Why does endoscopic aqueductoplasty fail so frequently? Analysis of cerebrospinal fluid flow after endoscopic third ventriculostomy and aqueductoplasty using cine phase-contrast magnetic resonance imaging

Clinical article

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Object

The aim of this study was to evaluate and compare CSF flow after endoscopic third ventriculostomy (ETV) and endoscopic aqueductoplasty (EAP) in patients presenting with obstructive hydrocephalus caused by aqueductal stenosis.

Methods

In patients harboring aqueductal stenosis who underwent EAP (n = 8), ETV (n = 8), and both ETV and EAP (n = 6), CSF flow through the restored aqueduct and through the ventriculostomy was investigated using cine cardiac-gated phase-contrast MRI. For qualitative evaluation of CSF flow, an in-plane phase-contrast sequence in the midsagittal plane was used. The MR images were displayed in a closed-loop cine format. Quantitative through-plane measurements were performed in the axial plane perpendicular to the aqueduct and/or floor of the third ventricle.

Results

Evaluation revealed significantly higher CSF flow through the ventriculostomies compared with flow through the aqueducts. This was true both when comparing the ETV group with the EAP group and when comparing the flow of the ventriculostomy and aqueduct within the ETV and EAP group. There was no difference in aqueductal CSF flow between patients who underwent EAP alone and patients who underwent ETV and EAP. There was also no difference in ventriculostomy CSF flow between patients who underwent ETV alone and patients who underwent ETV and EAP. Fifty percent of the restored aqueducts became occluded at a mean of 46 months after surgery (range 18–126 months). In contrast, all ETVs remained patent in the mean follow-up period of 110 months after surgery, although 1 patient required shunt placement after 66 months.

Conclusions

Cerebrospinal fluid flow through ventriculostomies is significantly higher than aqueductal CSF flow after EAP. This could be one factor to explain why the reclosure rate of aqueducts after EAP is higher than the reclosure rate of the ventriculostoma after ETV.

Abbreviations used in this paper:EAP = endoscopic aqueductoplasty; ETV = endoscopic third ventriculostomy; ROI = region of interest.

Article Information

Address correspondence to: Henry W. S. Schroeder, M.D., Ph.D., Ernst Moritz Arndt University, Department of Neurosurgery, Sauerbruchstrasse, D-17475 Greifswald, Germany. email: Henry.Schroeder@uni-greifswald.de.

Please include this information when citing this paper: published online May 11, 2012; DOI: 10.3171/2012.3.JNS111926.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    CSF flow quantification. A: Sagittal T1-weighted scout MR image showing the phase-contrast imaging plane perpendicular to the aqueduct (solid line) and ventriculostoma (dashed line) for assessing CSF flow. B: Axial phase-contrast image perpendicular to the ventriculostoma showing an annular ROI around the ventriculostoma. C: Axial phase-contrast image perpendicular to the aqueduct showing an annular ROI around the aqueduct.

  • View in gallery

    Graph of the CSF flow waveform. Time after R wave in milliseconds is plotted on the x axis and CSF velocity in cm/second is plotted on the y axis. Positive deflections represent caudocranial flow (CSF diastole) and negative deflection represents craniocaudal flow (CSF systole). Early diastole (curved dotted line) was a portion of the waveform that was not evaluated because of prospective cardiac gating. R-D = time after R wave to onset of CSF diastole; R-PS = time after R wave to peak CSF systole; R-S = time after R wave to onset of CSF systole; VPeakDias = peak end-diastolic CSF velocity; VPeakSyst = peak systolic CSF velocity. Originally published in Schroeder et al.: J Neurosurg 93:237–244, 2000.

  • View in gallery

    Magnetic resonance imaging obtained after ETV (upper row), after EAP (center row), and after ETV and EAP (lower row). A: Sagittal turbo inversion-recovery spin-echo image showing a strong flow void within the ventriculostoma (arrow). B: Axial phase-contrast image perpendicular to the ventriculostoma showing a hyperintense signal (arrow) indicating caudal flow of CSF systole. C: Axial phase-contrast image perpendicular to the ventriculostoma showing a hypointense signal (arrow) indicating cranial flow of CSF diastole. D: Sagittal turbo inversion-recovery spin-echo image showing a flow void within the aqueduct (arrow). E: Axial phase-contrast image perpendicular to the aqueduct showing a hyperintense signal (arrow) indicating caudal flow of CSF systole. F: Axial phase-contrast image perpendicular to the aqueduct showing a hypointense signal (arrow) indicating cranial flow of CSF diastole. G: Sagittal turbo inversion-recovery spin-echo image showing a strong flow void within the ventriculostoma (arrow) and a moderate flow void within the aqueduct (arrowhead). H: Axial phase-contrast image perpendicular to the ventriculostoma showing a hyperintense signal (arrow) indicating caudal flow of CSF systole. I: Axial phase-contrast image perpendicular to the ventriculostoma showing a hypointense signal (arrow) indicating cranial flow of CSF diastole. J: Axial phase-contrast image perpendicular to the aqueduct showing a hyperintense signal (arrow) indicating caudal flow of CSF systole. K: Axial phase-contrast image perpendicular to the aqueduct showing a hypointense signal (arrow) indicating cranial flow of CSF diastole.

  • View in gallery

    Graphs showing CSF velocity profiles within the ventriculostoma in a patient who underwent ETV (A), within the aqueduct in a patient who underwent EAP (B), within the ventriculostoma in a patient who underwent ETV and EAP (C), and within the aqueduct in a patient who underwent ETV and EAP (D). Time after R wave in milliseconds is plotted on the x axis and CSF velocity in cm/second is plotted on the y axis.

  • View in gallery

    Midsagittal phase-contrast images of the brain and upper spinal cord obtained after ETV (upper row), after EAP (center row), and after ETV and EAP (lower row). A: Early in the cardiac cycle, there is a hyperintense signal in all CSF spaces indicating cranial flow (end of CSF diastole). B: Caudal flow (hypointense signal, CSF systole) started in the cervical subarachnoid space, whereas in the aqueduct/ventriculostoma cranial flow remains. C: During CSF mid-systole, there is caudal flow in all CSF spaces. D: During CSF diastole, there is cranial flow in all CSF spaces.

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