Surgical outcome of pediatric hydrocephalus treated by endoscopic III ventriculostomy: prognostic factors and interpretation of postoperative neuroimaging

In order to analyze the surgical outcome according to clinical characteristics and to evaluate the correlation between clinical improvement and neuroimaging changes, we retrospectively reviewed 32 children who had undergone endoscopic III ventriculostomy (ETV) from February 1994 to May 1998. There were 15 boys and 17 girls, with a mean age of 5.2 years (range: 1 month to 13 years). The etiology of the hydrocephalus was primary aqueductal stenosis in 18 patients, secondary aqueductal stenosis caused by tumors in 5, IV ventricle outlet obstruction in 5, and hydrocephalus associated with meningomyelocele in 4. The mean duration of follow-up was 19.4 months (range 1–50 months). Overall, surgical outcome was regarded as good in 21 of 29 patients. Surgical outcome was poor in patients younger than 1 year (P<0.05). Neuroimaging 1 month after ETV showed a decrease in ventricular size in 11 of the 16 patients with good surgical outcomes. Five showed minimal changes only. In patients with good outcomes, ventricular size tended to decrease as time passed. Resolution of periventricular edema, flow void in the III ventricle on T2-weighted axial images, and cine-MR imaging were sensitive indicators of good outcome. We suggest that ETV be considered as a primary treatment option in patients older than 1 year of age with noncommunicating hydrocephalus. In addition, time factors should be taken into consideration when surgical outcome is judged. Changes in ventricular size could not predict surgical outcome completely in themselves. Therefore, a comprehensive postoperative assessment should be made with the help of T2-weighted MRI and cine-MRI. Received: 24 May 1999 Revised: 7 August 1999     

Hemorrhagic subdural effusion complicating an endoscopic III ventriculostomy

Subdural effusion, a common postoperative complication of extracranial shunting for hydrocephalus, is usually caused by excessive drainage of cerebrospinal fluid. Subdural effusion is thought to occur less frequently after a neuroendoscopic III ventriculostomy, and no reported cases have been symptomatic. We encountered a symptomatic subdural effusion with a component of hemorrhage 5 days after the latter procedure was performed to treat massive hydrocephalus in a 2-year-old boy. Received: 21 September 1998 Revised: 20 July 1999     

Outcome analysis of endoscopic III ventriculostomy

A retrospective chart review was performed on 54 patients who had undergone endoscopic III ventriculostomy (E3V) in the past 6 years. Patient charts were reviewed to establish age at the time of operation, sex, preoperative diagnosis, preoperative shunt procedures, success or failure of the E3V, duration of success, and complications. Success of an E3V was determined by the resolution of preoperative symptoms and avoidance of a CSF shunt. The most recent clinic visit with adequate documentation of signs and symptoms of hydrocephalus was used as the last date of follow-up. The overall success rate was 74%. Children over the age of 3 years with an acquired CSF obstruction had a significantly greater probability of successful treatment (P=0.05). Younger children, especially those with hydrocephalus attributable to obstruction of the arachnoid villi, as in intraventricular hemorrhage (IVH), were less likely to benefit from E3V. Received: 2 October 1999 Revised: 12 January 2000     

Risk reduction of subdural collections following endoscopic third ventriculostomy

Object To evaluate the efficacy and safety using fibrin glue and absorbable hemostats for packing the endoscopic tract in a pediatric population in the prevention of subdural fluid collections after endoscopic third ventriculostomy. Materials and methods Twenty-one endoscopic third ventriculostomies were performed in 20 hydrocephalic children with a mean age of 22 months over a 4-year period using uniformly this technique. Six children, with age ranged 6 days to 22 months (mean 9 months), had severe ventriculomegaly with thin brain mantle less than 10 mm. There was no mortality and no permanent morbidity related to the endoscopic procedure. One child developed an asymptomatic collection, which could be managed conservatively and was most likely attributed to the young age of the child and the assumed poor cerebrospinal fluid absorption ability. Lost compliance of the brain parenchyma may play an additional role, which was not related to the thickness of the brain mantle. No adverse effects regarding the material used for sealing were observed over a mean follow-up of 23 months. Conclusions Subdural fluid collections could be prevented in 20 out of 21 procedures by using this technique regardless of the thickness of the brain mantle, the application of mixture of fibrin glue and hemostatic agents seems to be safe, and we consider this technique effective in reducing the risk of this potential complication.     

Efficacy of endoscopic treatment for chronic subdural hematoma surgery

Endoscopic treatment is a potential therapeutic addition to chronic subdural hematoma (CSDH) surgery. However, the effect of endoscopic treatment remains controversial. Herein, we examined the optimal indication for endoscopic treatment in CSDH surgery. We retrospectively analyzed 380 consecutive patients with CSDH who underwent single burr-hole craniostomy. We defined postoperative rebleeding as radiological re-accumulation or increased computed tomography value of the hematoma. Reoperation was performed following further hematoma accumulation and/or neurological deterioration. Complicated CSDH was radiologically defined as a hematoma with a clot and/or fibrous septum. There were no differences in baseline characteristics or postoperative mortality and morbidity between the endoscope (97 patients) and control (283 patients) groups. The incidence of postoperative rebleeding (9.3% vs 25.1%, respectively; P = 0.001) and reoperation (0% vs 9.2%, respectively; P = 0.004) were significantly lower in the endoscope group versus controls. Multivariate analysis showed that males (odds ratio 2.14, 95% confidence interval 1.19–3.81; P = 0.012) and endoscopy (odds ratio 0.29, 95% confidence interval 0.13–0.59; P = 0.001) were independently associated with postoperative rebleeding. When CSDHs were divided into two types based on hematoma component, 175 patients exhibited complicated CSDH. There was a significant reduction in postoperative rebleeding (6.5% vs 23.0%, respectively; P = 0.010) and reoperation (0% vs 9.7%, respectively; P = 0.027) in complicated CSDH patients. Endoscopic treatment in CSDH surgery does not increase the risk of surgical complications. Complicated CSDH with a clot and/or septum may be an optimal indication for endoscopic treatment in CSDH surgery to reduce postoperative recurrence.     

An acute postoperative intractable hyperventilation after an endoscopic third ventriculostomy

This report describes a rare case of postoperative hyperventilation attack after an endoscopic third ventriculostomy in a 46-year-old woman. About 60 min after the termination of the operation, an intractable hyperventilation started with respiratory rate of 65 breaths/min and EtCO(2), 16.3 mm Hg. Sedation with benzodiazepine, thiopental sodium, fentanyl, and propofol/remifentanil infusion was tried under a rebreathing mask at a 4 L/min of oxygen. With aggressive sedative challenges, ventilation pattern was gradually returned to normal during the 22 hrs of time after the surgery. A central neurogenic hyperventilation was suspected due to the stimulating central respiratory center by cold acidic irrigation solution during the neuroendoscopic procedure.     

Endocrine evaluation after endoscopic third ventriculostomy (ETV) in children

Objective Endoscopic third ventriculostomy (ETV) is a standard procedure for the treatment of obstructive hydrocephalus in children. Main part of the procedure is the perforation of the third ventricle floor (tuber cinereum). This structure is part of the hypothalamic–pituitary neuronal network of cerebral endocrine regulation. There are no systematic data available about the endocrine status after ETV in children. Materials and methods We examined 20 children who had undergone ETV. Examination included laboratory tests (adrenocorticotropic hormone, prolactin, insulin-like growth factor 1 [IGF-1], IGF-binding protein 3 [IGFBP-3], fT3, fT4, thyroid-stimulating hormone [TSH], serum osmolarity, electrolytes, glucose, urea, follicle-stimulating hormone [FSH] and luteinizing hormone [LH], and testosterone in selected patients), measurement of weight, height, and head circumference, and physical examination. The study was approved by the Ethics Committee of the Medical Faculty of Kiel University. Results In seven patients, prolactin was moderately elevated. One patient demonstrated a significantly increased prolactin (56.3 ng/ml). In all eight patients, this was the only laboratory value that was out of the normal range; all other parameters were normal. Three other patients showed one abnormal parameter (decrease in FSH and LH, increase in TSH, decrease in IGF-1 and IGFBP-3). In nine patients, weight or height was not within the 3rd to 97th centiles for age. Discussion and conclusion More patients than expected demonstrated endocrine laboratory abnormalities. However, there was no clinical relevance in any of the studied patients. It remains inconclusive whether ETV contributes to the abnormalities of prolactin levels or to other endocrine parameters in pediatric patients. Longitudinal studies are necessary to delineate the effect of ETV on endocrine regulation. Presented at the Third World Conference of the International Study Group on Neuroendoscopy (ISGNE), Marburg, Germany, 15–18 June 2005.     

Infantile head injury, with special reference to the development of chronic subdural hematoma

An infantile head injury has unique features in that infants are totally helpless and dependent on their parents, and biomechanical characteristics of the skull and brain are very different from those of other age groups. The authors reviewed a total of 16 infant head injury patients under 12 months of age who were treated in our hospital from 1989 to 1997. Birth head injury was excluded. The most common age group was 3–5 months. Early seizures were noted in 7 cases, and motor weakness in 6. Three patients with acute intracranial hematoma and another 3 with depressed skull fracture were operated on soon after admission. Chronic subdural hematomas (SDHs) developed in 3 infants. Initial CT scans showed a small amount of SDH that needed no emergency operation. Resolution of the acute SDH and development of subdural hygroma appeared on follow-up CT scans within 2 weeks of injury. Two of these infants developed early seizures. Chronic SDH was diagnosed on the 68th and 111th days after the injuries were sustained, respectively. The third patient was the subject of close follow-up with special attention to the evolution of chronic SDH in view of our experience in the previous 2 cases, and was found to have developed chronic SDH on the 90th day after injury. All chronic SDH patients were successively treated by subduro-peritoneal shunting. In conclusion, the evolution of chronic SDH from acute SDH is relatively common following infantile head injury. Infants with head injuries, especially if they are associated with acute SDH and early development of subdural hygroma, should be carefully followed up with special attention to the possible development of chronic SDH Received: 5 November 1999 Revised: 15 January 2000     

37例慢性硬膜下血肿的临床诊疗体会

目的研究慢性硬膜下血肿的治疗及预后。方法对我院2009-10～2011-07 37例慢性硬膜下血肿行单孔钻孔引流术,对手术病人及病历进行回顾性分析。结果 37例病例中,36例痊愈出院。3例遗留少量硬膜下积液,5例颅内积气,均未特殊处理,门诊随访6～11个月后自愈。4例因血肿包膜机化严重,术后效果不佳二次开瓣手术,1例术后并发重症肺炎转入ICU后死亡。结论慢性硬膜下血肿虽然手术打击不重,但因病人年龄问题易出现并发症,应注意术前综合评估及术后护理。     

梗阻性脑积水经第三脑室底造瘘术后颅内压变化规律

目的回顾性总结经内镜第三脑室底造瘘术(ETV)治疗梗阻性脑积水的手术技巧、疗效及术后颅内压(ICP)的变化规律及动态ICP监护的价值。方法经内镜行ETV治疗梗阻性脑积水共146例,病因包括导水管狭窄98例、颅内肿瘤48例(第三脑室及松果体区肿瘤)。术后行动态ICP监护53例(导水管狭窄36例、肿瘤17例),平均监护时长96 h。结果随访8个月至6年,术后脑积水明显缓解或消失138例(94.5%),8例脑积水缓解不明显或无效(5.5%),改行脑室腹腔分流术。ICP监护显示:术后6 h内平均ICP明显下降,低于10 mm Hg,此后缓慢轻度上升,96 h稳定于12 mm Hg;单纯导水管狭窄性脑积水平均ICP上升较缓慢、波动较小,最后达到10 mm Hg;而肿瘤性脑积水上升较快、波动较大,最后达到15 mm Hg。并发症28例(19.2%):术后发热22例,双额部硬膜外血肿1例、切口脑脊液漏2例、脑室少量积血2例、硬膜下积液1例。本组无死亡。结论 1第三脑室底造瘘治疗梗阻性脑积水(尤其是导水管狭窄脑积水)安全、有效,应作为其首选治疗手段;2术后行ICP动态监护,不仅可监测颅内压的变化,判断手术是否有效,同时可以观察有无脑室继发性出血等并发症及指导术后用药。     

Shunts vs endoscopic third ventriculostomy in infants: are there different types and/or rates of complications?

Introduction The decision-making process when we compare endoscopic third ventriculostomy (ETV) with shunts as surgical options for the treatment of hydrocephalus in infants is conditioned by the incidence of specific and shared complications of the two surgical procedures. Review Our literature review shows that the advantages of ETV in terms of complications are almost all related to two factors: (a) the avoidance of a foreign body implantation and (b) the establishment of a ‘physiological’ cerebrospinal fluid (CSF) circulation. Both these kinds of achievements are particularly important in infants because of the relative high rate of some intraoperative (i.e. abdominal) and late (secondary craniosynostosis, slit-ventricle syndrome) shunt complications in this specific subset of patients. On the other side, the main factor which is claimed against ETV is the relatively high risk of immediate mortality and neurological complications. Clinical manifestations of neurological structure damage seem to be more frequent in infants, probably due to the more relevant effect of parenchymal and vascular damage in this age group; however, both the immediate mortality and neurological damage risk of ETV procedures should be weighted against the long-term mortality and the late neurological damage which is not infrequently described as a consequence of shunt malfunction and proximal shunt revision procedures. Infections are possible in both ETV and extrathecal CSF procedures, especially in infants. However, the incidence of infective complications is significantly lower in case of ETV (1–5% vs 1–20%). Moreover, different from shunting procedures, infections in children with third ventriculostomy have a more benign course, being generally controlled by antibiotic treatment alone.     

The fate of the cerebrospinal fluid after neuroendoscopic third ventriculostomy

This paper describes the case of a 9-year-old girl with a posterior thalamic/pineal region lesion and secondary obstructive hydrocephalus. The hydrocephalus was treated by neuroendoscopic third ventriculostomy (NTV), and she underwent simultaneous transendoscopic biopsy. The tumour biopsy was haemorrhagic, but the bleeding settled with constant irrigation. The patient remained neurologically unchanged, but subsequent imaging revealed an asymptomatic thoracolumbar spinal subdural haematoma thought to be due to blood flowing out through the NTV into the subdural space. This demonstrates the subdural location of the cerebrospinal fluid after NTV. Received: 17 May 2000 Revised: 22 June 2000     

磁共振3D-CISS序列检查在三脑室造瘘术前后的意义

目的 探讨三脑室的MR3D—CISS（three dimensional constructive inference in steady state）序列扫描对梗阻性脑积水病人诊断分析意义，及其在内镜三脑室底造瘘（endoscopic third ventriculostomy ETV）手术前后的临床血用价值。方法采用回颐性分析方法，对本组46例梗阻性脑积水在1．5T超导MRI仪行3D—CISS序列扫描，通过对MRI图像的观察、测量来分析三脑室扩大程度与三脑室底厚度、脑积水程度的相关程度：对本组中行单纯神经内镜下ETV手术的12例病人作手术前后3D—CISS序列扫描的较为详细的影像学评价。结果梗阻性脑积水三脑室扩大程度与三脑室底的厚度、脑积水程度均具有明显的相关性。3D—CISS三脑室底清晰显示率达96％（44／46），基底动脉（BA）显示率达91％（42／46）：ETV术前可根据矢状位3D—CISS扫描，作切口的体表定位，充分了解三脑室扩大程度与三脑室底厚簿即穿刺造瘘的难易，可了解基底动脉的方位并通过确定造瘘点避免其损伤；术后行3D—CISS可测量瘘口大小、观察CSF的流动方向、评价手术效果。结论3D—CISS序列技术在显示三脑室方面敏感精确，为ETV手术前后评价提供了可靠依据。梗阻性脑积水三脑室扩大程度决定三脑室底的厚度与术中造瘘的难易。     

A new evaluation method for the intracranial volume changes and subdural effusion of patients following endoscopic third ventriculostomy

Objective

Endoscopic third ventriculostomy (ETV) is a procedure commonly applied in the treatment of non-communicating (obstructive) hydrocephalus. One of the rare complications that can occur following ETV is a subdural effusion, even though this procedure is considered to be a more controlled and natural method of cerebrospinal fluid drainage compared to external drainage. In this study, we evaluated the intracranial volume changes and subdural effusion of patients following ETV using Cavalieri method.

Method

Volumes analysis of the cranial cavity, brain, ventricles and subdural effusions of two patients after ETV were performed on computed tomography images using the Cavalieri principle, one of the stereological methods.

Results

The preoperative total intracranial volumes and the preoperative brain volumes decreased for both patients during the postoperative 3rd, 10th and 30th days. Following ETV, the volumes of the lateral ventricles of both patients initially decreased during the postoperative 3rd and 10th days, however, the volumes returned almost to their preoperative size by the end of the 30th day. The effusions were seen on the postoperative 3rd and 10th days resolved by the end of the 30th day.

Conclusion

Our results show that the Cavalieri method can be used to unbiased prediction of intracranial volume changes and to follow the subdural effusion after the ETV surgery.     

Hygromas after endoscopic third ventriculostomy in the first year of life: incidence,management and outcome in a series of 34 patients

Background Overdrainage in shunted patients is a known predisposing factor for the formation of hygromas, but little is known about risk factors in endoscopic third ventriculocisternostomy (ETV). Materials and methods We retrospectively analysed data of 34 patients younger than 1 year with obstructive hydrocephalus, undergoing ETV, with respect to incidence, management, outcome and possible risk factors for the formation of hygromas. Hygromas were arbitrarily defined as a collection of cerebrospinal fluid of more than 10 mm in diameter over the paramedian hemispheric convexities, diagnosed by ultrasonography. Results They occurred in 9 of 34 (26%) patients 3 to 28 days after ETV. They were on the operated side in four and bi-lateral in five cases. There was no relevant age difference between patients with hygromas (median 127 days) and those without hygromas (median 166 days). Etiology of obstructive hydrocephalus had no impact on the frequency of hygromas. Hygromas occurred somewhat less frequently when a paediatric endoscope with an outer diameter of 3 mm was used for ETV instead of an endoscope with a diameter of 6 mm. Hygromas were asymptomatic and conservatively managed in five cases; 4 of 34 (12%) patients underwent surgery because of clinical symptoms of increasing intracranial pressure or increasing hygroma diameter. Two patients were treated with a temporary external drainage only and another two patients with an external drainage first and eventually a subduro-peritoneal shunt. There were no neurological long-term sequelae. Conclusion Clear predisposing factors for the formation of hygromas could not be identified, but the outer diameter of the endoscope may play a role.     

The importance of valve alignment in determining the pressure/flow characteristics of differential pressure shunt valves with anti-gravity devices

Object: The proper functioning of shunt valves in vivo is dependent on many factors, including the valve itself, the anti-siphon device or ASD (if included), patency of inlet and outlet tubing, and location of the valve. One important, but sometimes overlooked, consideration in valve function is the valve location relative to the tip of the ventricular inlet catheter. As with any pressure measurement, the zero or reference position is an important concept. In the case of shunt valves, the position of the proximal inlet catheter tip is fixed and therefore serves as the reference point for all pressure measurements. This study was conducted to document the importance of this relationship for the pressure/flow characteristics of the shunt valve. Methods: We bench-tested differential pressure valves (with integral anti-gravity devices; AGDs) from three manufacturers. Valves were connected to an ”infinite” reservoir, and the starting head pressure for each was determined from product inserts. The inlet catheter tip was fixed at this position, and the valve body was moved in relation to the inlet catheter tip. Outflow rates were determined gravimetrically for positions varying between 4 cm above and 8 cm below the inlet catheter tip. Conclusions: All differential pressure valves utilized in this study that contained AGDs showed significant increases in outflow rate as the valve body was moved incrementally below the level of the inlet catheter tip. To allow functioning as a zero- hydrostatic pressure differential pressure valve, the AGD and the inlet catheter tip should be aligned at the same horizontal level. Received: 27 March 2000 Revised: 14 July 2000     

Spontaneous regression of a symptomatic pineal cyst after endoscopic third-ventriculostomy

With the advent of modern diagnostic tools for neuroimaging, the incidental detection of pineal cysts in asymptomatic subjects has increased. Only rarely do pineal cysts present with the clinical signs and symptoms of increased intracranial pressure or with neurological deficits in relation to compression and distortion of the adjacent nervous structures and cerebrospinal fluid pathways. While asymptomatic cysts are considered to be normal variants for which no further investigations are usually required, surgical treatment is suggested for symptomatic cysts, with the goal of eliminating the block in the cerebrospinal fluid circulation and/or the mass effect exerted by the lesion. In this report we describe a pediatric case of symptomatic pineal cyst, revealed by repeated episodes of headache caused by secondary obstructive hydrocephalus. Following an endoscopic third-ventriculostomy, serial magnetic resonance imaging studies demonstrated that not only had the ventriculomegaly resolved but also that the pineal cyst had regressed over time. A to-and-fro movement of fluid through the cyst wall, the direction of which depends on the equilibrium existing between the inner pressure of the cyst and the outer cerebrospinal fluid pressure, is suggested as a possible mechanism accounting for this unexpected result – to our knowledge, the first reported in literature. Received: 16 February 2000     

Management of residual subdural hematoma after burr-hole evacuation. The role of fluid therapy and review of the literature

A vast amount of literature has been published investigating the factors associated to the recurrence of a chronic subdural hematoma (SDH). However, little exists in the literature about the best medical management of the residual SDH in order to prevent the recurrence. Moreover only few studies quantitatively assess clinical and radiological outcomes of residual post-operative SDH. In this study, to our knowledge, we report the first series of chronic SDH with a quantitative outcomes analysis of the effects of fluid therapy on residual post-operative SDH. Moreover we discuss the pertinent literature. We reviewed clinical and outcome data of 39 patients (44 SDH; 12 F, 27 M) submitted to a burr-hole evacuation of a SDH. The mean age was 76.97 ± 7.77 years. All patients had a minimum 3-month follow-up (FU). Post-operatively, an intravenous saline solution was started in all cases (2000 ml in 24 h) and administered for 3 days. Then an oral hydration with 2 l per day of water was started and continued as outpatients. Glasgow Coma Scale (GCS), Karnofsky Performance Status (KPS), SDH volume and midline shift were evaluated pre-operatively, post-operatively and at FU. We found a statistically significant improvement of post-operative and at FU GCS and KPS compared to the pre-operative. SDH volume and midline shift were also statistically significant reduced in the post-operative and at FU. No complication occurred. Only 1 patient required a reoperation at 3 months FU for neurological worsening. Oral fluid therapy is a safe and effective treatment for residual SDH.