Extra-Axial Third Ventriculostomy Through Lamina Terminalis with Multiple Cisternostomies - Rescue Surgery for Patients with Failed Shunt Surgeries and Hydrocephalus

Background and Aim

Contemporary management of hydrocephalus involves various modes of cerebrospinal fluid (CSF) diversion, including shunt surgery and endoscopic ventriculostomy. However, there are times when either of these procedures have either failed or are not feasible. Highly invasive procedures aimed at internal CSF have been described previously, which, with the aid of modern microsurgical techniques, can be attempted in cases with very limited options. Our aim was to study the utility of extra-axial third ventriculostomy via lamina terminalis fenestration with multiple cisternostomies in the treatment of failed hydrocephalus.

Materials and Methods

Forty-five patients with hydrocephalus were operated for extra-axial trans-lamina terminalis third ventriculostomy with multiple cisternostomies from January 2017 to January 2019. A minimally invasive supraorbital craniotomy was performed with subfrontal fenestration of the lamina terminalis and trans-lamina terminalis fenestration of the floor of the third ventricle with multiple cisternostomies including the optico-carotid cistern and opening of the Liliequist membrane.

Results

Tuberculous meningitis was the most common etiology in the series, and multiple shunt procedures and incompatible CSF profiles were the most common reasons that necessitated this alternate rescue procedure. At a mean follow-up of 6 months, no patient required a revision shunt surgery. There was one death due to cardiac failure with anasarca, unrelated to the procedure.

Conclusions

Extra-axial trans-lamina terminalis ventriculostomy with cisternostomies can safely be performed using minimally invasive micro-neurosurgical techniques, adding to the armamentarium of neurosurgeons in the management of complex cases of hydrocephalus.

Management Strategies of Cranial Encephaloceles: A Neurosurgical Challenge

Background:

Encephalocele is defined as herniation of cranial contents beyond the normal confines of the skull through a defect in the calvarium either along the midline or at the base of skull. These anomalies should be repaired in the first few months of life to prevent neurological deficits and facial disfigurement. The aim of the surgery is water tight dural closure at the level of internal defect, closure of skull defect, and reconstruction of external bony deformity.

Materials and Methods:

Fifty-four cases of encephalocoeles were studied in our hospital over a 6-year period from 2010 to 2016. Computed tomography (CT) and magnetic resonance imaging (MRI) brain were performed to delineate the bony defect and associated anomalies. Reconstruction of the bony defect was done using autologous calvarial bone graft, Osteopore polycaprolactone (PCL) bone scaffold filler and titanium mesh.

Results:

In our study, 54 patients (34 boys and 20 girls) whose age varied between 2 months and 14 years were evaluated. Frontoethmoidal (44.5%) and occipital encephaloceles (25.9%) were the most frequently seen varieties. Repair of the dural defect either primarily or using pericranium was done in all cases. Closure of the bony defect was done using autologous calvarial bone graft in 12 (22.22%) patients. Titanium mesh was used in eight and Osteopore PCL bone scaffold filler in four children. Cranioplasty was not done in remaining thirty children because of the small bone defect. Overall, 80% had no postoperative problem and were discharged between 7 and 10 days of surgery. Cerebrospinal fluid leak was the most frequent postoperative complication, noted in five patients. Re-exploration with repair was done in one and remaining four were managed conservatively. Overall, cosmetic results were acceptably good, with parents judging the cosmetic outcome as good to excellent in 70%, satisfactory in 18%, and poor in 3% at the last follow-up.

Conclusion:

Our study demonstrated that encephaloceles are associated with complex deformities and pose a technical challenge to the neurosurgeon. A multidisciplinary approach is necessary to manage these cases. MRI brain and three dimensional CT aids in evaluating the deformity better and surgical correction should be performed as soon as possible to prevent a further neurological deficit. Repair of dural defect and reconstruction of the skull defect results in a good long-term outcome. We present our experience on 54 cases of cranial encephaloceles managed surgically over a period of only 6 years which is one of the largest series reported from Asia.

Ectopic Solitary Cortical Anaplastic Ependymoma in a Child: A Rare Entity with Short Illustrative Review

Ependymomas are usually infratentorial and intraventricular. They originate from the ependymal cell lining of the ventricles. Cortical extraventricular supratentorial ependymomas are rare and fewer than 15 cases are reported worldwide. In pediatric age group, seven cases are reported. We report a rare case of 4-year-old boy with right frontoparietal anaplastic ependymoma who underwent gross total excision of lesion.

Unusual Case of Midline Middle Skull Base Lymphoma Mimicking as Invasive Pituitary Adenoma

Non-Hodgkin's lymphoma (NHL) is a rare tumor of the skull base. As the incidence of primary central nervous system (CNS) lymphoma has increased, atypical presentations involving the skull base are being reported. However, isolated involvement of middle skull base, that too predominantly the clivus and parasellar region, is rarely seen. We present a case of middle-age woman with midline skull base lesion located in the sella with invasion of the ventral part of upper part of clivus (posterior clinoid) and also the parasellar region causing involvement of optic and abducens nerve with preserved hormonal functions. She was operated endoscopically for partial resection of the lesion. Histopathology turned out to be non-Hodgkin's lymphoma of NK/T-cell variety. So far NK/T-cell lymphoma of the sella with invasion into the clivus has never been reported in literature to the best of our knowledge.

Symptomatic Multiple Level Lateral Meningoceles with Intraspinal Meningocele: A Case Study and Its Surgical Management

Lateral meningocele is rare disorder of unknown etiology that represents herniation of leptomeninges through enlarged neural foramina. Most patients are asymptomatic and do not need treatment. A symptomatic case with neurologic deficit requires well-planned surgical approach. We report a case of 9-year-old boy who presented with mid backache and progressive asymmetric paraparesis with urinary incontinence. The patient did not appear to have any neurologic disorder. Magnetic resonance imaging (MRI) of spine revealed bilateral multiple thoracic and lumbar paraspinal cerebrospinal fluid (CSF) intensity cystic lesions projecting from the neural foramen and extending laterally suggesting multiple bilateral meningoceles. He was surgically treated, meningocele repair was done, and thecoperitoneal shunt was inserted. Postoperatively he improved symptomatically. Bilateral multiple lateral meningoceles are very rare entity and those who are surgically treated are few. We emphasize our innovative surgical approach to this case.