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Endoscopic third ventriculostomy (ETV) is a treatment option for obstructive hydrocephalus; reported success rates vary. We investigated immediate postoperative magnetic resonance imaging to evaluate the role of imaging parameters associated with outcomes. Retrospective chart review was performed on patients undergoing initial ETV between 2005 and 2019. Patients with preoperative and postoperative magnetic resonance imaging with follow-up > one year were included. The following were noted: changes in subarachnoid cerebrospinal fluid, third ventricle diameter, bowing of the third ventricle floor, and postoperative flow void. Kaplan-Meier survival methods were used to assess ETV success and univariable and multivariable Cox proportional-hazards models were fitted to assess factors contributing to ETV success. Fifty-eight subjects were included. Nineteen (32.8%) experienced failure within one year; individually, no single imaging parameter predicted success. However, all cases of failure had no identifiable flow void. Any postoperative radiological change was not consistently associated with decreased odds of failure. Obstructive hydrocephalus treated with ETV demonstrated significantly better ETV success than patients treated with nonobstructive hydrocephalus. Interobserver reliability was moderate for 2 of the radiological variables and substantial for 1 of the radiological variables. Individually, none of the qualitative radiologic parameters measured in our study predicted ETV success. Absence of a flow void predicted ETV failure, but additional studies are needed to determine its true negative predictive value. Inability to clarify which specific parameter predicts success reflects the limited role of immediate postoperative imaging in influencing clinical management. [ABSTRACT FROM AUTHOR]

Vertebrobasilar dolichoectasia, a rare vascular anomaly, rarely presents with hydrocephalus. The traditional treatment for hydrocephalus is a ventriculoperitoneal shunt. Conventional endoscopic third ventriculostomy can avoid shunt-related complications but is considered risky due to the presence of the dolichoectatic vessel. A subfrontal extra-axial fenestration of the lamina terminalis can circumvent this anatomic constraint and establish cerebrospinal fluid communication between the third ventricle and subarachnoid space. We performed an extra-axial endoscopic third ventriculostomy to manage hydrocephalus due to vertebrobasilar dolichoectasia in a 26-year-old male. The clinical description, surgical technique, outcome, and rationale are described. The patient had symptomatic improvement in his headaches and vision. There was also improvement in the postoperative ventricular indices: Evans index—19% reduction, frontal occipital horn ratio—14.1% reduction, and third ventricle index—39.5% reduction. A cine-phase magnetic resonance image showed cerebrospinal fluid flow void through the lamina terminalis fenestration, suggesting patency. Extra-axial endoscopic third ventriculostomy may be a suitable treatment alternative to circumvent anatomic constraints produced by vertebrobasilar dolichoectasia in performing conventional endoscopic third ventriculostomy. [ABSTRACT FROM AUTHOR]

Background: Hydrocephalus is an abnormal excessive accumulation of cerebrospinal fluid (CSF) in the cavity and spaces of the brain. Endoscopic third ventriculostomy (ETV) has been an established treatment modality for congenital hydrocephalus. However, in very young infants, the results are challenging. In our study, we have evaluated whether ETV really offers an acceptable complication-free postoperative course.Objective: To study the complication and mortality rate in infants having congenital hydrocephalus treated with ETV.Materials and Methods: This is a single-center prospective study conducted at the Department of Neurosurgery, K. G. M. U, Lucknow, from January 2019 to February 2020. We studied 40 infants presenting with clinical and radiological features suggestive of congenital hydrocephalus. Follow-up was done at the first, third, and sixth months after discharge.Results: Nineteen infants (47.5%) required a second CSF diversion procedure at 6 months of follow-up. The failure rate was significantly higher in infants less than 3 months of age (P value of 0.04). The ETV site bulge was the most frequent complication encountered in the postoperative period, occurring in 20% of the cases. Eventually, all these infants required a ventriculoperitoneal shunt; 15% developed clinical features consistent with the diagnosis of post-ETV meningitis. The ETV site CSF leak occurred in 10% of the patients. Subdural hygroma developed in 7.5% of the patients; 17.5% of the patients contributed to mortality with a mean time of expiry of 22 days post-procedure. All these deaths had multifactorial causes and could not be said as a complication or failure of ETV.Conclusion: We do not recommend ETV for infants less than 3 months because of a high failure rate. The ETV site bulge was the most reliable and earliest marker of failure and a second CSF diversion surgery should be immediately considered. [ABSTRACT FROM AUTHOR]

Spontaneous cerebrospinal fluid (CSF) rhinorrhea represents an important clinical entity that is being observed with increasing prevalence, ranging from 14 to 55%. Spontaneous CSF rhinorrhea is associated with elevated intracranial pressure (ICP), which is rarely stopped without surgical intervention. Endoscopic endonasal repair is typically warranted for CSF rhinorrhea. However, the recurrence rate of CSF leaks after the endoscopic endonasal repair of skull base defects due to ICP is usually high. We describe a 25-year-old man without a history of head injury, tumor, or obesity. The onset of his symptoms occurred in 1 week in the form of a persistent clear left nostril rhinorrhea. Computed tomography (CT) and magnetic resonance images (MRI) showed signs of CSF in the left sphenoidal sinus, meningocele in the left frontal sinus, empty sella, hydrocephalus, and Chiari I malformation (CIM). Cine-MRI revealed the flow of CSF was obstructed at the aqueduct and the outlet of the fourth ventricle. Endoscopic third ventriculostomy (ETV) was performed for the patient with obstructive hydrocephalus. Post-operative CSF pressure measurement demonstrated elevated ICP. The patient still had case of CSF rhinorrhea, and subsequently underwent lumboperitoneal shunt (LPS) for treatment of ICP. The patient showed a prompt resolution of CSF leak. Ten months later, the patient showed a significant improvement in terms of his herniated tonsil and cessation of CSF rhinorrhea. [ABSTRACT FROM AUTHOR]

Background: Intraventricular tumors are ideal indications for neuroendoscopic surgery. Because intraventricular tumors often cause cerebrospinal fluid (CSF) pathway obstruction, resulting in ventricular dilation and sufficient space for maneuvering with the endoscopes is available. Objective: The aim of this study was retrospectively and antrospectively evaluation of the role and outcome of use of endoscope in intraventricular tumors in term of: 1-Diagnostic of the deep lesions. 2-Management of increased intra-cranial pressure (ICP). 3-Excision of tumor depends on the type. Patients and Methods: This prospective and retrospective study was carried on 30 patients who sought medical advice for intra ventricular tumor from 2015 to 2019 in Al-Hussein University Hospital. Tumors are removed or biopsied with or without ETV and septum pellucidostomy. Results: According to our study, we found that endoscopic removal of intraventricular tumors has low rate of complications. There were 25 cases with no complications (83.3%) and better outcome. There were 15 cases (50%) very good outcome and 10 cases (33.3%) were good outcome, as there was minimal dissection and brain retraction. Conclusion: Regarding endoscopic treatment of intra ventricular tumors, there are many advantages of the endoscopic approach as low rate of complications, minimal dissection, better outcome, brain retraction, rapid access to the target and excellent visualization of the lesion and surrounding structures. Endoscopic approach also has the ability of treatment of the associated hydrocephalus at the same session with low rate of failure or recurrence. [ABSTRACT FROM AUTHOR]

In this article, we present an optimized minimally invasive technique of ETV for children with occlusive hydrocephalus. The study comprises of 64 consecutive pediatric cases (34 boys and 30 girls aged from 1 month to 5 years) of occlusive hydrocephalus from various etiologies, which were treated with a modified technique of ETV. Mean clinical follow-up period after ETV was 24.2 ± 3.8 months. Application of the new technique made it possible to significantly reduce the length of the soft tissue incision for access, and the use of upgraded instruments allowed to perform a twist drill hole in the skull to less than half a usual size. Access to the brain and lateral ventricle was performed by blunt trephination of the dura without the need for significant corticectomy or coagulation, and yielded minimal damage to the brain, which is very important in patients of young age. Continued endoscopic control during the approach down to the lateral ventricle increases safety and decreases risk of injury, and can be performed in cases of pathologies affecting the anatomical relationships of the lateral and third ventricle. Mortality in our cohort was 0%, and there were no postoperative neurological, endocrinological, or infectious complications. Patency rates of the first ETV performed was 78%, with the remaining patients requiring additional surgical procedures for complicated settings. This new technique of minimally invasive ETV placement in pediatric patients is an effective and safe method to treat occlusive hydrocephalus and can be recommended for extensive clinical use. [ABSTRACT FROM AUTHOR]

Background: The pathogenesis of the hydrocephalus associated with myelomeningocele (MMC) has been the subject of an extensive number of studies. The contemporary reduction of the incidence of the Chiari II malformation and of the associated active hydrocephalus after closure of the spinal defect in utero is in line with previous studies suggesting a prominent role of the posterior cranial fossa abnormalities, where even the increased venous pressure might be at least mostly a consequence of the constriction of the posterior cranial fossa structures. Pure absorptive abnormalities however coexist, the main ones documented to be abnormal cisternal spaces and peculiar cerebrospinal fluid chemical features. Materials and methods: We reviewed the pertinent literature concerning the pathogenesis and management of the hydrocephalus associated to MMC. We also reviewed our personal experience in managing the hydrocephalus in such patients through an endoscopic third ventriculostomy. Results and conclusions: The literature review demonstrated an overall reduction in more recent series of children with MMC needing to be treated for the associated hydrocephalus postnatally, questioning the role of the prenatal care of the disease in this context. Less severe conditions and a more conservative neurosurgical attitude have certainly contributed to the reduction of the reported active postnatal hydrocephalus rate. Long-term cognitive evaluation of the children with MMC that we managed with an endoscopic third ventriculocisternostomy (ETV) as primary as well as secondary procedure did not demonstrate significant differences in the outcome compared with non-complicated extrathecally shunted children, favouring ETV as a valuable option in this subset of patients. [ABSTRACT FROM AUTHOR]

Introduction: The aim of this review is to present the contemporary role of radiology in evaluating pediatric hydrocephalus. Although conventional brain imaging with ultrasound (US), computed tomography (CT), and magnetic resonance imaging (MRI) reveal the degree of ventricular enlargement and often the etiology of the hydrocephalus, the diagnosis and management of hydrocephalus present common problems in pediatric populations. Discussion: US, usually sufficient to assess and monitor ventricular size, is used most commonly in preterm infants who have germinal matrix hemorrhages and not able to tolerate transport to the radiology department. Although CT can demonstrate gross dilatation of ventricles, in most cases, it will be necessary to more closely define the nature of the obstruction, either functionally or anatomically. MRI is the best imaging modality to provide such functional and anatomic information. However, since identification of obstructive pathologic processes at any level through the cerebrospinal fluid (CSF) pathway in patients with hydrocephalus is of significant importance because it can change the treatment options, avoiding shunt insertion, a more sophisticated MRI approach is needed instead of obtaining a routine cranial MRI. Furthermore, the outcome after neuroendoscopic procedures is clearly related to patient selection under guidance of neuroimaging. Conclusion: Therefore, the article focuses mainly on the effective usage of various MRI sequences in both diagnosis and follow-up of pediatric hydrocephalus, such as 3D CISS, cine PC, TSE, and GRE T2* sequences, to be able to investigate all possible obstructive pathology through the CSF pathway and to assess the efficiency of treatment in a standardized way. [ABSTRACT FROM AUTHOR]

Purpose/method: Brain stem glioma accounts for 6-9% of brain tumors in children. Tumor progression may lead to CSF pathway obstruction and development of hydrocephalus. We retrospectively reviewed charts of patients consecutively treated in our institution with diffuse intrinsic pontine glioma in order to assess incidence of hydrocephalus, its management, and its impact on overall survival. All patients had brain stem glioma not amenable to surgery. Cases with exophytic brain stem glioma were excluded. Results: Fifty-one children were treated from January 2005 to December 2010 for brain stem glioma in the Pediatric Neurosurgery Department of Necker Enfants Malades, Paris, France. Hydrocephalus occurred in 11 of them (22%). They were six boys and five girls; the average and median time from tumor diagnosis to onset of hydrocephalus were 5.3 and 3.2 months, respectively, while average and median time from onset of hydrocephalus to death were 5.3 and 2.8 months, respectively. Hydrocephalus was treated in nine patients by a ventriculoperitoneal (VP) shunt and in two patients by an endoscopic third ventriculostomy. Because of early failure, a VP shunt was implanted in one child. Conclusion: The overall 1-year survival rate was 33%. Survival rate of patients with such obstructive hydrocephalus was not significantly different from patients harboring brain stem glioma who did not develop hydrocephalus. Furthermore, hydrocephalus was not related to terminal tumor progression. Considering both risks and benefit of treatment, VP shunt could be proposed, on the base of our experience, as the first option in spite of the apparently obstructive nature of the hydrocephalus associated to a brain stem tumor. [ABSTRACT FROM AUTHOR]

Purpose. This prospective study was designed for intra-operative demonstration of cerebrospinal fluid (CSF) flow in ventricles and cisternal spaces before and after neuroendoscopic procedure. The aim of this study was to evaluate site of obstruction of CSF flow and subsequent stomal or aqueductal patency after endoscopic third ventriculostomy (ETV) or aqueductoplasty in patients with hydrocephalus of diverse aetiology. Method. Seventeen patients with hydrocephalus due to diverse aetiology underwent ETV ( n = 15) and aqueductoplasty ( n = 2) or cysto-ventrticulostomy ( n = 1) or transaqueductal removal of neurocysticercus cyst (NCC) ( n = 1). Intra-operatively, radio-opaque contrast agent (iohexol) instillation into the third ventricle was used for qualitative evaluation of obstruction and post-procedure CSF flow across the stoma into cisternal spaces. Result: 11 male and 6 female patients ranging from 3 to 50 years of age were included in the study. Post-procedure intra-operative ventriculo-stomography (IOVSG) showed free flow of dye across the endoscopic stoma ( n = 13) or aqueduct ( n = 2) into cisternal spaces. Diagnosis of fourth ventricular NCC was made in one patient with panventriculomegaly. In two patients of tuberculous meningitis hydrocephalus, poor flow of contrast in the prepontine area and basal cisterns was seen on IOVSG. They were subjected to ventriculoperitoneal shunt insertion in the same sitting. Cine MRI confirmed the patency of stoma or aqueduct in follow-up period in all patients with successful endoscopic procedure. Conclusion. IOVSG is a simple and safe technique that helps in confirming the adequacy of endoscopic procedure during surgery and thereby facilitates intra-operative decision about further management. [ABSTRACT FROM AUTHOR]

Background: The management of hydrocephalus associated with a posterior fossa tumor is debated. Some authors emphasize the advantages of an immediate tumor removal that may normalize the cerebrospinal fluid (CSF) dynamics. However, in clinical practice, the mere excision of the lesion has been demonstrated to be accompanied by a persisting hydrocephalus in about one third of the cases. Preoperative endoscopic third ventriculostomy (ETV) offers several advantages. It may control the intracranial pressure (ICP), avoid the necessity of an emergency procedure, allow appropriate scheduling of the operation for tumor removal, and eliminate the risks related to the presence of an external drainage. The procedure also reduces the incidence of postoperative hydrocephalus. A final advantage, more difficult to weight, but obvious to the neurosurgeon, is the possibility to remove the lesion with a relaxed brain and normal ICP. In the postoperative phase, ETV can be used in case of persisting hydrocephalus, both in patients who underwent only the excision of the tumor and in those whose preoperative ETV failed as a consequence of intraventricular bleeding with secondary closure of the stoma (redoETV). The main advantage of postoperative ETV is that the procedure is carried out only in case of persisting hydrocephalus; its use is consequently more selective than preoperative ETV. The disadvantage consists in the common use of an external CSF drainage in the first few postoperative days, which is necessary to control the pressure and for ruling out those cases that reach a spontaneous cure of the hydrocephalus. Methods: The authors review the criteria for patient selection and the results of ETV performed in case of hydrocephalus secondary to a posterior fossa tumor. Results and Conclusions: Preoperative ETV constitutes an effective procedure for controlling the hydrocephalus associated with posterior fossa tumors. It might lower the rate of persistent postoperative hydrocephalus and result in a short hospital stay. Low rates of patients requiring an extrathecal–CSF shunt device are also reported by authors who utilize ETV postoperatively. As, however, the assessment of the persistent hydrocephalus in these children is based on prolonged ICP monitoring through an external CSF drainage, their results are weighted by a major risk of infective complications and longer hospital stay. [Copyright &y& Elsevier]