Neuroendoscopic management of intraventricular hemorrhage.
BACKGROUND AND PURPOSE: We reviewed our 7-year experience in neuroendoscopic management of severe intraventricular hemorrhage (IVH) to evaluate its safety, efficiency, and efficacy. METHODS: Thirteen patients with spontaneous primary or secondary tetraventricular IVH underwent neuroendoscopy. In all procedures, we used a flexible instrument. CT scans obtained before and after surgery were compared for Graeb score and ventriculocranial ratio. Glasgow Outcome Scale was assessed at 12 months. RESULTS: In all patients, the procedure resulted in a substantial removal of ventricular blood. Graeb score was reduced by 65%, and ventriculocranial ratio was reduced by 30% (P<0.002). The procedure was carried out safely even in the presence of a vascular malformation, and no rebleeding or delayed hydrocephalus was observed in any case. Mortality at 12 months was 30.7%. Favorable outcome (Glasgow Outcome Scale, 3 to 5) was observed in 61.5% of cases. CONCLUSIONS: Neuroendoscopic management of severe IVH in this cohort of patients was safe, efficiently reduced the amount of ventricular blood and ventricular dilatation, and effectively produced an outcome profile that compares very favorably with other more conventional treatments. (+info)
Refining the staging evaluation of pineal region germinoma using neuroendoscopy and the presence of preoperative diabetes insipidus.
Treatment strategies for CNS germinoma are currently evolving. Current approaches include reducing the volume and dose of radiation by adding pre-irradiation chemotherapy. Very accurate staging is necessary with such an approach to prevent failures. Eight consecutive patients with pineal germinoma at one institution underwent endoscopic surgery for tumor biopsy, direct visualization of the third ventricular region, and third ventriculostomy for those with hydrocephalus. All patients were treated with 4 cycles of chemotherapy. Conformal field radiation therapy followed, with the dose to the tumor bed dependent on the response to chemotherapy. Patients who had MRI, endoscopic, or cerebrospinal fluid evidence of multicentric or disseminated disease also received craniospinal radiation. Six patients had diabetes insipidus (DI) at presentation. All 6 had tumor studding the floor of the third ventricle on endoscopic visualization, while only 4 of those patients had MRI evidence of disease in that region. All patients have completed therapy and are alive, with no evidence of disease at median follow-up of 31.5 months from diagnosis. Direct endoscopic visualization of the third ventricular region may be more sensitive than MRI for evaluating the presence of suprasellar disease and appears to add important information. This parameter should be added to the staging evaluation when feasible. In this series, the presence of DI was 100% predictive of suprasellar disease, even when the MRI was negative for involvement of that region. Patients should be evaluated for DI as part of the initial staging, and if it is present, the patients should be treated for suprasellar disease regardless of MRI findings. (+info)
Interventional MR imaging with an endospinal imaging coil: preliminary results with anatomic imaging of the canine and cadaver spinal cord.
Percutaneous intraspinal navigation (PIN) is a new minimally invasive approach to the subarachnoid space. Using conventional radiographic fluoroscopy, entrance is gained to the lumbar subarachnoid space, allowing navigation throughout the spinal canal. Using an antenna/guidewire introduced via PIN, we performed endospinal MR imaging of the thoracic spinal cord in a cadaver and canine subject. Comparison images were obtained with an optimal surface coil. PIN allows endospinal MR imaging of the spinal cord, providing significant signal-to-noise ratio gains over conventional imaging. (+info)
Tension pneumocephalus after a neuroendoscopic procedure--case report.
A 60-year-old female presented with gait disturbance, urinary incontinence, and recent memory disturbance. Computed tomography and magnetic resonance imaging revealed a partially calcified mass lesion without enhancement in the left caudate head and mild ventriculomegaly. She underwent endoscopic tumor biopsy. The histological diagnosis was astrocytoma grade 2. After the endoscopic procedure she presented with prolonged consciousness disturbance caused by tension pneumocephalus. Tension pneumocephalus is one of the potential complications of neuroendoscopic procedures. (+info)
Neuroendoscopic transventricular surgery for suprasellar cystic mass lesions such as cystic craniopharyngioma and Rathke cleft cyst.
Cystic mass lesions in the suprasellar cistern are often associated with neurological deficits, cognitive disorders, and endocrinological impairments. Many surgical approaches are available to treat these mass lesions, but are technically difficult and cannot remove the lesion completely without risking damage to neurological and endocrinological functions due to the proximity to the surrounding structures. Neuroendoscopic transventricular surgery was performed using a ventricular fiberscope for three patients with craniopharyngiomas and two patients with Rathke cleft cysts, with gamma knife radiosurgery for craniopharyngiomas. The endoscopic transventricular approach is safe and minimally invasive for congenital benign suprasellar cystic lesions, especially arachnoid cysts. (+info)
Value of Cushing reflex as warning sign for brain ischaemia during neuroendoscopy.
BACKGROUND: During an endoscopic neurosurgical procedure a sudden increase in intracranial pressure may occur at any time. We present a prospective study of haemodynamic changes during such procedures. METHODS: Physiological data were recorded during the whole operative procedure in 17 consecutive patients who underwent an endoscopic neurosurgical procedure under general anaesthesia. Monitoring included invasive blood pressure, intracranial pressure, electrocardiogram, end-expired carbon dioxide, pulse oximetry and heart rate. Pressure and ECG waveforms were recorded at 100 Hz and evaluated in a subsequent offline analysis. RESULTS: In almost every case, the occurrence of hypertension and tachycardia was clearly the result of an increase in intracranial pressure. Also, a Cushing reflex developed in almost every case where the cerebral perfusion pressure dropped below 15 mm Hg. The occurrence of bradycardia was not systematically associated with a low cerebral perfusion pressure. CONCLUSION: In this study, we describe the haemodynamic effects of increased intracranial pressure during endoscopic neurosurgical procedures and their respective sequence of events at high temporal resolution. Although most clinicians rely on the occurrence of bradycardia to diagnose intracranial hypertension during endoscopic neurosurgical procedures, we show that a simultaneous onset of hypertension and tachycardia is a better indicator of impaired brain perfusion. Waiting for a persistent bradycardia to alert the surgeon during endoscopic neurosurgical procedures could allow severe bradycardia or even asystole to develop. (+info)
Multiple epidermoid cysts located in the pineal and extracranial regions treated by neuroendoscopy.
A 22-year-old woman presented with a rare case of multiple epidermoid cysts located in the pineal and extracranial regions. Magnetic resonance (MR) imaging showed a lesion in the pineal region as hypointense on the T(1)-weighted image and hyperintense on the T(2)-weighted image, without enhancement. Neuroendoscopic treatment was performed under a diagnosis of pineal cyst. However, the cyst wall was too thick to perforate, although third ventriculostomy was performed. Diffusion-weighted MR imaging demonstrated the lesions in the pineal and extracranial regions as marked hyperintensity. The diagnosis was epidermoid cyst. Subsequently, neuroendoscopic treatment of the pineal epidermoid cyst was performed. Careful preoperative diagnosis of epidermoid cysts based on diffusion-weighted MR imaging is required. (+info)
Coiling and neuroendoscopy: a new perspective in the treatment of intraventricular haemorrhages due to bleeding aneurysms.
BACKGROUND: Intraventricular haemorrhages (IVHs) caused by bleeding aneurysms are critical conditions that often carry a severe prognosis. Two main problems must be urgently dealt with: the secondary damage caused by intraventricular clotting and the risk of early rebleeding. A protocol of ultra-early endoscopic ventricular evacuation, after securing the aneurysm with coils, is proposed to solve this challenge in the acute phase and within a few hours of onset. METHODS: Ten consecutive patients presenting with haematocephalus from aneurysm rupture were treated in our institute with coiling and endoscopic clot aspiration extended to the whole ventricular system. The only inclusion criteria were the presence of a massive IVH and an aneurysm appropriate for coiling. Computed tomography scans obtained before (within 4 h of symptom onset in all patients) and immediately after surgery were compared for Graeb score and ventriculocranial ratio (VCR); the Glasgow Outcome Scale (GOS) was assessed at 1 year. RESULT: All patients were treated within 2 days of onset. The procedure resulted in a mean 58% removal of ventricular blood and decrease of hydrocephalus; the mean (standard deviation (SD)) Graeb score reduced from 11.5 (0.7) to 4.7 (2.2) (p<0.001) and mean ventriculocranial ratio from 0.26 (0.06) to 0.17 (0.05) (p<0.001). No rebleeding or delayed hydrocephalus needing shunt was observed. Mortality at 1 year was 30%; marked disability (GOS = 3) and good recovery (GOS = 5) were observed in 40% and 30% of patients, respectively. CONCLUSIONS: Early neuroendoscopic removal of blood casting from the lateral to the fourth ventricle after coiling of bleeding aneurysms is a feasible approach, allowing in most instances the rapid improvement of the IVH. (+info)