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Nasser M. F. El-Ghandour

Object

The treatment of multiloculated hydrocephalus is a difficult problem in pediatric neurosurgery. Definitive treatment is surgical, yet the approach remains controversial. The author has therefore reviewed his results with endoscopic cyst fenestration (ECF) in the management of this disease.

Methods

The author presents the largest series to date of 24 patients with multiloculated hydrocephalus who were treated endoscopically. The group included 10 boys and 14 girls with a mean age of 12.5 months. Uniloculated hydrocephalus was not included in this study because it is a different entity that would be better studied separately.

Results

Neonatal meningitis was the most common cause (in 9 patients), followed by intraventricular hemorrhage (in 6 patients), postoperative gliosis (in 6 patients), and multiple neuroepithelial cysts (in 3 patients). Multiplanar magnetic resonance images made early diagnosis possible and are indicated if the computed tomography scan shows disproportionate hydrocephalus. Surgical treatment included ECF (in 24 patients), endoscopic revision of a malfunctioning preexisting shunt (in 6 patients), placement of a new shunt (in 15 patients), and third ventriculostomy (in 3 patients). The ECF was easily performed in all cases through devascularization of the cyst wall by coagulation to prevent recurrence. The results are encouraging with improvement of hydrocephalus in 18 patients (75%). The need for shunt insertion was avoided in 3 patients (12.5%). Endoscopy reduced shunt revision rate from 2.9 per year before fenestration to 0.2 per year after fenestration. During the overall mean follow-up period (30 months), repeated ECF was necessary in 8 patients (33%). Six (75%) of these 8 patients had already undergone shunt treatment before endoscopy. Endoscopic complications were minimal (2 cerebrospinal fluid leaks and 2 minor arterial hemorrhages), and there were no deaths (0%).

Conclusions

An ECF procedure is recommended in the treatment of multiloculated hydrocephalus because it is effective, simple, minimally invasive, and associated with low morbidity and mortality rates.

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Nasser M. F. El-Ghandour

Object

Quadrigeminal arachnoid cysts (QACs) are rare, comprising approximately 5%–10% of all intracranial arachnoid cysts. The management of these cysts is challenging, and their optimal surgical treatment is controversial. This study evaluates the role of endoscopy in the treatment of QACs in children, focusing on some factors or technical aspects that might influence the outcome.

Methods

Eighteen children with symptomatic QACs were the subject of this study. The group included 10 boys and 8 girls, with a mean age of 2.5 years. All patients had hydrocephalus. Surgical treatment included ventriculocystostomy (14 cases), endoscopic third ventriculostomy (14 cases), ventriculocystocisternostomy (2 cases), cystocisternostomy (2 cases), and removal of preexisting malfunctioning cystoperitoneal shunt (4 cases).

Results

Significant clinical improvement occurred in 15 cases (83.3%). Postoperative MRI showed a reduction in the cyst size in 14 cases (77.8%), whereas in the remaining 4 cases (22.2%) the cyst size was unchanged. A postoperative decrease in ventricular size was encountered in 16 cases (88.9%). Minor intraoperative bleeding occurred in 1 case (5.6%), which stopped spontaneously without any postoperative sequelae. Postoperative subdural hygroma occurred in 3 cases (16.7%) and required a subduroperitoneal shunt in 2 cases. During follow-up (mean 45.8 months), a repeat endoscopic procedure was performed in 7 patients (all 4 patients with a prior shunt and 3 patients without a prior shunt), and new shunt placement was required in 5 patients (all 4 patients with a prior shunt and 1 patient without a prior shunt). Thus, none of the patients with a prior shunt was able to become shunt independent, whereas 92.9% of patients without a prior shunt were able to avoid shunt placement.

Conclusions

Arachnoid cysts of the quadrigeminal cistern and the associated hydrocephalus can be effectively treated by endoscopy. The procedure is simple, minimally invasive, and associated with low morbidity and mortality rates. The fact that all patients who previously received shunts required a repeat endoscopic procedure and that none of these patients was able to become shunt independent makes it clear that endoscopic treatment should be considered the first choice in the management of patients with arachnoid cysts in the quadrigeminal cistern.

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Nasser M. F. El-Ghandour

Object

The treatment of uniloculated hydrocephalus is a difficult problem in pediatric neurosurgery. Definitive treatment is surgical, yet the approach remains controversial. This study evaluates the role of endoscopic cyst fenestration (ECF) in the management of this disease.

Methods

Thirty-one pediatric patients with uniloculated hydrocephalus who underwent endoscopic surgery, performed by the author, between May 1999 and December 2010 constitute the patient group for this study. The patients included 17 boys and 14 girls, with ages ranging from 5 months to 5 years (mean 22.9 months). Patients with multiloculated hydrocephalus were not included. The patients' charts were reviewed for demographic data, radiological findings, information regarding morbidity, improvement of hydrocephalus, incidence of recurrence, shunt dependency, and the need for shunt revision.

Results

Neuroepithelial cysts were the most common cause (17 cases), followed by postoperative gliosis due to previous shunt infection (9 cases), intraventricular hemorrhage (3 cases), and meningitis (2 cases). Multiplanar MRI was reliable in making the diagnosis and is indicated if CT shows disproportionate hydrocephalus. Surgical treatment included ECF (31 cases), endoscopic revision of malfunctioning preexisting shunts (9 cases), endoscopic third ventriculostomy (4 cases), and placement of a new shunt (3 cases). Endoscopic cyst fenestration was easily performed in all the cases, with devascularization of the cyst wall by coagulation to prevent recurrence. Improvement of hydrocephalus was observed in 26 cases (83.9%). Among the group of patients without prior shunts (22 cases), 3 patients (13.6%) required repeat ECF and 3 patients (13.6%) required placement of a shunt (new shunt placement). In the 9 patients with preexisting shunts, endoscopy reduced the mean rate of shunt revision from 2.7 revisions per year before fenestration to 0.25 per year after fenestration. Four of these 9 patients had multiple shunts, which could be converted to a single shunt; however, repeat ECF was necessary in all 9 patients. With a mean follow-up duration of 4.3 years, none of the patients with a prior shunt was able to become shunt-independent, whereas 86.4% of patients without a prior shunt were able to avoid shunt placement. Endoscopic complications were reversible (unilateral subdural effusion in 5 cases, minor arterial bleeding in 2 cases, CSF leakage in 1 case), and there was no death (0%).

Conclusions

Endoscopic cyst fenestration is recommended in the treatment of uniloculated hydrocephalus because it is effective, simple, minimally invasive, and associated with low morbidity and mortality rates. The fact that all previously shunt-treated patients needed repeat ECF and that none of these patients was able to become shunt-independent makes it clear that uniloculated hydrocephalus due to postoperative gliosis induced by previous shunt infection carries the worst prognosis.

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Nasser M. F. El-Ghandour

Object

Suprasellar arachnoid cysts (SACs) are rare, comprising approximately 10% of all intracranial arachnoid cysts. Although neuroendoscopic management is emerging as a safe effective alternative to microsurgery, the type of endoscopic surgery whether ventriculocystostomy (VC) or ventriculocystocisternostomy (VCC) is still controversial. This study evaluates the role of endoscopy in the treatment of SACs in children. It compares VC and VCC to determine which procedure is superior in the long term.

Methods

Twenty-five children (14 boys and 11 girls; mean age 26 months) with symptomatic SACs associated with hydrocephalus are the subject of this study. According to the surgical procedure adopted, patients were divided into 2 groups. Patients in Group A (11 patients) underwent VC with a mean follow-up of 55 months, and those in Group B (14 patients) underwent VCC with a mean follow-up of 64.7 months.

Results

Both procedures proved to be effective clinically and radiologically. The incidence of improvement of hydrocephalus-related symptoms was 63.6% in Group A compared with 85.7% in Group B. Improvement in cyst size and hydrocephalus after VC was 81.8% and 63.6%, respectively, compared with 100% and 85.7%, respectively, after VCC. There were no deaths or permanent morbidity, and no patient was left with a permanent shunt. Recurrence occurred in 3 cases after VC (27.3%), whereas no recurrence (0%) was encountered after VCC. At a second endoscopic procedure, the fenestration was found to be closed in all 3 recurrent cases.

Conclusions

An endoscopic procedure is recommended in the treatment of SACs in children because it is simple, effective, minimally invasive, and associated with low morbidity and mortality rates. Both procedures, VC and VCC, proved to be almost equally effective clinically and radiologically. Nevertheless, because of the statistically significant difference between the incidence of recurrence after VC and VCC during long-term follow-up, the author concludes that VCC should be considered as the procedure of choice in the treatment of these cases. The important finding of reclosure of the VC fenestration in the recurrent cases underscores the significance of performing cystocisternostomy at initial surgery to guard against cyst recurrence.

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Nasser M. F. El-Ghandour

Object

Arachnoid cysts located in the middle cranial fossa are common, comprising about half of all intracranial arachnoid cysts. The management of these cysts is challenging, and the optimal surgical treatment is controversial. This study evaluates the role of endoscopy in the treatment of middle cranial fossa arachnoid cysts (MCFACs) in children, focusing on some factors or technical aspects that might influence the outcome.

Methods

Thirty-two children with symptomatic MCFACs were the subject of this study. The group included 23 boys and 9 girls, with a mean age of 3.6 years. All patients underwent operations using a purely endoscopic cystocisternostomy procedure through a transtemporal approach.

Results

Significant clinical improvement occurred in 28 cases (87.5%). Postoperative MR imaging showed a reduction in cyst size in 23 cases (71.9%), whereas in the remaining 9 cases (28.1%), the cyst size was unchanged. Minor intraoperative bleeding occurred in 3 cases (9.4%), which stopped spontaneously without any postoperative sequelae. Ipsilateral subdural hygroma occurred in 2 cases (6.3%) and resolved within a few weeks without surgery; transient oculomotor palsy occurred in 1 case (3.1%). During follow-up (mean 4.6 years), 3 patients (9.4%) experienced recurrence of symptoms and an increase in cyst size. Interestingly, all 3 patients who had recurrence had also experienced intraoperative bleeding at initial surgery. At a second endoscopic procedure, the fenestration was found to be closed in all 3 patients.

Conclusions

Endoscopic cystocisternostomy is recommended in the treatment of MCFACs in children because it is simple, minimally invasive, and effective. It maintains the basic strategy of cyst fenestration into the basal cisterns without the invasiveness of open craniotomy. This procedure reduces operative and recovery times and is associated with low morbidity and mortality rates.

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Nasser M. F. El-Ghandour

Object

Arachnoid cysts account for 1% of all intracranial lesions. They usually occur in the subarachnoid space of the major cerebral fissures and arachnoid cisterns. They are very rarely located within the brain parenchyma devoid of communication with the subarachnoid space. The author of this study evaluated the role of endoscopy in the treatment of intraparenchymal arachnoid cysts (IPACs), which have a paraventricular location noncontiguous with the basal cisterns.

Methods

The records of all patients who had undergone surgery performed by one neurosurgeon between March 2004 and October 2011 were retrospectively reviewed to find cases of arachnoid cysts with a paraventricular location noncontiguous with the basal cisterns that were treated with a purely endoscopic cystoventriculostomy. Data were collected, summarized, and analyzed as regards improvement in symptomatology, decrease in cyst size, improvement in hydrocephalus, incidence of complications, surgical failure, and incidence of recurrence.

Results

Twelve pediatric patients with symptomatic IPACs were included in this study. The group included 7 boys and 5 girls with a mean age of 5.2 years. All of the patients had undergone endoscopic cystoventriculostomy. In addition, endoscopic third ventriculostomy had been performed during the same operative session in 3 patients who had associated hydrocephalus. Significant clinical improvement occurred in 10 patients (83.3%). Postoperative imaging showed a reduction in the cyst size in 9 patients (75%), whereas the cyst size was unchanged in the remaining 3 patients (25%). A reduction in ventricle size occurred in 2 (66.7%) of the 3 patients who had hydrocephalus. A postoperative subdural hygroma occurred in 2 patients (16.7%) and required the insertion of a subduroperitoneal shunt in 1 patient. During the follow-up period (mean 42.5 months), 1 patient had a recurrence and required a repeat endoscopic procedure.

Conclusions

Endoscopic cystoventriculostomy is recommended in the treatment of symptomatic IPACs. It maintains the basic strategy of cyst fenestration into the lateral ventricle without either the invasiveness of open craniotomy or the implantation of shunt systems. The procedure is simple, effective, and minimally invasive. It saves operative and recovery times and is associated with low morbidity and mortality rates.

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Jothy Kandasamy and Mark Souweidane