Endoscopic considerations treating hydrocephalus caused by basal ganglia and large thalamic tumors.

Jonathan Roth,Shlomi Constantini,Zvi Ram

doi:10.4103/2152-7806.154467

Abstract

Background:Deep basal-ganglia and large thalamic (BGT) tumors may cause secondary hydrocephalus by compressing the lateral and third ventricles. The ventricular distortion, as well as the infiltrative nature and friability of these tumors, raise specific considerations and risks when treating these patients. Treatment goals may therefore focus on cerebrospinal fluid (CSF) diversion and tissue sampling, followed by nonsurgical treatment options. We present our experience in applying endoscopic techniques for the initial management of such patients.Methods:Over a period of 15 months (January 2013 to April 2014), six patients with BGT tumors presented with signs and symptoms of increased intracranial pressure secondary to hydrocephalus. Data was collected retrospectively, including clinical, surgical, and outcome variables.Results:Six patients aged 9–41 years (25.6 ± 12.5) were included. Endoscopic procedures included endoscopic third ventriculostomy (4), septum pellucidotomy (5), foramen of Monro stenting (2), and endoscopic biopsy (3). One patient underwent a ventriculoperitoneal shunt placement and another stereotactic biopsy. Indications for endoscopic treatment included the infiltrative nature of the tumor preventing a resective procedure, combined with clinical deterioration related to increased intracranial pressure secondary to hydrocephalus. Pathology results included anaplastic astrocytoma (3) and anaplastic oligodendroglioma (1). Pathological sampling was not possible in two patients. Five patients enjoyed a good clinical recovery with no associated morbidity. There was one perioperative death, secondary to preoperative herniation.Conclusions:Endoscopic surgery may potentially play a significant role in the initial management of patients with large basal ganglia and large thalamic tumors causing obstructive hydrocephalus. Technical nuances and individualized goals are crucial for optimal outcomes.

Highlights

Basal‐ganglia and large thalamic (BGT) tumors cause ventricular distortion as well as medial compression, compressing the body of the third ventricle and the foramina of Monro and commonly produce obstructive hydrocephalus
All patients presented with obstructive hydrocephalus, most having moderately enlarged ventricles, and all having periventricular edema and diminished convexity subarachnoid space
This study provides a detailed analysis of the surgical considerations when treating patients with obstructive hydrocephalus secondary to deep‐seated tumors, focusing on the role of endoscopy

Summary

Introduction

Basal‐ganglia and large thalamic (BGT) tumors cause ventricular distortion as well as medial compression, compressing the body of the third ventricle and the foramina of Monro and commonly produce obstructive hydrocephalus. In this subgroup of BGT tumors, presenting symptoms are attributed to focal signs combined with elevated intracranial pressure (ICP). In contrast to hydrocephalus secondary to posterior third ventricular tumors, and small posterior‐medial thalamic tumors, which compress the aqueduct or posterior third ventricle and cause triventricular symmetrical hydrocephalus, large BGT tumors cause distorted ventricular anatomy, often distorting the region of the foramina of Monro, and the anterior third ventricle This distortion significantly increases the risks of surgical treatment. We present our experience in applying endoscopic techniques for the initial management of such patients

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Results

Conclusion