Endoport-Assisted Endoscopic Surgery for Removal of Lateral Ventricular Tumors: Our Experience and Review of the Literature.

Background: Endoscopic surgery has emerged in recent years as an alternative to conventional microsurgical approaches for removal of intraventricular tumors. Endoports have enhanced tumor access and visualization with a significant reduction in brain retraction. Objective: To evaluate the safety and efficacy of endoport-assisted endoscopic technique for the removal of tumors from the lateral ventricle. Methods: The surgical technique, complications, and postoperative clinical outcomes were analyzed with a review of the literature. Results: Tumors were primarily located in one lateral ventricular cavity in all 26 patients, and extension to the foramen Monro and the anterior third ventricle was observed in seven and five patients, respectively. Except for three patients with small colloid cysts, all other tumors were larger than 2.5 cm. A gross total resection was performed in 18 (69%), subtotal in five (19%), and partial removal in three (11.5%) patients. Transient postoperative complications were observed in eight patients. Two patients required postoperative CSF shunting for symptomatic hydrocephalus. All patients improved on KPS scoring at a mean follow-up of 4.6 months. Conclusions: Endoport-assisted endoscopic technique is a safe, simple, and minimally invasive method to remove intraventricular tumors. Excellent outcomes comparable to other surgical approaches can be achieved with acceptable complications.

Surgical Management of Tuberculum Sellae Meningioma: Our Experience and Review of the Literature.

BACKGROUND: Tuberculum sellae (TS) meningiomas are benign lesions that produce neurological deficits through a mass effect on vital neurovascular structures. The treatment of choice is surgical removal with the ultimate goal to improve vision and achieve total tumor removal. OBJECTIVE: We analyzed clinical features, tumor characteristics, and surgical approaches in 62 consecutive patients with TS meningiomas to identify factors influencing the postoperative outcome. METHODS: The authors reviewed the medical records of all patients of TS meningiomas who underwent surgery at our institute between 2005 and 2018. Pre- and postoperative clinical data, including the operative findings, of these patients were analyzed. RESULTS: Sixty-two patients who underwent surgery for removal of TSM, transcranial (TCA) in 38, and endoscopic endonasal (EEA) in 24, were identified. Gross total resection was performed in 84% and 87.5% patients in the TCA and EEA groups, respectively. A significantly higher rate of visual improvement was observed in the EEA group as compared to TCA (96% versus 79%). Visual worsening after surgery was greater with TCA than EEA (21% versus 4%). Fourteen (37%) patients in the TCA group experienced different postoperative complications, and CSF leak was the main complication in the EEA group. CONCLUSIONS: TCA and EEA are both associated with higher rates of GTR and visual improvement without compromising the safety of the procedure. An optimal outcome, however, depends on the careful selection of cases based on the tumor location and morphology, and the surgeon's familiarity with the surgical approach.

Management of Posthemorrhagic Hydrocephalus.

BACKGROUND: Although there are several successful treatment options available today, the optimal management of posthemorrhagic hydrocephalus (PHH) still remains undetermined. OBJECTIVE: To evaluate the efficacy and outcomes of contemporary treatment methods and to define current evidence-based management for PHH in premature infants. MATERIAL AND METHODS: Literature was reviewed to identify and analyze merits and demerits of the currently available temporizing measures and definitive treatment for premature low-birth weight babies with PHH. RESULTS AND CONCLUSIONS: Advances in treatment and increased experience have led to redefinition of treatment goals to optimize cognitive neurodevelopment, and quality of life in these premature infants with PHH. Current literature favors early diagnosis and intervention using temporizing measures, and prevention of future complications of PHH with a permanent CSF diversion method such as ventricular shunting or endoscopic third ventriculostomy.

Indian Society of Pediatric Neurosurgery Consensus Guidelines on Preventing and Managing Shunt Infection: Version 2020-21.

BACKGROUND: Shunt infection is the most significant morbidity associated with shunt surgery. Based on the existing literature for the prevention and management of shunt infection, region and resource-specific recommendations are needed. METHODS: In February 2020, a Guidelines Development Group (GDG) was created by the Indian Society of Paediatric Neurosurgery (IndSPN) to formulate guidelines on shunt infections, which would be relevant to our country and LMIC in general. An initial email survey identified existing practices among the membership of the IndSPN, and eight broad issues pertaining to shunt infection were identified. Next, members of the GDG performed a systematic review of the literature on the prevention and management of shunt infection. Then, through a series of virtual meetings of the GDG over 1 year, evidence from the literature was presented to all the members and consensus was built on different aspects of shunt infection. Finally, the guidelines document was drafted and circulated among the GDG for final approval. Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was used to grade the evidence and strength of recommendation. RESULTS: The guidelines are divided into eight sections. Level I and Level II evidence was available for only five recommendations and led to a moderate level of recommendations. Most of the available evidence was at Level III and below, and hence the level of recommendation was low or very low. A consensus method was used to provide recommendations for several issues. CONCLUSIONS: Although most of the recommendations for the prevention and management of shunt infections are based on a low level of evidence, we believe that this document will provide a useful reference to neurosurgeons not only in India but also in other low and middle income countries. These guidelines need to be updated as and when new evidence emerges.

Holocord Tanycytic Ependymoma: An Interesting Case with Unusual Presentation, Challenging Histological Diagnosis, and Single-staged Complete Tumor Resection.

An interesting case of intramedullary holocord cystic tumor in an 11-year old boy is reported, who presented with unusual clinical manifestations and radiological features. Gross total resection of the tumor was performed in a single-staged surgery. A rare combination of unusual presentation, uncommon histopathological findings, and challenges in the selection of surgical options were discussed with a detailed review of the literature.

Endoscopic endonasal transplanum transtuberculum approach for retrochiasmatic craniopharyngiomas: Operative nuances.

The surgical treatment of craniopharyngiomas is challenging. An optimal surgical approach is extremely important to achieve complete removal of the tumor, which is often the goal of treatment. Conventionally, the endoscopic transsphenoidal approach is used for resection of craniopharyngiomas that are essentially confined to the sellar cavity, or have smaller suprasellar extension. However, the tumors located in the retrochiasmatic space are difficult to remove surgically due to a poor access. Traditionally, various transcranial microsurgical routes have been employed with limited success for resection of retrochiasmatic craniopharyngiomas. The transcranial approaches generally do not provide adequate exposure of the tumors originating in the space under the optic chiasm and nerves. Recently, the extended endonasal endoscopic surgical route, obtained by removal of the tuberculum sellae and planum sphenoidale, has been used with great success in the surgical management of tumors lying ventral to the optic chiasm, including craniopharyngiomas. It offers a direct midline access to the retrochiasmatic space and provides excellent visualization of the undersurface of the optic chiasm. It also allows extracapsular dissection using binostril-bimanual technique and facilitates complete removal of these formidable tumors. In this report, we describe step-by-step, the technical details of the endonasal endoscopic transplanum transtuberculum approach with emphasis on the operative nuances for removal of retrochiasmatic craniopharyngiomas.

Current perspectives in the management of glomus jugulare tumors.

Glomus jugulare tumors are benign but locally aggressive tumors. Their location, spread to adjacent areas and biological behavior have been extensively studied and reported. However, controversy exists regarding the role of surgery and stereotactic radiosurgery. The optimal plan of management of the tumor in close proximity to the facial and lower cranial nerves, the internal carotid and vertebral arteries, the venous sinuses, and the neuraxis is still nebulous. This review will discuss the differing viewpoints and attempts to propose a rational strategy in dealing with these tumors.

Extended endoscopic endonasal transsphenoidal approach for retrochiasmatic craniopharyngioma: Surgical technique and results.

OBJECTIVE: Surgical treatment of retrochiasmatic craniopharyngioma still remains a challenge. While complete removal of the tumor with preservation of the vital neurovascular structures is often the goal of the treatment, there is no optimal surgical approach available to achieve this goal. Transcranial and transsphenoidal microsurgical approaches, commonly used in the past, have considerable technical limitations. The extended endonasal endoscopic surgical route, obtained by removal of tuberculum sellae and planum sphenoidale, offers direct midline access to the retrochiasmatic space and provides excellent visualization of the undersurface of the optic chiasm. In this report, we describe the technical details of the extended endoscopic approach, and review our results using this approach in the surgical management of retrochiasmatic craniopharyngiomas. METHODS: Fifteen children, including 9 girls and 6 boys, aged 8 to 15 years underwent surgery using extended endoscopic transsphenoidal approach between 2008 and 2014. Nine patients had a surgical procedure done previously and presented with recurrence of symptoms and regrowth of their residual tumors. RESULTS: A gross total or near total excision was achieved in 10 (66.7%) patients, subtotal resection in 4 (26.7%), and partial removal in 1 (6.7%) patient. Postoperatively, headache improved in 93.3%, vision recovered in 77.3%, and the hormonal levels stabilised in 66.6%. Three patients (20%) developed postoperative CSF leaks which were managed conservatively. Three (20%) patients with diabetes insipidus and 2 (13.3%) with panhypopituitarism required long-term hormonal replacement therapy. CONCLUSIONS: Our early experience suggests that the extended endonasal endoscopic approach is a reasonable option for removal of the retrochiasmal craniopharyngiomas. Compared to other surgical approaches, it provides better opportunities for greater tumor removal and visual improvement without any increase in risks.

Surgical management of selected pituitary macroadenomas using extended endoscopic endonasal transsphenoidal approach: early experience.

BACKGROUND AND OBJECTIVES: The endoscopic transsphenoidal approach is commonly used surgical approach for pituitary adenomas. However, adenomas with dumbbell configuration, pure suprasellar location, and fibrous consistency are difficult to remove by this approach. Recently, the extended endoscopic endonasal approach (EEEA) has been utilized to excise this subgroup of pituitary adenomas successfully. MATERIALS AND METHODS: Between January 2009 and December 2011, 13 patients with pituitary macroadenomas were treated with EEEA. The tumor subgroups included: Dumbbell tumor configuration (4), pure suprasellar tumor location (2), and large suprasellar tumors with subfrontal extension (2). Five patients had fibrous/recurrent tumors and required addition of transtubercular-transplanum extension to the standard endoscopic endonasal exposure for radical resection. RESULTS: The tumor removal was gross total in 8 (61.5%) patients, subtotal in 4 (30.7%), and partial in 1 (7.7%) patient. Clinical improvement was observed in almost all patients, immediate relief in headaches in 88% and normalization of vision in 90% of patients with pre-operative visual disturbances. Three patients with secreting adenomas, two with growth hormone-secreting adenomas and one with prolactin-secreting adenoma, had normalization of hormonal status. Three patients developed temporary diabetes insipidus two patients suffered transient ischemic attacks and one patient with a recurrent giant pituitary adenoma experienced a serious injury to the perforating artery. Four patients (30.7%) developed post-operative cerebrospinal rhinorrhea and two patients required surgical repair. CONCLUSIONS: Our early experience suggests that the EEEA offers a potentially viable treatment option in certain pituitary tumors which are difficult to remove by the standard endoscopic approaches. However, longer follow-up and larger series are needed to establish the efficacy of this approach.

Reducing CSF shunt placement in patients with spinal myelomeningocele.

OBJECT: The incidence of hydrocephalus requiring shunts in children with myelomeningocele (MMC) is reported to be very high. Shunt-related complications are a significant cause of morbidity and mortality in this population. In order to minimize shunt placements, we used very rigid clinical selection criteria and followed them in all patients who had myelomeningocele and enlarged ventricles. The follow-up outcome of this retrospective study is reported. METHODS: From 2000 to 2007, 23 patients with myelomeningocele and variable degree of hydrocephalus were treated at our institute with primary surgical closure of their myelomeningoceles without a CSF diversion procedure. Patients with severe hydrocephalus who required immediate shunt insertion, and those with no significant associated hydrocephalus were not included in this study. Data regarding the surgical results and complications, postoperative management, and the outcome at follow-up were obtained from their hospital records. RESULTS: Initially increased size of the ventricular system was found to have decreased or stabilized in 17 (81%) patients postoperatively. However, ventriculomegaly continued to progress further in 4 (19%) out of 21 patients. Of 11 patients who presented with enlarged head, eight (73%) patients showed reduction or stabilization in their head circumference. Three (27%) children continued to have progressive head enlargement in the postoperative period and required shunt placement. Signs of raised intracranial pressure observed in six patients on admission, improved in two (33%) and persisted or worsened in four (67%) patients who eventually improved after the insertion of a shunt. Eight (35%) patients experienced wound-related complications following closure of the MMC, including CSF leak in four, wound infection in three, wound breakdown in three, and pseudomeningocele in two patients. Shunt placement was required in the postoperative period in 13 (56.5%) patients to treat raised intracranial pressure in 11 and CSF leak from the wound in two patients. CONCLUSIONS: Our experience suggests that the placement of shunts can be reduced by adopting a policy with strict clinical and radiographic criteria. Shunt insertion should be reserved for only those patients who have severe hydrocephalus with clinical features of elevated intracranial pressure. Mild to moderate ventricular dilatation, persistent ventriculomagaly, and some increase in ventricular size after myelomeningocele repair can be treated successfully without a shunt.

Cauda equina paraganglioma presenting with intracranial hypertension: case report and review of the literature.

An unusual case of intradural paragangliomas in the cauda equina region in a 29-year-old male is presented. The patient presented with signs and symptoms of raised intracranial pressure. The symptoms resolved after tumor resection.