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.

Chronic subdural hematoma treatment

Chronic subdural hematoma treatment

A variety of clinical factors must be taken into account in the treatment of chronic subdural hematoma (cSDH), and the multifaceted treatment paradigms continue to evolve 1).

There is lack of uniformity about the treatment strategies, such as the role of burr holetwist drillcraniotomy, etc., in CSDH amongst various surgeons. There is also disagreement about the use of drainirrigation, and steroid 2) 3).

Surgery is usually the treatment of choice, but conservative treatment may be a good alternative in some situations.

see DECSA trial.

see Middle Meningeal Artery Embolization.

Chronic subdural hematoma surgery

Systematic reviews

Soleman et al., provide a systematic review of studies analysing the conservative treatment options and the natural history of cSDH. Of 231 articles screened, 35 were included in this systematic review. Studies evaluating the natural history and conservative treatment modalities of cSDH remain sparse and are predominantly of low level of evidence. The natural history of cSDH remains unclear and is analysed only in case reports or very small case series. “Wait and watch” or “wait and scan” management is indicated in patients with no or minor symptoms (Markwalder score 0-1). However, it seems that there are no clear clinical or radiological signs indicating whether the cSDH will resolve spontaneously or not (type C recommendation). In symptomatic patients who are not worsening or in a comatose state, oral steroid treatment might be an alternative to surgery (type C recommendation). Tranexamic acid proved effective in a small patient series (type C recommendation), but its risk of increasing thromboembolic events in patients treated with antithrombotic or anticoagulant medication is unclear. Angiotensin converting-enzyme inhibitors were evaluated only as adjuvant therapy to surgery, and their effect on the rate of recurrence remains debatable. Mannitol showed promising results in small retrospective series and might be a valid treatment modality (type C recommendation). However, the long treatment duration is a major drawback. Patients presenting without paresis can be treated with a platelet activating factor receptor antagonist (type C recommendation), since they seem to promote resolution of the haematoma, especially in patients with subdural hygromas or low-density haematomas on computed tomography. Lastly, atorvastatin seems to be a safe option for the conservative treatment of asymptomatic or mildly symptomatic cSDH patients (type C recommendation). In conclusion, the knowledge of the conservative treatment modalities for cSDH is sparse and based on small case series and low grade evidence. However, some treatment modalities seem promising even in symptomatic patients with large haematomas. Randomised controlled trials are currently underway, and will hopefully provide us with good evidence for or against the conservative treatment of cSDH 4).

Surveys

The aim of a study was to survey aspects of current practice in the UK and Ireland. A 1-page postal questionnaire addressing the treatment of primary (i.e. not recurrent) CSDH was sent to consultant SBNS members in March 2006. There were 112 responses from 215 questionnaires (52%). The preferred surgical technique was burr hole drainage (92%). Most surgeons prefer not to place a drain, with 27% never using one and 58% using drain only in one-quarter of cases or less. Only 11% of surgeons always place a drain, and only 30% place one in 75% of cases or more. The closed subdural-to-external drainage was most commonly used (91%) with closed subgaleal-to-external and subdural-to-peritoneal conduit used less often (3 and 4%, respectively). Only 5% of responders claimed to know the exact recurrence rate. The average perceived recurrence rate among the surgeons that never use drains and those who always use drains, was the same (both 11%). Most operations are performed by registrars (77%). Postoperative imaging is requested routinely by 32% of respondents and 57% of surgeons prescribe bed rest. Ninety four per cent surgeons employ conservative management in less than one-quarter of cases. Forty-two per cent of surgeons never prescribe steroids, 55% prescribe them to those managed conservatively. This survey demonstrates that there are diverse practices in the management of CSDH. This may be because of sufficiently persuasive evidence either does not exist or is not always taken into account. The current literature provides Class II and III evidence and there is a need for randomized studies to address the role of external drainage, steroids and postoperative bed rest 5).


Cenic et al. developed and administered a questionnaire to Canadian Neurosurgeons with questions relating to the management of chronic and subacute subdural hematoma. Our sampling frame included all neurosurgery members of the Canadian Neurosurgical Society.

Of 158 questionnaires, 120 were returned (response rate = 76%). The respondents were neurosurgeons with primarily adult clinical practices (108/120). Surgeons preferred one and two burr-hole craniostomy to craniotomy or twist-drill craniostomy as the procedure of choice for initial treatment of subdural hematoma (35.5% vs 49.5% vs 4.7% vs 9.3%, respectively). Craniotomy and two burr-holes were preferred for recurrent subdural hematomas (43.3% and 35.1%, respectively). Surgeons preferred irrigation of the subdural cavity (79.6%), use of a subdural drain (80.6%), and no use of anti-convulsants or corticosteroids (82.1% and 86.6%, respectively). We identified a lack of consensus with keeping patients supine following surgery and post-operative antibiotic use.

The survey has identified variations in practice patterns among Canadian Neurosurgeons with respect to treatment of subacute or chronic subdural hematoma (SDH). Our findings support the need for further prospective studies and clinical trials to resolve areas of discrepancies in clinical management and hence, standardize treatment regimens 6).

Glucocorticoids

Since glucocorticoids have been used for treatment of cSDH in 1962 their role is still discussed controversially in lack of evident data. On the basis of the ascertained inflammation cycle in cSDH dexamethasone will be an ideal substance for a short lasting, concomitant treatment protocol.

A study is designed as a double-blind randomized placebo-controlled trial 820 patients who are operated for cSDH and from the age of 25 years are included after obtaining informed consent. They are randomized for administration of dexamethasone (16-16-12-12-8-4 mg/d) or placebo (maltodextrin) during the first 48 hours after surgery. The type I error is 5% and the type II error is 20%. The primary endpoint is the reoperation within 12 weeks postoperative.

This study tests whether dexamethasone administered over 6 days is a safe and potent agent in relapse prevention for evacuated cSDH 7).

Chronic subdural hematoma seizure prophylaxis

Anticoagulation resumption after chronic subdural hematoma

References

1)

Sahyouni R, Goshtasbi K, Mahmoodi A, Tran DK, Chen JW. Chronic Subdural Hematoma: A Historical and Clinical Perspective. World Neurosurg. 2017 Dec;108:948-953. doi: 10.1016/j.wneu.2017.09.064. Epub 2017 Sep 19. Review. PubMed PMID: 28935548.
2) , 5)

Santarius T, Lawton R, Kirkpatrick PJ, Hutchinson PJ. The management of primary chronic subdural haematoma: a questionnaire survey of practice in the United Kingdom and the Republic of Ireland. Br J Neurosurg. 2008 Aug;22(4):529-34. doi: 10.1080/02688690802195381. PubMed PMID: 18686063.
3)

Cenic A, Bhandari M, Reddy K. Management of chronic subdural hematoma: a national survey and literature review. Can J Neurol Sci. 2005 Nov;32(4):501-6. PubMed PMID: 16408582.
4)

Soleman J, Noccera F, Mariani L. The conservative and pharmacological management of chronic subdural haematoma. Swiss Med Wkly. 2017 Jan 19;147:w14398. doi: smw.2017.14398. PubMed PMID: 28102879.
6)

Cenic A, Bhandari M, Reddy K. Management of chronic subdural hematoma: a national survey and literature review. Can J Neurol Sci. 2005 Nov;32(4):501-6. PubMed PMID: 16408582.
7)

Emich S, Richling B, McCoy MR, Al-Schameri RA, Ling F, Sun L, Wang Y, Hitzl W. The efficacy of dexamethasone on reduction in the reoperation rate of chronic subdural hematoma – the DRESH study: straightforward study protocol for a randomized controlled trial. Trials. 2014 Jan 6;15(1):6. doi: 10.1186/1745-6215-15-6. PubMed PMID: 24393328; PubMed Central PMCID: PMC3891985.

Bed rest for unintended durotomy treatment

Bed rest for unintended durotomy treatment

Duration of post-operative bed rest was not related to complication rate but led to delays in discharge. Robson et al. did not find evidence that early mobilization lead to an increased likelihood of complications 1).


Although bed rest × 4–7 days is often advocated to reduce symptoms and facilitate healing when watertight dural closure has been achieved, normal post-op mobilization is not associated with a high failure rate (bed rest is recommended if symptoms develop) 2). In one report of 8 patients with leaks that appeared post-op, reoperation was avoided when treated by resuturing the skin under local anesthesia, followed by bed rest in slight Trendelenburg position (to reduce pressure on the leakage site), broad-spectrum antibiotics and antibiotic ointment over the skin incision, and daily puncture and drainage of the subcutaneous collection 3).


Among German neurosurgeons, no consensus exists concerning the intra- and postoperative management of accidental durotomies in lumbar spine surgery. Despite not being proved to reduce the rate of cerebrospinal fluid fistulas, bed rest is frequently used. As bed rest prolongs the hospital stay with additional costs and has the potential of a higher rate of medical complications, a prospective multicenter trial is warranted 4).

References

1)

Robson CH, Paranathala MP, Dobson G, Ly F, Brown DP, O’Reilly G. Early mobilisation does not increase the complication rate from unintended lumbar durotomy. Br J Neurosurg. 2018 Nov 4:1-3. doi: 10.1080/02688697.2018.1508641. [Epub ahead of print] PubMed PMID: 30392385.
2)

Hodges SD, Humphreys C, Eck JC, et al. Management of Incidental Durotomy Without Mandatory Bed Rest. Spine. 1999; 24:2062–2064
3)

Waisman M, Schweppe Y. Postoperative Cerebrospinal Fluid Leakage After Lumbar Spine Operations. Conservative Treatment. Spine. 1991; 15:52–53
4)

Clajus C, Stockhammer F, Rohde V. The intra- and postoperative management of accidental durotomy in lumbar spine surgery: results of a German survey. Acta Neurochir (Wien). 2015 Jan 11. [Epub ahead of print] PubMed PMID: 25577453.
WhatsApp WhatsApp us
%d bloggers like this: