the epidural approach should be used with less invasion to the brain tissue. And to the giant petroclival tumor, the combined-tentorial approach can provide an excellent access and exposure to the tumor.</p>

Observación del sistema ventricular y espacio subaracnoideo de la base del cráneo por neuroendoscopia flexible: Estructuras normales / Observation of the ventricular system and subarachnoid space in the skull base by flexible neuroendoscopy: normal structures

En las últimas dos décadas a nivel mundial y en la última década en Latinoamérica, especialmente en México, la endoscopia cerebral como parte de la cirugía neurológica de mínima invasión ha sido un paso de gran importancia para el tratamiento de enfermedades neurológicas T4 como hidrocefalia congénita o adquirida, malformaciones Chiari, neurocisticercosis, enfermedad vascular cerebral, tumores o quistes ventriculares y paraventriculares, quistes aracnoideos e hidrocefalias secundarias a disfunciones valvulares. Entre las regiones más inaccesibles al sistema nervioso central se encuentran los ventrículos laterales, el tercer ventrículo, el acueducto cerebral, el cuarto ventrículo y el espacio subaracnoideo de la base del cráneo. Gracias a los sistemas de fibra óptica y luz en combinación con la experiencia de nueve años consecutivos y más de 600 endoscopias realizadas, en su mayoría endoscopias cerebrales flexibles, presentarnos el abordaje por medio de neuronavegación con endoscopía cerebral flexible de la anatomía normal y sus variantes de todo el sistema ventricular y el espacio subaracnoideo de la base del cráneo, incluyendo el espacio subaracnoideo de la médula cervical. También presentamos las estructuras relacionadas a estos sitios como: venas, arterias, nervios craneales, glándula pituitaria y plexos coroideos.

Worldwide in the last two decades, in Latin America in the last decade, and Mexico in particular cerebral endoscopy as part of the minimally invasive neurological surgery, has constituted a significant advance for the treatment of neurological diseases such as congenital or acquired hydrocephalus, Chiari malformation, neurocysticercosis, stroke, ventricular and paraventricular tumors and cysts, arachnoidal cyst and hydrocephalus secondary to shunt malfunction. The lateral ventricles, the third ventricle, the cerebral aqueduct, the fourth ventricle, and the subarachnoid basal cisterns are among the most non accessible regions of the central nervous system. Due to light rand fiber optic systems in combination with the experiences of nine consecutive year's and more than 600 endoscopies, most of them flexible neuroendoscopies, we present the neuroendoscopic approach with flexible cerebral endoscope to the anatomy and its normal variants of the whole ventricle system and the subarachnoid basal cisterns including the subarachnoid space of the cervical spine. We also describe their site related structures including veins, arteries, cranial nerves, pituitary gland, choroidal plexus and their normal anatomic variants.

Endoscope-assisted Microsurgery to Internal Carotid Artery Aneurysms

OBJECTIVE: Complete obliteration of aneurysm while preserving the parent artery, its branches, and perforators is sometimes difficult in case of internal carotid artery(ICA) aneurysm because of its anatomic feature. To solve this problem, we report an experience of neuroendoscope in the surgery of the ICA aneurysm. METHODS: Between September 2002 and May 2003, eighteen patients with 19 ICA aneurysms underwent microsurgical clipping with the help of the neuroendoscope. A rigid rod lens neuroendoscope (Karl Storz, Tuttllingen, Germany) with the diameter of 4.0mm and angles of 0 or 30 degrees was used for all patients. RESULTS: The clips were repositioned or changed in 6 patients with detection of remnant aneurysm in neuroendoscope. Occlusion of the branch of anterior choroidal artery by clip in 2 patients was observed along the aneurysmal neck in neuroendoscope. There were no neuroendoscope-related complications. CONCLUSION: Neuroendoscope is a safe and useful instrument to confirm the optimal position of the clip in the microsurgery of patients with ICA aneurysm.

Stereotactic Endoscopic Evacuation of Intraventricular Hematomas

Over the last decades, the use of endoscope in neurosurgery gradually gained importance. Although the major indication of neuroendoscopic procedure is intraventricular procedures, the experience of neuroendoscopic intervention of intraventricular hemathoma is rather small. The authors present our experience of four patients with acute ventricular dilatation with intraventricular hematoma through frame-based stereotactic guidance. Through neuroendoscopic intervention, the clot was removed more than 80% each procedure. After the procedure, the silastic catheter was left for continuous intraventricular pressure monitoring. Neither thrombolytic agent nor hyperosmolar treatment was needed postoperatively. There was no mortality or morbidity directly related to endoscopic procedure itself. Brief overview of this technique is given.

Stereotactic Endoscopic Evacuation of Basal Ganglionic Intracerebral Hematoma - Three Case Report -

The application of stereotactic techniques and endoscopy dates back to the beginning of this century and is almost as old as neurosurgery itself. However, endoscopic techniques progressed slowly for several reasons. A reappraisal of endoscopic techniques become popular about 1985. The major indication of endoscope in neurosurgical field is intraventricular procedures. Recently it can be used selectively in the intraaxial mass lesion associated cavity. For example, cystic mass, with liquefied necrosis, blood clot can be approached with endoscope. Authors present its intraaxial application in basal ganglionic hematoma in three patients. Conventional stereotactic guidance of neuroendoscope was done and the hematoma was gently removed through continuous irrigation and suction under video-guidance. The clinical course was uneventful. Brief overview is given of this intraaxial neuroendoscopic procedure.