Endoscopic third ventriculostomy in tuberculous meningitis

INTRODUCTION: We report our preliminary experience with two cases of tuberculous meningitis (TBM) in which endoscopic third ventriculostomy (ETV) was performed to treat non-communicating hydrocephalus. For many years, the insertion of ventriculoperitoneal shunts has been the standard treatment for hydrocephalus in patients with TBM, although the indications for and timing of surgery are not uniformly accepted. Shunt insertion is associated with a high incidence of complications, particularly with long-term follow-up. An alternative treatment for hydrocephalus in this group of patients would clearly be of great benefit. The indications for ETV have increased in the last decade, and there are reports of some effectiveness of the procedure in patients with hydrocephalus due to bacterial meningitis. To our knowledge, ETV has not been described in the management of TBM. METHODS: We report the early results of our preliminary experience with ETV in two patients who presented with neurological compromise due to hydrocephalus and raised intracranial pressure. The clinical context and pre-operative investigation of these patients are presented. The emphasis is placed on the distinction between communicating and non-communicating pathologies as a guide to management options. We detail our surgical findings and the peculiar endoscopic challenges that the condition presented to us. Follow-up in these patients included clinical and investigational data suggesting early effectiveness of the procedure in converting non-communicating hydrocephalus into a communicating one, which can then be treated medically. DISCUSSION: Endoscopic third ventriculostomy is presented as a new application of a procedure accepted for other indications in the treatment of non-communicating hydrocephalus. There are particular aspects of the use of this procedure related to the unique pathology of TBM that are significantly different. We explain our rationale for endoscopy in these patients, and suggest a protocol in which endoscopy may play a role in the management of patients with raised intracranial pressure due to tuberculous hydrocephalus.     

Endoscopic third ventriculostomy.

Among patients with idopathic aqueductal stenosis or impedance of cerebrospinal fluid (CSF) flow in the posterior fossa due to tumour, endoscopic fenestration of the floor of the third ventricle creates an alternative route for CSF flow to the subarachnoid space via the prepeduncular cistern. By reestablishing CSF flow, this procedure dissipates any pressure gradient on midline structures. This may obviate the need for traditional CSF shunt diversion techniques in such settings. Currently, endoscopic third ventriculostomy is indicated in approximately 25% of patients with hydrocephalus and can be performed instead of shunt placement. Appropriate patients are those with aqueductal stenosis (10%), obstructive tumours (10%), and obstructive cysts (5%). Additional recent data suggest the favorability of third ventriculostomy over shunt implantation in additional patient cohorts. Operative technique is discussed.     

Endoscopic third ventriculostomy in infants

BACKGROUND: Endoscopic third Ventriculostomy (ETV) is one of the surgical options for obstructive hydrocephalus. There are varying opinions about results of ETV in infants. We are therefore presenting the results of ETV in 54 infants. MATERIALS AND METHODS: A prospective study of 54 infants undergoing ETV in our institution in the last 2 years was carried out. There were 48 cases of congenital hydrocephalus with aqueductal stenosis, 6 of post tubercular meningitis hydrocephalus. Average follow up was 18 months. RESULTS: There was 83.3% (45 cases) clinical success rate in our study. Infection, persistent cerebro-spinal fluid (CSF) leak and bleeding occurred in 4 (8%) cases each while blockage of stoma was observed in 8 (14.8%) patients. Majority of ETV stoma closure (6 out of total 8) occurred following infection (4) or bleeding during surgery (2). One patient (2%) had transient diabetes insipidus. Overall failure rate in our study was 16.7% (8 stoma blocks and 1 procedure abandoned). Low birth weight pre mature infants had higher failure rate (3 out of 5 infants 60%) compared to full term infants with normal birth weight (12.3%). Age did not have any impact on the success rate (P>0.05). Success rates were not significanlty different in patients with aqueductal stenosis (85.4%) and TBM (66.6%) (Fisher's exact test, P=0.3). CONCLUSION: ETV was fairly safe and effective in full term normal birth weight infants while the results in low birth weight pre mature infants were poor.     

Endoscopic third ventriculostomy in obstructed hydrocephalus

Forty-three ETV were performed in 46 patients of obstructive hydrocephalus. Study was divided into two groups. Group 1 was with 29 children of less than two years age. Group 2 had seventeen patients of more than 2 years, adolescent and adults. Group 1 had 70% clinical and 63% radiological improvement whereas Group 2 showed 100% clinical and 73% radiological improvement. ETV failed in relieving the symptoms of hydrocephalus in eight patients. They were eventually benefited with VP Shunt. There was one postoperative death, which was not related to the procedure. ETV is an important alternative to VP Shunt in relieving hydrocephalus due to obstruction in CSF pathway.     

第三脑室底造瘘治疗梗阻性脑积水

目的：探讨对梗阻性脑积水患者采用在神经内窥镜下进行第三脑室底造瘘的手术方法。分析手术成功与失败的原因,方法：对21例不同原因造成的梗阻性脑积水患者进行了23次神经内视镜下的第三脑室底造瘘手术。结果：随访1-33个月,平均19个月,显效15例,有效2例,4例无效患者改行V-P分流术,2例接受2次造瘘;手术并发症包括颅内感染2例,严重硬膜下积液1例,暂时性脑疝1例,暂时性动眼神经麻痹1例,中脑及丘脑出血各1例,无死亡病例,结论：神经内窥镜下的第三脑室底造瘘对治疗梗阻性脑积水是一种安全、有效的手术方法,但为了提高手术疗效,减少手术并发症,应采用良好的手术器械、熟练掌握手术方法,选择适当手术患者。     

脑室镜三脑室造瘘术治疗小儿阻塞性脑积水

目的分析本组49例病例，就手术病种和年龄的选择、手术方法及技巧做一介绍。方法全组49例，年龄1个月-18岁，平均33个月。CT、MRI及^99Tc^m-DTPA证实为脑脊液吸收功能正常的阻塞性脑积水。手术方法为经侧脑室、室间孔、三脑室置入神经内镜，于三脑室底与脚间池造一瘘孔。结果术后随访半年-5年，39例有好转；10例因无改善于术后3个月再行脑室腹腔分流手术，术后脑脊液漏3例，未有出血、感染及神经功能损伤等并发症。结论脑室镜三脑室底脚间池造瘘适用于脑脊液吸收功能正常的阻塞性脑积水。脑脊液吸收功能判断需靠同位^99Tc^m-DTPA检查。继发性脑积水治疗效果好于原发性脑积水，大龄儿童效果好于婴幼儿。     

神经内镜下第三脑室底造瘘术治疗交通性脑积水

目的 探讨神经内镜下第三脑室底造瘘术成功治疗交通性脑积水的手术机制和指征.方法 回顾性分析18例神经内镜下第三脑室底造瘘术治疗交通性脑积水患者的临床资料.结果 11例患者术前MRI显示第四脑室异常扩张和“喇叭形”中脑导水管出口,其中9例效果良好;另外7例无此影像学特征的均失败而需进一步行分流术.结论 神经内镜下第三脑室底造瘘术是 治疗部分交通性脑积水的有效手段,而近端脑池梗阻可能是其重要的作用机制.第四脑室相对第三脑室异常扩张和“喇叭形”中脑导水管出口可能是此类患者的影像学特征,可作为第三脑室底造瘘术治疗交通性脑积水的手术指征之一.     

内镜下行第三脑室底造瘘术治疗脑室炎后慢性脑积水

目的 探讨应用神经内镜在治疗慢性复杂脑积水的效果.方法 回顾性分析了15例用神经内镜行第三脑底造瘘术并脑室冲洗治疗的慢性复杂脑积水的病人资料.结果 15病人获得良好的效果,无并发症发生,1例病人术后15 d,脑积水复发,冉次行第三脑底造瘘时发现造瘘口闭合,二次造瘘后恢复良好.结论 神经内镜行第三脑底造瘘术并脑室冲洗治疗慢性复杂脑积水的病人有确实效果.     

第三脑室底造瘘术治疗梗阻性脑积水与分流术的疗效比较

目的 比较梗阻性脑积水的两种手术方法的疗效及并发症。方法 采用经神经内镜第三脑室底造瘘术治疗梗阻性脑积水35例，脑室腹腔分流术治疗梗5且性脑积水63例。结果 造瘘组：平均用时35min，症状缓解34例(97.1％)，复发1例(2．9％)，并发症3例(8.6％)，为非感染性发热；分流组：平均用时78min，症状缓解63例(100％)，复发16例(25．4％)，并发症18例(28．6％)，为分流管堵塞、感染、颅内血肿及分流管外露等。两组均无死亡。结论 经神经内镜第三脑室底造瘘术治疗梗5且性脑积水较脑室腹腔分流术的疗效相当，并发症及复发率明显降低，手术时间缩短，应作为梗阻性脑积水的首选治疗方法。     

Endoscopic third ventriculostomy for malfunction in previously shunted infants

Introduction  The usage of endoscopic third ventriculostomy (ETV) as an alternative to shunt revision in the management of shunt malfunction is gaining popularity. Methods  We review the clinical data of 45 patients who underwent ETV because of ventriculopritoneal shunt malfunction at Hacettepe University School of Medicine Department of Neurosurgery between January 2002 and August 2007. Medical records of the patients were retrospectively studied. Results  Male-to-female ratio was 23/22. The cause of the hydrocephalus was aqueduct stenosis in 21 (46.9%) patients, newborn meningitis in nine (20%) patients, tumor in six (13.3%) patients, newborn intraventricular hemorrhage in four (8.8%) patients, myelomeningocele in three (6.6%), and trauma in two (2.2%) patients. Of the patients, 27 (60%) had triventricular and 18 (40%) had tetraventricular hydrocephalus at their radiologic evaluation. On admission, all patients had at least one episode of shunt dysfunction prior to ETV. Follow-up duration after surgery was 1–5 years (mean 2.46 ± 1.64 years). Postoperative cerebrospinal fluid flow studies using the cine-PC MR imaging were performed on all patients. The overall success rate for ETV after shunt malfunction was 80% with 36 patients and failure rate was 20% with nine patients. All of these nine patients had undergone shunt insertion within 10 days–1 month after unsuccessful ETV. Conclusion  Endoscopic third ventriculostomy is an effective treatment for shunt malfunction.     

神经内窥镜第三脑室底造瘘术治疗梗阻性脑积水

目的 探讨对梗阻性脑积水患者采用神经内窥镜下进行第三脑室底造瘘的手术方法．分析手术成功与失败的原因。方法梗阻性脑积水原因分别为第三脑室后部肿瘤5例，中脑顶板胶质瘤2例，Chiari畸形2例，另12例为不明原因引起的导水管梗阻或狭窄。同位素^99Tcm-TPA脑池显像显示为非脑脊液吸收障碍性阻塞性脑积水。神经内窥镜从侧脑室经蒙氏孔进入第三脑室，在乳头体前方第三脑室底最薄处造一瘘口与脚间池相通。结果术后随访12～26个月，所有患者脑积水症状均缓解，脑室体积缩小。结论神经内窥镜行第三脑室底造瘘治疗非脑脊液吸收障碍性脑积水是一种有效的微创手术。     

脑室镜下三脑室底造瘘术治疗非交通性脑积水

目的探讨脑室镜下第三脑室底造瘘术方法。方法回顾性分析2001～2005年行脑室镜下第三脑室底造瘘术的30例非交通性脑积水患者临床资料。结果30例患者近期疗效满意,1例症状复发改行脑室-腹腔分流术,无严重并发症。结论脑室镜下第三脑室底造瘘术可迅速有效地改善症状,脑脊液通过瘘孔进入生理性循环,可避免感染和过度分流,且安全可靠。     

Endoscopic third ventriculostomy in previously shunted children: a retrospective study

Purpose

The aim of this study was to assess the mid-term results, success rates, and time-to-failure of secondary endoscopic third ventriculostomy (secondary ETV), as well as the complex management of preoperative and postoperative cares.

Methods

To this purpose, a retrospective analysis of a pediatric population of 22 children who underwent endoscopic third ventriculostomy (ETV) after shunt malfunction (secondary ETV) was performed.

Results

The failure rate, given by the percentage of new shunt replacement in the first 3 months after ETV, was 36%, with a mean time to failure of 14.3 days. All the failures were evident within 1 month after the ETV. Despite the small number of patients in our series, we found no significant correlation between ETV failure and both patient age and hydrocephalus etiology (p?=?0.47 and p?=?0.78, respectively).

Conclusions

In our experience, ETV secondary to shunt malfunction in pediatric patients has a success rate of 64%. As it is a safe and rapid treatment option even in emergency conditions, it is worth performing this procedure in previously shunted children.     

Endoscopic ventriculostomy of the third ventricle in adults. Own experience

Only few reports can be found on endoscopic third ventriculostomy (ETV) in the Polish literature, and the majority of other reports concern paediatric or mixed population. This has induced the authors to report their experience with ETV in adults, reporting the results and discussing the usefulness and effectiveness of this procedure, causes of complications and failure. ETV was carried out in 20 patients aged over 18 years in a two-year period, beginning in 1999. In 13 cases (64%) the cause was external compression of CSF system by tumour leading to hydrocephalus. In 3 cases aqueduct stenosis was producing hydrocephalus, in 3 cases arachnoid cyst, perisellar or situated in posterior part of the third ventricle, was the cause, and in one case colloidal cyst of the third ventricle. The outcome were analysed according to clinical and radiological criteria finding that the ETV was successful in 90% of cases by clinical criteria, and in 88% by radiological criteria. Only unimportant clinical complications were reported without major consequences. It is concluded that ETV is a very useful method for hydrocephalus treatment in adults, especially if caused by blockade of CSF pathways by tumour or arachnoid cysts in the vicinity of the third ventricle.     

Endoscopic third ventriculostomy for hydrocephalus in brainstem glioma: a case series

Object

A brainstem glioma is an incurable brain tumor that can be complicated by hydrocephalus. A ventriculoperitoneal (VP) shunt is generally performed for the control of hydrocephalus. This study aimed to reveal the safety and efficacy of an endoscopic third ventriculostomy (ETV) for hydrocephalus in brainstem gliomas.

Methods

Six patients who had pontine glioma with hydrocephalus underwent an ETV between May 2010 and November 2015. In all the cases, there were one or more symptoms of hydrocephalus (headache, nausea, vomiting, or lethargy). Retrospective review of these patients was performed using the medical records and neuroimagings.

Result

The ETV was performed safely and there were no intraoperative complications in all patients. The mean follow-up period was 12.3 months. An immediate symptomatic relief of hydrocephalus and an adequate control of symptoms were achieved without a VP shunt in all patients.

Conclusions

The ETV is considered to be an effective and safe procedure for the treatment of hydrocephalus in brainstem gliomas. Determining the ventriculostomy site according to the preoperative MRI in each case is considered to be important for the safe procedure.

     

Endoscopic third ventriculostomy in children younger than 2 years of age

Introduction Endoscopic third ventriculostomy (ETV) for the treatment of hydrocephalus of different etiologies is still controversial in children younger than 2 years of age. The success rate of ETV in this group of patients is analyzed in this study. Materials and methods The series consisted of 21 patients treated with ETV. The mean age of the patients was 6.7 months, ranging from 9 days to 15 months (16 patients were younger than 1 year). The study included hydrocephalus due to idiopathic aqueductal stenosis (eight) and other congenital anomalies (four) as well as posthemorrhagic (three) and tumor-related occlusive hydrocephalus (three). Two patients presented with shunt infection and one with a shunt failure. ETV was considered to be successful when shunting could be avoided. Results ETV was successful in nine patients, with a mean follow-up period of 26.2 months. The procedure was successful in four patients with idiopathic aqueductal stenosis, in two with other congenital anomalies, in one posthemorrhagic, and in two with a tumor-related hydrocephalus. In 12 patients, the ETV was unsuccessful after a mean follow-up of 3.3 months. These patients required a shunt. Ten of them were less than 1 year old when ETV was performed. In one tumor-related hydrocephalus, a shunt was inserted after a meningitis after tumor removal. Conclusions The success of ETV in children younger than 2 years of age suffering from non-communicating hydrocephalus seems to be dependent on both age and etiology. Our results show an overall success rate of 43%. In 37.5% of the children younger than 1 year of age, ETV was successful. ETV in patients with hydrocephalus due to idiopathic aqueductal stenosis seems to be more beneficial than in other causes of hydrocephalus. Presented at the Third World Conference of the International Study Group on Neuroendoscopy (ISGNE), Marburg, Germany, 15–18 June 2005.