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Jonathan Roth and Shlomi Constantini

OBJECT

Tumors leading to occlusion of the sylvian aqueduct include those of pineal, thalamic, and tectal origins. These tumors cause obstructive hydrocephalus and thus necessitate a CSF diversion procedure such as an endoscopic third ventriculostomy (ETV), often coupled with an endoscopic biopsy (EBX). Lesions located posterior to the massa intermedia pose a technical challenge, as the use of a rigid endoscope for performing both an ETV and EBX is limited. The authors describe their experience using a combined rigid and flexible endoscopic procedure through a single bur hole for both procedures in patients with posterior third ventricular tumors.

METHODS

Since January 2012, patients with posterior third ventricular tumors causing hydrocephalus underwent dual ETV and EBX procedures using the combined rigid-flexible endoscopic technique. Following institutional review board approval, data from clinical, radiological, surgical, and pathological records were retrospectively collected.

RESULTS

Six patients 3.5–53 years of age were included. Lesion locations included pineal (n = 3), fourth ventricle (n = 1), aqueduct (n = 1), and tectum (n = 1). The ETV and EBX were successful in all cases. Pathologies included pilocytic astrocytoma, pineoblastoma, ependymoma Grade II, germinoma, low-grade glioneural tumor, and atypical choroid plexus papilloma. One patient experienced an immediate postoperative intraventricular hemorrhage necessitating evacuation of the clots and resection of the tumor, eventually leading to the patient's death.

CONCLUSIONS

The authors recommend using a combined rigid-flexible endoscope for endoscopic third ventriculostomy and biopsy to approach posterior third ventricular tumors (behind the massa intermedia). This technique overcomes the limitations of using a rigid endoscope by reaching 2 distant regions.

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Jonathan Roth, Marian M. Bercu and Shlomi Constantini

Hypothalamic hamartomas (HHs) are typically located within the vicinity of the third ventricle. They can be attached to the walls of the third ventricle, within the interpeduncular cistern (third ventricle floor), and/or attached to the mammillary bodies and hypothalamus. Depending on their location, resection is performed either through the third ventricle, approaching from above, or via a frontotemporal craniotomy (pterional or frontoorbital), approaching from below. “Above” approaches typically include the transcallosal–anterior interforniceal approach, and recently, purely endoscopic approaches performed transforaminally.

The authors present a combined open and endoscopic approach for resection of HHs located within the third ventricle. They used this approach in 2 young girls with relatively small lateral and third ventricles. Following an interhemispheric, transcallosal approach and exposure of the right foramen of Monro, an endoscope was inserted through the foramen, which enabled safe resection of the HH.

The main advantage of the combined approach is when the lateral and third ventricles are relatively small, making a purely endoscopic approach more challenging and possibly riskier.

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Gyang Markus Bot, Shlomi Constantini and Jonathan Roth

Cavum septum pellucidum (CSP) cysts are relatively rare. The most common presenting symptom is headache, which is thought to be secondary to elevated intracranial pressure. Many CSP cysts are treated surgically; conservative treatment is seldom recommended. The authors describe 3 cases of pediatric CSP cysts that were managed without surgery.

The patients ranged in age from 5 months to 8 years old. Two presented with headaches, which were associated with mild ventricular enlargement in 1 case. Over the course of 5–15 months, 2 cysts became markedly reduced in size, and in one of these 2 cases a substantial reduction in ventricle size was also observed. At last follow-up, all 3 children were asymptomatic.

The authors note that CSP cysts are often associated with headaches. In the absence of hydrocephalus, they recommend conservative management with clinical and radiological follow-up.

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Harold L. Rekate

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Zvi Lidar, Shlomi Constantini, Gilad J. Regev and Khalil Salame

Postlaminectomy cervical kyphosis is one of the most challenging entities in spine surgery. Correction of this deformity usually requires anterior fusion with plating and a strut graft or interbody cage and posterior fusion with screws and rods. The situation is more complicated in the young child because fusion may affect future growth of the cervical spine. There is also a paucity of adequate instrumentation for the small bony structures. Some authors have reported utilization of absorbable cervical plates for fusion in pediatric patients with favorable results.

The authors present a modified surgical technique that was used for circumferential fusion in a 2-year-old girl with cervical kyphosis and recurrent neurofibroma. Anterior fusion was performed using an autologous rib graft and an absorbable cervical plate. This was followed by posterior fusion using rib bone and cables. Previous reports on the use of absorbable cervical plates are reviewed and the advantages of the current technique are discussed.

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Dimitrios Paraskevopoulos, Naresh Biyani, Shlomi Constantini and Liana Beni-Adani

Object

The rationale for using endoscopy to treat complex cysts and multiloculated hydrocephalus is to combine several CSF compartments into a minimum number, establish a connection to functioning CSF compartments (that is, ventricles), and decrease shunt dependency. The aim is to decrease the number of proximal shunt catheters, the number of shunt revisions, and in selected cases even to avoid a shunt. In cases of distorted anatomy and multiloculated cysts, endoscopy may be problematic because of orientation issues. Standard navigation becomes useless soon after CSF loss due to brain shift. Therefore, the concept of “real-time” navigation and intraoperative imaging in combination with endoscopic surgery has been previously suggested. The goal of the present study was to assess the feasibility and efficacy of combining intraoperative MR (iMR) imaging and navigated neuroendoscopy in infants.

Methods

The authors report their experience in treating 5 infants (aged 6–14 months), who underwent surgery for multicystic hydrocephalus presenting with shunt malfunction (4 patients) and a quadrigeminal fetal arachnoid cyst (1 patient). In all infants, a low-field portable iMR imaging system (0.12-T PoleStar N-10/0.15-Tesla PoleStar N-20) was used in conjunction with navigated endoscopy. The authors used e-steady, T1-weighted, and T2-weighted sequences (acquisition time 24 seconds to 3.5 minutes).

Results

The iMR imaging system provided clear images that correlated with the endoscopic appearance of the cystic membranes in all patients, and the images were helpful in determining trajectories and redefining targets. The iMR images documented brain shift and changes in CSF spaces during surgery. There were no intraoperative complications or technical difficulties of visualization. No infection or any other immediate postoperative complication occurred. Patients were followed up for 9 months to 7 years. The infant presenting with the quadrigeminal cyst remains shunt free since surgery, and the patients with multicystic hydrocephalus have 1–2 shunts each. Following endoscopic, iMR imaging–guided surgery, shunt catheter positioning was found to be optimal and as planned according to the postoperative imaging.

Conclusions

Navigated neuroendoscopy and iMR imaging may complement each other, offering an advantage over other modalities in complicated cases of hydrocephalus. Whenever targets and trajectories need to be redefined, the iMR images provided an updated navigation data set, allowing accurate navigation of the endoscope and minimizing the number of CSF compartments. Direct vision through the endoscope provides microanatomical details for the optimization of fenestration and catheter positioning. The combined usage of the two modalities may transform a conventional procedure into a visually controlled real-time navigated process.

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Matthew J. McGirt, Shlomi Constantini and George I. Jallo

Object

Postoperative progressive spinal deformity often complicates functional outcome after resection of pediatric intramedullary spinal cord tumors (IMSCTs). The authors propose a preoperative grading scale that correlates with the postoperative development of progressive spinal deformity requiring subsequent fusion.

Methods

The data obtained in 164 patients who underwent resection of an IMSCT at a single institution were retrospectively collected and analyzed to determine the development of progressive spinal deformity requiring fusion. A grading scale (range of scores I–V) was created based on the presence or absence of 4 preoperative variables: preoperative scoliosis, involvement of the thorocolumbar junction, age < 13 years, and number of surgeries for an IMSCT. The grading scale was then retrospectively applied to this series of 164 children to assess the correlation of variables with subsequent spinal deformity.

Results

Nine patients presented with Grade I status, 41 patients with Grade II, 58 patients with Grade III, 44 patients with Grade IV, and 12 patients with Grade V. Overall, 44 patients (27%) developed progressive spinal deformity requiring fusion at a mean follow-up of 5 years after surgery. A higher preoperative grade was associated with an increasing need for subsequent fusion for progressive spinal deformity (Grade I [0%], Grade II [5%], Grade III [26%], Grade IV [40%], and Grade V status [75%]).

Conclusions

Application of this grading scheme to a series of resected pediatric IMSCTs has demonstrated its correlation with the incidence of postoperative progressive spinal deformity requiring fusion. The application of a standardized grading scheme will assist in the process of surgical decision making and postoperative evaluation.

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Shlomi Constantini, Vitaly Siomin, Yves Bitton and Avi Hassner

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Elka Miller, Liat Ben-Sira, Shlomi Constantini and Liana Beni-Adani

Object

The goal of this study was to determine the importance magnetic resonance (MR) imaging holds as a complementary fetal imaging modality to ultrasonography in deciding postnatal neurosurgical management.

Methods

Between 1999 and 2003, 320 fetal MR imaging studies were performed at a single institution. Twenty-four fetuses were found to have central nervous system abnormalities that could potentially require a neurosurgical intervention. The diagnoses included spinal anomalies (scoliosis, myelomeningocele, and closed spinal dysraphism) and brain anomalies (ventriculomegaly with or without hemorrhage, intracranial cyst, craniosynostosis, and encephalocele).

Fourteen of the 24 fetuses underwent surgery based on findings of prenatal MR imaging. In seven cases the pregnancy was terminated, and in three cases conservative follow up continues.

Conclusions

In a variety of brain and spine disorders, prenatal MR imaging can delineate and characterize the abnormality, and thus assist in the diagnosis and in the planning of postnatal surgery and management. This modality provides important multiplanar images and may obviate the need for early postnatal computed tomography or MR imaging. Postnatal management can often be guided by prenatal MR imaging findings.

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Liat Ben-Sira, Noam Goder, Haim Bassan, Shlomi Lifshits, Yaniv Assaf and Shlomi Constantini

OBJECT

The object of this study was to use diffusion tensor imaging (DTI) to evaluate and characterize white matter changes in hydrocephalus.

METHODS

The authors performed a retrospective analysis of DTI in a cohort of patients with hydrocephalus (n = 35), 19 of whom had both pre- and postsurgical imaging studies. These patient’s DTI values were compared with values extracted from age-dependent trend lines computed from a healthy subject group (n = 70, age span 14 months-14 years). Several DTI parameters in different regions of interest (ROIs) were evaluated to find the most sensitive parameters for clinical decision making in hydrocephalus.

RESULTS

Compared with healthy controls, patients with active hydrocephalus had a statistically significant change in all DTI parameters. The most sensitive and specific DTI parameter for predicting hydrocephalus was axial diffusivity (λ1) measured at the level of the corona radiata. Diffusion tensor imaging parameters correlated with several conventional radiological parameters in the assessment of hydrocephalus but were not superior to them. There was no convincing correlation between clinical disease severity and DTI parameters. When examining the pre- and postsurgical effect, it was found that DTI may be a sensitive tool for estimating tissue improvement.

CONCLUSIONS

This large-cohort study with a multidisciplinary approach combining clinical, neurological, radiological, and multiple DTI parameters revealed the most sensitive DTI parameters for identifying hydrocephalus and suggested that they may serve as an important tool for the disorder’s quantitative radiological assessment.