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Giuseppe Cinalli, Alessia Imperato, Giuseppe Mirone, Giuliana Di Martino, Giancarlo Nicosia, Claudio Ruggiero, Ferdinando Aliberti and Pietro Spennato

OBJECTIVE

Neuroendoscopic removal of intraventricular tumors is difficult and time consuming because of the lack of an effective decompression system that can be used through the working channel of the endoscope. The authors report on the utilization of an endoscopic ultrasonic aspirator in the resection of intraventricular tumors.

METHODS

Twelve pediatric patients (10 male, 2 female), ages 1–15 years old, underwent surgery via a purely endoscopic approach using a Gaab rigid endoscope and endoscopic ultrasonic aspirator. Two patients presented with intraventricular metastases from high-grade tumors (medulloblastoma, atypical teratoid rhabdoid tumor), 2 with subependymal giant cell astrocytomas (associated with tuberous sclerosis), 2 with low-grade intraparaventricular tumors, 4 with suprasellar tumors (2 craniopharyngiomas and 2 optic pathway gliomas), and 2 with pineal tumors (1 immature teratoma, 1 pineal anlage tumor). Hydrocephalus was present in 5 cases. In all patients, the endoscopic trajectory and ventricular access were guided by electromagnetic neuronavigation. Nine patients underwent surgery via a precoronal bur hole while supine. In 2 cases, surgery was performed through a frontal bur hole at the level of the hairline. One patient underwent surgery via a posterior parietal approach to the trigone while in a lateral position. The endoscopic technique consisted of visualization of the tumor, ventricular washing to dilate the ventricles and to control bleeding, obtaining a tumor specimen with biopsy forceps, and ultrasonic aspiration of the tumor. Bleeding was controlled with irrigation, monopolar coagulation, and a thulium laser.

RESULTS

In 7 cases, the resection was total or near total (more than 90% of lesion removed). In 5 cases, the resection was partial. Histological evaluation of the collected material (withdrawn using biopsy forceps and aspirated with an ultrasonic aspirator) was diagnostic in all cases. The duration of surgery ranged from 30 to 120 minutes. One case was complicated by subdural hygroma requiring a subduro-peritoneal shunt implant.

CONCLUSIONS

In this preliminary series, endoscopic ultrasonic aspiration proved to be a safe and reliable method for achieving extensive decompression or complete removal in the management of intra- and/or paraventricular lesions in pediatric patients.

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Pietro Spennato, Giuseppe Cinalli, Claudio Ruggiero, Ferdinando Aliberti, Vincenzo Trischitta, Emilio Cianciulli and Giuseppe Maggi

Object

The authors performed a retrospective analysis of data obtained in a series of 30 patients suffering from multiloculated hydrocephalus and treated endoscopically. The goal of the study was to evaluate the effectiveness of neuroendoscopic treatment as an alternative to the placement of multiple shunts to relieve intracranial hypertension, to simplify the shunt system, and to reduce the high rate of shunt revision.

Methods

The endoscopic procedures included intraventricular septum fenestration, aqueductoplasty, Monro foram-inoplasty, and third ventriculostomy. The patients were divided into two groups: Group A included 23 children in whom a shunt was already in place at the time of endoscopy, and Group B included seven children in whom a shunt had never been placed.

The control of hydrocephalus by a single shunt placement or the absence of a shunt was achieved in 25 (83.3%) of 30 children. In Group A, five children no longer had shunts, 14 needed a single shunt, three required two shunts, and one required three shunts. The mean preendoscopy shunt revision rate in this group decreased from 2.07/year to 0.35/ year following the endoscopic procedure. Seven patients required endoscopic reoperations (endoscopic reoperation rate 0.31/year, total reoperation rate [shunt revisions plus endoscopic reoperation] 0.66/year). In Group B, three children did not require shunts, three needed a single shunt, and one required two shunts. Two patients required repeated endoscopic surgery (endoscopic reoperation rate 0.19/year), and two patients required shunt revisions (shunt revision rate 0.07/year) (total operation rate 0.26/year).

Conclusions

Neuroendoscopic procedures are a valid alternative to shunt revision in the management of multiloculated hydrocephalus. Early diagnosis comprising close monitoring with high-resolution magnetic resonance imaging and early treatment are the keys of success.

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Giuseppe Cinalli, Pietro Spennato, Luciano Savarese, Claudio Ruggiero, Ferdinando Aliberti, Lorenzo Cuomo, Emilio Cianciulli and Giuseppe Maggi

Object.

In this study the authors conducted a retrospective evaluation of the effectiveness of endoscopic aqueductoplasty, performed alone or accompanied by placement of a stent, in the treatment of an isolated fourth ventricle (IFV) in seven patients afflicted with loculated hydrocephalus after a hemorrhage or infection.

Methods.

Seven children with symptomatic IFV and membranous aqueductal stenosis underwent endoscopic aqueductoplasty alone or combined with placement of a stent in the cerebral aqueduct. The mean age of the patients at the time of surgery was 10 months. The mean duration of follow up was 26 months. In all patients a supratentorial shunt had already been implanted, and in five patients neuroendoscopy had already been performed because other isolated compartments had been present inside the ventricular system. Aqueductoplasty alone was performed in three patients and aqueductoplasty and aqueductal stent placement in four. A precoronal approach was performed in five patients and a suboccipital approach in two. Signs and symptoms of intracranial hypertension resolved in all cases. Stent placement was successful in all five cases, resulting in clinical and neuroimaging-confirmed improvements in the IFV. Restenosis of the aqueduct occurred in two patients in whom stents had not been placed. In one of these patients restenosis was managed by an endoscopic procedure, during which the aqueduct was reopened and a stent implanted; in the other patient a shunt was placed in the fourth ventricle. Hydrocephalus was controlled by a single shunt in six cases (86%) and by a double shunt in one case.

Conclusions.

Endoscopic placement of a stent in the aqueduct is more effective in preventing the repeated occlusion of the aqueduct than aqueductoplasty alone and should be indicated as the initial treatment in each case of compatible anatomy.

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Giuseppe Cinalli, Paola Peretta, Pietro Spennato, Luciano Savarese, Antonio Varone, Paola Vedova, Gianpina Grimaldi, Paola Ragazzi, Claudio Ruggiero, Emilio Cianciulli and Giuseppe Maggi

Object

Interhemispheric arachnoid cysts are very rare, and they are often associated with complex brain malformations such as corpus callosum agenesis and hydrocephalus. Debate remains concerning the proper management of these lesions. Placement of shunts and microsurgical marsupialization of the cyst are the traditional options. Using endoscopic methods to create areas of communication between the cyst, the ventricular system, and/or the subarachnoid space is an attractive alternative to the use of shunts and microsurgery.

Methods

Between 2000 and 2005, seven consecutive pediatric patients with interhemispheric arachnoid cysts underwent neuroendoscopic treatment involving cystoventriculostomy in two patients, cystocisternostomy in two, and cystoventriculocisternostomy in three. There were three cases of associated hydrocephalus, six cases of corpus callosum agenesis, and one case of corpus callosum hypogenesis.

The follow-up period ranged from 12 to 49 months (mean 31.6 months). Endoscopic procedures were completely successful in all but two patients. In one of the remaining two patients, a repeated endoscopic cystocisternostomy was performed with success because of closure of the previous stoma. In the other, a subcutaneous collection of cerebrospinal fluid (CSF) was managed by insertion of an lumboperitoneal shunt. A subdural collection of CSF developed in three patients; it was treated with insertion of a subduroperitoneal shunt in one patient and managed conservatively in the other two patients, resolving spontaneously without further treatment. Neurodevelopmental evaluation performed in six patients showed normal intelligence (total intelligence quotient [IQ] > 80) in three patients, mild developmental delay (total IQ 50–80) in two, and severe developmental delay (total IQ < 50) in one.

Conclusions

Endoscopic treatment of interhemispheric cysts can be considered a useful alternative to traditional treatments, even if some complications are to be expected, such as subdural or subcutaneous CSF collections and CSF leaks due to thinness of cerebral mantle and to the often-associated multifactorial hydrocephalus.

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Giuseppe Cinalli, Pietro Spennato, Laura Columbano, Claudio Ruggiero, Ferdinando Aliberti, Vincenzo Trischitta, Maria Consiglio Buonocore and Emilio Cianciulli

Object

In this paper, the authors' goal was to evaluate the role of neuroendoscopy in the treatment of arachnoid cysts of the quadrigeminal cistern.

Methods

Between March 1995 and February 2008, 14 patients affected by arachnoid cysts of the quadrigeminal cistern were treated endoscopically. The cysts were classified according to their anatomical and radiological appearance. The most frequent form (Type I) extended infratentorially and supratentorially with a dumbbell shape. Type II cysts were confined to the infratentorial space and were associated with the most severe and acute form of hydrocephalus. Type III cysts presented a significant asymmetric expansion toward the temporal fossa. Ten patients underwent an endoscopic procedure as primary treatment and 4 as an alternative to shunt revision. In 6 cases, the first endoscopic procedure was ventriculocystostomy (VC) together with endoscopic third ventriculostomy (ETV). In the other 8 cases, the first endoscopic procedure was VC alone.

Results

In the 6 cases in which VC was performed with an ETV, the procedure was successful, and the patients did not require further surgery. Of the 8 cases in which the first endoscopic procedure performed was VC without ETV, 7 underwent reoperation. Four of these patients underwent endoscopic procedures (by reopening the obstructed VC and performing ETV or cystocisternostomy) 2, 4, 4, and 5 months later with final success in all cases. Three patients (all of whom were previously treated using ventriculo- or cystoperitoneal shunts) required shunt reimplantation (complete failure). Subdural collection developed in 1 case, which was managed by transient insertion of a subduroperitoneal shunt. Neurological and developmental outcomes were good except for 1 patient who did not show improvement in preoperative developmental delay. No transient or permanent morbidity or mortality was observed.

Conclusions

The analysis of this series suggests that arachnoid cysts of the quadrigeminal cistern and the associated hydrocephalus can be effectively treated by endoscopy; this approach allows the patient to be shunt independent in more than 78% of the cases. If endoscopy is used as first option, the success rate of endoscopic procedures observed in this series was 90%. Endoscopic third ventriculostomy should be associated with a VC to offer the highest success rate with a single procedure.

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Giuseppe Cinalli, Daniel T. Aguirre, Giuseppe Mirone, Claudio Ruggiero, Daniele Cascone, Lucia Quaglietta, Ferdinando Aliberti, Serena de’ Santi, Maria Consiglio Buonocore, Anna Nastro and Pietro Spennato

OBJECTIVE

In the past, the outcome of surgical treatment for thalamic tumor was poor. These lesions were often considered inoperable. However, contemporary microsurgical techniques, together with improvements in neuroimaging that enable accurate presurgical planning, allow resection to be accomplished in a safer way.

METHODS

The medical records, imaging studies, and operative and pathology reports obtained for pediatric patients who were treated for thalamic tumors at the authors’ department were reviewed. Neuronavigation and intraoperative monitoring of motor and somatosensory evoked potentials were used. Preoperative tractography, which helped to identify internal capsule fibers, was very important in selecting the surgical strategy. Postoperatively, an MRI study performed within 24 hours was used to assess the extent of tumor resection as partial (≤ 90%), subtotal (> 90%), or gross total (no residual tumor).

RESULTS

Since 2002, 27 children with thalamic tumors have been treated at the authors’ department. There were 9 patients with unilateral thalamic tumors, 16 with thalamopeduncular tumors, and 2 with a bilateral tumor. These last 2 patients underwent endoscopic biopsy and implantation of a ventriculoperitoneal shunt. Thirty-nine tumor debulking procedures were performed in the remaining 25 patients. Different surgical approaches were chosen according to tumor location and displacement of the posterior limb of the internal capsule (as studied on axial T2-weighted MRI) and corticospinal tract (as studied on diffusion tensor imaging with tractography, after it became available). In 12 cases, multiple procedures were performed; in 7 cases, these were done as part of a planned multistage resection. In the remaining 5 cases, the second procedure was necessary because of late recurrence or regrowth of residual tumor.

At the end of the surgical phase, of 25 patients, 15 (60%) achieved a gross-total resection, 4 (16%) achieved a subtotal resection, and 6 (24%) achieved a partial resection. Eighteen patients harbored low-grade tumors in our series. In this group, the mean follow-up was 45 months (range 4–132 months). At the end of follow-up, 1 patient was dead, 12 patients were alive with no evidence of disease, 4 patients were alive with stable disease, and 1 was lost to follow-up. All patients were independent in their daily lives. The outcome of high-grade tumors in 9 patients was very poor: 2 patients died immediately after surgery, 6 died of progressive disease, and 1 was alive with residual disease at the time of this report.

CONCLUSIONS

This institutional review seems to offer further evidence in favor of attempts at radical resection in pediatric patients harboring unilateral thalamic or thalamopeduncular tumors. In low-grade gliomas, radical resection in a single or staged procedure can be curative without complementary treatment. Recurrences or residual regrowth can be safely managed surgically. In high-grade tumors, the role of and opportunity for radical or partial resection remains a matter of debate.

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Giuseppe Cinalli, Paola Peretta, Pietro Spennato, Luciano Savarese, Antonio Varone, Paola Vedova, Gianpina Grimaldi, Paola Ragazzi, Claudio Ruggiero, Emilio Cianciulli and Giuseppe Maggi

Object

Interhemispheric arachnoid cysts are very rare, and they are often associated with complex brain malformations such as corpus callosum agenesis and hydrocephalus. Debate remains concerning the proper management of these lesions. Placement of shunts and microsurgical marsupialization of the cyst are the traditional options. Using endoscopic methods to create areas of communication between the cyst, the ventricular system, and/or the subarachnoid space is an attractive alternative to the use of shunts and microsurgery.

Methods

Between 2000 and 2005, seven consecutive pediatric patients with interhemispheric arachnoid cysts underwent neuroendoscopic treatment involving cystoventriculostomy in two patients, cystocisternostomy in two, and cystoventriculocisternostomy in three. There were three cases of associated hydrocephalus, six cases of corpus callosum agenesis, and one case of corpus callosum hypogenesis.

The follow-up period ranged from 12 to 49 months (mean 31.6 months). Endoscopic procedures were completely successful in all but two patients. In one of the remaining two patients, a repeated endoscopic cystocisternostomy was performed with success because of closure of the previous stoma. In the other, a subcutaneous collection of cerebrospinal fluid (CSF) was managed by insertion of a lumboperitoneal shunt. A subdural collection of CSF developed in three patients; it was treated with insertion of a subduroperitoneal shunt in one patient and managed conservatively in the other two patients, resolving spontaneously without further treatment. Neurodevelopmental evaluation performed in six patients showed normal intelligence (total intelligence quotient [IQ] > 80) in three patients, mild developmental delay (total IQ 50–80) in two, and severe developmental delay (total IQ < 50) in one.

Conclusions

Endoscopic treatment of interhemispheric cysts can be considered a useful alternative to traditional treatments, even if some complications are to be expected, such as subdural or subcutaneous CSF collections and CSF leaks due to thinness of cerebral mantle and to the often-associated multifactorial hydrocephalus.