Complications and pitfalls of neuroendoscopic surgery in children

Evaluation of the ETV success score and its predictive value in pediatric occlusive hydrocephalus: implications for patient counseling

INTRODUCTION

Endoscopic Third Ventriculostomy (ETV) is a well-established treatment for pediatric hydrocephalus, particularly in cases of aqueductal stenosis. The ETV Success Score (ETVSS) is a predictive tool widely used to estimate the likelihood of ETV success based on factors like age. Its accuracy, especially in infants under 3 months, is still debated.

PATIENTS AND METHODS

This study evaluates the age-dependency of ETV success in 54 pediatric patients compared to ETVSS predictions. Patients were divided into age and pathology groups according to Kulkarni. Success was defined according the ETVSS criteria. Minimum follow-up was 12 months and included MRI to demonstrate a flow void at the floor or the third ventricle.

RESULTS

Our institutional data revealed a higher overall success rate SR (88%) compared to the ETVSS-predicted rate of 73%. Despite small numbers within subgroups, especially in very young children < 1 month, the success rate was higher than predicted by ETVSS.

DISCUSSION

Our results show significantly higher actual SR across all age groups compared to ETVSS predictions (p = 0.035) when selected and performed by an experienced physician. The age groups > 1 year had significantly higher SR close to 100% (p < 0.0001 and p = 0.0038, respectively). This suggests that ETV may be underutilized, particularly in infants, where predicted success rates are pessimistic.

CONCLUSION

ETVSS is a useful tool for counseling of parents, but differences in institution-specific outcomes should not be neglected. Depending on that, physicians might opt in favor of ETV as primary treatment in occlusive hydrocephalus of very young children, counterbalancing risks and sequalae of VP-shunting.

Assessment of the efficacy and safety of neuroendoscopic procedures for intracranial pathologies: A single-centre retrospective study with 318 intracranial endoscopic procedures

Introduction

Neuroendoscopy has become a well-established procedure for treating various intracranial conditions.

Research question

We evaluated the advantages of that technique, with focus on adverse events.

Material and methods

Retrospective analysis included all patients who underwent neuroendoscopic procedures between January 2017 and December 2023. We conducted comparative analysis considering factors such as age, gender, follow-up duration, etiology, preoperative symptoms, clinical and radiological benefits, as well as surgical and nonsurgical adverse events rates.

Results

Total of 318 neuroendoscopic procedures within 257 surgeries in 225 patients were included, with mean age of 18.8 ± 21.4 years. 170 cases (66.1%) were pediatric versus 87 cases adults (33.9%). Most common aetiologies were peri- and intraventricular cysts (27.2%), idiopathic aqueduct stenosis (24.9%), tumours (23.7%), and post-haemorrhagic hydrocephalus (17.1%). Procedures included endoscopic third ventriculostomy (51.0%), cyst fenestration (21.0%), and endoscopic-assisted ventricular catheter placements (19.5%). Headache was predominant preoperative symptom (42.0%). During follow-up, 84.8% and 82.5% of cases showed clinical and radiological improvement, respectively. Early surgical adverse events were observed in 5.4% of cases, while non-surgical adverse events occurred in 3.1%. There was no significant difference in the surgical adverse events rate between children and adults (4.7% vs. 6.9%, p = 0.563), compared to significant higher non-surgical adverse events in adults (6.9% vs 1.2%, p=0.020).

Discussion and conclusion

Neuroendoscopy has demonstrated effectiveness and safety in treating intracranial diseases, boasting a low adverse events rate. Our study found no significant difference in the surgical adverse events rates between pediatric and adult groups.

Myelomeningocele: Long-Term Neurosurgical Management

Open spina bifida, also known as myelomeningocele (MMC), is the most challenging and severe birth defect of the central nervous system compatible with life and it is due to a failure in the dorsal fusion of the nascent neural tube during embryonic development. MMC is often accompanied by a constellation of collateral conditions, including hydrocephalus, Arnold - Chiari II malformation, brainstem disfunction, hydrosyringomyelia, tethered cord syndrome and scoliosis. Beyond early surgical repair of the dorsal defect, MMC requires lifelong cares. Several additional surgical procedures are generally necessary to improve the long-term outcomes of patients affected by MMC and multidisciplinary evaluations are crucial for early identification and management of the various medical condition that can accompany this pathology. In this chapter, the most common pathological entities associated with MMC are illustrated, focusing on clinical manifestations, treatment strategies and follow up recommendations.

Intracranial Neuroendoscopy in Children and Adults: Where Do the Differences Lie?

BACKGROUND

Intraventricular neuroendoscopy has evolved into an essential adjunct in neurosurgery and is used across all age groups for various indications. However, studies comparing neuroendoscopic procedures between children and adults are scarce. The aim of this study is to compare various aspects between adults and children undergoing neuroendoscopy.

METHODS

We retrospectively analyzed the data from consecutive patients dichotomized into 2 cohorts, pediatric (age <18 years) and adult (age ≥18 years) groups, in whom intracranial neuroendoscopy was performed between 2013 and 2020 (pediatric group) and 2010 and 2020 (adult group).

RESULTS

Of 132 patients who underwent intracranial neuroendoscopic surgery, 47 (35.6%) were children and 85 (64.4%) were adults. The most common indications for the children and adults were intraventricular or paraventricular tumors (23.4%) and aqueduct stenosis (40%), respectively. Their clinical condition at the last follow-up was unchanged or improved for 90.5% of the children and 92.1% of the adults. An increased endoscopic third ventriculostomy success score was predictive of endoscopic third ventriculostomy success in the pediatric cohort (odds ratio, 1.073; P = 0.043). The postoperative rates of transient (pediatric, 23.4%; adult, 18.8%) and permanent (pediatric, 0%; adult, 1.2%) complications were comparable. The rate of secondary surgery was higher for the pediatric cohort (38.3%) than for the adult cohort (17.6%).

CONCLUSIONS

The indications for neuroendoscopy vary between adults and children, although the long-term clinical outcome is comparable. The rate of secondary surgery is significantly higher for pediatric patients, especially for those aged <1 year. Because neuroendoscopy is considerably more frequent in pediatric patients, including pediatric neurosurgeons in adult neuroendoscopic cases could potentially help lower the complication rates and increase the success rates.

Costs of pediatric hydrocephalus treatment for the Brazilian public health system in the Northeast of Brazil

PURPOSE

To estimate the costs of the surgical treatment of pediatric hydrocephalus, specifically ventriculoperitoneal shunt (VPS) and endoscopic third ventriculostomy (ETV), for the Brazilian public health system (SUS).

METHODS

Retrospective cohort study of health records of patients < 14 years of age with a diagnosis of hydrocephalus who underwent VPS or ETV between September 2009 and June 2016, regularly followed up for 24 months.

RESULTS

Seventy-six medical records were included. The groups of children who underwent VPS and ETV consisted of 60 and 16 patients, respectively. Complications during 2 years of follow-up were identified in 56% of the children undergoing VPS and in 18% of those undergoing ETV (p = 0.0103). The initial cost of VPS was lower than that of ETV up to approximately 1 year of post-surgical follow-up. After that, VPS generated higher expenses for the SUS due to higher rates of late post-surgical complications and repeated readmissions.

CONCLUSION

Higher public expenditures were observed in the group of children undergoing VPS due to higher rates of infectious and mechanical complications requiring repeated hospitalizations and prosthesis replacements. Public policies must be tailored to offer the best treatment to children with hydrocephalus and to make judicious use of public resources without compromising the quality of treatment.

Combined Neuroendoscopic Techniques in the Management of Pediatric Brain and Skull Base Tumors: A Single-Institutional Case Series

BACKGROUND

Central nervous system tumors encompass the leading cause of cancer-related death in the pediatric population. Neuroendoscopic techniques have been optimized over the years, becoming an important tool for the management of brain tumors. Our study aims to review the indications for neuroendoscopic procedures and the feasibility of combined interventions.

METHODS

This is a single-center, self-adjudicated, retrospective experience. Inclusion criteria consisted of pediatric patients (≤18 years old) who underwent management of brain tumor or related diseases with the employment of neuroendoscopy.

RESULTS

A total of 47 patients undergoing 51 procedures met inclusion criteria. The mean age was 9.8 ± 4.6 years, and the majority were female (55.3%). Common indications for endoscopic intervention were hydrocephalus management (n = 24; 16 endoscopic third ventriculostomies and 9 septostomies), tumor biopsy (n = 19), cyst fenestration (n = 16), and tumor resection (n = 9). In one third of the cases, combined interventions occurred during a single operative session. Hydrocephalus was successfully managed in 74.4% of cases; tumor biopsy confirmed the diagnosis in 95.8% of cases, and gross total resection was achieved in 88.9% of cases. Cyst fenestration required reintervention in 3 cases: one case associated with initial cyst enlargement and 2 cases with the development of new tumor cysts separated from the originally fenestrated cyst. The overall complication rate was 6.3%, with only one major safety event, which was successfully managed.

CONCLUSIONS

Neuroendoscopy is an important minimally invasive tool for diagnosing and treating pediatric patients with brain tumors, permitting to address multiple problems in a single surgery.

Aborting a neurosurgical procedure: analyzing the decision factors, with endoscopic third ventriculostomy as a model

Aborting a neurosurgical procedure is a situation in which the surgeon modifies the original surgical plan and decides to stop a procedure without achieving the pre-operative goal. While adhering to predefined goals is important, intra-operative judgment, especially in terms of adjusting the risk/benefit ratio in response to real-time data, may change the balance and lead, in selective scenarios, to aborting of a procedure. The literature regarding aborting a surgical procedure is sparse, with no objective guidelines on when, and how, to make such a decision. Defining "when to abort" is difficult and is influenced by many factors, including unexpected intraoperative findings, the surgeon's surgical experience and perspective, and the patient and family perspective. Aborting a procedure is a decision that must be ultimately determined by the surgical findings and the individual treatment alternatives. The aim of this paper is to discuss the condition of aborting a neurosurgical procedure, using the relatively common endoscopic third ventriculostomy (ETV) as a model procedure prototype.

Biopsy During Minimally Invasive Intracerebral Hemorrhage Clot Evacuation

BACKGROUND

The safety and efficacy of brain parenchyma biopsy during minimally invasive (MIS) intracerebral hemorrhage (ICH) clot evacuation has not been previously reported. The objective of this study was to establish the safety and diagnostic efficacy of brain biopsy during MIS ICH clot evacuation and to validate the modified Boston criteria as a predictor of cerebral amyloid angiopathy (CAA) in this cohort.

METHODS

From October 2016 to March 2018, superficial and perihematomal biopsies were collected for 40 patients undergoing MIS ICH clot evacuation and analyzed by the pathology department to assess for various ICH etiologies. Additionally, the admission magnetic resonance imaging or computed tomography scan of each patient was analyzed and evaluated for the likelihood of a CAA etiology based on the modified Boston criteria. Student t test was used to analyze intergroup differences in continuous variables, and a 2-tailed Fisher exact test was used to determine intergroup differences of categorical variables, with significance set at P < 0.05.

RESULTS

Two of the 40 patients (5%) experienced postoperative rebleed. Four of the 40 patients (10%) had evidence of CAA on biopsy. Patients with CAA on biopsy were older (P = 0.005) and had a higher prevalence of parietal lobe (P = 0.02) and occipital lobe (P = 0.001) hemorrhage. The modified Boston criteria had a sensitivity of 100% (95% confidence interval [CI], 39.6%-100%) and a specificity of 72.2% (95% CI, 54.6%-84.2%) for predicting CAA on biopsy.

CONCLUSIONS

Brain biopsy in MIS ICH clot evacuation is safe and allows for the diagnosis of various ICH etiologies.

Successful endoscopic third ventriculostomy in children depends on age and etiology of hydrocephalus: outcome analysis in 51 pediatric patients

PURPOSE

Endoscopic third ventriculostomy (ETV) has become the method of choice in the treatment of hydrocephalus. Age and etiology could determine success rates (SR) of ETV. The purpose of this study is to assess these factors in pediatric population.

METHODS

Retrospective study on 51 children with obstructive hydrocephalus that underwent ETV was performed. The patients were divided into three groups per their age at the time of the treatment: < 6, 6-24, and > 24 months of age. All ETV procedures were performed by the same neurosurgeon.

RESULTS

Overall SR of ETV was 80% (40/51) for all etiologies and ages. In patients < 6 months of age SR was 56.2% (9/16), while 6-24 months of age was 88.9% (16/18) and > 24 months was 94.1% (16/17) (p = 0.012). The highest SR was obtained on aqueductal stenosis. SR of posthemorrhagic, postinfectious, and spina bifida related hydrocephalus was 60% (3/5), 50% (1/2), and 14.3% (1/7), respectively. While SR rate at the first ETV attempt was 85.3%, it was 76.9% in patients with V-P shunt performed previously (p = 0.000).

CONCLUSIONS

Factors indicating a potential failure of ETV were young age and etiology such as spina bifida, other than isolated aqueductal stenosis. ETV is the method of choice even in patients with former shunting. Fast healing, distensible skulls, and lower pressure gradient in younger children, all can play a role in ETV failure. Based on our experience, ETV could be the first method of choice for hydrocephalus even in children younger than 6 months of age.

Venous Air Embolism During Endoscopic Third Ventriculostomy

Neuroendoscopic procedures are increasingly performed nowadays due to the significant technological improvement of endoscopic instrumentation. It carries various advantages such as speed, simplicity, avoidance of implants, and no brain dissection or retraction. Although considered to be safe, it is associated with a host of complications. We hereby report a case of venous air embolism in an infant who was undergoing endoscopic third ventriculostomy. The complication occurred at the completion of surgery when surgeons were withdrawing the endoscope. The successful management of this uncommon event is being discussed.

Keyhole approach in the neuroendoscopic treatment for hydrocephalus

The aim of the study was to explore keyhole approach and dura suture in the neuroendoscopic treatment for hydrocephalus.Twelve cases of hydrocephalus patients who were treated with neuroendoscope by this approach were analyzed retrospectively from April 2015 to April 2016 in our department. The basic steps of this procedure was using drill and milling cutter to form a small bone flap instead of burr hole, and then making a cruciate incision on the dura. After endoscopic third ventriculostomy or endoscopic third ventriculostomy + ventriculocystostomy finished, dura was sutured and the bone flap was reset.All 12 patients could suture dura effectively, and no cerebrospinal fluid leak and subcutaneous cerebrospinal fluid collection happened; symptoms of hydrocephalus were also improved. Moreover, during the operation, we found this approach could suspend dura, and avoid the cerebral sulcus and cortical coarse vein effectively, which could reduce the risk of intracranial hemorrhage. In addition, we found this approach could increase the reachable range of the neuroendoscope significantly.Keyhole approach can suture dura and avoid the cerebral sulcus and cortical coarse vein effectively, increase the indications, and reduce complications of neuroendoscope. So, this approach has clinical values and can be used in hydrocephalus.

Ventricular endoscopy in the pediatric population: review of indications

INTRODUCTION

Neuroendoscopy has greatly impacted pediatric neurosurgery over the past few decades. Improved optics and microsurgical tools have allowed neuroendoscopes to be used for a multitude of neurosurgical procedures.

DISCUSSION

In this review article, we present the breadth of intraventricular neuroendoscopic procedures for the treatment of conditions ranging from hydrocephalus and brain tumors to congenital cysts and other pathologies. We critically discuss treatment indications and reported success rates for neuroendoscopic procedures. We also present novel approaches, technical nuances, and variations from recently published literature and as practiced in the authors' institution.

Neuroendoscopic surgery in children: an analysis of 200 consecutive procedures

OBJECTIVE

Neuroendoscopic surgery in children has particular features and is associated with different success rates (SR). The aim of this study was to identify putative factors that could influence the outcome in pediatric patients.

METHODS

Clinical data of 177 patients under 18 years of age submitted to 200 consecutive neuroendoscopic procedures from January 2000 to January 2010 were reviewed.

RESULTS

The overall success rate was 77%. Out of the patients with successful outcomes, 46% were under six months, 68% were between six months and one year of age, and 85% older than one year. Neuroendoscopic techniques provide very good results for a wide number of indications in children. Tumor-related cerebrospinal fluid (CSF) circulation problems and aqueductal stenosis seem to be particularly well suited to neuroendoscopic treatment regardless of the patient's age.

CONCLUSION

Patients' age and etiology of hydrocephalus were associated with a different outcome. In all cases, surgical experience is extremely important to reduce complications.

The success of endoscopic third ventriculostomy in children: analysis of prognostic factors

OBJECTIVE

The treatment of hydrocephalus in children with endoscopic third ventriculostomy (ETV) has particular features and is associated with different success rates (SR). The aim of this study was to identify putative factors that could influence the outcome of ETV in children.

METHODS

Clinical data of 114 consecutive patients under 18 years of age who underwent 116 consecutive ETVs from January 2000 to January 2010 were reviewed. Data were analyzed with regards to clinical and radiological SR. The actual long-term SR was compared to that predicted by the ETV Success Score (ETVSS) model.

RESULTS

The study group included 49 males (43%) and 65 females (57%) with a mean age of 6.17 ± 1.02 years (ranging from 11 days to 18 years) at surgery. Concerning the etiology of hydrocephalus, tumors and aqueductal stenosis (AS) were the most frequently observed, with each occurring in 33 cases (29%), followed by malformations in 24 (21%), cystic lesions in 6 (5%) and other etiologies in 18 patients (16%). The overall SR at the first ETV attempt was 80% (91/114), compared to 74.8% (variance 14.35, 95% CI 69.37-78.22) predicted by the ETVSS. Regarding age, SR was 58% in patients under 6 months of age, 65% in children between 6 months and 1 year, and 86% in children older than 1 year. SR for AS and hydrocephalus associated with posterior fossa tumors were 88 and 90%, respectively. Unsatisfactory results were related to previous intraventricular hemorrhage and infection. The overall complication rate in this series was 13%.

CONCLUSION

ETV is safe and effective in children. In this series, the age of the patient and etiology of hydrocephalus were related to SR. Also, the ETVSS was accurate to predict outcome. In a long-term follow-up, surgical experience was statistically significant in reducing complications.

The oculomotor nerve: anatomic relationship with the floor of the third ventricle

PURPOSE

Endoscopic third ventriculostomy (ETV) has become first-line treatment for obstructive hydrocephalus. Many complications have been described, but the literature about oculomotor palsy after ETV is scarce. Therefore we undertook an anatomical study of the relationship of the oculomotor nerve to the floor of the third ventricle.

METHODS

Distances and angles between the third nerve and the bottom of the third ventricle were studied both in two cadaver heads and in high-definition CISS images in 16 MRI scans. The angles of the trajectories putting the nerve at risk or not were compared. Finally, in a retrospective analysis of intraoperative images the appearance of the membranous portion of the floor was defined and if visible, the distance of the third nerve to the midline was estimated by comparing with the 8-mm balloon catheter.

RESULTS

The course of the third nerve is approximately 8 mm laterally and approximately 17 mm caudally distant from the midpoint of the floor of the third ventricle. The angle of the trajectory to damage the third nerve is at least 12° greater than any safe angle of ETV trajectory through a normal burr hole.

CONCLUSIONS

The third nerve is not always visible during ETV procedures, but the angular and linear measurements imply that the risk to damage the nerve should be relatively small. Confirmation of these data in hydrocephalic patients with distorted anatomy is needed.