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Endoscopic Third Ventriculostomy – Effectiveness of the Procedure for Obstructive Hydrocephalus with Different Etiology in Adults

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Endoscopic Third Ventriculostomy – Effectiveness of the Procedure for Obstructive Hydrocephalus with Different Etiology in Adults View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by Jagiellonian Univeristy Repository Original paper Videosurgery Endoscopic third ventriculostomy – effectiveness of the procedure for obstructive hydrocephalus with different etiology in adults Krzysztof Stachura, Ewelina Grzywna, Borys M. Kwinta, Marek M. Moskała Department of Neurosurgery and Neurotraumatology, Jagiellonian University Medical College, Krakow, Poland Videosurgery Miniinv 2014; 9 (4): 586–595 DOI: 10.5114/wiitm.2014.46076 Abstract Introduction: After a time of domination of shunt placement, endoscopic third ventriculostomy (ETV) has been in- creasingly applied in treatment of obstructive hydrocephalus. Aim: To assess the effectiveness of ETV in treatment of adults with three-ventricle hydrocephalus of different etiology. Material and methods: Ninety-six patients with obstructive hydrocephalus were studied: 24 with primary aque- ductal stenosis, 61 with brain tumor, and 2 with basilar tip aneurysm. In 9 patients the etiology of hydrocephalus remained undetermined. The assessment of treatment results was based on clinical and radiological criteria. Results: Clinical improvement was observed in 74 (77.1%) patients, and radiological improvement in 52 (54.2%). One patient died. Follow-up of 24 patients with primary aqueductal stenosis has shown that in 20 (83.3%) of them clin- ical improvement has been stable, and in 14 (58.3%) radiological improvement has been observed. Two patients re- quired shunt placement due to hydrocephalus recurrence 12–24 months after the ETV procedure. Among 9 patients with undefined hydrocephalus, 3 required shunt placement within 6 months after ETV (2 shunted previously). Endo- scopic third ventriculostomy treatment in a patient with hydrocephalus caused by basilar tip aneurysm succeeded. The assessment of ETV effectiveness in oncological patients has been indirect in view of the underlying disease. Conclusions: The best results of ETV treatment have been demonstrated for patients with primary aqueductal ste- nosis. Ventricle size cannot determine the effectiveness of treatment as an individual requirement. Endoscopic third ventriculostomy is effective in previously shunted patients although the prediction of outcome should be cautious. Endoscopic third ventriculostomy enables preparation for further therapy and is palliative treatment in oncological patients with secondary hydrocephalus. Key words: endoscopic third ventriculostomy, obstructive hydrocephalus, long-term outcome. Introduction been subject to evolution for years – from the first Obstructive hydrocephalus develops due to experience of Dandy and Mixter with an endoscop- a blockage in circulation of the cerebrospinal flu- ic approach, through shunt placement introduced id (CSF). From the clinical point of view, obstructive by Nulsen and Spitz, to the increasingly appreciated hydrocephalus results from diseases causing an endoscopic third ventriculostomy (ETV) nowadays occlusion in the ventricular system, and it is also [2]. Endoscopic third ventriculostomy is a well-es- termed non-communicating hydrocephalus [1]. The tablished method of treatment in pediatric neuro- issue of treatment in obstructive hydrocephalus has surgery, allowing a reduction in the number of shunt Address for correspondence Krzysztof Stachura MD, PhD, Department of Neurosurgery and Neurotraumatology, Jagiellonian University Medical College, 3 Botaniczna St, 31-503 Krakow, Poland, phone: +48 12 424 86 60, e-mail: [email protected] 586 Videosurgery and Other Miniinvasive Techniques 4, December/2014 Endoscopic third ventriculostomy – effectiveness of the procedure for obstructive hydrocephalus with different etiology in adults placements, while there are fewer reports on this top- sulci were found. In 3 cases, due to suspicion of vas- ic in adults [3, 4]. So far there is no effective, simple cular malformation (basilar tip aneurysm), diagnos- diagnostic method that allows for proper selection of tic procedures were expanded by: digital subtraction patients for ETV. Theoretically, the greatest efficacy angiography in 2 cases and angio-CT scan in 1 case. of ETV should be achieved in cases of non-communi- Etiology of obstructive hydrocephalus in the study cating hydrocephalus with preserved patency of the group is presented in Table II. In 9 cases the cause subarachnoid space, up to the point of absorbing the of hydrocephalus remained undetermined with un- CSF [4]. However, in practice, the qualification for ETV equivocal radiological presentation of hydrocepha- often is based on empirical grounds. lus. In 1 patient with primary aqueductal stenosis, the MRI scan revealed in the vicinity of the sylvian Aim aqueduct a small hyperintense lesion of unknown etiology, observed in further scans. In patients with The aim of this study is to present short- and tumor of the posterior portion of the third ventricle, long-term results of ETV treatment in adults with in 14 patients with cerebellopontine angle tumor three-ventricle hydrocephalus of different etiology. and in 10 patients with cerebellar tumor the ETV procedure was preparation for the further stages of Material and methods treatment. In 3 patients with cerebellopontine angle Ninety-six patients with obstructive hydroceph- tumor and in 2 patients with cerebellar tumor (in all alus undergoing operations over the past 10 years cases: large tumor size, poor general condition of pa- in our Neurosurgery Department were studied. The tient, advanced age of patient) as well as in patients study group consisted of 41 women and 55 men with multiple metastases and in patients with mes- aged 18–82 years (average age 47 years). In all pa- encephalic tumor ETV was a palliative procedure. tients the initial diagnosis was made based on head Five patients with hydrocephalus of undetermined computed tomography (CT) or magnetic resonance etiology had been previously shunted and were ad- imaging (MRI) scan or both, performed before or at mitted with symptoms of shunt dysfunction. Stud- the time of admission. A variety of findings present- ied patients have not received any particular phar- ed in neurological examination were associated with macological treatment. In case of coexisting brain hydrocephalus alone and in some cases with under- edema, a standard approach was implemented. lying disease causing hydrocephalus (Table I). In case The aim of ETV is to communicate the third ven- of uncertainty about the final diagnosis, head MRI tricle with the interpeduncular cistern and create T2-weighted images were of critical importance. In flow which bypasses an obstruction to the circula- 56 patients active hydrocephalus with periventricu- tion of the CSF. The important step in preoperative lar lucency of the CSF and clamping of the cerebral planning is the assessment of conditions for fenes- Table I. Clinical symptoms in 96 patients with Table II. Etiology of the obstructive hydrocepha- obstructive hydrocephalus lus in studied patients Type of symptoms Number Cause of hydrocephalus Number of patients of patients Symptoms of intracranial hypertension 71 Primary aqueductal stenosis 24 Cognitive disorders 51 Tumor of posterior portion of the third 19 ventricle Gait disturbance 45 Cerebellopontine angle tumor 17 Urine incontinence 33 Cerebellar tumor 12 Locomotor ataxia 25 Multiple metastases 8 Mesencephalic tumor 5 Cranial nerve palsy 18 Basilar tip aneurysm 2 Hemiparesis 12 Undefined 9 Parinaud’s symptom 10 Total 96 Videosurgery and Other Miniinvasive Techniques 4, December/2014 587 Krzysztof Stachura, Ewelina Grzywna, Borys M. Kwinta, Marek M. Moskała tration in the floor of the third ventricle. In all pa- ies and if possible the dorsum sellae and basilar tip tients the final selection for the ETV procedure was were indentified. The infundibular recess and mam- based on neuroimaging analysis with at least axial millary bodies form a triangle, which is an anatom- and sagittal sections. In several cases initial diagnos- ical equivalent of the tuber cinereum – a structure tics had to be supplemented to meet these require- that, in the case of hydrocephalus, is usually thin. ments. The width of lateral ventricles, the width of Ventriculostomy was performed in the anterior part the third ventricle and the distance between the cli- of the described triangle by perforation of the floor vus and basilar artery were analyzed. Their appropri- of the third ventricle to the interpeduncular cistern. ate size allows handling of the endoscope without The technique of fenestration was dependent on the an increased risk to the surrounding structures and structure of the floor. If the floor was thin, use of performing safe ventriculostomy. The optimal trajec- a Fogarty balloon catheter no. 3 was sufficient. In tory of the endoscopic approach to the floor of the case of increased vascularization of the floor, bipolar third ventricle was obtained by a burr hole placed coagulation was used first and then a Fogarty cath- in the right frontal area 1 cm in front of the coronal eter or forceps to enlarge the perforation. Occasion- suture and 2–3 cm from the midline (Kocher’s point). ally occurring bleeding was brought under control by In some patients placement of the entry point was irrigation of the operative field with Ringer’s solution modified based on planimetric measurements made at the temperature of 36–37°C. After withdrawal of on sagittal scans. the neuroendoscope, the hole in the dura was closed During the ETV procedure the patient was po- with TachoSil.
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