Failure of third ventriculostomy in the treatment of aqueductal stenosis in children

OBJECT: The goal of this study was to analyze the types of failure and long-term efficacy of third ventriculostomy in children. METHODS: The authors retrospectively analyzed clinical data obtained in 213 children affected by obstructive triventricular hydrocephalus who were treated by third ventriculostomy between 1973 and 1997. There were 120 boys and 93 girls. The causes of the hydrocephalus included: aqueductal stenosis in 126 cases; toxoplasmosis in 23 cases, pineal, mesencephalic, or tectal tumor in 42 cases; and other causes in 22 cases. In 94 cases, the procedure was performed using ventriculographic guidance (Group I) and in 119 cases by using endoscopic guidance (Group II). In 19 cases (12 in Group I and seven in Group II) failure was related to the surgical technique. Three deaths related to the technique were observed in Group I. For the remaining patients, Kaplan-Meier survival analysis showed a functioning third ventriculostomy rate of 72% at 6 years with a mean follow-up period of 45.5 months (range 4 days-17 years). No significant differences were found during long-term follow up between the two groups. In Group I, a significantly higher failure rate was seen in children younger than 6 months of age, but this difference was not observed in Group II. Thirty-eight patients required reoperation (21 in Group I and 17 in Group II) because of persistent or recurrent intracranial hypertension. In 29 patients shunt placement was necessary. In nine patients in whom there was radiologically confirmed obstruction of the stoma, the third ventriculostomy was repeated; this was successful in seven cases. Cine phase-contrast (PC) magnetic resonance (MR) imaging studies were performed in 15 patients in Group I at least 10 years after they had undergone third ventriculostomy (range 10-17 years, median 14.3 years); this confirmed long-term patency of the stoma in all cases. CONCLUSIONS: Third ventriculostomy effectively controls obstructive triventricular hydrocephalus in more than 70% of children and should be preferred to placement of extracranial cerebrospinal shunts in this group of patients. When performed using ventriculographic guidance, the technique has a higher mortality rate and a higher failure rate in children younger than 6 months of age and is, therefore, no longer preferred. When third ventriculostomy is performed using endoscopic guidance, the same long-term results are achieved in children younger than 6 months of age as in older children and, thus, patient age should no longer be considered as a contraindication to using the technique. Delayed failures are usually secondary to obstruction of the stoma and often can be managed by repeating the procedure. Midline sagittal T2-weighted MR imaging sequences combined with cine PC MR imaging flow measurements provide a reliable tool for diagnosis of aqueductal stenosis and for ascertaining the patency of the stoma during follow-up evaluation.     

Stereotactic third ventriculostomy in patients with nontumoral adolescent/adult onset aqueductal stenosis and symptomatic hydrocephalus

Sixteen consecutive patients with obstructive hydrocephalus due to nontumoral aqueductal stenosis of adolescent or adult onset underwent computerized tomography-guided stereotactic third ventriculostomy. Computer-assisted angiographic target-point cross-registration was used in surgical planning to reduce morbidity. The procedure was used as primary treatment in five previously unshunted patients and in 11 patients who had previously received shunts and who presented when their shunts became obstructed (five patients), became infected (five patients), or required multiple revisions (one patient). At the time of third ventriculostomy, shunt hardware was removed in patients with infected shunts and the distal element of the shunt was ligated in all patients with obstructed shunts except one, who later required repeat third ventriculostomy; the distal shunt was ligated at that time. Follow-up data (range 1 to 5 years, mean 3 1/2 years, after surgery) showed that only one of the 16 patients had undergone a shunting procedure after the third ventriculostomy. The other 15 patients are asymptomatic and shunt-independent. In previously shunt-dependent patients, the peripheral subarachnoid space and cerebrospinal fluid absorption mechanism remained patent in spite of shunts placed earlier. Therefore, in patients with obstructive hydrocephalus due to aqueductal stenosis of adolescent or adult onset, stereotactic third ventriculostomy should be seriously considered as primary surgical management in previously unshunted patients and in shunt-dependent patients with obstructed or infected shunts.     

Elastance correlates with outcome after endoscopic third ventriculostomy in adults with hydrocephalus caused by primary aqueductal stenosis

OBJECTIVE: To study prospectively the correlation between clinical outcome after endoscopic third ventriculostomy (ETV) and resistance to the outflow of cerebrospinal fluid (R(out)) and elastance in adults with hydrocephalus caused by primary aqueductal stenosis (AS). METHODS: R(out) and elastance were measured in the subarachnoid space and intraventricularly before ETV in 15 consecutive patients. Three months after the ETV, the clinical effect was evaluated by standardized indices, and R(out) and elastance were measured. If symptoms persisted and the ETV was patent, shunt surgery was offered. The effect of the shunt operation and R(out) were measured after 3 months. RESULTS: Four patients experienced excellent improvement, six improved slightly, and five had unchanged or deteriorated symptoms after ETV. R(out) before ETV did not correlate with outcome. R(out) decreased after ETV with correlation to the clinical effect; in the six patients who had shunt surgery, R(out) decreased further. High preoperative elastance correlated strongly with a good outcome and reduction of ventricle size. Elastance did not change after ETV. CONCLUSION: R(out) intraventricularly and in the subarachnoid space could not predict the outcome of the ETV, but the reduction in R(out) correlated positively with clinical improvement. Preoperative elastance correlated positively with clinical improvement, and elastance was unchanged after ETV. Clinical improvement correlated positively with reduction in ventricle size.     

Endoscopic stent placement for treatment of secondary bilateral occlusion of the Monro foramina following endoscopic third ventriculostomy in a patient with aqueductal stenosis. Case report

Nontumoral bilateral occlusion of the Monro foramina is a rare clinical condition. Treatment includes shunt placement, endoscopic procedures, or both. The authors describe the case of a 22-year-old woman who had previously undergone placement of a ventriculoperitoneal shunt via a right frontal approach for management of triventricular dilation due to aqueductal stenosis. Six years postoperatively she presented with right-sided slit-ventricle syndrome and stenosis of the right Monro foramen, which was treated with an endoscopic third ventriculostomy and fenestration of the septum pellucidum. Two years later she presented with bilateral lateral ventricular dilation. Inspection of the right lateral ventricle with a fiberscope revealed occlusion of the septum pellucidum fenestration; on observation, the right Monro foramen was covered by thick, tough granulation tissue and the left was occluded by thin membranous tissue. Repeated fenestration of the septum pellucidum and left Monro foraminoplasty were therefore performed by perforating this thin tissue. A stent was then introduced into the third ventricle via the right lateral ventricle, the fenestration in the septum pellucidum, and the left Monro foramen. The authors note that fiberscopes are in general more maneuverable than rigid endoscopes and conclude that they are particularly useful for the treatment of this type of hydrocephalus.     

Clinical manifestations of aqueductal stenosis in adults.

The authors review 17 cases of aqueductal stenosis in adults and describe five modes of clinical presentation. The average duration of symptoms was 6 years. Dementia was infrequent. Skull x-ray films frequently demonstrated some degree of cranial enlargement and signs of chronic increased intracranial pressure. Characteristic alterations of the sella included elongation of the anterior wall and flattening, erosion, and anterior displacement of the dorsum. Aqueductal configurations as defined by ventriculography and pneumoencephalography in all cases, and the angiographic findings in seven cases are described. Most of the patients improved substantially after shunt insertion. The clinical findings suggested that aqueductal narrowing and associated hydrocephalus had been present in most of these patients since early life.     

良性胆道狭窄的介入治疗

目的探讨良性胆道狭窄的介入治疗方法。方法1998年2月-2003年12月间采用介入方法治疗ll例良性胆道梗阻患者，均有腹腔镜和开腹胆道手术史，经超声、CT和MRI证实为胆道狭窄。结果1l例胆道狭窄共进行了19次介入治疗，其中单纯扩张15次，9例扩张后置入了塑料内涵管并在3个月后拔除，余2例扩张后放置了金属内支架治疗，2例在形成胆管结石后进行了经皮取石术。1例胆肠瘘形成后在内涵管拔除后又长期放置了内外引流管。所有患者在采取各种介入治疗方法后胆道阻塞均得到了长期缓解。结论经皮穿刺单纯扩张和放置内涵管治疗各种医源性胆管良性狭窄是一种理想的方法，其主要优点是胆管长期开通率高，创伤小，可避免进一步的外科手术。     

Angiographic diagnosis of non-neoplastic aqueductal stenosis in children (author's transl)]

Angiograpic diagnosis of non-neoplastic aqueductal stenosis in 4 children were described. The materials were selected from 160 vertebral angiograms of children below 15 years, performed at the Kyushu University Hospital from July 1967 to March 1974. There were 4 cases of angiographically demonstrated non-neoplastic aqueductal stenosis. These cases were confirmed by pneumoence-phalogram and/or pneumoventriculograms, which were performed before and after the Tolkildens procedure. Ages of the patients varied from 6 to 15 years with average of 11.8 years. All the angiographic findings of these 4 patients with non-neoplastic aqueductal stenosis were explained on the basis of 5 major morphological changes such as 1) marked symmetrical obstructive hydrocephalus, 2) dilatation of the third ventricle and aqueduct above the obstruction with resultant downward displacement and compression up the upper brain stem and posterior displacement of the precentral cerebellar fissure, 3) maintenance of normal shape and position of the lower half of the posterior fossa structure, 4) absence of midline shaft of the median and paramedian vessels, 5) morphologic changes of the subarachonoid cisterns. These angiographic findings coincided with the angiographic features as described by Huang et al. (1968), under the experience with 10 cases of non-neoplastic aqueductal stenosis of adults, averaging of 43 years. Special emphasis was placed on the diagnostic value of the small veins and arteries in the posterior fossa vascular system. We also emphasized that the vertebral angiography should be performed as the first investigative procedure using the contrast media in the posterior fossa lesions.     

Endovascular treatment of sigmoid sinus stenosis in benign intracranial hypertension

Sinovenous stenosis is suggested to be related to benign intracranial hypertension. Endovascular treatment is effective in improving vision by overcoming these stenoses. We reported a case of benign intracranial hypertension with underlying right sigmoid sinus stenosis and left hypoplastic transverse sinus. Angioplasty for the right sigmoid sinus stenosis was carried out and the patient's vision improved. However, the intracranial pressure was still high approximately 1 year after angioplasty.     

Operative and non-operative treatment of benign subglottic laryngotracheal stenosis.

OBJECTIVE: Surgery is the first line of treatment for laryngotracheal stenosis; Montgomery tube or permanent tracheostomy have been so far the only alternatives. Nd-YAG laser resection and indwelling endotracheal stents have rarely been used in subglottic stenosis for anatomic and technical reasons. We have used the latter approach to optimize the timing of surgery or to achieve palliation without tracheostomy. METHODS: Between 1991 and 2001 we have treated 18 patients with subglottic stenosis (10 males, 8 females; age range 14-78, mean 34). The upper margin of the stricture was 2mm to 1cm below the vocal cords; the stenotic segment extended from 1.5 to 5 cm. Three patients had tracheostomy done elsewhere. Four patients (Group I) had laser and stenting by a Dumon prosthesis as the only treatment; six had laser and stenting (#4) followed after 1-6 months by laryngotracheal resection (Group II); eight had surgery alone (Group III). RESULTS: In Group I, one patient required repositioning of the stent and in two the stent was removed; two patients died of their underlying disease; at a follow-up of 2-9 years all living patients did well but required permanent aerosolized therapy and periodical bronchoscopy. In Group II, we had two wound infections due to airway colonization by staphylococcus aureus. In Group III, two patients developed anastomotic postoperative stenosis, treated by laser (#2) and stenting (#1), and one patient with previous tracheostomy had a wound infection. Overall, in the 14 surgical patients (Groups II and III) stenosis occurred in 14.2% and infection in 21.3%. After a follow up of 15 months to 12 years, all surgical patients breathe and speak well. CONCLUSIONS: Laser resection and endoluminal stenting can be a viable alternative to surgery or optimize the timing of operation in patients with subglottic stenosis.     

声门下喉气管良性狭窄的临床分型及外科治疗

目的探讨良性声门下喉气管狭窄(SLTS)的临床分型和外科治疗方法。 方法回顾2010年1月至2014年8月上海交通大学附属胸科医院治疗的30例良性SLTS患者,其中男性21例,平均年龄47岁,合并气管食管瘘3例。根据病变上缘位置分为4型：Ⅰ型-环状软骨下缘、Ⅱ型-环状软骨前壁、Ⅲ型-环状软骨环周、Ⅳ型-临近或累及声带。 结果所有患者中,Ⅰ型6例、Ⅱ型10例、Ⅲ型13例、Ⅳ型1例。治疗方式包括1例内镜保守治疗、3例气管切开、11例T管置入、15例SLTS节段切除并一切吻合重建。一期根治手术的15例患者中,Ⅰ型病变5例,Ⅱ型4例,Ⅲ型5例,Ⅳ型1例,其中1例Ⅱ型患者术后出现再狭窄,T管支撑6个月后成功脱管,1例Ⅲ型和1例Ⅳ型患者手术失败,分别转为T管支撑和气管切开,总体脱管率86.7%(13/15)。单纯T管治疗患者通气满意。全组无死亡病例。 结论声门下部分喉气管联合切除手术可有效治愈Ⅰ～Ⅲ期良性SLTS,对于无法耐受外科手术治疗的,Montgomery T型硅酮支架是很好的临时或终末治疗手段。     

Bifluranol in the treatment of benign prostatic hyperplasia (BPH)

Bifluranol, a fluorinated bibenzyl drug with antiandrogenic properties has been studied for its efficacy in the treatment of benign prostatic hyperplasia. Thirty five patients with bladder outflow obstruction received either Bifluranol 1.5 mg orally, t.d.s. or placebo in a double-blind trial. After twelve weeks there was improvement in symptoms of flow, urinary stream (p <0.01) and frequency (p <0.05) in the Bifluranol treated group. A significant reduction in residual urine volume was noted in the active treated group (p <0.05) but mean and peak urine flow rates, voided volume and prostate volume did not reach statistical significance. It is concluded that Bifluranol has a measurably beneficial effect in urinary outflow obstruction due to BPH and further investigative studies with this drug are in progress.     

Differential patterns of cognitive impairment in patients with aqueductal stenosis and normal pressure hydrocephalus

Summary. Methods. We report a preoperative neuropsychological evaluation for ten adult patients with aqueductal stenosis, and compare the results of this group with a normal pressure hydrocephalus group.Findings. For executive functions, aqueductal stenosis patients failed on isolated tests and results were heterogeneous; the normal pressure hydrocephalus group was more impaired, except for tasks which required memory processing. Memory deficits in aqueductal stenosis group are qualitatively dissimilar and more homogeneous and severe, despite the younger age, than in the normal pressure hydrocephalus group.Interpretation. These findings indicate that neuropsychological deficits of patients with aqueductal stenosis are linked with fornix damage and frontal dysfunction. In the normal pressure hydrocephalus group, deficits could be linked with a prefrontal lobe disconnection.     

24例胆总管末端良性狭窄的诊治体会

目的探讨胆总管末端良性狭窄的病因和诊断与治疗。方法回顾性总结我院1986年以来收治的24例胆总管末端良性狭窄的诊治资料。胆囊切除术后10例，胆囊切除、胆道探查术后7例，胆源性胰腺炎术后2例，慢性胰腺炎5例。作0ddi括约肌切开成形术11例，其中加作壶腹间隔切开成形术2例，胆肠内引流术9例，内窥镜下括约肌切开术(EST)2例，胰十二指肠切除术2例。结果术后并发十二指肠漏1例，胰漏2例，胆漏、胰漏1例。治愈23例，死亡1例。经1～15年随访20例。偶发胆管炎3例，频发较重胆管炎1例，其余效果满意。结论对有胆道手术史和慢性胰腺炎病人出现反复上腹或右上腹疼痛、黄疸等症状，应考虑有胆总管末端良性狭窄，影像学检查和内镜检查结合手术探查，必要时行术中活检是主要诊断手段。应根据狭窄的类型和程度选择合适的手术方式。