Prognostic factors for endoscopic third ventriculostomy success in hydrocephalus with myelomeningocele.

PURPOSE: Myelomeningocele (MMC) is a prevalent neural tube closure defect often associated with hydrocephalus, necessitating surgical intervention in a significant proportion of cases. While ventriculoperitoneal shunting (VPS) has been a standard treatment approach, endoscopic third ventriculostomy (ETV) has emerged as a promising alternative. However, factors influencing the success of ETV in MMC patients remain uncertain. This retrospective observational study aimed to identify clinical and radiological factors correlating with a higher success rate of ETV in MMC patients. METHODS: Medical records of MMC patients who underwent ETV at a tertiary care center between 2015 and 2021 were reviewed. Demographic, clinical, and radiological data were analyzed. ETV success was defined as the absence of further hydrocephalus treatment during follow-up. RESULTS: Of 131 MMC patients, 21 met inclusion criteria and underwent ETV. The overall success rate of ETV was 57.1%, with a six-month success rate of 61.9%. Age ≤ 6 months was significantly associated with lower ETV success (25%) compared to older patients (76.9%) (OR: 0.1; 95% CI 0.005-2.006; p = 0.019). Radiological factors, including posterior fossa dimensions and linear indices, did not exhibit statistically significant associations with ETV success. CONCLUSION: Age emerged as a significant factor affecting ETV success in MMC patients, with younger patients exhibiting lower success rates. Radiological variables did not significantly influence ETV outcomes in this study. Identifying predictors of ETV success in MMC patients is crucial for optimizing treatment strategies and improving patient outcomes.

Purely Endoscopic Supracerebellar Infratentorial Approach to the Pineal Region in Pediatric Population.

Pineal lesions represent less than 1% of all brain tumors (Villani et al., Clin Neurol Neurosurg 109:1-6, 2007). The abysmal location and critical neurovascular structures remain a surgical challenge, despite the advent of microneurosurgery. The classical wide surgical suboccipital craniotomy with the supracerebellar infratentorial approach, described by Sir Victor Horsley (Victor, Proc R Soc Med 3:77-78, 1910), is infamous for its considerable surgical morbidity and mortality. This was later upgraded microneurosurgically by Stein to improve surgical outcomes (Stein, J Neurosurg 35:197-202, 1971).Ruge et al. reported the first purely endoscopic fenestration of quadrigeminal arachnoid cysts via this corridor (Ruge et al., Neurosurgery 38:830-7, 1996). A cadaver-based anatomical study by Cardia et al. demonstrated the viability for endoscope-assisted techniques (Cardia et al., J Neurosurg 2006;104(6 Suppl):409-14). However, the first purely endoscopic supracerebellar infratentorial (eSCIT) approach to a pineal cyst was performed in 2008 by Gore et al. (Gore PA et al., Neurosurgery 62:108-9, 2008).Unlike transventricular endoscopy, eSCIT approach poses no mechanical risk to the fornices and can be utilized irrespective of ventricular size. More vascular control and resultant reduction in uncontrolled hemorrhage improve the feasibility of attaining complete resection, especially around corners (Zaidi et al,, World Neurosurg 84, 2015). Gravity-dependent positioning and cerebrospinal fluid (CSF) diversion aid cerebellar relaxation, creating the ideal anatomical pathway. Also, angle of the straight sinus, tentorium, and tectal adherence can often influence the choice of approach; thus direct endoscopic visualization not only counteracts access to the engorged Galenic complex but also encourages sharp dissection of the arachnoid (Cardia et al., J Neurosurg 104:409-14, 2006). These tactics help provide excellent illumination with magnification, making it less fatiguing for the surgeon (Broggi et al., Neurosurgery 67:159-65, 2010).The purely endoscopic approach thwarts the dreaded risk of air embolisms, via simple copious irrigation from a small burr hole (Shahinian and Ra, J Neurol Surg B Skull Base 74:114-7, 2013). The tiny opening and closure are rapid to create, and the smaller wound decreases postoperative pain and morbidity. Recent literature supports its numerous advantages and favorable outcomes, making it a tough contender to traditional open methods.

A Single-Centre Experience of the Management and Surgical Outcomes of Late-Onset Idiopathic Aqueductal Stenosis.

Background Although idiopathic aqueductal stenosis is a congenital disorder, some patients present in adulthood. Many theories have tried to account for the late-onset presentation; however, the aetiology remains uncertain. This study aimed to investigate the clinical presentation, management, and outcomes of patients with late-onset idiopathic aqueductal stenosis (LIAS) managed at our centre. Methodology A retrospective study of patients with a diagnosis of LIAS managed at our centre between 1996 and 2018 was undertaken. Data on clinical presentation, imaging, management, and outcomes were retrieved from patient records and radiology reports. Results A total of 20 patients were diagnosed with LIAS during the study period. Endoscopic third ventriculostomy (ETV) was the initial modality of treatment for nine patients, ventriculoperitoneal shunt (VPS) for four patients, and conservative management in seven patients, in four of them intracranial pressure (ICP) was found to be normal following a period of ICP monitoring. The median follow-up period was three years (1 month to 24 years). One patient was lost to follow-up. One ETV failed in the first six months necessitating VPS insertion. Two cases that were initially managed conservatively required a VPS three and nine years following the initial presentation. Of the patients undergoing VPS insertion, all subsequently required valve adjustment or surgical revision. Conclusions The majority of patients with LIAS undergoing ETV were managed successfully, whereas VPS insertion was associated with a high rate of revision surgery in this cohort. ETV should be considered as the treatment of choice to avoid the long-term complications of shunting for patients with LIAS.

The Landscape of Pediatric Hydrocephalus in the Province of KwaZulu-Natal: A Comparative Analysis of the Referral Pattern, Etiology, and Management Outcomes in 4 Distinct 5-Year Periods.

BACKGROUND: Pediatric hydrocephalus is a significant health burden globally, particularly in low- and middle-income countries. Data from specific regions such as KwaZulu-Natal, South Africa, are lacking. This study aimed to investigate pediatric hydrocephalus by comparing 4 distinct 5-year periods. METHODS: Data were collected retrospectively (2003-2007, 2008-2012, and 2013-2017) and prospectively (2018-2022). Children (≤18 years old) treated for hydrocephalus were included. Data on demographics, referral patterns, etiology, treatment modalities, and outcomes were collected and analyzed. RESULTS: A total of 3325 children were treated. The peak period was 2008-2012 (35.3%). Most children (51.4%) were from rural areas (P = 0.013), and 47.9% were referred from regional hospitals (P < 0.001). Boys (56.4%) and infants (60.2%) were predominant groups (P < 0.001). Postinfectious etiology (32.7%) was predominant (P < 0.001), particularly tuberculous meningitis (54.1%). Ventriculoperitoneal shunts were the mainstay treatment (84.2%), with notable complication rates (20.4%), including infections (9.6%). Human immunodeficiency virus co-infection was diagnosed in 2.5% of cases. Weekend procedures were associated with ventriculoperitoneal shunt complications (hazard ratio [HR] = 1.3, 95% confidence [CI]1.03-1.66, P = 0.03). Mortality rate was 7.9%, and age ≥1 year (HR = 2.43, 95% CI 1.87-3.17, P < 0.001), tertiary hospital referral (HR = 1.48, 95% CI 1.06-2.04, P = 0.019), ventriculoperitoneal shunt infection (HR = 3.63, 95% CI 2.66-4.95, P < 0.001), acute abdomen (HR = 2.17, 95% CI 1.11-4.25, P = 0.024), and pneumonia (HR = 7.32, odds ratio = 4.84-11.06, P < 0.001) were associated with mortality. CONCLUSIONS: This study provides comprehensive insights into pediatric hydrocephalus in KwaZulu-Natal. Monitoring temporal trends and predictors of outcomes will guide future interventions to mitigate the burden of pediatric hydrocephalus in the region.

Is endoscopic third ventriculostomy a viable treatment option for normal pressure hydrocephalus? A systematic review.

Background: Endoscopic third ventriculostomy (ETV) is considered an alternative treatment for hydrocephalus and has become a standard of care for obstructive hydrocephalus. Recent studies have also explored its role in normal pressure hydrocephalus (NPH). We conducted a systematic review aiming to assess the outcomes of this minimally invasive endoscopic technique as a viable treatment option for NPH. Methods: A systematic literature search was performed using PubMed and Scopus databases, using iterations of search terms "Endoscopic third ventriculostomy," "Idiopathic normal pressure hydrocephalus," and "Normal pressure hydrocephalus." To be eligible for inclusion in the review, articles had to report the usage of ETV as a primary treatment modality for NPH, report its outcomes, and be published in the English language. Results: Out of the 13 studies selected for qualitative synthesis, nine supported the use of ETV for NPH as an effective treatment option with improvement in the preoperative symptoms. Two studies favored shunt over ETV, stating that quality of life is better with VP shunt insertion. One study reported that ETV has higher perioperative mortality rates that outweigh its benefits. One study reported it to be an ineffective surgical option. Conclusion: The current review of evidence does not support the use of ETV for the treatment of NPH, except perhaps in a small subset of patients. These patients have a shorter duration of symptoms and a better preoperative neurological status. The lumbar infusion test and ventricular infusion test are modalities useful for selecting these candidates.

Huge hydrocephalus: a rare case series with insights into management and outcomes of this neglected cohort.

PURPOSE: This study aims to discuss the management challenges of huge hydrocephalus (HH), a severe subset of hydrocephalus, presenting predominantly in underprivileged backgrounds. Insights into the condition's characteristics, factors affecting outcomes, and associated morbidity are discussed. METHODS: A retrospective review of all operated cases of hydrocephalus with head circumference greater than body length (HC>L) was conducted (January 2019-January 2023). Data on epidemiological parameters, associated cranial abnormalities, cortical mantle thickness, peri-conceptional folic acid intake, surgical interventions, age-appropriate milestones, and complications were collected. Follow-up was conducted for at least 12 months or until expiration. RESULTS: The cohort consisted of 7 males and 5 females with age ranging from 3 to 48 months. 33% of them had associated neurological abnormalities, and 18 surgical interventions were needed for these 12 cases, including ventriculoperitoneal shunt or endoscopic diversion. A 17% wound breakdown rate requiring re-suturing was present, and 33% of cases had postoperative CSF infection, with 33% mortality, with only one case having age-appropriate development seen. The average hospital stay was 11.9 days, six times our center's average. All cases with an Evans index with an average of 0.7 expired within 12 months. None of the 12 mothers took peri-conceptional folic acid, and no case agreed to reduction cranioplasty. CONCLUSION: Huge hydrocephalus is a rare cohort with significant management challenges and poor prognosis even after treatment. Factors such as delayed intervention and low socioeconomic status contribute to adverse outcomes. Prevention through peri-conceptual folic acid intake and addressing socioeconomic disparities is crucial in reducing disease burden and improving prognosis.

Treatment of hydrocephalus following fetal repair of myelomeningocele: comparing endoscopic third ventriculostomy with choroid plexus cauterization to ventricular shunting.

OBJECTIVE: The aim of this study was to compare clinical and craniometric outcomes of patients treated for hydrocephalus following fetal myelomeningocele repair (fMMR) via a ventriculoperitoneal shunt (VPS) or endoscopic third ventriculostomy with choroid plexus cauterization (ETV/CPC). METHODS: This was a retrospective cohort study of children who were treated for hydrocephalus following fMMR via VPS or ETV with or without CPC (ETV ± CPC) at Vanderbilt between 2012 and 2021. The primary outcomes were treatment failure and time to failure (TTF). Secondary outcomes included changes in hydrocephalus metrics (fronto-occipital horn ratio [FOHR] and head circumference measurements) and healthcare resource utilization (number of hospital admissions, clinic visits, and neuroimaging findings). RESULTS: Among 88 patients who underwent fMMR, 37 (42%) required permanent CSF diversion, of whom 19 received treatment at the authors' institution. Twelve patients underwent ETV ± CPC, and 7 underwent VPS placement at a median corrected age of 23 weeks versus 1 week (p = 0.002). The preoperative median head circumference percentiles and z-scores for patients in the ETV ± CPC cohort were similar to those of the VPS cohort (percentiles: 98.5 vs 94.0, p = 0.064; z-scores: 2.32 vs 1.60, p = 0.111). There was no difference in preoperative median FOHR measurements between the two cohorts (0.57 vs 0.59, p = 0.53). At 6 months postoperatively, the median head circumference percentile and z-score for the ETV ± CPC cohort remained similar between the two cohorts (percentiles: 98.0 vs 67.5, p = 0.315; z-scores: 2.12 vs 0.52, p = 0.307). There was no difference in the change in FOHR (-0.06 vs -0.09, p = 0.37) and change in head circumference percentile (-1.33 vs -28.6, p = 0.058) between the cohorts 6 months after the index CSF diversion procedure. One patient in the ETV ± CPC cohort experienced a seizure and a nonoperative subdural hemorrhage postoperatively; no other complications were observed. Six of the 7 patients in the VPS cohort required shunt revision with a median TTF of 9.8 months while 2 of the 12 ETV ± CPC patients required a repeat ETV at a median of 17.5 months (86% vs 17%, p = 0.013). The median number of hydrocephalus-related hospital readmissions was significantly lower in the ETV ± CPC cohort than in the VPS cohort (0 vs 1, p = 0.006). The ETV ± CPC cohort had fewer CT scans (0 vs 2, p = 0.004) and radiographs (0 vs 2, p < 0.001) than the VPS cohort. CONCLUSIONS: In a single-center cohort, hydrocephalic fMMR patients treated via ETV ± CPC remained shunt free, while a majority of patients receiving an upfront shunt required revision. This is the first study comparing ETV ± CPC with VPS in the fMMR hydrocephalus population. While larger, multicenter studies are needed, these results suggest that ETV/CPC may be a preferred means of CSF diversion following fMMR.

Endoscopic Third Ventriculostomy for the Management of Obstructive Hydrocephalus in Pregnancy: A Case Report and Review of the Literature.

Introduction Hydrocephalus is a condition characterized by the abnormal accumulation of cerebrospinal fluid within the brain's ventricular system. It can stem from obstructive and nonobstructive causes. Pregnancy introduces physiopathological changes that may heighten the risk of developing or worsening symptomatic hydrocephalus. Nevertheless, comprehensive reports on this aspect, especially regarding surgical interventions, remain scarce. Case Report A young woman with a history of recurrent headaches experienced a worsening of her symptoms at the onset of her pregnancy. A magnetic resonance imaging (MRI) in the first trimester revealed increased ventricular dilation, indicating an obstructive cause due to aqueduct stenosis. During a neurosurgical board meeting, treatment options were discussed, considering the identifiable obstruction, the heightened intra-abdominal pressure associated with pregnancy, and the risk of ventricular shunt dysfunction. The patient underwent an endoscopic third ventriculostomy (ETV) without complications, leading to both symptom relief and a successful conclusion to the pregnancy. Discussion Neurosurgical procedures in pregnant women are uncommon due to the increased risks to both the mother and the fetus. However, when performed by a qualified multidisciplinary team, they can lead to positive outcomes. In cases of hydrocephalus during pregnancy, ETV appears to be a viable alternative for surgical intervention, particularly when hydrocephalus becomes symptomatic and an obstructive cause is identified, whether in patients with existing shunts or those with newly developed hydrocephalus.

Ventriculoperitoneal shunt placement following endoscopic third ventriculostomy failure in the treatment of pediatric hydrocephalus.

OBJECTIVE: The goal of this study was to evaluate the impact of endoscopic third ventriculostomy (ETV) failure on subsequent risk of ventriculoperitoneal shunt (VPS) placement. METHODS: A retrospective chart review was performed to identify pediatric patients receiving ETV followed by a VPS at Oklahoma Children's Hospital between January 1, 2016, and December 31, 2021. A control group of patients receiving a VPS alone was also gathered. Complication and shunt failure rates were compared between the 2 groups at 12 months postoperatively. RESULTS: A total of 222 patients were included in this study. The VPS placement after ETV failure (VPSEF) group included 21 patients; 53% were male and 47% were female, with a mean age of 2.2 years and standard deviation of 4.3 years. The etiology of hydrocephalus was chiefly intraventricular hemorrhage (43%) and neural tube defects (19%). At 12 months after VPS placement, the complication rate was 24%, predominantly including infection (19%) or CSF leakage (10%). The VPS-only (VPSO) group included 201 patients; 51% were male and 49% were female, with a mean age of 4.2 years and standard deviation of 6.5 years. The etiology of hydrocephalus was chiefly intraventricular hemorrhage (26%) and neural tube defects (30%). At 12 months postoperatively, the complication rate was 10%, predominantly including infection (6%) or catheter-associated hemorrhage (3%). The difference in complication rates between the VPSEF and VPSO groups was not significant at 12 months postoperatively (p = 0.07); however, on subgroup analysis there was a significantly higher rate of CSF leakage at 12 months in the VPSEF group compared to the VPSO group (p = 0.0371). CONCLUSIONS: There was no difference in overall complication rates for the treatment of pediatric hydrocephalus by VPS following failed ETV compared to VPS placement alone, yet prior ETV may predispose patients to a higher rate of CSF leaks within 12 months of VPS placement. Further study is indicated to determine whether a prior ETV procedure predisposes patients to a higher complication rate on VPS placement.

Standardized Criteria to Initiate External Ventricular Drain (EVD) Weaning in a Neurological Intensive Care Unit to Increase the Safety of EVD Discontinuation and Reduce the Need for a Shunt.

Introduction Patients with subarachnoid hemorrhages (SAH) with external ventricular drains (EVD) can develop chronic hydrocephalus (HCP), requiring permanent cerebrospinal fluid (CSF) diversion via an external shunt. Two different strategies have been used to assess for dependence on EVD: 1) prompt closure, and 2) gradual weaning. Gradual weaning of EVDs is performed by increasing drainage resistance to outflow over days. However, when to start one strategy or the other is up to the physician. No uniform guidelines exist raising a question: Are standardized criteria necessary to initiate the EVD weaning process for SAH patients to increase the safety of EVD discontinuation and reduce the need for a shunt? This study shares criteria used to initiate EVD weaning that displayed increased safety of EVD discontinuation for patients with subarachnoid hemorrhage requiring EVD, particularly with regards to length of hospital stay (LOS), hospital-acquired infection rates, and ventriculoperitoneal shunt/endoscopic third ventriculostomy (VPS/ETV) placement. Methods One hundred and fifty-one SAH patients from January 2016 to January 2019 were analyzed. 60 aneurysmal SAH (aSAH) and 18 non-aneurysmal nontraumatic SAH (naSAH) patients required EVD placement. A gradual EVD weaning protocol was initiated if patients met the following criteria: 1. The reason for EVD placement has resolved or is resolving, 2. The quantity of CSF output is <250mL over 24 hours, 3. Quality of CSF is nonbloody, 4. Intracranial Pressure (ICP) must be within normal limits, and 5. The patient must be neurologically stable. It was acceptable to initiate the weaning process when the patient had mild cerebral vasospasm, but not moderate to severe cerebral vasospasm. EVD weaning was performed by increasing the drain (chamber) height by 5 millimeters of mercury every 24 hours if the criteria were met. Charts were reviewed for LOS, infection rates, and rate of VPS/ETV. Gender, age, race, wean failure incidence, Hunt-Hess scores, modified Fisher scores, and syndrome of inappropriate antidiuretic hormone/cerebral salt wasting (SIADH/CSW) rates were obtained. Results The average LOS for aSAH patients with EVD was 20.35 days. The incidence of VPS/ETV was 11%. A chi-square analysis revealed that aSAH patients had higher rates of VPS/ETV placement (p<0.001) and EVD wean failures (p<0.001) than naSAH patients. aSAH patients had a lower incidence of VPS/ETV placement of 11% compared to 21% nationally. Conclusions Standardized criteria to initiate EVD weaning provided a reduction in VPS/ETV placement among aSAH patients compared to national averages and provided a uniform approach to EVD management. Comparable infection rates and LOS for SAH patients requiring EVDs compared to national averages were found.

Epileptic Seizures in a Pediatric Patient With Vein of Galen Aneurysmal Malformation and Obstructive Hydrocephalus: A Rare Case Report.

The vein of Galen aneurysmal malformation (VGAM) is a rare congenital arteriovenous fistula of the embryonic median prosencephalic vein of Markowski, resulting in its pathological dilation. If left untreated, it can lead to multiple severe complications in the neonatal period, among which obstructive hydrocephalus. We present a case report of a six-year-old male patient with severe status epilepticus and a clinical history of VGAM and obstructive hydrocephalus, diagnosed via an MRI and an MR-angiography. The hydrocephalus was treated via a ventriculostomy at the age of six months, while the VGAM underwent a partial transarterial endovascular embolization when the patient was four years old. The procedures were successful, and there were no significant post-operative complications observed. The epileptic seizures began at a later point and were successfully medicated with valproate. However, they resumed due to a lowering of the medication dosage by the patient's parents. The patient was given a new valproic acid regimen with an appropriate dosage, and his parents reported no further seizures. This case report emphasizes the use of appropriate prenatal and neonatal diagnostic methods for VGAM and explores the nature of the multi-procedural therapy approach towards the pathology and its complications in relation to a possibly idiopathic co-pathology, namely epilepsy.

Utility of intracranial pressure monitoring as a diagnostic tool in pediatric ventriculomegaly.

OBJECTIVE: Intracranial pressure (ICP) monitoring is commonly utilized for identifying pathologic ICP in cases of traumatic brain injury; however, its utility in hydrocephalic children has not been elucidated. Although patients with typical (pressure-active) hydrocephalus present with clear signs and/or symptoms and the need for cerebrospinal fluid (CSF) diversion is often clear, others may have arrested or pressure-compensated hydrocephalus with pathologic ICP elevation masked by ambiguous signs or are completely asymptomatic. Without treatment these pathologic ICP elevations may affect neurologic development or crescendo over time leading to neurological decline. The purpose of this study is to investigate the utility of ICP monitoring as a diagnostic tool in this relatively common patient population and identify ventriculomegaly patients with and without pathologic ICP, thus improving accuracy of identifying those with and without surgical needs. METHODS: 36 patients (≤ 17 years old) underwent 41 inpatient ICP recording sessions between 2016 and 2022 and were retrospectively reviewed. This included patients with a history of severe, nonprogressive ventriculomegaly and normal fundoscopic examinations lacking traditional signs and symptoms concerning for elevated ICP. Nighttime pathological plateau waves were defined as sustained elevations of ICP ≥ 2x baseline for a duration of ≥ 5 minutes. RESULTS: The mean age of patients was 5.5 years old (range 0-17 years old). 46.3% of patients had prior endoscopic third ventriculostomy (ETV), 14.6% had prior ventriculoperitoneal shunt (VPS), and 39% were without prior surgical intervention. Roughly half (51.2%) of patients had congenital ventriculomegaly while other patients had ventriculomegaly due to other pathologies such as germinal matrix hemorrhage/intraventricular hemorrhage (GMH/IVH) (29.3%), stroke (4.9%), cerebral infections/meningitis (2.4%), or unknown etiology (12.2%). The average procedure time was 19.1 ± 10.5 minutes, and mean length of stay was 2.8 ± 0.7 days. Pathologic ICP was demonstrated in 12 cases (29.3%), 4 (33.3%) of which were asymptomatic. Pathologic ICP was found in 7 of 19 (36.8%) in the prior ETV group, 1 of 6 (16.7%) in prior shunt group, and 4 of 16 (25%) in the non-surgical group (p = 0.649). Among those with pathologic ICP, 6 (50%) cases received an ETV, 5 (41.7%) cases underwent VPS placement, and 1 (8.3%) case underwent a VPS revision. There were no infectious complications or cases of hemorrhage. 4 patients required repositioning of the ICP monitor due to dislodgement. CONCLUSION: Inpatient ICP monitoring is a safe and effective diagnostic tool for evaluating the presence of pathologic ICP in severe, persistent non-progressive ventriculomegaly. The use of ICP monitoring may aid in identifying patients with pressure-compensated hydrocephalus who demonstrate pathologic ICP where surgical intervention may be warranted, while preventing unnecessary CSF diversion in those without pathology.

Evolution of Surgical Management of Pineal Region Tumors in the Pediatric Population: A 17-Year Experience at a Single Institution.

INTRODUCTION: Pineal region tumors have historically been challenging to treat. Advances in surgical techniques have led to significant changes in care and outcomes for these patients, and this is well demonstrated by our single institution's experience over a 17-year-period in which the evolution of diagnosis, treatment, and outcomes of pineal tumors in pediatric patients will be outlined. METHODS: We retrospectively collected data on all pediatric patients with pineal region lesions treated with surgery at Children's National Hospital (CNH) from 2005 to 2021. Variables analyzed included presenting symptoms, presence of hydrocephalus, diagnostic and surgical approach, pathology, and adverse events, among others. IRB approval was obtained (IRB: STUDY00000009), and consent was waived due to minimal risk to patients included. RESULTS: A total of 43 pediatric patients with pineal region tumors were treated during a 17-year period. Most tumors in our series were germinomas (n = 13, 29.5%) followed by pineoblastomas (n = 10, 22.7%). Twenty seven of the 43 patients (62.8%) in our series received a biopsy to establish diagnosis, and 44.4% went on to have surgery for resection. The most common open approach was posterior interhemispheric (PIH, transcallosal) - used for 59.3% of the patients. Gross total resection was achieved in 50%; recurrence occurred in 20.9% and mortality in 11% over a median follow-up of 47 months. Endoscopic third ventriculostomy (ETV) was employed to treat hydrocephalus in 26 of the 38 patients (68.4%) and was significantly more likely to be performed from 2011 to 2021. Most (73%) of the patients who received an ETV also underwent a concurrent endoscopic biopsy. No difference was found in recurrence rate or mortality in patients who underwent resection compared to those who did not, but complications were more frequent with resection. There was disagreement between frozen and final pathology in 18.4% of biopsies. CONCLUSION: This series describes the evolution of surgical approaches and outcomes over a 17-year-period at a single institution. Complication rates were higher with open resection, reinforcing the safety of pursuing endoscopic biopsy as an initial approach. The most significant changes occurred in the preferential use of ETVs over ventriculoperitoneal shunts. Though there has been a significant evolution in our understanding of and treatment for these tumors, in our series, the outcomes for these patients have not significantly changed over that time.

Endovascular balloon usage in endoscopic third ventriculostomy for hydrocephalus during a national shortage: case series and technical note.

Endoscopic third ventriculostomy (ETV) is a well-established surgical technique for treating hydrocephalus. Many providers have transitioned to utilizing the specialized Neuroballoon for the stoma dilation in ETV; however, these devices are intermittently unavailable during supply chain shortages. We present the experience of employing cardiac angioplasty and neurovascular balloons as substitutes for the Neuroballoon in 3 patients. The scepter balloon (Microvention), priced at $1800 compared to the standard $300 Neuroballoon (Integra), proved effective, but its pliability presented technical challenges. The substantial cost differential compared to a Neuroballoon ($300) raises economic considerations. The Cardiac TREK balloon (Abbott) was similarly effective, while also being easier to manage endoscopically and cheaper at $158. These experiences support the viability of non-neuroendoscopic specialized balloons as alternatives for ETV dilation of the floor of tuber cinereum.

Immunocompetent isolated cerebral mucormycosis presenting with obstructive hydrocephalus: illustrative case.

BACKGROUND: Isolated cerebral mucormycosis is rare in immunocompetent adults and is only sparsely reported to be associated with obstructive hydrocephalus. OBSERVATIONS: Here, the authors report a case of obstructive hydrocephalus secondary to central nervous system mucormycosis without other systems or rhino-orbital involvement and its technical surgical management. A 23-year-old, incarcerated, immunocompetent patient with history of intravenous (IV) drug use presented with syncope. Although clinical and radiographic findings failed to elucidate an infectious pathology, endoscopy revealed an obstructive mass lesion at the level of the third ventricle, which, on microbiological testing, was confirmed to be Rhizopus fungal ventriculitis. Perioperative cerebrospinal fluid diversion, endoscopic third ventriculostomy, endoscopic biopsy technique, patient outcomes, and the literature are reviewed here. The patient received intrathecal and IV amphotericin B followed by a course of oral antifungal treatment and currently remains in remission. LESSONS: The patient's unique presentation and diagnosis of isolated cerebral mucormycosis reveal this pathogen as a cause of ventriculitis and obstructive hydrocephalus in immunocompetent adult patients, even in the absence of infectious sequelae on neuroimaging.

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.

[Microsurgical ventriculostomy of the third ventricle with access through a burrhole in the treatment of midly located deep-seated brain tumors]. / Mikrokhirurgicheskaya ventrikulostomiya III zheludochka s dostupom cherez frezevoe otverstie v lechenii sredinno raspolozhennykh glubinnykh opukholei golovnogo mozga.

BACKGROUND: Currently, endoscopic third ventriculostomy and simultaneous biopsy of deep midline brain tumors are a generally accepted option in neurooncology. Nevertheless, effectiveness of this surgery and diagnostic accuracy of biopsy are not without drawbacks. An alternative to endoscopic surgery may be simultaneous microsurgical third ventriculostomy and biopsy of deep midline tumors. OBJECTIVE: To evaluate effectiveness and safety of burr hole microsurgical third ventriculostomy in the treatment of deep midline brain tumors. MATERIAL AND METHODS: We used transcortical (25 cases) and transcallosal (8 cases) approaches for microsurgical third ventriculostomy. RESULTS: Initially scheduled biopsy was performed in 19 cases, partial resection in 6 cases, subtotal resection in 4 cases and total resection in 4 cases. All patients underwent microsurgical third ventriculostomy. In 12 cases, stenting of stoma was performed in addition to ventriculostomy. Biopsy was informative in all cases. Postoperative follow-up period ranged from 3 to 44 months (mean 29 months). There was no postoperative hydrocephalus and need for shunting procedure. CONCLUSION: Burr hole microsurgery may be an alternative to endoscopic surgery for the treatment of pineal, periaqueductal and third ventricular tumors.

Combined Predictive Model for Endoscopic Third Ventriculostomy Success in Adults and Children.

BACKGROUND: The selection of patients in whom endoscopic third ventriculostomy (ETV) can be effective remains poorly defined. The ETV success score (ETVSS) and the presence of bowing of the third ventricle have been identified as independent factors for predicting success, each with limitations. The objective of this study is to elaborate a combined predictive model to predict ETV success in a mixed cohort of patients. METHODS: Demographic, intraoperative, postoperative, and radiologic variables were analyzed in all ventriculostomies performed consecutively at a single institution from December 2004 to December 2022. Qualitative and quantitative measurements of preoperative, immediate, and late postoperative magnetic resonance imaging were conducted. Univariate analysis and logistic regression models were performed. RESULTS: 118 ETVs were performed in the selected period. Of these procedures, 106 met the inclusion criteria. The overall success rate was 71.7%, with a median follow-up of 3.64 years (interquartile range, 1.06-5.62). The median age was 36.1 years (interquartile range, 11.7-53.5). 35.84% were children (median, 7.81 years). Among the 80 patients with third ventricle bowing, the success rate was 88.8% (P < 0.001). Larger third ventricle dimensions on preoperative mid-sagittal magnetic resonance imaging were associated with increased ETV success. The model with the best receiver operating characteristic curves, with an area under the curve of 0.918 (95% confidence interval, 0.856-0.979) includes sex, ETVSS, presence of complications, and third ventricle bowing. CONCLUSIONS: The presence of bowing of the third ventricle is strongly associated with a higher ETV success rate. However, a combined predictive model that integrates it with the ETVSS is the most appropriate approach for selecting patients for ETV.

Simultaneous Single-Trajectory Endoscopic Biopsy and Third Ventriculostomy in Pineal Region Tumors: A Systematic Review and Single Arm Meta-Analysis.

OBJECTIVE: To assess the efficacy and surgical outcomes of the simultaneous single-trajectory endoscopic biopsy and third ventriculostomy (ETV) in pineal region tumors. METHODS: A systematic review and meta-analysis adhering to Cochrane Standards and PRISMA framework were conducted. PubMed, Embase, and Web Of Science databases were searched until December 2023. Outcomes included rate of histopathologic diagnosis success, ETV success, complications, required VPS, and mortality. RESULTS: Seventeen studies (N = 388) met inclusion criteria. Histopathologic diagnosis success rate was 90% for general population (95% CI: 86%-95%; I2 = 42%) and 94% for pediatric patients (95% CI: 89%-98%; I2 = 19%). ETV Success rate was 93% (95% CI: 88%-97%; I2 = 60%). An estimated risk of postoperative ETV complications was found to be 16% for the general population (95% CI: 5%-28%; I2 = 90%) and 5% for pediatric patients (95% CI: 0%-13%; I2 = 51%). The risk of requiring VPS was estimated as 2% (95% CI: 0%-4%; I2 = 39%) and for the pediatric population it was 7% (95% CI: 0%-16%; I2 = 69%). Mortality risk was found to be 1% (95% CI: 0%-3%; I2 = 0%). CONCLUSIONS: Simultaneous endoscopic biopsy and ETV demonstrated high diagnostic and therapeutic success rates. The procedure's safety profile, with low mortality and complications, supports its role in treating hydrocephalus associated to pineal region tumors. Subgroup analyses revealed higher diagnostic success rates and required VPS in the pediatric population, whilst it had lower complication rates.

Stereotactic anatomy of the third ventricle.

PURPOSE: Endoscopic third ventriculostomy (ETV) is a surgical procedure that can lead to complications and requires detailed preoperative planning. This study aimed to provide a more accurate understanding of the anatomy of the third ventricle and the location of important structures to improve the safety and success of ETV. METHODS: We measured the stereotactic coordinates of six points of interest relative to a predefined stereotactic reference point in 23 cadaver brain hemi-sections, 200 normal brain magnetic resonance imaging (MRI) scans, and 24 hydrocephalic brain MRI scans. The measurements were statistically analyzed, and comparisons were made. RESULTS: We found some statistically significant differences between genders in MRIs from healthy subjects. We also found statistically significant differences between MRIs from healthy subjects and both cadaver brains and MRIs with hydrocephalus, though their magnitude is very small and not clinically relevant. Some stereotactic points were more posteriorly and inferiorly located in cadaver brains, particularly the infundibular recess and the basilar artery. It was found that all stereotactic points studied were more posteriorly located in brains with hydrocephalus. CONCLUSION: The study describes periventricular structures in cadaver brains and MRI scans from healthy and hydrocephalic subjects, which can guide neurosurgeons in planning surgical approaches to the third ventricle. Overall, the study contributes to understanding ETV and provides insights for improving its safety and efficacy. The findings also support that practicing on cadaveric brains can still provide valuable information and is valid for study and training of neurosurgeons unfamiliar with the ETV technique.