Endoscopic Third Ventriculostomy for Obstructive Hydrocephalus

Endoscopic Third Ventriculostomy for Obstructive Hydrocephalus

Treatment options include endoscopic approaches, which should be individualized to the child. The long-term outcome for children that have received treatment for hydrocephalus varies. Advances in the brain imagingtechnology, and understanding of the pathophysiology should ultimately lead to improved treatment of the disorder. 1).


Age and etiology play a crucial role in the success of endoscopic third ventriculostomy (ETV) as a treatment of obstructive hydrocephalus. The outcome is worse in infants, and controversies still exist whether ETV is superior to shunt placement.

El Damaty et al. retrospectively analyzed 70 patients below 2 years from 4 different centers treated with ETV and assessed success.

Children < 2 years who received an ETV within 1994-2018 were included. Patients were classified according to age and etiology; < 3, 4-12, and 13-24 months, etiologically; aqueductal stenosisposthemorrhagic hydrocephalus (PHH), tumor-related, fourth ventricle outlet obstruction, with Chiari type 2 malformation and following cerebrospinal fluid infection. They investigated statistically the predictors for ETV success through computing Kaplan-Meier estimates using the patient’s follow-up time and time to ETV failure.

They collected 70 patients. ETV success rate was 41.4%. The highest rate was in tumor-related hydrocephalus and fourth ventricle outlet obstruction (62.5%, 60%) and the lowest rate was in Chiari-type II and following infection (16.7%, 0%). The below 3 months age group showed a relatively lower success rate (33.3%) in comparison to older groups which showed similar results (46.4%, 46.6%). Statistically, a previous VP shunt was a predictor for failure (p-value < 0.05).

Factors suggesting a high possibility of failure were age < 3 months and etiology such as Chiari type 2 malformation or following cerebrospinal fluid infection. Altered CSF dynamics in patients with posthemorrhagic hydrocephalus and under-developed arachnoid villi may play a role in ETV failure. They do not recommend ETV as first-line in children < 3 months of age or in case of Chiari II or following infection 2).

Hydrocephalus/Myelomeningocele

A role for endoscopic third ventriculostomy (ETV) in myelomeningocele (MM) has provoked much debate, principally due to anatomical variants described, which may complicate the procedure.

Perez da Rosa et al. present 7 cases of children with MM and hydrocephalus undergoing a total of 10 ETV procedures. All patients demonstrated clinical improvement (in acute/subacute cases) or stabilization (in chronic cases). Three patients requiring a second ETV have shown clinical stability and renewed radiological evidence of functioning ventriculostomies in follow-up since reintervention. ETV can be used, albeit cautiously, in selected cases of hydrocephalus associated with MM. However, the frequency with which anatomical variation is encountered and the difficulty of the assessment of success make the procedure more challenging than usual 3).

Idiopathic normal pressure hydrocephalus

The only randomized trial of endoscopic third ventriculostomy (ETV) for idiopathic normal pressure hydrocephalus (iNPH) compares it to an intervention which is not a standard practice (VP shunting using a non-programmable valve). The evidence from this study is inconclusive and of very low quality. Clinicians should be aware of the limitations of the evidence. There is a need for more robust research on this topic to be able to determine the effectiveness of ETV in patients with iNPH 4).

Endoscopic third ventriculostomy (ETV) provides a physiological restoration of cerebrospinal fluid and a shunt-free option for pediatric hydrocephalus. Continuous developments in techniques and instruments have improved ETV as the first-line treatment.

Endoscopic third ventriculostomy with choroid plexus cauterization (ETV/CPC) offers an alternative to shunt treatment for infantile hydrocephalus.

More patients undergo ETV with a better outcome, identifying a new era of hydrocephalus treatment. Deeper understanding of ETV will improve a better shunt-free survival for pediatric hydrocephalus patients 5).

Hydrocephalus from thalamic hemorrhage

ETV is a safe and effective technique for the management of hydrocephalus resulting from an extraventricular obstruction in ETV is a safe and effective technique for the management of hydrocephalus resulting from an extraventricular obstruction in thalamic hemorrhage. It can avoid the need for permanent shunting in this patient population. Larger studies should be conducted to validate and further analyze this intervention.

It can avoid the need for permanent shunting in this patient population. Larger studies should be conducted to validate and further analyze this intervention 6).

References

1)

Kahle KT, Kulkarni AV, Limbrick DD Jr, Warf BC. Hydrocephalus in children. Lancet. 2015 Aug 6. pii: S0140-6736(15)60694-8. doi: 10.1016/S0140-6736(15)60694-8. [Epub ahead of print] Review. PubMed PMID: 26256071.
2)

El Damaty A, Marx S, Cohrs G, Vollmer M, Eltanahy A, El Refaee E, Baldauf J, Fleck S, Baechli H, Zohdi A, Synowitz M, Unterberg A, Schroeder HWS. ETV in infancy and childhood below 2 years of age for treatment of hydrocephalus. Childs Nerv Syst. 2020 Mar 28. doi: 10.1007/s00381-020-04585-8. [Epub ahead of print] PubMed PMID: 32222800.
3)

Perez da Rosa S, Millward CP, Chiappa V, Martinez de Leon M, Ibáñez Botella G, Ros López B. Endoscopic Third Ventriculostomy in Children with Myelomeningocele: A Case Series. Pediatr Neurosurg. 2015 May 27. [Epub ahead of print] PubMed PMID: 26021675.
4)

Tudor KI, Tudor M, McCleery J, Car J. Endoscopic third ventriculostomy (ETV) for idiopathic normal pressure hydrocephalus (iNPH). Cochrane Database Syst Rev. 2015 Jul 29;7:CD010033. doi: 10.1002/14651858.CD010033.pub2. Review. PubMed PMID: 26222251.
5)

Feng Z, Li Q, Gu J, Shen W. Update on Endoscopic Third Ventriculostomy in Children. Pediatr Neurosurg. 2018 Aug 15:1-4. doi: 10.1159/000491638. [Epub ahead of print] Review. PubMed PMID: 30110690.
6)

Zeineddine HA, Dono A, Kitagawa R, Savitz SI, Choi HA, Chang TR, Ballester LY, Esquenazi Y. Endoscopic Third Ventriculostomy for Hydrocephalus Secondary to Extraventricular Obstruction in Thalamic Hemorrhage: A Case Series. Oper Neurosurg (Hagerstown). 2020 May 4. pii: opaa094. doi: 10.1093/ons/opaa094. [Epub ahead of print] PubMed PMID: 32365205.

Ossified chronic subdural hematoma

Ossified chronic subdural hematoma

Calcified chronic subdural hematoma or ossified chronic subdural hematoma (CSDH), characterized by slowly progressing neurological symptoms, is a rarely seen entity that may remain asymptomatic for many years.

Incidence of calcified or ossified CSDH is high in certain countries, including the USAJapan and Turkey, with a steady increase in recent years 1).

They should be considered in the differential diagnosis at the time when we encounter because of its infrequency and variable clinical manifestation, following shunting in children or head trauma in adults 2).

Differential diagnosis

Calcified epidural hematoma, calcified empyema, meningioma, calcified arachnoid cyst, and calcified convexity of the dura mater with acute epidural hematoma should be considered for the differential diagnosis 3).

Treatment

Management of CSDH has improved dramatically in recent years thanks to advances in diagnostic tools, but there is still some controversy regarding the optimal treatment strategy.

Systematic reviews

In a systematic review, PRISMA guidelines were followed to query existing online databases between January 1930 and December 2018. We found a total of 88 articles containing 114 cases of calcified or ossified CSDH, 83 patients operated and 31 ones not operated.

There were 78 males and 29 females (7 with unreported gender) from 25 countries, ages ranging from 4 months to 86 years (mean 33.7 years), with etiologies of head trauma in 33.3%, shunting for hydrocephalus in 27.2%, or following cranial surgery in 4.4%. The duration of symptoms ranged from acute onset to 20 years, with a mean of 24.1 months. Imaging techniques such as X-ray, computed tomography, and magnetic resonance imaging were used with pathological confirmation of CSDH and complete recovery in 56.4% of patients.

Incidence of calcified or ossified CSDH is high in certain countries, including the USAJapan and Turkey, with a steady increase in recent years. Therapy of choice is surgery in these patients and it should be considered in the differential diagnosis at the time when we encounter because of its infrequency and variable clinical manifestation, following shunting in children or head trauma in adults 4).


Yang X, Qian Z, Qiu Y, Li X. Diagnosis and Management of Ossified Chronic Subdural Hematoma. J Craniofac Surg. 2015 Sep;26(6):e550-1. doi: 10.1097/SCS.0000000000002025. PubMed PMID: 26352368.

Case reports

A 59-year-old man presented with epileptic seizures interpreted as episodic syncope in the past 3 years and the patient had a history of head trauma about 4 years ago. Computed tomography revealed an ossified chronic subdural hematoma involving the right frontotemporoparietal region, which was totally resected using microsurgical technique. Postoperatively, weakness developed in the right arm and magnetic resonance imaging revealed a bilateral tension pneumocephalus, which was immediately treated by a left frontal burr hole trepanation, and the patient was discharged uneventfully 5).


A 46-year-old man with a history of alcohol abuse and a right frontotemporoparietal and left frontal ossified CSH that was diagnosed 2 years previously presented with headache and memory loss over 6 days. The patient was being followed with serial imaging, which showed the static state of the mass and no other lesions 7 months before admission. He underwent right frontotemporoparietal craniectomy to remove the ossified CSH and tumor. When the bone was lifted and the thin dura was opened, a hard, thick, ossified capsule was observed. No apparent tumor invasion was noted in the skull or epidural space. Despite refusing further chemotherapy and radiation therapy, the patient has been disease-free and working for 5 years.

Based on reported cases and relevant literature, large B-cell lymphoma may be associated with ossified CSH 6).


A 81-year-old woman with calcified chronic subdural hematoma. The patient underwent an osteoplastic left craniotomy, evacuation of chronic subdural mass with careful dissection and successful removal of the inner and outer membrane. Postoperative CT scan showed removal of subdural hematoma, a decrease of the left shift of median line and good brain re-expansion. The postoperative period was without any serious complications.

The subdural hematoma was successfully removed, resulting in a good recovery with complete resolution of patient’s symptoms. They highly recommend surgical treatment in cases of chronic symptomatic calcified subdural hematomas 7).


A Giant Ossified Chronic Subdural Hematoma 8).


Fang et al. reported a case of ossified chronic subdural hematoma in a 7-year-old female child, with a literature review 9).


Siddiqui et al. reported one case with diabetes insipidus 10).


A young girl affected by a syndromal hydrocephalus who developed a bilateral ossified chronic subdural hematoma with the typical radiological appearance of “the armored brain”. Bilateral calcified chronic subdural hematoma is a rare complication of ventriculoperitoneal shunt. There is controversy in the treatment, but most published literature discourages a surgical intervention to remove the calcifications 11).


Turgut et al. published one Ossified chronic subdural hematoma 12).


A 22-year-old male who had presented with severe headache consequent to brain compression caused by bifronto-parieto-temporal ossified subdural hematoma. We evaluated our method and surgical intervention in the light of the literature. The question whether the ossified membrane should be excised or not excised in these cases is a matter of controversy. They think that an ossified membrane causing an armored brain appearance should be excised in symptomatic, young patients with prominent cerebral compression. During this dissection, the relatively thickened arachnoid mater provides a safe border 13).


A 67-year-old man presented with headache, dysphasia, and left-sided hemiparesis. Routine skull x-ray showed a huge calcification extending from the frontal to the parietal regions in the right side. CT and MRI scan revealed a huge ossified SDH covering the right hemisphere. Right frontoparietal craniotomy was performed and the ossified SDH was completely removed. Severe adhesion was noticed between the pia mater and the inner surface of the ossified mass. The subdural mass had ossified hard outer and inner rims and a soft central part. The postoperative course was uneventful and 3 months after the operation, the patient was neurologically intact. The authors report the successful treatment of a patient with a huge ossified SDH covering the right hemisphere. Careful dissection and total removal are needed in such symptomatic cases to avoid cortical injury and to improve results 14).


A 24-year-old man with a history of tonic-clonic convulsions since 7 months of age was admitted because of increasing frequency and duration of seizures. Computed tomography and magnetic resonance imaging demonstrated a fusiform extra-axial lesion just above the tentorium and adjacent to the cerebral falx. A calcified and ossified chronic subdural hematoma was noted and was almost completely removed by craniotomy. Better seizure control was achieved by the removal of the calcified chronic subdural hematoma. Calcified subdural hematoma, calcified epidural hematoma, calcified empyema, meningioma, calcified arachnoid cyst, and calcified convexity of the dura mater with acute epidural hematoma should be considered for the differential diagnosis of an extra-axial calcified lesion 15).


Turgut et al. reported the successful removal of an ossified crust-like chronic subdural hematoma (SDH) covering the hemisphere in a 16-year-old boy. In this article, the importance of the surgical approach is stressed, and the rarity of this condition in the neurosurgical literature is also outlined 16).


A case of ossified chronic subdural hematoma is presented in a 13-year-old male in whom the mass was surgically removed. His neurological deficits continued afterward but were less severe 17).

References

1) , 2) , 4)

Turgut M, Akhaddar A, Turgut AT. Calcified or Ossified Chronic Subdural Hematoma: A Systematic Review of 114 Cases Reported during Last Century with a Demonstrative Case Report. World Neurosurg. 2019 Nov 1. pii: S1878-8750(19)32791-3. doi: 10.1016/j.wneu.2019.10.153. [Epub ahead of print] Review. PubMed PMID: 31682989.
3) , 15)

Yan HJ, Lin KE, Lee ST, Tzaan WC. Calcified chronic subdural hematoma: case report. Changgeng Yi Xue Za Zhi. 1998 Dec;21(4):521-5. PubMed PMID: 10074745.
5)

Turgut M, Yay MÖ. A Rare Case of Ossified Chronic Subdural Hematoma Complicated with Tension Pneumocephalus. J Neurol Surg Rep. 2019 Oct;80(4):e44-e45. doi: 10.1055/s-0039-1694738. Epub 2019 Dec 31. PubMed PMID: 31908905; PubMed Central PMCID: PMC6938459.
6)

Liu X, Zhou J, Shen B, Sun D, Zhang Z, Li H, Zhang J. Ossified Chronic Subdural Hematoma and Subsequent Epstein-Barr Virus-Positive Large B-Cell Lymphoma: Case Report and Literature Review. World Neurosurg. 2019 Oct;130:165-169. doi: 10.1016/j.wneu.2019.07.011. Epub 2019 Jul 9. PubMed PMID: 31299306.
7)

Snopko P, Kolarovszki B, Opsenak R, Hanko M, Benco M. Chronic calcified subdural hematoma – case report of a rare diagnosis. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub. 2019 Sep 26. doi: 10.5507/bp.2019.041. [Epub ahead of print] PubMed PMID: 31558846.
8)

Tian W, Meng X, Zou J. A Giant Ossified Chronic Subdural Hematoma. J Coll Physicians Surg Pak. 2019 Sep;29(9):905. doi: 10.29271/jcpsp.2019.09.905. PubMed PMID: 31455496.
9)

Fang J, Liu Y, Jiang X. Ossified Chronic Subdural Hematoma in Children: Case Report and Review of Literature. World Neurosurg. 2019 Jun;126:613-615. doi: 10.1016/j.wneu.2019.03.144. Epub 2019 Mar 27. PubMed PMID: 30926556.
10)

Siddiqui SA, Singh PK, Sawarkar D, Singh M, Sharma BS. Bilateral Ossified Chronic Subdural Hematoma Presenting as Diabetes Insipidus-Case Report and Literature Review. World Neurosurg. 2017 Feb;98:520-524. doi: 10.1016/j.wneu.2016.11.031. Epub 2016 Nov 17. Review. PubMed PMID: 27867130.
11)

Viozzi I, van Baarsen K, Grotenhuis A. Armored brain in a young girl with a syndromal hydrocephalus. Acta Neurochir (Wien). 2017 Jan;159(1):81-83. doi: 10.1007/s00701-016-2991-1. Epub 2016 Oct 25. PubMed PMID: 27778104; PubMed Central PMCID: PMC5177664.
12)

Turgut M, Samancoğlu H, Ozsunar Y, Erkuş M. Ossified chronic subdural hematoma. Cent Eur Neurosurg. 2010 Aug;71(3):146-8. doi: 10.1055/s-0030-1253346. Epub 2010 May 3. PubMed PMID: 20440672.
13)

Kaplan M, Akgün B, Seçer HI. Ossified chronic subdural hematoma with armored brain. Turk Neurosurg. 2008 Oct;18(4):420-4. PubMed PMID: 19107693.
14)

Moon HG, Shin HS, Kim TH, Hwang YS, Park SK. Ossified chronic subdural hematoma. Yonsei Med J. 2003 Oct 30;44(5):915-8. PubMed PMID: 14584111.
16)

Turgut M, Palaoğlu S, Sağlam S. Huge ossified crust-like subdural hematoma covering the hemisphere and causing acute signs of increased intracranial pressure. Childs Nerv Syst. 1997 Jul;13(7):415-7. PubMed PMID: 9298279.
17)

Iplikçioğlu AC, Akkaş O, Sungur R. Ossified chronic subdural hematoma: case report. J Trauma. 1991 Feb;31(2):272-5. PubMed PMID: 1994092.

Third ventricular tumor treatment

Third ventricular tumor treatment

A plethora of surgical strategies have been described to reach deep-seated lesions situated within the third ventricle including the Rosenfeld, or transcallosal anterior interfoniceal approach.

Third ventricle tumors are surgical challenges because of the complex surrounding structures, including the hypothalamus, infundibulum, optic pathways, limbic system, and nearby vasculature 1).

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.

Roth and Constantini, 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 2).

The first choice treatment option for third ventricle lesions with dilated ventricles was endoscopic management 3). Among microsurgical approaches, the expanded transcallosal transforaminal approach was a more recently practiced and safe method of accessing the anterior and middle third ventricle. With this approach, the risk of damage to most of the vital structures, such as the fornix or the thalamus was avoided 4). The location of the junction of the anterior septal and internal cerebral vein is essential. Preoperative magnetic resonance (MR) venography can identify the junction. Some areas remain inaccessible, such as the anterosuperior and posterosuperior regions of the third ventricle 5).

The expanded transcallosal transforaminal approach remains a safe and relatively secure method of gaining access to the third ventricle 6).


There are three broad categories – anterior, lateral, and posterior routes. The anterior routes include transforaminal, interforniceal, transchoroidal, and subchoroidal. The subtemporal route is the main lateral corridor to the third ventricle and recommended if the tumor is located lateral to the sella turcica or extends into the middle cranial fossa 7). A transtubular access to the third ventricle is also practical. It enables blunt dissection of the corpus callosum which may minimize retraction injuries. Three-dimensional endoscopic visualization, coupled with a transparent plastic retractor, provides absolute and undeviating monitoring of the surgical corridor 8). In the third ventricle’s anterior portion, the endoscopic endonasal approach permits surgical maneuverability. The lamina terminalis and tuber cinereum are thought to be safe entry points for this approach 9). Tumors leading to the blockage of the Sylvian aqueduct can cause obstructive hydrocephalus; this calls for a CSF diversion procedure, endoscopic third ventriculostomy, combined with an endoscopic biopsy. Posterior third ventricular tumors should be approached using a combination of a rigid-flexible endoscope 10).


Colloid cyst treatment.

Choroid plexus papilloma treatment.

Craniopharyngioma treatment.


Operative approaches to tumors of the third ventricle, mainly the bifrontal approach through the lamina terminalis, has several advantages. First, the main arteries can be exposed and the operative field is sufficiently wide to render the operative procedure safe. Second, cortical incision or excision is unnecessary. By cutting the lamina terminalis, which is usually thin and expanded as a result of hydrocephalus, even a large tumor can be removed. In addition, lethal complications are avoided, because this approach has less possibility of damage to the lateral wall of the third ventricle. Seventeen cases of tumor in the third ventricle underwent operation via this approach. The operative technique for the bifrontal approach through the lamina terminalis and three representative cases are reported. This approach can be applied not only to tumors, but to arteriovenous malformations or giant aneurysms adjacent to the third ventricle 11).

References

1)

Tomasello F, Cardali S, Angileri FF, Conti A. Transcallosal approach to third ventricle tumors: How I do it. Acta Neurochir. 2013;155:1031–4.
2) , 10)

Roth J, Constantini S. Combined rigid and flexible endoscopy for tumors in the posterior third ventricle. J Neurosurg. 2015 Jun;122(6):1341-6. doi: 10.3171/2014.9.JNS141397. Epub 2015 Mar 27. PubMed PMID: 25816082.
3)

Chibbaro S, Di Rocco F, Makiese O, Reiss A, Poczos P, Mirone G, Servadei F, George B, Crafa P, Polivka M, Romano A. Neuroendoscopic management of posterior third ventricle and pineal region tumors: technique, limitation, and possible complication avoidance. Neurosurg Rev. 2012 Jul;35(3):331-38; discussion 338-40. doi: 10.1007/s10143-011-0370-1. Epub 2012 Jan 19. PubMed PMID: 22258494.
4) , 6)

Patel P, Cohen-Gadol AA, Boop F, Klimo P Jr. Technical strategies for the transcallosal transforaminal approach to third ventricle tumors: expanding the operative corridor. J Neurosurg Pediatr. 2014 Oct;14(4):365-71. doi: 10.3171/2014.6.PEDS1452. Epub 2014 Aug 8. PubMed PMID: 25105512.
5)

Ahmed SI, Javed G, Laghari AA, Bareeqa SB, Aziz K, Khan M, Samar SS, Humera RA, Khan AR, Farooqui MO, Shahbaz A. Third Ventricular Tumors: A Comprehensive Literature Review. Cureus. 2018 Oct 5;10(10):e3417. doi: 10.7759/cureus.3417. Review. PubMed PMID: 30542631; PubMed Central PMCID: PMC6284874.
7)

Cikla U, Swanson KI, Tumturk A, Keser N, Uluc K, Cohen-Gadol A, Baskaya MK. Microsurgical resection of tumors of the lateral and third ventricles: operative corridors for difficult-to-reach lesions. J Neurooncol. 2016 Nov;130(2):331-340. Epub 2016 May 27. Review. PubMed PMID: 27235145; PubMed Central PMCID: PMC5090015.
8)

Shoakazemi A, Evins AI, Burrell JC, Stieg PE, Bernardo A. A 3D endoscopic transtubular transcallosal approach to the third ventricle. J Neurosurg. 2015 Mar;122(3):564-73. doi: 10.3171/2014.11.JNS14341. Epub 2015 Jan 2. PubMed PMID: 25555026.
9)

Cavallo LM, Di Somma A, de Notaris M, Prats-Galino A, Aydin S, Catapano G, Solari D, de Divitiis O, Somma T, Cappabianca P. Extended Endoscopic Endonasal Approach to the Third Ventricle: Multimodal Anatomical Study with Surgical Implications. World Neurosurg. 2015 Aug;84(2):267-78. doi: 10.1016/j.wneu.2015.03.007. Epub 2015 Mar 28. PubMed PMID: 25827043.
11)

Suzuki J, Katakura R, Mori T. Interhemispheric approach through the lamina terminalis to tumors of the anterior part of the third ventricle. Surg Neurol. 1984 Aug;22(2):157-63. PubMed PMID: 6740479.
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