Intraventricular Endoscopy Research Articles

Ensuring Neurosurgical Equity: Setup for Safe Ventricular Endoscopy and Predictors of Clinical Outcome in a Resource-Limited Health Care System

Background/ObjectiveNeuroendoscopic surgeries require specialized equipment, which may not be universally available or equitably distributed in most neurosurgical units of resource-limited healthcare systems. This review reports on the use of locally available resources to perform safe ventricular endoscopic surgeries in patients with hydrocephalus and cystic craniopharyngioma, in a resource-limited health care system. MethodsThis study, described the use of locally available resources to perform intraventricular endoscopic surgeries, and retrospectively reviewed a three-year outcome of these surgeries, The authors, used a 24Fr, 2-way Foley's catheter, that served as an endoscopic working sheet. A transparent 9mm naso-tracheal tube, that served as a retractor and a peel-away sheet. An intravenous fluid (IVF) giving set, was used for irrigation, and a metallic stylet of External ventricular drain(EVD) was used for third ventricular floor or cyst wall fenestration. ResultsTwenty-one intraventricular endoscopic surgeries were performed, consisting; of endoscopic third ventriculostomy (ETV), septostomies, cystostomies, and intraventricular biopsies. Mortality occurred in four patients, with one of the mortality, directly related to intraoperative hemorrhage. Most (3/21) of the complications were post-operative CSF leakage and partial wound dehiscence. Of the 17 surviving patients, the ETV success rate was 82.4% (14/17). Logistic regression analysis revealed that the patient's age, etiology, ETV success score (ETVSS) and procedure performed were not predictive of ETV success or mortality. ConclusionsPatients accessing neurosurgical care in resource-limited healthcare systems can benefit from safe and successful intraventricular endoscopy. However, this may require the innovative use of locally available resources that can be adapted to local neurosurgical needs.

Intraventricular endoscopy and intraventricular antibiotics in the treatment of multiloculated hydrocephalus with ventriculitis in a neonate and an infant: Two case reports

Background: We present two pediatric cases, a neonate and an infant, who presented with treatment-refractory ventriculitis and multiloculated hydrocephalus treated with simultaneous intraventricular endoscopy and antibiotics. This is the first report of this combined therapy in children. Case Description: Using intraventricular endoscopic surgery and antibiotics, hydrocephalus was treated with a minimum number of ventricular shunt systems. In addition, treatment-refractory ventriculitis was treated in both patients using intraventricular antibiotics. Conclusion: Endoscopic surgery and intraventricular antibiotic administration are useful strategies for treating multiloculated hydrocephalus and ventriculitis in children.

Review of surgical spproaches for posterior fossa tumors in pediatric population and illustrative cases

Introduction/Background: Posterior fossa tumors are common in the pediatric population, and various surgical approaches have been described to reach them based on their specific location. This paper aims to review the most common posterior fossa approaches in pediatric patients and present illustrative cases to provide insights into their successful application in specific clinical scenarios. Case report: Three cases are presented, each demonstrating a different approach and surgical outcome. Case 1 involved a telovelar approach for the resection of a medulloblastoma, resulting in complete removal without neurological deficits. Case 2 required a combination of telovelar and supracerebellar infratentorial approaches to achieve gross total resection of a pilocytic astrocytoma. In Case 3, an occipital transtentorial approach was utilized to access and completely resect an atypical teratoid rhabdoid tumor. Connclusion: The paper discusses the telovelar and transvermian approaches, the supracerebellar infratentorial approach, the transtentorial suboccipital approach, and intraventricular endoscopy as individual or combined approaches for posterior fossa tumors. The presented cases highlight the importance of tailoring the surgical approach to each patient and provide valuable insights for neurosurgeons managing similar clinical scenarios.

Primary Intraventricular Phaeohyphomycosis: An Atypical Presentation of Neurotropic Fungus

Cerebral fungal infections are usually reported secondary to contiguous spread from paranasal sinuses or orbit, hematogenous spread, traumatic brain injury, or immunocompromised conditions. Primary isolated intraventricular phaeohyphomycosis is rare. We report a 29-year-old man who presented with acute symptomatic unilateral hydrocephalus with an intraventricular lesion. Intraventricular endoscopy demonstrated 3 lesions along the choroid plexus with turbid cerebrospinal fluid. The lesions were yellowish in appearance. Excision of all lesions was done along with septostomy. The histopathology of the lesion as well as cerebrospinal fluid showed thin, septate, pigmented hyphae suggestive of phaeohyphomycosis. The patient initially responded to oral voriconazole but later developed acute symptoms and died 3 months after surgery despite continuous antifungal treatment. Primary intraventricular phaeohyphomycosis is uncommon and may have a dismal prognosis even with early diagnosis and prompt treatment.

Endoscopic lavage of the cerebral ventricular system for ventriculitis treatment in a patient with complicated new coronavirus infection (COVID‑19)

Introduction. The new coronavirus infection (COVID‑19) has a wide spectrum of complications. Frequency of neurological symptoms varies between 17.3 and 36.4 %. In 8 % of cases, COVID‑19 can be accompanied by bacterial or fungal infection. Since few descriptions of bacterial meningitis in adult patients with COVID‑19 and a single description of surgical treatment of purulent meningitis complicated by empyema of the 4th ventricle in a patient with COVID‑19 were found, and there are no meta‑analyses in this area, descriptions of such cases are of high scientific and practical value.Aim. The describe a case of surgical treatment of purulent ventriculitis in an adult (during treatment of the new coronavirus infection COVID‑19).Materials and methods. A man, 69 years old, with previously established diagnosis of the new coronavirus infection COVID‑19 and a comorbid pathology was admitted to the Moscow City Clinical Hospital No. 40 with newly diagnosed seizure disorder. Computed tomography imaging showed ventriculitis confirmed by MRI with obstructive hypertensive triventricular hydrocephalus.Results. The patient underwent treatment: three‑time endoscopic lavage of the ventricular system, removal of newly formed fibrin membranes with interventricular septostomy, removal of obstruction at the level of the Sylvian aqueduct; the surgery was concluded by external draining of the lateral ventricles, administration of an antibiotic intro the ventricular system and intravenously. Cerebrospinal fluid flow was restored, ventriculitis manifestations completely negated.Conclusion. Development of ventriculitis as one of the first signs of bacterial infection accompanying COVID‑19 is a very rare and life‑threatening complication requiring active surgical intervention. In was shown that endoscopic lavage of the ventricular system for ventriculitis treatment is an effective action against infection and cerebrospinal fluid flow disorders. Use of intraventricular endoscopy for ventriculitis treatment has several advantages compared to needle ventriculostomy. Further studies and analysis of treatment of bacterial ventriculitis using endoscopic surgical techniques in patients with and without the new coronavirus infection are needed.

Developing a dynamic simulator for endoscopic intraventricular surgeries

A novel dynamic simulator brain model with hydrocephalus has been developed for endoscopic intraventricular procedures. Detachable components allow enhancement of the walls of the ventricle by choroid plexus, ependymal veins and the membranous floor of the third ventricle which are derived from cadaveric lab animal tissues to give a lifelike appearance. These can be changed for every exercise. Ventricles are filled with injection of saline to give appropriate transparent medium and connected to a device transmitting pulsations creating conditions similar to live surgeries. Thirty-five participants have used this model over the last 1year and found it to be useful for conducting third ventriculostomy. Further development of the model for septostomy, aqueductoplasty and tumour biopsy has also been recently tested successfully by 12 participants. It is hoped that this simulator model for intraventricular endoscopy is comprehensive as a learning tool in carrying out most of thethe surgical procedures currently practised.

Neuroendoscopic surgery in children: does age at intervention influence safety and efficacy? A single-center experience.

OBJECTIVE The aim of this study was to review the safety of pediatric intraventricular endoscopy across separate age groups and to determine whether intraventricular endoscopy is associated with an increased risk of complications or reduced efficacy in infants younger than 1 year. METHODS In this retrospective cohort study, 286 pediatric patients younger than 17 years underwent intraventricular endoscopy at Great Ormond Street Hospital between December 2005 and December 2014. The primary diagnosis, procedure, and complications were recorded. RESULTS Neuroendoscopic surgery was performed in 286 pediatric patients (51 neonates 0-6 months [Group 1]; 37 infants 6-12 months [Group 2]; 75 patients 1-5 years [Group 3]; 54 patients 5-10 years [Group 4]; and 69 patients ≥ 10 years [Group 5]; male/female ratio 173:113). The most common procedures included endoscopic third ventriculostomy (ETV) in 159 patients and endoscopic fenestration of intracranial cysts in 64 patients. A total of 348 consecutive neuroendoscopic procedures were undertaken. Nine different complications were identified, of which postoperative seizures (1.7%), CSF leak (3.1%), CSF infection (2.4%), and intracranial hemorrhage (1.7%) were the most common. Specifically, no significant difference in complication rate (11.9%) or infection rate (2.4%) was observed among age groups (p = 0.40 and p = 0.91, respectively). In addition, there were no perioperative deaths; 30-day mortality was 1.1%. After neuroendoscopy for CSF diversion (n = 227), a significantly higher rate of shunt insertion was observed in the youngest group (Group 1, 63.0%) when compared with older groups (Group 2, 46.4%; Group 3, 26.3%; Group 4, 38.6%; and Group 5, 30.8%; p = 0.03). Similarly, for patients who underwent ETV as their initial neuroendoscopic procedure or in combination with additional surgical interventions (n = 171), a significantly higher rate of shunt insertion was also observed within young infants (Group 1, 67.9%; Group 2, 47.6%; Group 3, 19.6%; Group 4, 27.3%; and Group 5, 23.3%; p = 0.003). CONCLUSIONS Intraventricular endoscopy is a safe neurosurgical intervention in pediatric patients of all ages, although it might be associated with increased shunt rates after endoscopic surgery, specifically ETV, in younger infants.

Specification Analysis, Design, and Prototyping of a Burr Hole Endoscope Stabilization Device.

Aim of this study was to develop a prototype for an innovative, burr-hole mounted device, for stabilizing endoscopes during intracranial surgery. The objective was an easily maneuverable device, freeing one hand without compromising flexibility and safety. This could avoid the need for a second surgeon or a bulky holder, thus improving coordination. The initial concept arose from the observation that intraventricular endoscopy is often performed by 2 surgeons, 1 navigating the endoscope and 1 inserting/handling instruments through the working channel. A specification analysis was performed. Desired properties were specified through a literature review, as well as informal interviews with surgeons and engineers. Tools used for the design included blueprints, 3-dimensional computer aided-design and cooperating with engineers. The final prototype was 3D-printed and the toruses were produced with molding. A prototype named BuESta (Burr hole Endoscope Stabililizer) was produced. This consists of 2 half hollow sphere parts and interchangeable toruses and has the following features: easy to produce, inexpensive, not prolonging surgical time, semirigid, variable fixation, easy to fix/release, safe, no bulky articulated arms, mimicking basic concepts of second hand fixation (index finger/thumb fixation, hand resting/stabilizing on skull). This work represents a feasibility study including specification analysis, design and prototyping of a novel Burr hole endoscope stabilizing device. The device offers variable support for the endoscope, from complete free-hand to semirigid to rigid, thus freeing one hand which is often used to stabilize the endoscope. It can potentially help achieve solo surgery.

Neuroendoscopy for Intraventricular Tumor Resection

n recent decades, the endoscope has become an increasingly important tool in the armamentarium of the neurosurI geon. In pediatrics in particular, intraventricular endoscopy has become a routine part of neurosurgical practice and training. Improvements in image quality, ergonomics of endoscope use, neuronavigation, and a host of other technical factors have contributed to an ever-expanding range of indications for endoscopic treatment of intraventricular pathology. In addition, based in part of the remarkable success of endoscopic third ventriculostomy (ETV)/choroid plexus cauterization in treating hydrocephalus in Uganda, North American centers are beginning to expand the use of endoscopic treatment for hydrocephalus as well. The natural consequence of these developments is increasing familiarity of pediatric neurosurgeons with using the endoscope and increasing comfort in using the endoscope for more complex undertakings, particularly the resection of intraventricular tumors. There are several important factors, however, that must be considered to maximize the chances of successful intraventricular neuroendoscopy.

Neurosurgical endoscopic training via a realistic 3-dimensional model with pathology.

Training in intraventricular endoscopy is particularly challenging because the volume of cases is relatively small and the techniques involved are unlike those usually used in conventional neurosurgery. Present training models are inadequate for various reasons. Using 3-dimensional (3D) printing techniques, models with pathology can be created using actual patient's imaging data. This technical article introduces a new training model based on a patient with hydrocephalus secondary to a pineal tumour, enabling the models to be used to simulate third ventriculostomies and pineal biopsies. Multiple models of the head of a patient with hydrocephalus were created using 3D rapid prototyping technique. These models were modified to allow for a fluid-filled ventricular system under appropriate tension. The models were qualitatively assessed in the various steps involved in an endoscopic third ventriculostomy and intraventricular biopsy procedure, initially by 3 independent neurosurgeons and subsequently by 12 participants of an intraventricular endoscopy workshop. All 3 surgeons agreed on the ease and usefulness of these models in the teaching of endoscopic third ventriculostomy, performing endoscopic biopsies, and the integration of navigation to ventriculoscopy. Their overall score for the ventricular model realism was above average. The 12 participants of the intraventricular endoscopy workshop averaged between a score of 4.0 to 4.6 of 5 for every individual step of the procedure. Neurosurgical endoscopic training currently is a long process of stepwise training. These 3D printed models provide a realistic simulation environment for a neuroendoscopy procedure that allows safe and effective teaching of navigation and endoscopy in a standardized and repetitive fashion.

The foramen of Monro: a review of its anatomy, history, pathology, and surgery.

The foramen of Monro lies at the junction between the paired lateral ventricles and the third ventricle of the brain. A comprehensive review of the literature was performed focusing on the foramen of Monro. A good understanding of the anatomy of the foramen of Monro is essential for the neurosurgeon, especially with the increasing use of intraventricular endoscopy.

Small-ventricle neuroendoscopy for pediatric brain tumor management

The use of intraventricular endoscopy to achieve diagnosis or to resect accessible intraventricular or paraventricular tumors has been described in the literature in both adults and children. Traditionally, these techniques have not been used in patients with small ventricles due to the perceived risk of greater morbidity. The authors review their experience with the effectiveness and safety of endoscopic brain tumor management in children with small ventricles. Between July 2002 and December 2009, 24 children with endoscopically managed brain tumors were identified. Radiological images were reviewed by a radiologist blinded to study goals and clinical setting. Patients were categorized into small-ventricle and ventriculomegaly groups based on frontal and occipital horn ratio. Surgical success was defined a priori and analyzed between groups. Trends were identified in selected subgroups, including complications related to pathological diagnosis and surgeon experience. Six children had small ventricles and 18 had ventriculomegaly. The ability to accomplish surgical goals was statistically equivalent in children with small ventricles and those with ventriculomegaly (83% vs 89%, respectively, p = 1.00). There were no complications in the small-ventricle cohort, but in the ventriculomegaly cohort there were 2 cases of postoperative hemorrhages and 1 case of infection. All hemorrhagic complications occurred in patients with high-grade tumor histopathological type and were early in the surgeon's endoscopic career. Based on our experience, endoscopy should not be withheld in children with intraventricular tumors and small ventricles. Complications appear to be more dependent on tumor histopathological type and surgeon experience than ventricular size.

Feasibility of ventricular expansion postmortem: a novel laboratory model for neurosurgical training that simulates intraventricular endoscopic surgery

Cadavers are often used in the teaching of various neurosurgical procedures. One aspect of this resource that has not been previously explored is the postmortem dilation of the ventricular system, which is often collapsed, for the purpose of training neurosurgeons in the use of intraventricular endoscopy. Nine adult cadavers without a history of hydrocephalus or other known intracranial pathology were used for this study. Four specimens were obtained post embalming, and 5 specimens were fresh (time from death until the procedure < 5 hours). In all cadavers catheters were placed into the lateral ventricles; saline and then air were injected into the ventricles through the catheters. Ventriculostomy sites were filled with rubber stoppers, and in fresh specimens, formal embalming was performed with cadavers in the Trendelenburg position. Lastly, serial horizontal sectioning of the cranium was performed in all cadavers to verify ventricular dilation. None of the 4 embalmed specimens were found to have ventriculomegaly following injection. However, this condition was found in 4 of the 5 fresh specimens. In the single fresh cadaver without ventriculomegaly, the cause of death had been massive intracranial subarachnoid hemorrhage, which distorted the ventricular system. This may have prevented cannulation of the ventricle and ventricular expansion in this specimen. The ventricular system of fresh human cadavers can be dilated postmortem. The method described herein may be useful to neurosurgical trainees or those trained neurosurgeons wishing to practice intraventricular endoscopy.

Report of the Joint Meeting of the World Federation of Neurosurgical Societies Course in Africa and the First Cameroon Neurosurgery Society Congress, Cameroon, October 2007

To the Editor: Access to neurosurgery remains a luxury in sub-Saharan Africa. To date, some African countries of this region cannot even boast of one neurosurgeon, whereas others have one to five neurosurgeons; countries with as many as 10 neurosurgeons are the exception. In its wish to expand and develop neurosurgery in those regions of the world that do not yet have this specialty, the World Federation of Neurosurgical Societies (WFNS) chose Africa as the site of an international course on October 2 and 3, 2007. Yaoundé, the capital of the Republic of Cameroon, was designated to host this course. The newly created Cameroon Neurosurgery Society seized this opportunity to organize its first-ever congress from October 1 to 4, 2007, and to ensure that the event ran concurrently with the WFNS meeting. This joint meeting was called the “African Week of Neurosurgery.” This event, which was the first of its kind in sub-Saharan Africa, enabled the gathering of 32 neurosurgeons from 17 countries (Belgium, France, Spain, Italy, Switzerland, Brazil, Morocco, Zimbabwe, Cameroon, Nigeria, Gabon, Congo, Niger, Burkina Faso, Côte d'Ivoire, Senegal, Guinea) and three continents (Europe, South America, and Africa). The WFNS delegation was headed by the President of the WFNS, accompanied by the Chairman of the Education and Training Committee and seven lecturers. The WFNS lecturers gave 25 lectures (anterolateral spinal meningiomas, management of parasitic meningiomas, spinal cord tumors, surgical treatment of anterior circulation aneurysms, surgical treatment of brain arteriovenous malformations, pterional approach, external ventricular drainage, modern aspects of craniosynostosis, modern treatment of hydrocephalus, laminotomy and laminoplasty, brainstem cavernomas, management of low-grade gliomas, petroclival meningiomas, foramen magnum meningiomas, intraventricular endoscopy, posterior microforaminotomy in the treatment of cervical herniated disc, brainstem tumors, the basic principles of the treatment of severe head injuries, craniopharyngiomas in adults, spinal trauma, transsphenoidal approach, intracranial suppurations, lumbar spinal stenosis, central nervous system parasitosis, and injury resuscitation and management with minimal resources). The Cameroon Neurosurgery Society congress was marked by two major events: 1) 17 oral communications, whose principal themes were neurotraumatology, malformations of the central nervous system, intracranial suppurations, and spinal degenerative diseases in Africa; and 2) the creation of the Association of Neurological Surgeons of Africa (ANSA), which will serve as the link between Africa and the WFNS to bridge the gap of communications. This event recorded a great scientific success. The Cameroon Neurosurgery Society extends special thanks to the Cameroon government, which permitted the realization of this event through its support; the WFNS, its lecturers, and all participants; the Faculty of Medicine and Biomedical Sciences, University of Yaoundé; the “Cabinet ELESYST”; and all who contributed to the success of this event. Victor C. Eyenga Aurelien Ndoumbe Joseph E. Ngah Yaoundé, Cameroon

Surface rendering-based virtual intraventricular endoscopy: Retrospective feasibility study and comparison to volume rendering-based approach

Objective: Virtual endoscopic simulations using volume rendering (VR) have been proposed as a tool for training and understanding intraventricular anatomy. It is not known whether surface rendering (SR), an alternative to VR, can visualize intraventricular and subependymal structures better and thus making the virtual endoscope more useful for simulating the intraventricular endoscopy. We sought to develop SR-virtual endoscopy and compared the visibility of anatomical structures in SR and VR using retrospective cases. Materials and methods: Fourteen patients who underwent endoscopic intraventricular surgery of third ventricle enrolled the study. SR-virtual endoscopy module was developed in open-source software 3D Slicer and virtual endoscopic scenes from the retrospective cases were created. VR virtual endoscopy of the same cases was prepared in commercial software. Three neurosurgeons scored the visibility of substructures in lateral and third ventricle, arteries, cranial nerves, and other lesions Results: We found that VR and SR-virtual endoscopy performed similarly in visualization of substructures in lateral and third ventricle (not significant statistically). However, the SR was statistically significantly better in visualizing subependymal arteries, cranial nerves, and other lesions ( p < 0.05, respectively). Conclusions: We concluded that SR-virtual endoscopy is a promising tool to visualize critical anatomical structures in simulated endoscopic intraventricular surgery. The results lead us to propose a hybrid technique of volume and surface rendering to balance the strength of surface rendering alone in visualizing arteries, nerves and lesions, with fast volume rendering of third and lateral ventricles.