Is the routine placement of a CSF reservoir following endoscopic third ventriculostomy justified?

Endoscopic third ventriculostomy complications: avoidance and management in a stepwise manner

Background

Various complications of endoscopic third ventriculostomy (ETV) have been described. One has to recognize these complications and learn how to avoid them.

Methods

We performed a literature review regarding the reported complications of ETV procedures discussed in a correlated manner with the surgical steps. Furthermore, we reviewed the technical notes described by experienced neuroendoscopists, including surgical indications, choice of the endoscopic entry point and trajectory, anatomic orientation, proper bleeding control and tight closure, to prevent and deal with such complications.

Results and conclusion

A lesson learned that comprehensive knowledge of ventricular anatomy with proper orientation by studying the preoperative images is mandatory and one should be aware of all complication types and rates.

Porencephalic cyst after endoscopic third ventriculostomy and Ommaya reservoir placement: case report and review of the literature

BACKGROUND

A 13-year-old female patient was diagnosed with a tectal glioma (TG), a subgroup of astrocytoma that can result in obstructive hydrocephalus secondary to aqueductal stenosis. Endoscopic third ventriculostomy (ETV) is used to treat this type of hydrocephalus with a good success rate. Our institution performs ETV and Ommaya reservoir (OR) placement in these cases. The OR allows measurement of intracranial pressure (ICP) and cerebrospinal fluid (CSF) access and a method for performing ventricular dye studies to evaluate third ventricular stoma (TVS) patency. In this case, a porencephalic cyst (PC) developed around the OR's ventricular catheter (OVC) two and a half months after surgery.

CONCLUSION

The PC is thought to have developed in association with TVS stoma closure and resolved after ETV revision.

Pre-operative imaging and post-operative appearance of standard paediatric neurosurgical approaches: a training guide for neuroradiologists

A short-cut narrative review was conducted according to the SANRA guidelines to identify studies describing normal and abnormal postoperative radiological features of the most common paediatric neurosurgical procedures. Rather than focusing on the original pathology addressed by neurosurgical means, this review explored three main areas of operative neurosurgery: ventricular access, supratentorial & infratentorial craniotomies, and posterior fossa/craniocervical junction decompression. A total of twenty-three landmark papers were included for review based on their relevance to address the research question and serve as a practical guide for paediatric neuroradiology trainees and fellows. Accurate in text referencing of the ClinicalTrials.gov identifier, and weblink, has also been provided for all trials discussed in the results section. All the above is complemented by relevant iconography meant to describe a wide range of postoperative changes and early complications. Finally, the review is enriched by a discussion touching upon haemostatic agents, intentionally retained foreign bodies and the future of machine learning for neuroradiology reporting. Overall, the information presented in a systematic fashion will not only help trainees and fellows to deepen these topics and expand their knowledge in preparation for written and oral boards, but will also represent a useful resource for everyone including trained neuroradiologists and neurosurgeons themselves.

Neurocognitive Complications after Ventricular Neuroendoscopy: A Systematic Review

In recent years, neuroendoscopic treatment of hydrocephalus and various ventricular pathologies has become increasingly popular. It is considered by many as the first-choice treatment for the majority of these cases. However, neurocognitive complications following ventricular neuroendoscopic procedures may occur leading mostly to amnesia, which might have a grave effect on the patient's quality of life. Studies assessing neurocognitive complications after ventricular neuroendoscopic procedures are sparse. Therefore, we conducted a systematic review assessing the available literature of neurocognitive complications and outcome after ventricular neuroendoscopy. Of 1216 articles screened, 46 were included in this systematic review. Transient and permanent neurocognitive complications in 2804 ventricular neuroendoscopic procedures occurred in 2.0% (n = 55) and 1.04% (n = 28) of the patients, respectively. Most complications described are memory impairment, followed by psychiatric symptoms (psychosyndrome), cognitive impairment not further specified, declined executive function, and confusion. However, only in 20% of the series describing neurocognitive complications or outcome (n = 40) was neurocognition assessed by a trained neuropsychologist in a systematic manner. While in most of these series only a part of the included patients underwent neuropsychological testing, neurocognitive assessment was seldom done pre- and postoperatively, long-term follow up was rare, and patient's cohorts were small. A paucity of studies analyzing neurocognitive complications and outcome, through systematic neuropsychological testing, and the correlation with intraoperative lesions of neuronal structures (e.g., fornix) exists in the literature. Therefore, the neurocognitive and emotional morbidity after ventricular neuroendoscopic procedures might be underestimated and warrants further research.

The effect and evolution of patient selection on outcomes in endoscopic third ventriculostomy for hydrocephalus: A large-scale review of the literature

Endoscopic third ventriculostomy (ETV) has become a popular technique for the treatment of hydrocephalus, but small sample size has limited the generalizability of prior studies. We performed a large-scale review of all available studies to help eliminate bias and determine how outcomes have changed and been influenced by patient selection over time. A systematic literature search was performed for studies of ETV that contained original, extractable patient data, and a meta-analytic model was generated for correlative and predictive analysis. A total of 130 studies were identified, which included 11,952 cases. Brain tumor or cyst was the most common hydrocephalus etiology, but high-risk etiologies, post-infectious or post-hemorrhagic hydrocephalus, accounted for 18.4%. Post-operative mortality was very low (0.2%) and morbidity was only slightly higher in developing than in industrialized countries. The rate of ETV failure was 34.7% and was higher in the first months and plateaued around 20months. As anticipated, ETV is less successful in high-risk etiologies of hydrocephalus and younger patients. Younger patient age and high-risk etiologies predicted failure. ETVs were performed more often in high-risk etiologies over time, but, surprisingly, there was no overall change in ETV success rate over time. This study should help to influence optimal patient selection and offer guidance in predicting outcomes.

External drainage with an Ommaya reservoir for perioperative hydrocephalus in children with posterior fossa tumors

PURPOSE

This study aims to evaluate an external drainage using an Ommaya reservoir for relieving perioperative hydrocephalus and reducing postoperative complications in children with posterior fossa tumors.

METHODS

We retrospectively analyzed the data from 48 children with posterior fossa tumors who underwent tumor resection between May 2006 and June 2012. An Ommaya reservoir was placed in the right lateral ventricle forehead for continuous perioperative drainage of cerebrospinal fluid (CSF).

RESULTS

Tumors were successfully removed from all patients. Intracranial infection occurred in nine patients and was controlled by antibiotic treatment. Preoperative obstruction and obstructive hydrocephalus were relieved, and the need for a shunt or endoscopic third ventriculostomy was avoided. One patient who underwent a second surgical procedure had intracranial infection, hydrocephalus, and occipital pseudomeningocele. After continuous drainage and anti-infective treatment, hydrocephalus and intracranial infection were effectively controlled.

CONCLUSIONS

Using an Ommaya reservoir for perioperative external ventricular CSF drainage enabled tumors to be wholly and safely removed. Restoring CSF circulation provided an effective means of controlling and preventing hydrocephalus secondary to posterior fossa tumors in children.

Endoscopic third ventriculostomy

Endoscopic third ventriculostomy (ETV) is considered as a treatment of choice for obstructive hydrocephalus. It is indicated in hydrocephalus secondary to congenital aqueductal stenosis, posterior third ventricle tumor, cerebellar infarct, Dandy-Walker malformation, vein of Galen aneurism, syringomyelia with or without Chiari malformation type I, intraventricular hematoma, post infective, normal pressure hydrocephalus, myelomeningocele, multiloculated hydrocephalus, encephalocele, posterior fossa tumor and craniosynostosis. It is also indicated in block shunt or slit ventricle syndrome. Proper Pre-operative imaging for detailed assessment of the posterior communicating arteries distance from mid line, presence or absence of Liliequist membrane or other membranes, located in the prepontine cistern is useful. Measurement of lumbar elastance and resistance can predict patency of cranial subarachnoid space and complex hydrocephalus, which decides an ultimate outcome. Water jet dissection is an effective technique of ETV in thick floor. Ultrasonic contact probe can be useful in selected patients. Intra-operative ventriculo-stomography could help in confirming the adequacy of endoscopic procedure, thereby facilitating the need for shunt. Intraoperative observations of the patent aqueduct and prepontine cistern scarring are predictors of the risk of ETV failure. Such patients may be considered for shunt surgery. Magnetic resonance ventriculography and cine phase contrast magnetic resonance imaging are effective in assessing subarachnoid space and stoma patency after ETV. Proper case selection, post-operative care including monitoring of ICP and need for external ventricular drain, repeated lumbar puncture and CSF drainage, Ommaya reservoir in selected patients could help to increase success rate and reduce complications. Most of the complications develop in an early post-operative, but fatal complications can develop late which indicate an importance of long term follow up.

Placement of Ommaya reservoir following endoscopic third ventriculostomy in pediatric hydrocephalic patients: a critical reappraisal

PURPOSE

Endoscopic third ventriculostomy (ETV) has become standard for obstructive hydrocephalus. Even a successful ETV can obstruct, leading to recurrence of symptoms and even death. A possible solution to this problem is leaving an Ommaya reservoir (OR) following the ETV. OR can be tapped in an emergency and for diagnostic purposes. No specific complications have been attributed to OR in this setting. We present our experience with OR in children undergoing ETV for hydrocephalus.

MATERIALS AND METHODS

A retrospective study was conducted in hydrocephalic children that underwent ETV with OR insertion over 13 years (1997-2010) from a single institution. Data were collected from charts and follow-ups.

RESULTS

Twelve patients (from 200 patients who had an ETV) underwent placement of OR with ETV. OR was reserved for a subgroup of patients in whom we anticipated complications-in children that presented with acute hydrocephalus and were in deteriorating condition, for pathologies believed to have a low predicted ETV success rate, or when the surgeon felt that the ETV procedure was suboptimal. OR was tapped in eight patients. Complications occurred in four patients: two cases of subdural effusion, one case of chronic subdural hematoma, and one CSF leak. Four ORs were removed due to complications, and four were converted to shunts.

CONCLUSIONS

OR should be considered in selected patients undergoing ETV. Despite its obvious advantages, OR may be associated with a relatively high risk of extraaxial fluid collections. This association requires further investigation.