Endoscopic evacuation of intraventricular hematoma and third ventriculostomy

We described our experience of three cases treated with endoscopic evacuation of intraventricular hematoma and third ventriculostomy for a tight intraventricular hematoma associated with intracerebral hemorrhage. A steerable endoscope was introduced into the anterior horn of the lateral ventricle contralaterally to the intracerebral hemorrhage, through a 14 Fr. peel-away sheath. First, the hematoma in the lateral ventricle contralateral to the hemorrhage was evacuated by direct aspiration using a syringe connected to the operative channel of the endoscope, and evacuation of the hematoma was subsequently carried on the third ventricle, aqueduct and the fourth ventricle. After the evacuation of the intraventricular hematoma, third ventriculostomy was performed for acute obstructive hydrocephalus. Finally, the procedure was completed with septostomy and evacuation of the hematoma in the lateral ventricle ipsilateral to the hemorrhage. Sufficient evacuation of the hematoma was obtained in all cases and no major complications were encountered. We conclude that for patients with intraventricular hematoma associated with intracerebral hemorrhage endoscopic evacuation of intraventricular hematoma brings about sufficient removal of hematoma, reduction of hospitalization time and prevention of subsequent hydrocephalus.     

Biportal endoscopic removal of a primary intraventricular hematoma: case report.

Primary intraventricular hematomas account for approximately 6% of all intracerebral hematomas. If the clot blocks cerebrospinal fluid (CSF) pathways, surgical intervention, which may be of different types, can be life-saving. In the case reported here, after careful preoperative planning the use of two rigid endoscopes permitted the removal of most of the intraventricular clot and restoration of CSF circulation by creation of a 3rd ventriculostomy within the same procedure and no later treatment was necessary. Repeated CT scans proved that only a small portion of the intraventricular clot remained in the ventricular system. The ventricular size normalised, and the patency of the artificial hole in the floor of the 3rd ventricle was demonstrated both by the rapidly improving clinical picture of the patient and by flow-sensitive MRI studies. For individuals who suffer primary intraventricular hemorrhage and later develop occlusive hydrocephalus, endoscopic removal of the clot and 3rd ventriculostomy might offer a more adequate treatment option than external ventricular drainage.     

Chronic subdural hematoma as a complication of endoscopic third ventriculostomy

BACKGROUND: Endoscopic third ventriculostomy has become a popular alternative to ventricular shunts for noncommunicating hydrocephalus. Although endoscopic third ventriculostomy is a safe procedure, several complications related to this procedure have been reported in the literature. The authors present a rare case of symptomatic bilateral subdural hematomas after an uneventful endoscopic third ventriculostomy. CASE DESCRIPTION: A 51-year-old male patient presented with symptoms of obstructive hydrocephalus, headaches and memory disturbance. Magnetic resonance imaging demonstrated hydrocephalus secondary to aqueductal stenosis. An endoscopic third ventriculostomy was performed. The patient was discharged home in several days without complication. He then presented with headaches 3 weeks following surgery. A computed tomography study demonstrated bilateral subdural hematomas. These were treated with burr hole evacuation and drainage. Postoperatively, his headaches improved. At last follow-up he remains symptom-free and has radiographic evidence of a patent ventriculostomy. CONCLUSION: This case confirms chronic subdural hematoma formation is a possible complication following third ventriculostomy. Patients should be followed closely for possible subdural hematoma formation.     

Long-term resolution of acute, obstructive, triventricular hydrocephalus by endoscopic removal of a third ventricular hematoma without third ventriculostomy. Case report and review of the literature

The authors describe a new extension of the use of neuroendoscopy beyond that which is ordinarily performed. The authors report on the resolution of acute, obstructive, triventricular hydrocephalus in a 42-year-old woman with hypertensive caudate hemorrhage that migrated into the ventricular system. The patient underwent emergency endoscopic removal of a third ventricular hematoma, which was obstructing the orifice of the aqueduct, and restoration of cerebrospinal fluid (CSF) flow but no third ventriculostomy. The authors believe that this is the first such case to be reported. In selected cases of third ventricular hemorrhage, endoscopic removal of the intraventricular hematoma may represent a useful and effective treatment option even in emergency conditions as well as a better alternative to prolonged CSF external ventricular drainage. A reduction in the duration of hospitalization is a beneficial consequence. The authors assert that third ventriculostomy is not always needed.     

Fatal subarachnoid hemorrhage after endoscopic third ventriculostomy. Case report.

In recent years, endoscopic third ventriculostomy has become a well-established procedure for the treatment of various forms of noncommunicating hydrocephalus. Endoscopic third ventriculostomy is considered to be an easy and safe procedure. Complications have rarely been reported in the literature. The authors present a case in which the patient suffered a fatal subarachnoid hemorrhage (SAH) after endoscopic third ventriculostomy. This 63-year-old man presented with confusion and drowsiness and was admitted in to the hospital in poor general condition. Computerized tomography scanning revealed an obstructive hydrocephalus caused by a tumor located in the cerebellopontine angle. An endoscopic third ventriculostomy was performed with the aid of a Fogarty balloon catheter. Some hours postoperatively, the patient became comatose. Computerized tomography scanning revealed a severe perimesencephalic-peripontine SAH and progressive hydrocephalus. Despite emergency external ventricular drainage, the patient died a few hours later. Although endoscopic third ventriculostomy is considered to be a simple and safe procedure, one should be aware that severe and sometimes fatal complications may occur. To avoid vascular injury, perforation of the floor of the third ventricle should be performed in the midline, halfway between the infundibular recess and the mammillary bodies, just behind the dorsum sellae.     

Re-ventriculostomy for treatment of obstructive hydrocephalus in cases of stoma dysfunction.

In this article, 12 re-ventriculostomies in the treatment for obstructive hydrocephalus are described. The etiology of the hydrocephalus was a benign aqueductal stenosis in 9 patients, a tumor around the aqueduct in 2 patients and intraventricular bleeding in one patient. In all cases the initial ventriculostomy was successful, but after a time interval of 2 weeks to 6 years the patients developed similar clinical symptoms as preoperatively. In all except one case the radiological findings spoke in favour of stoma closure. Intraoperatively the stoma was completely closed in 9 patients and in 3 patients a subtotal closure was observed. In all cases a re-ventriculostomy was performed bluntly with a Fogarty catheter in loco typico at the floor of the third ventricle. Of the 12 patients 6 had an excellent outcome postoperatively, one patient improved and one had a benefit from the re-ventriculostomy although he died of cardiac problems. In the remaining 4 patients the re-ventriculostomy was not successful and the patients needed a shunt operation. In conclusion, after initially successful endoscopic third ventriculostomy, re-ventriculostomy should be considered as a sufficient treatment option in case of suspected stoma dysfunction.     

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.     

Hématome extradural précoce après dérivation interne du liquide céphalorachidien pour hydrocéphalie non communicante

We present the first case of early epidural hematoma after CSF shunt probably caused by defective material. A 26-year-old man was treated for obstructive hydrocephalus associated with a tonsillar herniation, revealed by headaches and papillary edema. Ventriculoperitoneal shunt was preferred to endoscopic ventriculostomy. Three hours after the operation, the patient fell into a coma, developing a voluminous bifrontal epidural hematoma that was evacuated immediately. The patient completely recovered neurologically. One month later, to treat persistent hydrocephalus, endoscopic ventriculostomy was performed without incident. Then the shunt was removed and an opening threshold close to zero was discovered. Distant MRI showed a reduction in ventricular size, normalization of the tonsils’ position and a tumor of the tectal plate. To our knowledge, this is the only case of early epidural hematoma after ventriculoperitoneal shunt. We discuss the choice of treatments for obstructive hydrocephalus and its risks and complications.     

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.     

Endoscopic Surgery for Hemorrhagic Pineal Cyst Following Antiplatelet Therapy: Case Report

Pineal cysts of the third ventricle presenting with acute obstructive hydrocephalus due to internal cystic hemorrhage are a rare clinical entity. The authors report a case of a 61-year-old man taking antiplatelet medication who suffered from a hemorrhagic pineal cyst and was treated with endoscopic surgery. One month prior to treatment, the patient was diagnosed with a brainstem infarction and received clopidogrel in addition to aspirin. A small incidental pineal cyst was concurrently diagnosed using magnetic resonance (MR) imaging which was intended to be followed conservatively. The patient presented with a sudden onset of headache and diplopia. On admission, the neurological examination revealed clouding of consciousness and Parinaud syndrome. Computerized tomography (CT) scans demonstrated a hemorrhagic mass lesion in the posterior third ventricle. The patient underwent emergency external ventricular drainage with staged endoscopic biopsy and third ventriculostomy using a flexible videoscope. Histological examination revealed pineal tissue with necrotic change and no evidence of tumor cells. One year later MR imaging demonstrated no evidence of cystic lesion and a flow void between third ventricle and prepontine cistern. In patients with asymptomatic pineal cysts who are treated with antiplatelet therapy, it is important to be aware of the risk of pineal apoplexy. Endoscopic management can be effective for treatment of hemorrhagic pineal cyst with obstructive hydrocephalus.     

Third ventriculocisternostomy in cerebellar haematomas

Summary. Summary.   Background: We prospectively evaluated the role of endoscopic third ventriculocisternostomy in the management of acute obstructive hydrocephalus created by cerebellar hematomas.   Method: Following a therapeutic diagram based on clinical and radiological signs, endoscopic third ventriculocisternostomy was used to treat hydrocephalus associated with cerebellar hematomas in 8 patients (male: 5, female: 3, mean age: 67 years-old). Causes of cerebellar hemorrhage were spontaneous in 6 cases, traumatic in 1 case, and acute bleeding of a posterior fossa tumor (lung metastasis) in the remaining case. Deeply comatose patients (Glasgow Coma Score between 3 and 5) and patients with signs of brainstem compression were initially excluded from this study.   Findings: Overall clinical improvement after third ventriculocisternostomy was achieved in all patients and was associated with the decrease of the ventricle size on follow-up CT scans. One patient who initially had a clot evacuation associated with an external ventricular drainage and persistant hydrocephalus had a successful third ventriculocisternostomy in the post operative course. No complication related to the procedure was noted.   Interpretation: In selected patients, third ventriculocisternostomy can be used to treat hydrocephalus associated with posterior fossa hematomas.     

Endoscopic third ventriculostomy for hydrocephalus.

The authors report on 125 patients who underwent endoscopic third ventriculostomy for obstructive hydrocephalus in three Italian Neurosurgical Centers. The series includes 77 cases of primary aqueductal stenosis, 33 with triventricular hydrocephalus due to external tumor compression, and 15 with tetraventricular hydrocephalus. The operations were carried out mainly under general anesthesia, using a flexible endoscope. Decrease of size of the third ventricle and the presence of a signal void at the level of the fenestration are the main postoperative MRI findings. Signs of intracranial hypertension, increased head circumference and Parinaud syndrome respond more frequently to the endoscopic treatment. The overall rate of good results (shunt-independent patients) in this series is 86.4%; primary aqueductal stenosis (93.5%) and triventricular hydrocephalus due to external compression (84.8%) are associated to the higher rate of good postoperative results than tetraventricular hydrocephalus (53.3%). Because of the very low invasivity of this technique, the absence of postoperative mortality and the scarce and usually transient postoperative complications, the authors advise to enlarge the indications for endoscopic third ventriculostomy to all patients with obstructive hydrocephalus when the third ventricle is large enough and there are no alterations of the CSF resorption.     

Clinical features in patients requiring reoperation after failed endoscopic procedures for hydrocephalus.

The aim of this study was to clarify the clinical features of patients at risk of secondary obstruction following endoscopic fenestration. Clinical notes and endoscopic findings for 15 patients treated with endoscopic procedures were retrospectively reviewed. Endoscopic third ventriculostomy (ETV) was performed as initial treatment in 4 patients with non-communicating hydrocephalus, including a neonate with myelomeningocele, and as an alternative to shunt revision in 4 patients. Two patients with non-communicating hydrocephalus caused by tumor or arachnoid cyst were also managed with third ventriculostomy. Four patients with loculated hydrocephalus underwent endoscopic septostomy. A child with an isolated fourth ventricle was treated with endoscopic aqueductoplasty. Of the 15 patients undergoing endoscopic procedure, 4 required reoperation. Of the 10 patients treated with ETV, only the neonate with myelomeningocele required a ventriculoperitoneal shunt because of failure of the initial procedure. Of the 4 patients treated with endoscopic septostomy, 2 children with loculated hydrocephalus following intraventricular hemorrhage (IVH) underwent a second septostomy. In a patient with an isolated fourth ventricle following posthemorrhagic hydrocephalus, recurrence was noted 8 months after the initial procedure. He underwent a second procedure using a stent implanted into the aqueduct to maintain CSF circulation. Sufficient stomal size or implantation of a stent may be required in the under-2-year age group with hydrocephalus accompanied by IVH and associated with myelomeningocele, in whom the risk of secondary obstruction may be high.     

Traumatic primary intraventricular hemorrhage

Two patients with primary intraventricular hemorrhage following mild head injury are presented. Both patients experienced a rapid loss of consciousness after a lucid interval following the head injury. Conray ventriculography or computerized tomography revealed intraventricular hematoma originating in the third ventricle and causing an obstructive hydrocephalus. Both patients made good recoveries promptly after ventricular drainage.     

Neuroendoscopic stent procedure in obstructive hydrocephalus due to both foramina of monro occluding craniopharyngioma: technical note

BACKGROUND: The development of various neuroendoscopic surgical instruments has offered more options for endoscopic procedures in the treatment of intraventricular tumors. Not only tumor biopsy or tumor resection but also restoration of an obstructed cerebral spinal fluid (CSF) pathway can be performed using the same approach. METHOD: A 76-year-old woman with a cardiac pacemaker for an underlying heart disease was diagnosed with obstructive hydrocephalus because of a third ventricular tumor 8 years ago. The patient had been treated with ventriculo-peritoneal shunt placement. At admission she presented with a subcutaneous infection of the shunt catheter and an abdominal mass of unknown etiology. Neuroendoscopic stenting between lateral and third ventricle was performed to restore the obstructed CSF pathway, and the infected shunt system was removed in the same setting. RESULT: The postoperative course was uneventful. Contrast ventriculography demonstrated a restored CSF pathway between the lateral and third ventricle. Histologic examination of the intraventricular tumor revealed a craniopharyngioma, and the abdominal mass was diagnosed as a gastrointestinal adenocarcinoma. CONCLUSION: The neuroendoscopic foraminoplasty technique should be considered as an alternative treatment for patients who present with an obstructive hydrocephalus caused by a tumor that occludes both foramina of Monro when shunt placement or endoscopic third ventriculostomy is not feasible.     

Endoscopic third ventriculostomy in obstructive hydrocephalus due to giant basilar artery aneurysm

OBSTRUCTIVE: hydrocephalus due to giant basilar artery (BA) aneurysm is a rare finding, and endoscopic treatment has not been reported. Here the authors present their experience with endoscopic third ventriculostomy (ETV) in obstructive hydrocephalus due to giant BA aneurysm. Between December 2000 and March 2007, 3 patients (2 men and 1 woman; age range 32-80 years) underwent an ETV for the treatment of obstructive hydrocephalus caused by a giant BA aneurysm. All 3 patients presented with cephalgia, nausea, vomiting, and a variable decrease in consciousness. An obstructive hydrocephalus caused by a giant BA aneurysm was found in each case as the underlying pathological entity. Intraoperatively, a narrowing of the third ventricle by upward displacement of the tegmentum was found in all 3 patients. A standard ETV was performed and included an inspection of the prepontine cisterns. The endoscopic treatment was successful in all patients with respect to clinical signs and radiological ventricular enlargement. No complications were observed. In all, the endoscopic ventriculostomy was proven to be a successful treatment option in obstructive hydrocephalus even if it is caused by untreated giant BA aneurysm.     

Severe parkinsonism following endoscopic third ventriculostomy for non-communicating hydrocephalus--case report

A 23-year-old male with non-communicating hydrocephalus caused by intraventricular hemorrhage from an arteriovenous malformation was treated by endoscopic third ventriculostomy (ETV) after repeated ventricular cerebrospinal fluid drainage and removal of ventriculoperitoneal shunt due to infection. Postoperatively, the patient developed robust rigidity and akinesia with mutism, suggesting secondary parkinsonism. These symptoms showed marked improvement after administration of levodopa, and were not aggravated after discontinuation. The pathophysiology of this case might involve dysfunction of the dopaminergic system caused by repeated compression and release of the paraventricular white matter. Careful perioperative management not leading to excessive dilation of the the ventricles should be considered for ETV for non-communicating hydrocephalus to avoid this unexpected complication.     

Endoscopic third ventriculostomy is the treatment of choice for obstructive hydrocephalus due to pediatric pineal tumors.

Pineal lesions in the pediatric patient are often complicated by the development of hydrocephalus due to obstruction of the aqueduct or the third ventricle by tumor masses. In such cases, hydrocephalus treatment has the highest priority and should be performed prior to any surgical treatment of the pineal tumor itself. The golden standard in obstructive hydrocephalus treatment remains placement of a temporary or permanent cerebrospinal fluid shunt, although there are many long-term complications associated with a shunt system. To avoid these and to render the patients independent from a failure-prone shunt system, we employed endoscopic third ventriculostomy for permanent relief of elevated intracranial pressure prior to surgical removal of the pineal lesions. The present study summarizes the results of this approach in 7 pediatric patients with obstructive hydrocephalus. No complications of the endoscopic procedure were encountered, and the ventriculostomy remained patent in all cases, as confirmed by motion sensitive MRI. The advantages of endoscopic third ventriculostomy as compared with other techniques are discussed, and its increasing role in the management of children with space occupying lesions of the pineal region is defined.     

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.