Operative management of third ventriculostomy in cases of thickened, non-translucent third ventricular floor: technical note.

Today, endoscopic third ventriculostomy is an established operative modality in occlusive hydrocephalus. The elemental step in third ventriculostomy is the perforation of the floor of the third ventricle. Especially with a thickened third ventricular floor, anatomical orientation can be disturbed and perforation of third ventricular floor technically difficult. The combination of a neuronavigation system with an endoscope provides interactive image-guided neuroendoscopy. Exact planning of the approach is thus possible and the ideal trajectory to the target area can be determined. We have combined interactive neuronavigation and intraoperative fluoroscopy for incorporating real-time feedback to optimize endoscopy in patients with a thickened third ventricular floor selected for third ventriculostomy.     

Traumatic subependymal hematoma during endoscopic third ventriculostomy in a patient with a third ventricle tumor: case report.

Endoscopic third ventriculostomy has become a routine intervention for the treatment of non-communicating hydrocephalus. This technique is largely considered safe and a very low incidence of complications is reported. However, hemorrhage in the course of neuroendoscopy is still a problem difficult to manage. The authors present a case in which endoscopic third ventriculostomy and tumor biopsy were performed in a young patient with a huge tumor growing in the posterior part of the third ventricle. The surgical approach to realize the stoma was difficult because the tumor size reduced the third ventricle diameter. Surgical manipulation produced a traumatic subependymal hematoma. This hematoma drained spontaneously after few minutes into the ventricle and the blood was washed away. The postoperative neurological course was uneventful and the ventriculostomy showed to work well by reducing the size of the lateral ventricles and the intracranial pressure in three days. This complication during endoscopic third ventriculostomy has never been reported before. We emphasize the difficulty of endoscopic procedures in patients with huge tumors in the third ventricle. Where reduction in size of the third ventricle and of the foramen of Monro ist present we suggest a careful approach to the third ventricle.     

Cadaver anatomic analysis of the best site for chemical lumbar sympathectomy

The lumbar sympathetic ganglia and their surroundings were examined anatomically in 19 human cadavers. The locations of the ganglia on the lumbar vertebral column at the level of the second and third lumbar vertebral bodies were analyzed statistically using a "ganglion score". The ganglia were most frequently found at the level of the lower third of the second lumbar vertebra, at the L2-3 interspace, and at the level of the upper third of the third lumbar vertebra on both the right and left sides. The points at which the sympathetic chain and the lumbar arteries crossed were at the middle third of the vertebral body in both the second and third lumbar vertebra. These results suggest that the most suitable point for placement of the tip of the needle used for chemical lumbar sympathectomy is not the midpoint of a vertebral body, but rather the lower third of the second vertebral body or the upper third of the third vertebral body.     

Rate of third nerve palsy recovery following endovascular management of cerebral aneurysms

Endovascular management of cerebral aneurysms resulting in third nerve palsies has been proposed as an alternative to microsurgical clip ligation. Third nerve function recovery following endovascular treatment in a large patient population has not been evaluated. A literature search of MEDLINE, PubMed, and Cochrane databases for third nerve palsies and endovascular management of cerebral aneurysms was performed. All reported patients in these studies were systematically compiled. Fifty-two patients with third nerve palsies secondary to cerebral aneurysms underwent endovascular treatment. Endovascular management resulted in some degree of third nerve recovery in 65% of patients. The extent of recovery was reported in 21 patients. Of these, 71% had complete recovery. At least two procedure-related third nerve palsies are reported in the literature. One was permanent. One case of recurrent painful palsy is also reported. Microsurgical clip ligation of cerebral aneurysms has a 93% rate of third nerve palsy recovery and a 43% rate of complete third nerve recovery. Endovascular management of cerebral aneurysms can alleviate third nerve palsies in some patients. In reviewing the world literature, however, microsurgical clip ligation is associated with a higher rate of third nerve recovery. Endovascular management, in the subset of patients in whom extent of recovery was documented, demonstrated a higher rate of complete recovery.     

Acute distortion of the anatomy of the third ventricle during third ventriculostomy. Report of four cases

The authors report on four third ventriculostomy procedures in which upward ballooning of the third ventricular floor occurred immediately after perforation of the floor and withdrawal of a Fogarty catheter. The floor herniated into the third ventricle, hindering the endoscopic view. Preoperative magnetic resonance imaging demonstrated a similar anatomy in all four cases, consisting of hydrocephalus, extreme dilation of the third ventricle, and disappearance of the interpeduncular cistern due to a very thin, membranous floor of the third ventricle, which herniated downward, draping over the basilar artery. The authors suggest that excessive rinsing in combination with this anatomical configuration provoked the phenomenon of upward ballooning of the third ventricular floor, which is described in this report.     

Death after late failure of third ventriculostomy in children. Report of three cases

Late failure following successful third ventriculostomy for obstructive hydrocephalus is rare, and death caused by failure of a previously successful third ventriculostomy has been reported only once. The authors present three patients who died as a result of increased intracranial pressure (ICP) after late failure of a third ventriculostomy. Through a collaborative effort, three patients were identified who had died following third ventriculostomy at one of the authors' institutions. A 13-year-old girl with neurofibromatosis Type 1 underwent third ventriculostomy for obstructive hydrocephalus caused by a tectal lesion. Three years later her condition deteriorated rapidly over the course of 6 hours and she was found dead at home. A 4-year-old boy treated with third ventriculostomy for aqueductal stenosis presented 2 years postoperatively with symptoms of increased ICP. This patient suffered a cardiorespiratory arrest while under observation and died despite external ventricular drainage. A 10-year-old boy with previous ventriculoperitoneal (VP) shunt placement underwent conversion to a third ventriculostomy and shunt removal. Eight months after the procedure his condition deteriorated. with evidence of raised ICP, and he underwent emergency insertion of another VP shunt, but remained in a vegetative state and died of complications. Neuropathological examinations in two cases demonstrated that the third ventriculostomy was not patent, and there was also evidence of increased ICP. Late failure of third ventriculostomy resulting in death is a rare complication. Delay in recognition of recurrent ICP symptoms and a false feeling of security on the part of family and caregivers because of the absence of a shunt and the belief that the hydrocephalus has been cured may contribute to fatal complications after third ventriculostomy. Patients with third ventriculostomies should be followed in a manner similar to patients with cerebrospinal fluid shunts.     

Endoscopic third ventriculostomy with cystoventricular stent placement in the management of dandy-walker malformation: technical case report of three patients

OBJECTIVE AND IMPORTANCE: Dandy-Walker malformation has conventionally been managed with placement of cystoperitoneal or ventriculoperitoneal shunts. However, associated aqueductal obstruction requires simultaneous drainage of both the supratentorial and infratentorial compartments. CLINICAL PRESENTATION: Three children with Dandy-Walker malformation and aqueductal obstruction were managed with endoscopic third ventriculostomy and placement of a stent from the third ventricle to the posterior fossa cyst. INTERVENTION: After an endoscopic third ventriculostomy was performed, the stent was placed from the third ventricle to the posterior fossa cyst through the thinnest part of the posteroinferior wall of the aqueduct. There was no operative morbidity. In one patient, the stent was malpositioned, requiring a repositioning. The endoscopic third ventriculostomy was successful in two patients, whereas it failed in one, requiring a ventriculoperitoneal shunt placement. CONCLUSION: Cystoventricular stent placement with endoscopic third ventriculostomy is a promising alternative in patients with Dandy-Walker malformation with aqueductal obstruction.     

Techniques of endoscopic third ventriculostomy

Modem techniques of endoscopic third ventriculostomy (ETV) are based on the concept of establishing a natural conduit for cerebral spinal fluid (CSF) flow through the floor of the third ventricle. Through the years, a wide variety of techniques have been used as a means to this end and have included both open and closed approaches. However, the relatively recent application of endoscopic technology to intraventricular surgery has allowed neurosurgeons to perform third ventriculostomies in a minimally invasive fashion. Advances in third ventriculostomy technique have been based on a detailed understanding of third ventricular anatomy, surgical trajectories, and improved instrumentation. The goal of this article is to discuss these issues in detail and to point out the relevant risks and known complications associated with them.     

Successful aqueductal plasty and stenting for tectal plate tumor after failed third ventriculostomy: a case report

BACKGROUND: Tectal region tumors can lead to hydrocephalus secondary to aqueductal compression. Surgical options for these patients include extracranial cerebrospinal fluid (CSF) shunts, third ventriculostomy, and/or aqueductal plasty. In cases of third ventriculostomy failure, the accepted alternative is an extracranial CSF shunt. We report a patient in whom a repeat third ventriculostomy with aqueductal plasty and stenting was successful after a failed initial third ventriculostomy. CASE PRESENTATION: A 12-year-old patient with hydrocephalus secondary to a tectal tumor presented with headaches and blurry vision. She had no focal neurologic findings. She underwent a third ventriculostomy. Five months after the procedure she had recurrence of her symptoms. Therefore, she underwent a secondary third ventriculostomy with aqueductal plasty and stenting. She has been symptom-free for 1 year. CONCLUSION: Aqueductal plasty with stenting may be an alternative to CSF shunts in some patients with hydrocephalus because of aqueductal compression resulting from tectal tumors.     

Clavicle fractures: a comparison of five classification systems and their relationship to treatment outcomes

We compared five classification systems for clavicle fractures. The aim of this study was to evaluate the prognostic value of each system. Over a two-year period we reviewed all new radiographs of the shoulder region and identified 487 clavicle fractures. Each radiograph was classified using five classification systems. We reviewed all subsequent X-rays and clinical records until the patient was discharged. We assessed each classification system’s prognostic value in predicting delayed/non-union. Our data show that 79.3% of clavicle fractures occur in the middle third, 19.3% in the lateral third and 1.4% in the medial third. The overall prevalence of delayed/non-union was 7.3%, with 3.2% requiring operative management and 4.1% developing asymptomatic non-union. The incidence of non-union in the lateral third was 9.6%, but only 0.4% required operative management. Craig’s classification had the greatest prognostic value for lateral third fractures, and Robinson’s classification had the greatest prognostic value for middle third fractures. Fractures of the clavicle are common injuries but non-union is an uncommon occurrence. Non-union is more common in the lateral third, but we found these to be mostly asymptomatic. Middle third fractures are more likely to require operative fixation. Middle third fractures should be classified according to Robinson’s classification system and lateral third fractures according to Craig’s classification. We did not assess sufficient medial third fractures for the data to be significant.     

Endoscopic removal of a third ventricular cysticercal cyst

We report the case of a young man who presented with acute obstructive hydrocephalus previously treated with bilateral ventriculo-peritoneal shunts. Previous magnetic resonance imaging studies were consistent with aqueduct stenosis; no intraventricular pathology was identified. Neuroendoscopy was performed in order the third ventricle and perform a third ventriculostomy. This revealed a cysticercal lesion of the third ventricle which was removed endoscopically. In addition, a third ventriculostomy was performed and both shunt systems removed. Following a course of albendazole the patient went on to make a full recovery, and currently remains shunt independent.     

The reverse posterior interosseous flap: A solution for flap necrosis based on a review of 87 cases.

PURPOSE: The relationship of the flap necrosis to the placement of the flaps on the forearm was outlined and a solution in avoiding flap necrosis is discussed. METHODS: The relationship of the flap necrosis to the placement of the flaps on the forearm was investigated in 87 consecutive posterior interosseous island flaps used for the reconstruction of the hand and wrist. Fifty-eight flaps were taken from the middle and proximal thirds of the forearm, the distal edges being within the middle third of the forearm in 24 and the distal edges being within the distal third of the forearm in 34. Twenty-nine flaps were harvested within the boundaries of the distal two-thirds of the forearm, the distal edge being proximal to the distal third of the forearm in 23 and the distal edge being distal to the third of the forearm in six. The Length of the flaps varied from 6.5 cm to 12 cm. The pedicle length measure 4-13 cm. The number of perforators for each flap was recorded also. RESULTS: Flaps survived complete in 78 (89.6%) patients. Six patients had superficial necrosis of the distal part of the flap (6.8%). Three flaps were totally lost and alternative coverage was used (3.8%). The flaps that ended up with partial necrosis appeared to be in related to the site it was taken from. One flap with total necrosis and one with partial ncrosis were taken within the boundaries of the proximal third of the forearm while the distal edge was proximal to the level of distal third. One flap with total necrosis and one with partial necrosis were taken from the proximal third of the forearm while their distal edge were at the limits of the distal third of the forearm. The remaining flap ending up with total necrosis was taken from the distal third of the forearm with a short pedicle. CONCLUSIONS: For the reverse posterior interosseous flap to be reliable the flap should include the septocutaneous perforators in the distal third of the forearm. To cover distant defects reliably by a flap with a long pedicle, the flap should extend up to the distal third of the forearm to include a piece of skin with numerous perforators.     

Endoscopic reverse third ventriculostomy via the cisterna magna: anatomical study and proposal of a novel procedure.

Basilar artery injury has been known as a potential lethal complication of endoscopic third ventriculostomy. In order to avoid this complication, endoscopic reverse third ventriculostomy via a trans-cisterna-magna route was studied. A cadaveric study was performed for navigation of a flexible endoscope through the cisterna magna. Three fresh, unfixed cadavers were used for this endoscopic navigation. In the prone position, a small vertical paramedian skin incision is made at the mid-portion of the posterior neck. An 11-mm threaded plastic tube is inserted towards the posterior arch of the atlas. After a partial hemilaminectomy of the atlas, a flexible endoscope is introduced into the cisterna magna and is navigated cephalad along the vertebrobasilar artery to the inferior aspect of the floor of the third ventricle. Through the working channel of a fiberscope, third ventriculostomy is performed in a reverse direction. Additional detailed anatomy was studied in fixed cadaveric head specimens with a rigid rod-lens endoscope for anatomic orientation. A novel technique of a trans-cisterna-magna reverse third ventriculostomy was studied in cadaveric specimens. This technique may avoid basilar artery injury which occurs occasionally during conventional third ventriculostomy.     

Experimental third ventriculostomy performed using endovascular surgical techniques and their adaptation to percutaneous intradural neuronavigation: proof of concept cadaver study

OBJECTIVE: Endoscopic third ventriculostomy has developed into a therapeutic alternative to shunting for the management of carefully selected patients with primarily noncommunicating hydrocephalus. This procedure, however, requires a general anesthetic and necessitates violation of the brain parenchyma and manipulation near vital neural structures to access the floor of the third ventricle. Using two cadavers and off-the-shelf angiographic catheters, we sought to determine whether it was possible to navigate a catheter, angioplasty balloon, and stent percutaneously through the subarachnoid space from the thecal sac into the third ventricle so as to perform a third ventriculostomy from below. METHODS: Using biplane angiography and off-the-shelf angiographic catheters along with angioplasty balloons and stents, we were able to pass a stent coaxially from the thecal sac to and across the floor of the third ventricle so as to achieve a third ventriculostomy from below. RESULTS: Coaxial catheter techniques allowed for the percutaneous insertion of a stent across the floor of the third ventricle. Ventriculostomy was confirmed by injecting contrast medium into the lateral ventricle and seeing it pass through the stent and into the chiasmatic cistern. CONCLUSION: We describe the performance of third ventriculostomies in two cadavers by use of the new concept of percutaneous intradural neuronavigation. This procedure may obviate the need for general anesthetic and minimize the potential for brain and vascular injury, especially if ultimately combined with magnetic resonance fluoroscopy.     

Review of third and fourth re-excision for narrow or positive margins of invasive and intraductal carcinoma

The trend in breast surgery has shifted toward breast conservation. We reviewed our third and fourth breast re-excision cases, with an analysis of various factors used in making this decision. A retrospective analysis identified 585 patients who underwent re-excision surgery for positive or close margins of invasive carcinoma or ductal carcinoma in situ (DCIS). Of these patients 75 (13%) and 17 (3%) underwent third and fourth re-excisions, respectively. The indication for a third re-excision was the presence of positive and/or close (< or = 1 mm) margins for invasive carcinoma or DCIS in 72/75 patients. A third re-excision was done 31 days (range 8-123 days) after the second re-excision. Re-excision of margins was done in 45 (60%) patients, whereas 30 (40%) patients underwent mastectomy. Residual tumor mandated a fourth re-excision in 17 patients, which was done 45 days (range 14-87 days) after the third surgery. Re-excision of margins was done in 6 patients, whereas 11 patients underwent mastectomy. Involved or close margins with DCIS were the most common indication for re-excision, accounting for 61/75 (82%) of third and 16/17 (94%) of fourth re-excisions. Histopathology revealed that 28/75 (37%) of third and 7/17 (41%) of fourth re-excision patients had no residual tumor. In conclusion, the majority of re-excisions was done for margins < 1 mm. Lower rates of re-excision were noted in well-differentiated invasive carcinomas. A close or involved DCIS margin was more likely to lead to a third and even a fourth re-excision. The absence of residual tumors in 40% of patients undergoing third and fourth re-excisions calls for a review of margin guidelines for breast re-excision.     

Thrombosed basilar apex aneurysm presenting as a third ventricular mass and hydrocephalus

Summary Aneurysms presenting as third ventricular masses are uncommon; most are giant aneurysms arising from the basilar apex. We present a case of a thrombosed basilar apex aneurysm presenting as a third ventricular mass and hydrocephalus in a 55-year-old man. The case is unique in the literature as the aneurysm was completely thrombosed and angiographically occult. The lesion was explored to verify the diagnosis and a third ventriculostomy resolved the patients symptoms. Completely thrombosed aneurysms should be considered in the differential diagnosis of symptomatic third ventricular masses, even when angiographic studies are negative. The literature on aneurysms presenting as third ventricular masses is reviewed.     

Functional anatomy of the third ventricle. Neuropsychological data

The functional structures surrounding the third ventricle explain the occurrence of neuropsychological disorders when a tumor develops in this area. The functional environment of the third ventricle is involved in memory, motor executive control, endocrine and vegetative regulations. The types of memory deficit, the behavioural and emotional regulations, the interhemispheric transfer, and the regulation of executive functions are analyzed and correlated to the concerned anatomical structures. The review of the literature collected few specific considerations in neuropsychological dysfunctions occurring with tumors of the third ventricle. A retrospective study was conducted in 17 patients of the national series operated on for a third ventricle lesion : long-term memory and executive functions were frequently impaired in the patients, and the deficits were underestimated by usual follow-up. More systematic utilization of preoperative and postoperative test batteries is necessary for a better evaluation of neuropsychological disorders after third ventricle surgery.     

Prevention of third molar development in dog with long pulse diode laser: a preliminary report

INTRODUCTION: Wisdom teeth continue to plague man with a high rate of frequency. It may be possible to prevent their development in children at an early age with a non- or minimally invasive technique, even before the tooth begins to form, by treating the soft tissue overlying the site of their development. A previous study that treated the intra-oral soft tissues of newborn rats with a 20 watt diode laser stopped third molar development up to 80% of the time with minimum observable side effects. This brief report describes a similar use of the diode laser in a limited number of young beagle pups. It is the first reported attempt at preventing third molar development in an animal model close in size to man. MATERIALS AND METHODS: Four 6-7 week old beagle pups were treated on one side of their mandibles with either a 20 or a 100 watt, 800 nm diode laser at a time third molar tooth buds are just beginning to form under the oral mucosa. Six months following treatment, the pups were examined intra-orally and radiographically for evidence of third molar formation. RESULTS: The two intra-oral sites that received the 20 watt diode laser treatment showed normal third molar development. The two intra-oral sites that received the 100 watt diode laser treatment did not develop third molars. CONCLUSIONS: The diode laser may be capable of selectively stopping third molar development and further studies are warranted.     

Endoscopic surgery of the third ventricle: the subfrontal trans-lamina terminalis approach.

The authors describe an endoscopic approach to the anterior aspect of the third ventricle and demonstrate its use in the cadaver. This technique consists of a small supraorbital craniotomy and a subfrontal trans-lamina terminalis approach to the third ventricle. It may be helpful in the management of refractory third ventricular lesions that cannot be easily accessed endoscopically through the foramina of Monro.     

第三骨间掌侧肌及其肌支的解剖观察

目的观察第三骨间掌侧肌及其肌支的解剖学特点，探讨腕尺管综合征中小指内收恢复困难的解剖学基础。方法在2．5倍手术放大镜下对20具新鲜无外伤、无畸形成人手标本进行解剖，观察第三骨间掌侧肌及其肌支及邻近结构，测量了第三骨间掌侧肌的大小和第三骨间掌侧肌支的长度、宽度、厚度，并对所得数据进行统计学处理。结果第三骨间掌侧肌及第三骨间掌侧肌支分别是骨间掌侧肌和骨间掌侧肌支中最细小的，部分第三骨间掌侧肌浅层存在明显的腱束，对第三骨间掌侧肌支形成潜在的卡压。结论第三骨间掌侧肌及其肌支是骨间掌侧肌和肌支中最细小的，部分由第三骨间掌侧肌桡侧绕至尺侧入肌，而第三骨间掌侧肌掌侧存在明显的腱束，对第三骨间掌侧肌支形成潜在卡压，可以解释小指内收恢复困难的原因。