Endoscopic ventricular fenestration using a “saline torch”

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✓ The fiberoptic endoscope has never gained popularity among neurosurgeons although it is ideally suited for navigating within the cerebral ventricles. Recent advances in optics and miniaturization make the application of endoscopy in neurosurgery more practical. The authors report eight children who underwent ventriculoscopic fenestration of symptomatic loculated cerebrospinal fluid (CSF) collections. These CSF collections were either isolated ventricular cysts or trapped lateral ventricles secondary to obstruction at the foramen of Monro. Cyst wall dissection was carried out with a “saline torch” dissector which was introduced through a working channel in the ventriculoscope. The torch was used to coagulate vessels and to sculpt large windows in cyst walls or in the septum pellucidum. Ventriculoscope-guided cyst fenestration can be performed safely and easily under direct vision. The technique may permit simplification of shunt systems in some patients and elimination of shunts in others.

Article Information

Address reprint requests to: Alan R. Cohen, M.D., Department of Neurosurgery, Tufts New England Medical Center, 750 Washington Street, Boston, Massachusetts 02111.

© AANS, except where prohibited by US copyright law.

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Figures

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    Left: View through the venlriculoscope of the right foramen of Monro (arrowhead). The choroid plexus (cp) can he seen passing through the foramen into the third ventricle. Center: Close-up view of the right foramen of Monro (arrow). The septal vein is visible (arrowheads) as are the mamillary bodies (m) in the floor of the third ventricle. Right: View of the floor of the third ventricle. The mamillary bodies (m) and the infundibular recess (arrow) are readily visible.

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    The flexible steerable fiberoptic ventriculoscope connected to a 1 Tuohy Borst adapter (T) with a Teflon catheter passing through the working channel. The catheter can be seen protruding from the distal end of the ventriculoscope (arrow) and its internal wire is visible extending proximally from the Tuohy Borst hub of the adapter (arrowhead). Inset A: Isolated view of the adapter (T) and internal wire (arrowhead) extending proximally from the ventriculoscope. Inset B: Enlarged view of the catheter (arrow) extending from the end of the ventriculoscope.

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    Case 1. Left: Preoperative computerized tomography (CT) scan demonstrating a large interhemispheric cyst, mild dilatation of the lateral ventricles, and absence of the septum pellucidum. A thin membrane is visible between the cyst and the ventricles (arrowheads). Center: Immediate postoperative CT-ventriculography study demonstrating a large window of communication between the ventricles and the interhemispheric cyst. Right: Ten months later, a CT showed shunted hydrocephalus with a decrease in size of the ventricles and cyst.

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    Case 2. Upper Pair: Axial (left) and sagittal (right) T1-weighted magnetic resonance images of the brain demonstrating a right frontal “diverticulum” and hydrocephalus. Lower Pair: Computerized tomography-ventriculography studies, preoperative view (left), demonstrating no communication of cerebrospinal fluid between the loculated ventricular diverticulum and the ventricles, and postoperative view (right), showing a decrease in the size of the cyst and the lateral ventricles with free communication of contrast between compartments.

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    Computerized tomography-ventriculographic studies in Case 3. Upper Pair: Preoperative studies demonstrating a large trapped right lateral ventricle. The left lateral ventricle (arrowheads) is not enlarged. The single arrowhead indicates the foramen of Monro. Lower Pair: Postoperative studies showing decompression of the right lateral ventricle with free communication of contrast material across the septum pellucidum.

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