Craniopharyngiomas in children: surgical experience at Children’s Memorial Hospital

Objectives Craniopharyngioma during childhood poses difficulty in management because of the high incidence of surgical complications and treatment failure. In order to identify less detrimental and more effective treatment, a personal series of craniopharyngioma was reviewed in regard to various clinical factors, patient factors (age and sex), tumor factors (location and extension, relationship with chiasm, and hydrocephalus), and therapeutic modes [extent of resection and radiation therapy (RT)].Materials and methods Fifty-four childhood craniopharyngiomas treated from 1984 to 2003 were reviewed. Preoperative neuroimaging studies were classified depending upon tumor location and extension. In this series of 54 patients, 43 had total tumor resection and 11 had subtotal resection. Of the total resection group, ten showed evidence of residual tumor on postoperative neuroimaging studies. Following the initial resection, 46 did not have RT whereas 8 with subtotal resection received RT.Results There were no surgical deaths. Postoperative complications included pseudoaneurysm in 1, hemiparesis in 3, severe obesity in 5, panhypopituitarism in 50, and worsening of visual function in 7. During follow-up ranging from 12 months to 21 years, 24 patients had recurrence. Of the 33 patients with radiographic total resection, 9 (27.3%) had recurrence. Among the patients with total resection but radiographic residual and those with subtotal resection, the craniopharyngioma recurred in 90% and 100%, respectively. Three (37.5%) of eight patients with subtotal resection with RT had recurrence. Overall recurrence-free survival was 62% at 5 years and 49% at 10 years. The sex and age, location and extension of the tumor, nature of the optic chiasm, and hydrocephalus did not influence survival with statistical significance. However, the extent of surgical resection and use of RT showed significant differences for survival. Patients with total resection had a recurrence-free survival rate of 83% and 70% at 5 and 10 years, respectively. Patients with subtotal resection with RT had 71% at 5 years and 36% at 10 years. Patients who had subtotal resection or radiographically residual tumor without RT had a recurrence-free survival rate of only 9%. Among 22 patients whose recurrent tumor was treated with RT, a second recurrence-free survival rate was 90% at 5 years.Conclusion Total resection provided the best outcome. However, recurrence rates and surgical complications remained high following radical tumor resection. RT was effective for recurrent tumors and should be considered being the primary treatment for recurrences or difficult tumors, which are not amenable to total resections.     

Complications of endoscopic neurosurgery

Neuroendoscopy is rapidly becoming an essential part of the neurosurgeon's repertoire. Currently, very few studies have identified the complications of this new technique, yet many have warned of the steep learning curve associated with its practice. We have reviewed the last 173 neuroendoscopic procedures performed by one surgeon and identified two distinct groups of complications: those that have clinically significant sequelae and those that cause concern intraoperatively but no overt clinical problems. The 173 procedures were performed on 152 patients. Of these patients, 11 suffered significant complications (7%). Twenty-two of the procedures were complicated by intraoperative problems (13%). The incidence of insignificant complications appeared to decrease with experience, whereas that of the significant ones did not. These complications occurred in association with a wide variety of operations over a 2-year period. We conclude that neuroendoscopy is a relatively safe technique with an overall 7% complication rate and a steep learning curve, and that, with a few simple guidelines, it can be employed by all neurosurgeons for the betterment of their patients.     

Emergency Neuroendoscopic Management of Third Ventricular Neurocysticercosis Cyst Presented with Bruns Syndrome : Report of Two Cases and Review of Literature

Neurocysticercosis is the commonest parasitic disease of the human central nervous system. The incidence of intra ventricular form of neurocysticercosis (NCC) is less common accounting 10-20% that of total central nerve system cysticercosis. Intra ventricular NCC is complicated due, to its high incidence of acute hydrocephalus caused by ball valve mechanism. The only reliable tool for diagnosis of NCC is by neuroimaging with CT or MRI. MRI preferred over CT because of its high specificity and sensitivity. In emergency situations like acute hydrocephalus one can proceed with emergency endoscopic surgery. Through the endoscopic view, intra ventricular NCC (IVNCC) has distinguished morphological features like the full moon sign. This feature not only helps in identification of IVNCC, but also guides in further endoscopic treatment strategy. Authors report two cases of 3rd ventricular NCC with acute hydrocephalus managed with emergency endoscopy. Authors have discussed the clinical features, intra operative endoscopic findings and role of endoscopy in emergency surgery for NCC with acute hydrocephalus.     

神经内镜在囊性颅咽管瘤治疗中的作用

目的;探讨神经内镜在巨大囊性颅咽管瘤治疗中的作用。方法：对巨大囊性颅咽管瘤伴有梗阻性脑积水的9例患者,应用神经内镜先缩小肿瘤体积、解除梗阻性脑积水并穿通囊内分隔,之后再辅以放射或显微手术切除。结果：9例患者术后颅内压增高症均消失、术前症状改善。影像学复查（CT或MR）见肿瘤均缩小至鞍区、脑积水消失。除1例有暂时多尿及低钠外,余无其他严重并发症。再手术全切除肿瘤的3例患者术后反应明显减轻。结论：对有囊性变并伴有脑积水的巨大颅咽管瘤,先采用神经内镜手术,是提高进一步治疗效果、降低致残率和死亡率的有效方法。     

Endoscopic endonasal resection of symptomatic Rathke cleft cysts

We aimed to retrospectively evaluate the transsphenoidal endoscopic endonasal approach (EEA) for the resection of symptomatic Rathke’s cleft cysts (RCC) in 23 patients (11 male, 12 female, average age 43 years). The patients were followed-up for between 3 months and 36 months. Headache was the primary pre-operative symptom (15/23, 65%) and all patients with headache improved after surgery. Seven patients with initial visual symptoms (9/23, 39%) also improved after treatment. Three of the six patients with pre-operative pituitary dysfunction (6/23, 26%) showed post-operative improvement. There was no permanent pituitary dysfunction. One patient developed temporary diabetes insipidus and two patients had a post-operative infection. Three patients had post-operative cerebrospinal fluid leaks, two of which were repaired using the EEA and the other using a lumbar drain. Two patients had recurrent cysts and both patients refused reoperation. We concluded that the EEA is safe and effective in the treatment of symptomatic RCC. Fenestration and aspiration of the cysts with partial excision of the cyst wall is usually sufficient.     

Application of skull base techniques to pediatric neurosurgery

Techniques for skull base surgery have become well established over the last 10 years. Most of these techniques are used in adult patients for skull base tumors and neurovascular diseases. There are very few large series of pediatric patients in whom skull base approaches have been used, because of the rarity of these conditions. The authors would like to present a relatively large series of 26 pediatric patients who underwent skull base approaches for tumor resection. These tumors involved the anterior cranial base in 5 patients, the medial cranial skull base in 4 patients, and the posterior cranial base in 12 cases. Five patients had tumors that involved two or more fossae. The overall complication rate was 57%, which included temporary cranial nerve palsies, CSF leak and infection. Patients with permanent complications were 8 in number (37%). There was 1 postoperative death from pneumonia approximately 6 weeks after surgery. Complete tumor removal was achieved in 24 of the 26 patients. Skull base tumors in children are often extensive and present significant surgical challenges. Although complete tumor extirpation is the goal in most pediatric patients, this is often achieved only with some morbidity. This paper demonstrates the effectiveness of skull base approaches for these tumors and underscores the high stakes involved. Received: 1 October 1998     

Pediatric neuroendoscopy in ChileAnalysis of the first 100 cases

The personal series of the first 100 cases of neuroendoscopy performed at the Pediatric Neurosurgery Service of the Institute of Neurosurgery Alfonso Asenjo in Santiago-Chile is presented. The patients were the first to undergo endoscopic operations for different types of hydrocephalus and their ages ranged from newborn up to15 years. Their clinical records, surgical protocols, radiologic results, videos and follow-up are reviewed. A mortality of 2% and a morbidity of 7% were found in this group, hemorrhage, ventriculitis and CSF leakage being the main problems. Success was achieved in more than 75% of cases in the whole series. If we only consider the group of III ventriculostomies performed in noncommunicating hydrocephalus, our success rate rises to 90%. Follow-up ranges from 30 months in the first case to 2 months in the last case considered. All patients were operated on by the author using a rigid Gaab scope with 5.8 mm OD coupled to a Codman light source and a microcamera. Surgical technique was always the same using a right precoronal burr hole. Prophylaxis with vancomycin was indicated in all cases. General, partial and specific results are presented and allow the conclusion that this is an excellent procedure when it is well indicated. It means a great saving in shunts and treatments and has become an alternative to shunts in all neurosurgical units. Received: 19 October 1998 Revised: 27 December 1998     

Robust registration procedures for endoscopic imaging

This paper presents a robust algorithm for calibration and system registration of endoscopic imaging devices. The system registration allows us to map accurately each point in the world coordinate system into the endoscope image and vice versa to obtain the world line of sight for each image pixel. The key point of our system is a robust linear algorithm based on singular value decomposition (SVD) for estimating simultaneously two unknown coordinate transformations. We show that our algorithm is superior in terms of robustness and computing efficiency to iterative procedures based on Levenberg-Marquardt optimization or on quaternion approaches. The algorithm does not require the calibration pattern to be tracked. Experimental results and simulations verify the robustness and usefulness of our approach. They give an accuracy of less than 0.7 mm and a success rate >99%. We apply the calibrated endoscope to the neurosurgical relevant case of red out, where in spite of the complete loss of vision the surgeon gets visual aids in the endoscope image at the actual position, allowing him/her to manoeuvre a coagulation fibre into the right position. Finally, we outline how our registration algorithm can be used also for standard registration applications (establish the mapping between two sets of points). We propose our algorithm as a linear, non-iterative algorithm also for projective transformations and for 2D-3D-mappings. Thus, it can be seen as a generalization of the well-known Umeyama registration algorithm.     

神经内镜技术在联合入路治疗垂体腺瘤中的应用

目的 探讨神经内镜技术在分期手术时,采用经蝶窦和开颅联合入路治疗垂体腺瘤中的应用.方法 2009年3月至2013年3月天坛医院内镜神经外科专业组采用分期联合入路手术治疗32例垂体腺瘤患者,包括肿瘤残存患者20例,复发患者12例.分期手术中至少有一次为内镜下经鼻蝶窦入路手术.术后影像学检查确定肿瘤切除程度.结果 全切17例(53％),次全切4例(13％),大部切除7例(22％),部分切除4例(13％);其中残存肿瘤的全切率为35％(7/20),复发肿瘤的全切率为83％ (10/12).结论 神经内镜技术在分期手术联合入路治疗垂体腺瘤中具有重要应用价值.     

Historical trends of neuroendoscopic surgical techniques in the treatment of hydrocephalus

The treatment of hydrocephalus nowadays is still a challenge for neurosurgery. Neuroendoscopy is a valuable alternative of the CSF shunts in hydrocephalus management. Because of the complicated and always changeable pathophysiology of hydrocephalus, the history of the endoscopic treatment of hydrocephalus is also a history of severe frustrations, great expectations, and significant achievements. The historical milestones and state of the art of neuroendoscopic treatment of hydrocephalus are reviewed for each of its surgical techniques: choroid plexus coagulation, third ventriculostomy, aqueductoplasty, septostomy, foraminal plasty of the foramen of Monro, and foraminal plasty of the foramen of Magendie. The future trends of neuroendoscopic treatment of hydrocephalus such as robotics, image-guided neuroendoscopic surgical techniques, treatment "in utero", application of stem cell therapy, implementation of new technological solutions, and so on are discussed in the light of the approaching end of the century of neuroendoscopy.