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Bilateral occlusion of the foramina of Monro after third ventriculostomy

Case report

Ehab El Refaee, Joerg Baldauf, and Henry W. S. Schroeder

E ndoscopic third ventriculostomy has become a well-accepted treatment option for obstructive hydrocephalus. It is reported to be a straightforward procedure with a high success rate and low complication rate. Various complications can occur, however, although rarely. 10 We describe bilateral occlusion of both foramina of Monro 30 months after a successful third ventriculostomy in a patient with aqueductal stenosis. To our knowledge, this is the first report of a patient with bilateral occlusion of the foramina of Monro after ETV. Case Report

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Involution of enhancing intrinsic tectal tumors after endoscopic third ventriculostomy

Report of two cases

Ahmed M. Alkhani, Frederick A. Boop, and James T. Rutka

presenting with obstructive hydrocephalus in whom a small, tectal neoplasm is identified, cerebrospinal fluid (CSF) diversion alone suffices in treating the patient's symptoms. 18 In recent times, endoscopic third ventriculostomy has become an effective means by which aqueductal stenosis that causes hydrocephalus can be overcome without resorting to the implantation of permanent CSF shunting devices. 4, 6, 9, 10, 19 Success rates as high as 70% have been reported for long-term control of hydrocephalus after endoscopic third ventriculostomy. 4 In this report, we describe

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Endoscopic third ventriculostomy for tumor-related hydrocephalus in a pediatric population

Pulak Ray, George I. Jallo, R. Y. H. Kim, Bong-Soo Kim, Sean Wilson, Karl Kothbauer, and Rick Abbott

Object

Endoscopic third ventriculostomy (ETV) has become a common alternative for managing hydrocephalus in select patients. Nevertheless, there is still controversy regarding the indications for ETV as the primary procedure, given its variable success rates. The purpose of this study is to review the authors' experience with ETV for a variety of patients.

Methods

A total of 43 children underwent ETV between July 1992 and June 2003. Their medical records, operative reports, and imaging studies, when available, were retrospectively reviewed with regard to outcome, complications, and patency rate. Treatment failure was defined as the need to place a shunt within 4 weeks of performing ETV in the patient.

There were 20 male and 23 female patients with a mean age of 9.6 years (range 8 weeks–21 years). The overall success rate was 69.8%, and the mean follow-up duration was 24.6 months. Six patients underwent eight repeated ETVs at a mean interval of 25 months, with a patency rate of 62.5% after the second procedure. Only two surgeries were aborted for anatomical reasons. The highest success rates (100% in each instance) were achieved for obstructive hydrocephalus resulting from midbrain/tectal tumor (four patients) and pineal tumor (three patients).

Conclusions

The ETV procedure is an effective management tool for obstructive hydrocephalus in children. It should be considered the primary procedure, rather than ventriculoperitoneal shunts, in carefully selected children. The success rate is dependent on the origin of the hydrocephalus.

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Management of hydrocephalus in pediatric patients with posterior fossa tumors: the role of endoscopic third ventriculostomy

Christian Sainte-Rose, Giuseppe Cinalli, Franck E. Roux, Wirginia Maixner, Paul D. Chumas, Maheir Mansour, Alexandre Carpentier, Marie Bourgeois, Michel Zerah, Alain Pierre-Kahn, and Dominique Renier

The authors conducted a study to evaluate the effectiveness of endoscopically guided third ventriculostomy in the pre- and postoperative management of hydrocephalus in pediatric patients who harbored posterior fossa tumors.

Between October 1, 1993, and December 31, 1997, a total of 206 consecutive children with posterior fossa tumors underwent surgery at Hôpital Necker-Enfants Malades in Paris. Ten patients in whom shunts were implanted at the referring hospital were excluded. The medical records and neuroimaging studies obtained in the remaining 196 patients were reviewed. These patients were categorized into three groups: 67 patients with hydrocephalus on admission in whom endoscopically guided third ventriculostomy was performed prior to tumor removal (Group A); 82 patients with hydrocephalus in whom preliminary third ventriculostomy was not performed and who were managed in a “conventional way” (Group B); and 47 patients without ventricular dilation on admission (Group C).

There was no significant difference between Group A and Group B patients with respect to age at presentation, evidence of metastatic disease, degree of tumor resection, or follow up. In the patients in Group A, however, more severe hydrocephalus was present (p < 0.01). Patients in Group C were, in this respect, different from the other two groups.

Ultimately, only four patients (6%) in Group A as compared with 22 patients (27 %) in Group B (p = 0.001) had progressive hydrocephalus requiring treatment following removal of the posterior fossa tumor. Sixteen patients (20%) in Group B underwent insertion of a ventriculoperitoneal shunt, which is similar to the incidence of this procedure reported in the literature and significantly different from that in Group A (p < 0.016). The other six patients in Group B (6%) were treated by endoscopically guided third ventriculostomy after tumor removal. In Group C, two patients (4%) with postoperative hydrocephalus underwent endoscopically guided third ventriculostomy.

In three of the patients who required placement of cerebrospinal fluid shunts several episodes of shunt malfunction occurred; these were ultimately managed by performing endoscopic third ventriculostomy and definitive removal of the shunt.

There were no cases of death and four cases of transient morbidity associated with the ventriculostomy.

Third ventriculostomy is feasible even in the presence of posterior fossa tumors (including brainstem tumors). When performed prior to posterior fossa surgery, it significantly reduces the incidence of postoperative hydrocephalus. Furthermore, it provides a valid alternative to the placement of permanent shunts in cases in which hydrocephalus develops following posterior fossa surgery, and it may negate the need for the shunt in cases in which the shunt malfunctions.

Although the authors acknowledge that the routine application of third ventriculostomy in selected patients may result in a proportion of patients undergoing an “unnecessary” procedure, they believe that because of patients' less complicated postoperative course, the low morbidity rate, and the high success rate of third ventriculostomy, further investigation of this protocol is warranted.

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Bilateral retinal hemorrhage after endoscopic third ventriculostomy: iatrogenic Terson syndrome

Case report

Eelco W. Hoving, Mehrnoush Rahmani, Leonie I. Los, and Victor W. Renardel de Lavalette

E ndoscopic third ventriculostomy is considered to be an effective and safe treatment modality for obstructive hydrocephalus. The success rate of ETV in third ventricle hydrocephalus is reported to be ~ 75–80%. 4 , 6 Various complications related to intracranial endoscopy in general and to ETV in particular have been reported, of which arterial hemorrhages from prepontine cisternal vessels are considered the most serious. 3 , 22 A distinction can be made between perioperative complications and postoperative failure of the ETV. The latter can be further

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Amenorrhea complicating endoscopic third ventriculostomy in the pediatric age group

Report of 2 cases

Steven W. Hwang, George Al-Shamy, William E. Whitehead, Daniel J. Curry, Robert Dauser, Thomas G. Luerssen, and Andrew Jea

E ndoscopic third ventriculostomy is a widely accepted form of treatment for hydrocephalus in children. Many pediatric neurosurgeons consider it to be the therapy of choice in the control of obstructive hydrocephalus in select patients. Although ETV is thought to be safe, a variety of complications associated with the procedure have been reported, including herniation syndromes 4 , 19 and arrhythmia 13 , 16 at the time of ETV; injury to structures adjacent to the floor of the third ventricle, including cranial nerves 16 , 19 and major vessels, resulting

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Transcallosal approach for third ventriculostomy and removal of midbrain cavernous malformation

William T. Couldwell

Symptomatic brain stem cavernous malformations often present the dilemma of choosing an approach for their resection. Superior midline midbrain lesions are in a particularly challenging location, as they are less accessible via traditional lateral or posterior approaches. The author presents a case of a young woman who presented with a symptomatic cavernous malformation with surface presentation to the floor of the third ventricle. The lesion was causing sensory symptoms from local mass effect and hydrocephalus from occlusion of the Aqueduct of Sylvius. An approach was chosen to both perform a third ventriculostomy and remove the cavernous malformation. Through a right frontal craniotomy, a transcallosal–transforaminal approach was used to perform a third ventriculostomy. Through the same callosal opening, a subchoroidal approach was performed to provide access the cavernous malformation. The details of the procedure and nuances of technique are described in the narration.

The video can be found here: http://youtu.be/zKKnehp7l2c .

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Failure of third ventriculostomy in the treatment of aqueductal stenosis in children

Giuseppe Cinalli, Christian Sainte-Rose, Paul Chumas, Michel Zerah, Francis Brunelle, Guillaume Lot, Alain Pierre-Kahn, and Dominique Renier

Object

The goal of this study was to analyze the types of failure and long-term efficacy of third ventriculostomy in children.

Methods

The authors retrospectively analyzed clinical data obtained in 213 children affected by obstructive triventricular hydrocephalus who were treated by third ventriculostomy between 1973 and 1997. There were 120 boys and 93 girls. The causes of the hydrocephalus included: aqueductal stenosis in 126 cases; toxoplasmosis in 23 cases, pineal, mesencephalic, or tectal tumor in 42 cases; and other causes in 22 cases. In 94 cases, the procedure was performed using ventriculographic guidance (Group I) and in 119 cases by using endoscopic guidance (Group II). In 19 cases (12 in Group I and seven in Group II) failure was related to the surgical technique. Three deaths related to the technique were observed in Group I. For the remaining patients, Kaplan-Meier survival analysis showed a functioning third ventriculostomy rate of 72% at 6 years with a mean follow-up period of 45.5 months (range 4 days-17 years). No significant differences were found during long-term follow up between the two groups. In Group I, a significantly higher failure rate was seen in children younger than 6 months of age, but this difference was not observed in Group II. Thirty-eight patients required reoperation (21 in Group I and 17 in Group II) because of persistent or recurrent intracranial hypertension. In 29 patients shunt placement was necessary. In nine patients in whom there was radiologically confirmed obstruction of the stoma, the third ventriculostomy was repeated; this was successful in seven cases. Cine phase-contrast (PC) magnetic resonance (MR) imaging studies were performed in 15 patients in Group I at least 10 years after they had undergone third ventriculostomy (range 10–17 years, median 14.3 years); this confirmed long-term patency of the stoma in all cases.

Conclusions

Third ventriculostomy effectively controls obstructive triventricular hydrocephalus in more than 70% of children and should be preferred to placement of extracranial cerebrospinal shunts in this group of patients. When performed using ventriculographic guidance, the technique has a higher mortality rate and a higher failure rate in children younger than 6 months of age and is, therefore, no longer preferred. When third ventriculostomy is performed using endoscopic guidance, the same long-term results are achieved in children younger than 6 months of age as in older children and, thus, patient age should no longer be considered as a contraindication to using the technique. Delayed failures are usually secondary to obstruction of the stoma and often can be managed by repeating the procedure. Midline sagittal T2-weighted MR imaging sequences combined with cine PC MR imaging flow measurements provide a reliable tool for diagnosis of aqueductal stenosis and for ascertaining the patency of the stoma during follow-up evaluation.

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Endoscopic third ventriculostomy: outcome analysis in 368 procedures

Clinical article

Oumar Sacko, Sergio Boetto, Valérie Lauwers-Cances, Martin Dupuy, and Franck-Emmanuel Roux

E ndoscopic third ventriculostomy has been accepted as the procedure of choice for the treatment of obstructive hydrocephalus in children and adults, 33 although some controversies persist. The most controversial issue in the application of ETV is whether in children there is a lower age limit at which the treatment could be ineffective. 9 , 11 The main debate involving the general population is the outcome vis-à-vis the cause of hydrocephalus. There are reports that support the conflicting notions that outcome after ETV could be a function of previous

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Endoscopic transventricular third ventriculostomy through the lamina terminalis

Technical note

Joachim M. K. Oertel, Sonja Vulcu, Henry W. S. Schroeder, Moritz A. Konerding, Wolfgang Wagner, and Michael R. Gaab

transventricular ETV through the lamina terminalis is shown in a formalin-fixed cadaveric human head. Click here to view with Windows Media Player. Click here to view with Quicktime. Clinical Results Out of more than 800 endoscopic intracranial procedures and more than 400 ETVs, an ETV through the lamina terminalis was performed in only 4 cases by 1 of the authors (J.M.K.O., H.W.S.S, W.W., and M.R.G.). Preoperative Evaluation Endoscopic third ventriculostomy was always considered the first option in all cases of obstructive hydrocephalus ( Fig. 2a–c ). If there