Endoscopic options in children: experience with 134 procedures

Clinical article

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Object

There are frequent applications for endoscopy in neurosurgery. However, endoscopic surgery in children has peculiar characteristics and is associated with different rates of success. In this study, the authors report on their experience with 134 consecutive endoscopy procedures performed in 126 patients < 18 years of age.

Methods

Between April 1993 and October 2007, 134 endoscopic procedures were performed in 126 children. Indications for surgery included brain tumors in 48 children, cystic lesions in 24, aqueductal stenosis in 23, various malformations in 20, hemorrhage and infarction in 6, and isolated ventricles in 5 children. In this long-term followup study, data were analyzed with respect to clinical and radiological success rates, as well as shunt dependence both in relation to lesion origin, and to the type of endoscopic procedure performed (endoscopic third ventriculostomy [ETV], septostomy, aqueductoplasty, or cystocisternostomy). Finally, the influence of patient age on the success rate was evaluated.

Results

In 114 patients, restoration of CSF circulation was the goal of endoscopy, but in 2 patients only ventriculoscopy was performed followed by ventriculoperitoneal shunt placement. In 12 of 114 patients, tumor biopsy sampling or resection was performed simultaneously with shunt placement. In another 12 patients, only endoscopic tumor resection without CSF circulation restoration was done. The follow-up period ranged from 1 to 6 years. Thirteen tumor biopsies, 7 partial tumor resections, and 4 endoscopically complete tumor resections were performed. An intraoperative switch to microsurgery was made in 2 patients because of recurrent hemorrhage and an overly time-consuming endoscopic surgery. Cerebrospinal fluid circulation was successfully restored in 81 (72%) of 112 patients, with the use of endoscopy in the setting of tumor-related hydrocephalus providing the best results (86% success rate). However, of the various endoscopic procedures, cyst openings (cystocisternostomy, cystoventriculostomy, and ventriculocystocisternostomy) provided the best results—superior even to ETV—with a success rate of 77% and no complications. In contrast, endoscopic aqueductoplasty had a high failure and complication rate. Patients < 6 months old who underwent ETV, septostomy, or aqueductoplasty had poor results and became more frequently shunt dependent than older children.

Conclusions

Overall, endoscopy can be considered safe and effective in children. Based on the authors' data, acute hydrocephalus cases such as those caused by tumors are the best candidates for endoscopic CSF flow restoration. Interestingly, cyst openings to the ventricles or cisterns were the most successful endoscopic techniques with the lowest complication rate. Aqueductoplasty should be reserved for selected cases. Finally, the success rate of endoscopic techniques remains poor in infants < 6 months of age; this was not only true of ETV, but also other techniques such as septostomy and aqueductoplasty.

Abbreviation used in this paper: ETV = endoscopic third ventriculostomy.

Article Information

Address correspondence to: Joachim M. K. Oertel, M.D., Ph.D., Department of Neurosurgery, Universitaetsklinikum, Johannes-Gutenberg-University, Mainz, Germany. email: oertelj@freenet.de.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Graph of the percentages of clinical and radiological improvement and shunt dependence after all procedures according to patient age groups.

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    Images obtained in a 17-year-old boy with a large choroid plexus cyst. a and e: Coronal and sagittal T2-weighted MR images showing a large intraventricular cyst in the left lateral ventricle. b–d, f and g: Endoscopic views. Intraoperative view of the cyst with direct contact with the choroids plexus in the posterior part of the left lateral ventricle (b), cyst puncture with a needle and fluid aspiration (c), and piecemeal resection of the cyst wall (d). Such a large portion of the cyst wall is resected that an open ventriculocystostomy results (g). h: Sagittal T2-weighted MR image obtained 3 months after surgery. There are no signs of recurrence.

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    Graph of the percentage of clinical and radiological improvement and shunt dependence after ETV according to patient age group.

  • View in gallery

    Graph of the percentage of clinical and radiological improvement and shunt dependence after endoscopic CSF circulation restoration procedures (septostomy, aqueductoplasty, and cyst openings) after exclusion of ETV according to patient age groups.

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