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  • Author or Editor: Michel W. Bojanowski x
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Alexander G. Weil, Thomas Robert, Sultan Alsaiari, Sami Obaid and Michel W. Bojanowski

Retrochiasmatic craniopharyngiomas involving the anterior third ventricle are challenging to access. Although the pterional approach is a common route for suprasellar lesions, when the craniopharyngioma extends behind the chiasma into the third ventricle, access is even more difficult, and the lamina terminalis may offer a good working window. The translamina terminalis approach provides direct access to the retrochiasmatic portion of the tumor with minimal brain retraction and no manipulation of the visual nerves. In this video, we emphasize the utility of using the lamina terminalis corridor to resect the retrochiasmatic intraventricular portion of a craniopharyngioma.

The video can be found here: https://youtu.be/hrLNC0hDKe4.

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Thomas Robert, Alexander G. Weil, Sami Obaid, Hosam Al-Jehani and Michel W. Bojanowski

Large tumors located on the upper surface of the tentorium, extending to the posterior edge of the tentorial incisura and affecting the posterior temporo-mesial region, are challenging to reach without damaging the surrounding brain. Typically, these lesions are approached through a subtemporal or a transcortical transtemporal corridor. To avoid temporal lobe transgression or retraction, and venous drainage compromise, we use a supracerebellar transtentorial (SCTT) approach which gives a direct exposure to the posterior temporo-medial region and the posterior incisural space. In this video, we demonstrate the surgical technique of the SCTT approach.

The video can be found here: https://youtu.be/g3ilMO8vo4g.

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Moujahed Labidi, Pascale Lavoie, Geneviève Lapointe, Sami Obaid, Alexander G. Weil, Michel W. Bojanowski and André Turmel

OBJECT

Endoscopic third ventriculostomy (ETV) has become the first line of treatment in obstructive hydrocephalus. The Toronto group (Kulkarni et al.) developed the ETV Success Score (ETVSS) to predict the clinical response following ETV based on age, previous shunt, and cause of hydrocephalus in a pediatric population. However, the use of the ETVSS has not been validated for a population comprising adults. The objective of this study was to validate the ETVSS in a “closed-skull” population, including patients 2 years of age and older.

METHODS

In this retrospective observational study, medical charts of all consecutive cases of ETV performed in two university hospitals were reviewed. The primary outcome, the success of ETV, was defined as the absence of reoperation or death attributable to hydrocephalus at 6 months. The ETVSS was calculated for all patients. Discriminative properties along with calibration of the ETVSS were established for the study population. The secondary outcome is the reoperation-free survival.

RESULTS

This study included 168 primary ETVs. The mean age was 40 years (range 3–85 years). ETV was successful at 6 months in 126 patients (75%) compared with a mean ETVSS of 82.4%. The area under the receiver operating characteristic curve was 0.61, revealing insufficient discrimination from the ETVSS in this population. In contrast, calibration of the ETVSS was excellent (calibration slope = 1.01), although the expected low numbers were obtained for scores < 70. Decision curve analyses demonstrate that ETVSS is marginally beneficial in clinical decision-making, a reduction of 4 and 2 avoidable ETVs per 100 cases if the threshold used on the ETVSS is set at 70 and 60, respectively. However, the use of the ETVSS showed inferior net benefit when compared with the strategy of not recommending ETV at all as a surgical option for thresholds set at 80 and 90.

In this cohort, neither age nor previous shunt were significantly associated with unsuccessful ETV. However, better outcomes were achieved in patients with aqueductal stenosis, tectal compressions, and other tumor-associated hydrocephalus than in cases secondary to myelomeningocele, infection, or hemorrhage (p = 0.03).

CONCLUSIONS

The ETVSS did not show adequate discrimination but demonstrated excellent calibration in this population of patients 2 years and older. According to decision-curve analyses, the ETVSS is marginally useful in clinical scenarios in which 60% or 70% success rates are the thresholds for preferring ETV to CSF shunt. Previous history of CSF shunt and age were not associated with worse outcomes, whereas posthemorrhagic and postinfectious causes of the hydrocephalus were significantly associated with reduced success rates following ETV.