Stereotactic endoscopic treatment of colloid cysts of the third ventricle

Summary In order to avoid invasive procedures (transfrontal, transcallosal) in the surgical treatment of colloid cysts the stereotactic aspiration technique was introduced by Bosch, RÄhn and Backlund in 1978. The viscosity of the intracystic colloid and the displacement of the cyst away from the aspiration needle are possible reasons for unsuccessful aspiration. GT-guided stereotactic endoscopic technique gives the opportunity to fenestrate the cyst wall under direct visual control.After CT-guided stereotactic puncture of the right lateral ventricle with the foramen of Monro as target a steerable endoscope is introduced and the foramen of Monro is passed. The wall of the cyst is fenestrated and coagulated by means of monopolar (or laser) coagulation.Using this technique we have treated four patients with colloid cysts. Immediately postoperatively all of them were relieved of their complaints and have been symptomfree for a mean follow up period of twelve months. Studies of cerebrospinal fluid flow patterns, performed prior to and every six months after the endoscopic intervention, confirmed a remarkable reduction of foraminal obstruction.     

Endoscope-assisted removal of colloid cysts of the third ventricle

Colloid cysts are benign space-occuping lesions, which arise from the velum interpositum or the choroid plexus of the third ventricle and are able to produce symptomatic obstruction of the foramina of Monro with resultant hydrocephalus. In our department, we have operated on colloid cysts routinely in an endoscope-assisted microsurgical manner via a key–hole approach. During a period of 10 years, 28 microsurgical resections of colloid cysts of the third ventricle were performed. Seven patients demonstrated colloid cysts inside the third ventricle with obstruction of the right foramen Monro, two patients demonstrated cysts with obstruction of the left foramen Monro. Twelve patients suffered from cysts inside the third ventricle with obstruction of both foramina Monro and five patients demonstrated cysts lying into the third ventricle without obstruction of the foramina. In 21 patients no preoperative therapy was performed outside. Three patients had received shunt systems before in other hospitals, two patients received aspiration of the cysts under stereotactic conditions and two patients received external ventricular drains. Total removal of the cyst was achieved in all patients (100%). No patient received a second operation, because none had a recurrent cyst. All cysts were removed with the cyst wall. Overall clinical improvement was achieved in a long-standing period between 6 and 83 months in 27 (96%) patients. In one patient (4%) the psychomotor disturbance was unchanged and no patient deteriorated. From the microsurgical point of view, the combination of keyhole surgery under endoscopic visual control using preexisting anatomical windows offers an effective minimally invasive approach.     

Endoscopic fenestration of symptomatic septum pellucidum cysts: three case reports with discussion on the approaches and technique.

OBJECTIVES: We describe three patients with symptomatic septum pellucidum cysts treated by endoscopic fenestration and discuss the different endoscopic approaches to these cysts. CLINICAL PRESENTATION: The patients are an 8-year-old boy, a 7-year-old boy and a 21-year-old woman; this last also had a right frontal cavernous angioma and a pituitary microadenoma. All patients presented with headache, associated with vomiting in two and behavioral changes in one. In all cases magnetic resonance showed a septum pellucidum cyst. INTERVENTION: Two patients were operated upon by posterior approach through a right occipital burr hole and underwent fenestration from the right occipital horn to the cyst, with a second fenestration from the cyst to the left lateral ventricle in one. Another patient underwent microsurgical removal of a right frontal cavernoma and endoscopic cyst fenestration with both lateral ventricles through a right frontal craniotomy. Postoperatively, headache and vomiting resolved in all cases and behaviour changes improved in one. CONCLUSIONS: Endoscopic fenestration is the treatment of choice for septum pellucidum cysts, where it results in immediate relief of the mass effect of the cyst and in the remission of the associated symptoms. We suggest a posterior approach through a right occipital burr hole. It allows one to easily cannulate the occipital horn, which is usually larger than the frontal one, thus avoiding the risk of damaging the vascular and neural structures surrounding the foramen of Monro. Besides, the endoscopic trajectory is in our opinion more direct. The two-window technique, with fenestration of the cyst into both lateral ventricles, improves the chances of long-term patency.     

Endoscopic treatment of symptomatic septum pellucidum cysts: with some preliminary observations on the ultrastructure of the cyst wall: two technical case reports.

OBJECTIVE AND IMPORTANCE: We describe two patients with symptomatic septum pellucidum cysts managed by endoscopic fenestration. In each case, tissue from the cyst wall was studied to define the origin of the cyst wall and fluid. CLINICAL PRESENTATION: The patients, a 6-year-old boy and a 42-year-old man, each presented with headaches and a syncopal episode. Imaging studies demonstrated large septum pellucidum cysts with obstruction of the foramina of Monro. INTERVENTION: The patients underwent endoscopic transventricular cyst fenestration with a 4-mm steerable fiberscope. The fenestrations were created to allow communication with the right and left lateral ventricles. In one patient, adhesions between the cyst wall and the foramen of Monro were lysed with endoscopic monopolar cautery. Tissue from the cyst walls was removed for examination by electron microscopy. Postoperatively, the headaches and syncopal episodes resolved in both patients. CONCLUSION: Endoscopic fenestration of symptomatic septum pellucidum cysts produces immediate relief of the mass effect of the cyst and resolution of associated symptoms. Cannulation of the lateral ventricle before cyst fenestration prevents inadvertent injury to the fornices, thalamus, internal capsule, caudate nucleus, and septal and thalamostriate veins. The endoscopic approach allows the surgeon to ensure communication within the ventricular system, thus avoiding placement of a shunt. Preliminary ultrastructural analysis indicates that the cyst walls derive from the septum pellucidum rather than the choroid plexus or arachnoid. The cellular machinery necessary for fluid secretion was identified in some specimens.     

Fiberscopic fenestration and prophylactic stenting of periaqueductal cysts: technical report on three cases.

The authors report on three consecutive cases of periaqueductal cysts, causing non-communicating hydrocephalus, successfully treated with endoscopic fenestration and aqueductal stenting. Navigation and cyst fenestration were accomplished using a slim (1.1 mm outside diameter) optic fiberscope inserted via a pre-coronal-paramedian burr hole. Third ventriculostomy was also performed after cyst fenestration in two cases. Because of the lack of data regarding such lesions and the possible recurrence with simple fenestration, an aqueductal stent connected to a subcutaneous reservoir was placed, in all 3 cases, under direct visualization. Average duration of the procedure was less than sixty minutes and there were no intra- or perioperative complications. All patients recovered clinically and their postoperative neuroimaging assessment confirmed a decrease in size of both the ventricular system and cyst (mean follow-up: 6.8 months). The authors conclude than this minimally invasive procedure is a promising, safe and effective method to treat cerebral symptomatic periaqueductal cysts and associated non-communicating hydrocephalus.     

Complete Removal of Colloid Cyst via CT-Guided Stereotactic Biportal Neuroendoscopy

Four patients harbouring a colloid cyst of the 3rd ventricle were operated on endoscopically. With the "classical" monoportal technique, through a precoronal burr hole only partial removal could be achieved in the first case. As the crucial point of the procedure is the safe dissection of the cyst from the thela chorioidea and from the internal cerebral veins, adequate control of the posterior rim of the foramen of Monro and the roof of the 3rd ventricle is mandatory. Accordingly in other three cases a CT-guided biportal endoscopic technique was applied, which permitted radical removal of the entire cyst with maximum safety. CT-guidance is essential for optimal planning after careful study of the individual anatomy. In this way the rigid scopes are moved exclusively along their own axes throughout the procedure, the resulting brain damage thereby being minimal. With regard to all circumstances of the procedure, the use of flexible endoscopes appears to be inappropriate and biportal endoscopy offers itself as the method of choice.     

Cystic supratentorial gliomas: natural history and evaluation of modes of surgical therapy

The management of cystic supratentorial gliomas is hampered by lack of documentation of the natural history of these lesions and by a lack of evaluation of modes of surgical therapy. We analyzed these factors in 25 patients with solitary cysts operated upon over a 20-year period. Two distinctive patterns of symptoms were seen: short duration (increased pressure and hemiparesis), most often heralding a malignant lesion, and long duration (commonly seizure disorder), associated more often with a benign pathological condition. Large solitary cysts were found in tumors of all histological grades. Surgical procedures included extirpation, biopsy/partial resection, cyst communication to ventricle or marsupialization, burr hole aspiration, aspiration via an indwelling reservoir, and cyst-peritoneal shunting. Radiotherapy, given in all cases, did not prevent cyst recurrence. Of the 25 patients, 76% are alive and remain cyst free at follow-up intervals of 1 to 16 years (mean, 3.2). Five patients died from their tumors, with a mean survival of 33 months after decompression. In 7 of 8 patients with cysts largely or entirely within the basal ganglia or thalamus, successful operative cyst control was achieved. Patients with solitary cystic gliomas seem to have a favorable prognosis, and vigorous efforts to control cyst recurrence and limit disability are warranted. Analysis of our data suggests that craniotomy for tumor resection, cyst decompression, and tissue diagnosis is the initial procedure of choice. Cyst recurrence without major solid tumor should be controlled by computed tomography-guided tap or shunt drainage. Reexploration is indicated when cyst reaccumulation is accompanied by clear regrowth of a solid component.     

Mesencephalic ependymal cysts: treatment under pure endoscopic or endoscope-assisted keyhole conditions

OBJECT: Primary intracranial ependymal cysts are extremely rare. Similar to congenital intraparenchymal cysts in the mesencephalon they usually occur with symptoms of an occlusive hydrocephalus or symptoms like Parinaud syndrome, dizziness, or gait disturbance. The objective of this study was to evaluate the surgical methods for the treatment of these cysts and the clinical outcome of the patients. METHODS: The authors present the clinical records of 8 patients who were treated in their department for symptomatic mesencephalic ependymal cysts in the past 10 years. The patient age ranged from 22 to 60 years with a mean age of 44 years. In 4 cases the authors performed a suboccipital infratentorial supracerebellar approach by using endoscope-assisted microsurgery. The other 4 patients underwent a pure endoscopic procedure over a frontal bur hole trepanation. RESULTS: Four patients became symptom free, and the remaining 4 improved significantly after a mean follow-up duration of 38.5 months (range 5-119 months). One patient underwent 2 operations: first a ventriculocystostomy and 4 months later endoscopic third ventriculostomy because of recurrent hydrocephalus. In 1 case a second surgery was necessary because of a wound infection. In all of the patients an adequate fenestration of the cyst was achieved. CONCLUSIONS: A symptomatic mesencephalic ependymal cyst is an indication for neurosurgical intervention. These cysts can be treated successfully and most likely definitively by a pure endoscopic or endoscope-assisted keyhole neurosurgical technique. There were no morbid conditions or death due to the procedures in this group of 8 patients. Therefore, the authors regard these surgical procedures to be good alternatives to treatments such as shunt placement or stereotactic aspiration of the cysts.     

Interactive image-guided transcallosal microsurgery for anterior third ventricular cysts.

Although the treatment of colloid cysts remains controversial, high viscosity and small volume are poor prognostic indicators for successful burr hole aspiration and cortical incision via craniotomy may be associated with postoperative epilepsy. The anterior transcallosal approach provides a direct and adequate pathway to the lateral ventricles, where the foramen of Monro serves as a natural entrance into the anterior third ventricle, especially when the foramen is dilated by a lesion. When the midsuperior portion of the IIIrd ventricle cannot be reached, the interforniceal or the subchoroidal exposures have been advocated. Stereotactic techniques contribute to a minimal invasive approach and reduce morbidity. Nine patients harbouring anterior third ventricular cysts (seven colloids and two intrinsic craniopharyngiomas) underwent anterior transcallosal microsurgical excision assisted by an interactive infrared-based image guided system (EasyGuide, Neuro, Philips). There were 4 men and 5 women ranging in age from 15 to 42 years (mean 28.5). Transcallosal transforaminal (5 cases) or interforniceal (4 cases) approaches allowed total excision in eight patients and subtotal in one. Postoperative morbidity included a case of transient hemiparesis and a case of transient short-term memory disturbances; both resolved in the first months. Mortality was zero. Particular advantages of the method were accurate trajectory and position of callosotomy incision determination, visualisation and avoidance of superior saggital sinus, retraction of bridging veins and the often variable pericallosal arteries, spatial orientation within the ventricular system, and identification of the periventricular anatomical structures.     

Frameless navigation and endoscopy

OBJECT: Frameless computerized neuronavigation has been increasingly used in intracranial endoscopic neurosurgery. However, clear indications for the application of neuronavigation in neuroendoscopy have not yet been defined. The purpose of this study was to determine in which intracranial neuroendoscopic procedures frameless neuronavigation is necessary and really beneficial compared with a free-hand endoscopic approach. METHODS: A frameless infrared-based computerized neuronavi- gation system was used in 44 patients who underwent intracranial endoscopic procedures, including 13 third ventriculostomies, nine aqueductoplasties. eight intraventricular tumor biopsy procedures or resections, six cystocisternostomies in arachnoid cysts, five colloid cyst removals, four septostomies in multiloculated hydrocephalus, four cystoventriculostomies in intraparenchymal cysts, two aqueductal stent placements, and fenestration of one pineal cyst and one cavum veli interpositi. All interventions were successfully accomplished. In all procedures, the navigational system guided the surgeons precisely to the target. Navigational tracking was helpful in entering small ventricles, in approaching the posterior third ventricle when the foramen of Monro was narrow, and in selecting the best approach to colloid cysts. Neuronavigation was essential in some cystic lesions lacking clear landmarks, such as intraparenchymal cysts or multiloculated hydrocephalus. Neuronavigation was not necessary in standard third ventriculostomies, tumor biopsy procedures, and large sylvian arachnoid cysts, or for approaching the posterior third ventricle when the foramen of Monro was enlarged. CONCLUSIONS: Frameless neuronavigation has proven to be accurate, reliable, and extremely useful in selected intracranial neuroendoscopic procedures. Image-guided neuroendoscopy improved the accuracy of the endoscopic approach and minimized brain trauma.     

Frameless neuronavigation in intracranial endoscopic neurosurgery

OBJECT: Frameless computerized neuronavigation has been increasingly used in intracranial endoscopic neurosurgery. However, clear indications for the application of neuronavigation in neuroendoscopy have not yet been defined. The purpose of this study was to determine in which intracranial neuroendoscopic procedures frameless neuronavigation is necessary and really beneficial compared with a free-hand endoscopic approach. METHODS: A frameless infrared-based computerized neuronavigation system was used in 44 patients who underwent intracranial endoscopic procedures, including 13 third ventriculostomies, nine aqueductoplasties, eight intraventricular tumor biopsy procedures or resections, six cystocistemostomies in arachnoid cysts, five colloid cyst removals, four septostomies in multiloculated hydrocephalus, four cystoventriculostomies in intraparenchymal cysts, two aqueductal stent placements, and fenestration of one pineal cyst and one cavum veli interpositi. All interventions were successfully accomplished. In all procedures, the navigational system guided the surgeons precisely to the target. Navigational tracking was helpful in entering small ventricles, in approaching the posterior third ventricle when the foramen of Monro was narrow, and in selecting the best approach to colloid cysts. Neuronavigation was essential in some cystic lesions lacking clear landmarks, such as intraparenchymal cysts or multiloculated hydrocephalus. Neuronavigation was not necessary in standard third ventriculostomies, tumor biopsy procedures, and large sylvian arachnoid cysts, or for approaching the posterior third ventricle when the foramen of Monro was enlarged. CONCLUSIONS: Frameless neuronavigation has proven to be accurate, reliable, and extremely useful in selected intracranial neuroendoscopic procedures. Image-guided neuroendoscopy improved the accuracy of the endoscopic approach and minimized brain trauma.     

俯卧位背侧人路后腹腔镜肾囊肿去顶术的临床分析（附12例报告）

目的：探讨俯卧位经背侧人路后腹腔镜肾囊肿去顶术的方法和疗效。方法：回顾性分析俯卧位经背侧入路后腹腔镜肾囊肿去顶术治疗12例单纯性肾囊肿患者的临床资料。其中男7例,女5例,年龄为31～67岁,平均42．6岁。术前均行泌尿系B超、静脉尿路造影（IVu）和肾脏CT平扫及增强检查明确囊肿大小、数量及位置,证实与肾盂集合系统不相通。囊肿直径4．5～12．0cm,平均7．6cm。结果：12例患者均在后腹腔镜下顺利完成手术。手术时间30～105min,平均48．5min;术中出血量5～25ml,平均14．2ml;术后住院时间3～6天,平均4．8天。围手术期未出现并发症。随访12~20个月,平均15．3个月,未见囊肿复发。结论：俯卧位背侧入路后腹腔镜肾囊肿去顶术治疗单纯性肾囊肿安全可行。经背侧入路后腹腔镜手术的成功实施为临床手术路径的研究提供一种新的思路。     

Treatment of symptomatic intracranial arachnoid cysts by stereotactic cyst-ventricular shunting

BACKGROUND: The optimal treatment of symptomatic intracranial arachnoid cysts is controversial and different surgical approaches have been described. The aim of the treatment is to reduce the intracystic pressure. To accomplish this goal, many techniques have been proposed, each with specific limitations or failures. METHODS: Nine patients with symptomatic arachnoid cysts were treated by stereotactic cyst-ventricular shunting. One patient with suprasellar arachnoid cyst showed signs related to intracranial pressure, the remaining 8 patients complained of headache and/or drug-resistant epilepsy. All the intracranial cysts were supratentorial. The surgical procedure was performed under general anesthesia in 6 cases and local anesthesia in 3 cases. The CRW Stereotactic System (Radionics) was used. The acquisition of both target points (cyst and ventricle) was always realized by means of CT scan slices. A right precoronal burr hole was made and a silicon catheter was stereotactically inserted into the lateral ventricle. Another burr hole was subsequently performed close to the cyst; a silicon catheter was placed in the middle of the cavity in the shortest intracerebral crossing. Then both catheters were connected to a subcutaneous burr hole Ommaya reservoir. RESULTS: All patients tolerated the procedure well and the preoperative clinical signs progressively disappeared or improved. The CT scan at 1, 3, 6 and over 12 months showed progressive reduction in size of the cysts. No clinical recurrence was found at the follow-up (14-73 months). CONCLUSIONS: The successful outcome of the above cases suggests that, in carefully selected symptomatic intracranial arachnoid cysts, stereotactic cyst-ventricular shunting is likely to prove an effective operative method.     

Endoscopic resection of colloid cysts: indications, technique, and results during a 13-year period.

OBJECTIVE: Questions of recurrence and inadequacy of follow-up length persist regarding endoscopic treatment of colloid cysts. In this retrospective review, we report our long-term follow-up during a 13-year period in 35 patients who underwent endoscopic resection of colloid cysts. METHODS: The 19 males and 16 females (age range 14 to 58 years, mean 35.9 years) who had symptomatic colloid cysts that ranged in size from 5 mm to 4 cm underwent endoscopic resection in the period from 1991 to 2004. RESULTS: Of 2 patients who developed recurrences at 5.9 years and 4.3 years (1 and 6 mm, respectively) both remain asymptomatic. The rate of late asymptomatic recurrence in this series is 6.3%. Three endoscopic resections were converted to an open craniotomy. Three operative complications occurred (i.e., introducer tract hemorrhage, thalamic stroke secondary to thermal injury, epidural hematoma that required evacuation). Four patients noted minimal short-term memory loss without interference in daily living. Of 3 patients with shunts preoperatively, all have no evidence of hydrocephalus after shunt removal. Two patients have asymptomatic ventriculomegaly. Prophylactic anticonvulsants were not prescribed and no seizures were reported. No infections were recorded with antibiotic administration preoperatively, and 24 hours postoperatively. CONCLUSIONS: Our series represents the longest follow-up (mean of 7.8 years) of colloid cysts after endoscopic resection. We now use this technique as the first line of treatment for colloid cysts. The risk of recurrence is minimal with gross total resection and/or coagulation of the cyst wall.     

Colloid cysts with and without ventriculomegaly: Role of intraoperative real-time ultrasound

Intraoperative real-time ultrasound was used to assist localization and surgical removal of colloid cysts in patients without ventriculomegaly. In the most commonly used surgical approach for removal of colloid cysts, dilated lateral ventricles can expedite the localization of lesions because, once entered surgically, a dilated ventricle offers more space near the foramen of Monro in which to work. Additionally, the enlargement of the foramen of Monro, seen with hydrocephalus, provides greater accessibility to the colloid cyst. In patients with symptoms related to intermittent obstruction of cerebral fluid flow but with normal-sized ventricles, the precise localization of the foramen of Monro and colloid cyst is more difficult and may result in unnecessary exploration/resection of brain. Using intraoperative ultrasound, the colloid cyst and adjacent anatomic structures can be clearly visualized regardless of ventricular size. Intraoperative ultrasonography has a unique role in the operative treatment of patients with colloid cysts and nondilated ventricles.     

Endoscopic treatment of intracranial lesions. Apropos of 8 cases

The authors describe their initial experience involving endoscopic techniques used in the treatment of eight patients with varied brain lesions. Two tumours and a colloid cyst of the third ventricle, two paraventricular symptomatic cysts, one arachnoid cyst, one chronic intracerebral hematoma and one case of free catheter extraction in the lateral ventricle. The common characteristics of all these lesions were their liquid character and/or intraventricular location. Rigid endoscopes were used, with 9 and 6 mm work channels and independent aspiration and irrigation systems. The optic elbow makes direct visualization and adaptation to the TV monitor possible. The endoscope was manually directed at the lesion through a 12 mm burr hole in five cases and by means of a stereotactic frame in three cases. Biopsies were obtained in six cases. In three cases a communication between the cyst and the ventricular system or adjacent cisterns was established and in two cases vaporization of the lesion using a CO2 laser was performed. Tolerance to the endoscopic procedures was good in all cases. In the authors' opinion, endoscopic techniques constitute a low risk method, midway between stereotactic techniques and the microsurgical approach, and are especially indicated in the treatment of cystic brain lesions or those situated in or near the ventricular system. Their most notable advantages are: providing direct visualization of the lesion without interference from the instruments in the operating field; non-repercussion of the spatial changes derived from the liquid outlet and possibility of lesion coagulation and manipulation. Their disadvantages, related to the use of very long instruments and from a reduced work channel, must be overcome by specialized training.     

Neuroendoscopic approach to complex hydrocephalus. Personal experience and preliminary report

BACKGROUND: Neuroendoscopic premammilary third-ventriculocisternostomy in non-communicating hydrocephalus represents, to date, the less invasive and effective procedure, whereas the neuroendoscopic approach to complex-hydrocephalus is limited to several small anecdotal series. METHODS: Among 57 pediatric patients affected by obstructive hydrocephalus, ranging in age from prenatal diagnosis to 3 years (mean 1.2 year+/-11 months) and recruited over a 2-year period, we identified 11 cases with presurgical neuroradiological complex-hydrocephalus, at admission to our Department. In two cases Magnetic Resonance imaging showed bilateral atresic foramen of Monro and corpus callosum agenesya. In these cases an extracranial cerebrospinal fluid shunt device was implanted. The authors report retrospectively, the personal experience on a series of 9 pediatric patients with complex-hydrocephalus, such as multishunted (4 cases), multiloculated hydrocephalus (3 cases), and multiple ventricular cysts plus hydrocephalus (2 cases), in which a neuroendoscopic approach was performed. At admission, symptoms and signs of an increased intracranial pressure were presents in all cases. Follow-up ranged from 3 months to 2 years. In 8 cases third ventriculostomy was successfully performed whereas, in one case, the endoscopic procedure, in a patient younger than 1 month, was aborted and an extracranial cerebrospinal fluid device was implanted. RESULTS: In the postoperative period and during follow-up, a symptomatic relief and clinical improvement of preoperative signs and symptoms of increased intracranial pressure was seen in all cases. Nevertheless, in two patients psychomotor retardation worsened, respectively 6 and 7 months after the endoscopic procedure and then, an additional extracranial cerebrospinal fluid shunt device was implanted. CONCLUSIONS: In our selected cases of complex-hydrocephalus, the neuroendoscopic approach did not fail to determine clinical improvement after the first procedure, in spite of increased technical difficulties and minimum decreases of ventricular volume in postoperative images.     

Endoscopic treatment of colloid cysts of the third ventricle: 9 consecutive cases.

The purpose of this study is to evaluate the efficacy of the endoscopic technique for the treatment of the colloid cysts of the third ventricle. Between August 1995 and October 1997 a series of nine patients with colloid cyst of the third ventricle (6 males and 3 females) were treated with this method. The technique, consisting of cyst fenestration, aspiration of the colloid, and coagulation of the internal layer of the wall, was always effective in restoring CSF circulation. Operating time was 54-120 min (median 67 min). We recorded only one post-operative septic complication but no signs of direct surgical morbidity. Post-operation hospital stay was 2-30 days (median 5 days). Follow up was 14-40 months (mean 27 months). We did not observe any clinical or radiological recurrence. Endoscopic treatment of colloid cysts of the third ventricle is a safe and effective alternative to the well-established approaches of microsurgical removal and stereotactic aspiration. Only a very long follow-up will answer the question of the long-term effectiveness of this method.     

Freehand technique for putaminal hemorrhage--technical note

We designed a new endoscopic surgical procedure for putaminal hemorrhage (freehand technique) and evaluated its effectiveness and safety in patients with putaminal hemorrhage. Computed tomography (CT) data sets from 40 healthy patients were used. The CT data were transformed into three-dimensional images using AZE VirtualPlace(TM) Plus. The nasion and external auditory foramen were the intraoperative reference points. The median point from medial of the globus pallidus to the insula was the target point. The location of the burr hole point was 80-125 mm above and 27.5 mm lateral to the nasion, and the direction was parallel to the midline and a line drawn from the burr hole to the ipsilateral external auditory foramen. This point was used for 15 patients with putaminal hemorrhage. In all cases, only one puncture was required, and there were no complications. The median surgical time was 91.7 minutes, and the median hematoma removal rate was 95.9%. No recurrent bleeding or operative complications occurred. The freehand technique is a simple and safe technique for patients with putaminal hemorrhage. We believe that this technique of endoscopic hematoma evacuation may provide a less-invasive method for treating patients with putaminal hemorrhage.