Neuroradiological Correlation of the Lateral Third Periventricular, Pituitary Gland and Stalk, Pineal Gland, Cerebral Aqueduct, and Foramen Magendie and Luschka With Intraventricular Neuroendoscopic Images: A Case Series

Neuroendoscopy procedures in pediatrics have expanded beyond the endoscopic third ventriculostomy. As such, a direct and angled endoscope allows further visualization around the corner, capturing the surrounding anatomy. Intraoperative live images look different than radiological images. Hence, in this single institutional experience, we correlate neuroradiology images with intraoperative intraventricular endoscopic views of the third-fourth ventricle, pituitary, pineal gland, cerebral aqueduct, and foramen magendie and luschka. Our collective case series reveals a few interesting case scenarios of normal and abnormal findings during the procedure. Careful navigation of the neuroendoscope is crucial to prevent injury to the neurovascular bundle. A close relationship with normal anatomy from radiological imaging is necessary to prevent it from getting lost once inside the ventricular cavity.

Insights into morphometry and topography of corpus callosum among Indians

Corpus callosum is one of the major association fibre of brain performs an integral role of integration and communication of information between the two hemispheres. 50 formalin fixed cerebral hemispheres (25 right and 25 left) were used for the study. The longitudinal and vertical length of brain, longitudinal length and height of corpus callosum, distance of corpus callosum from various landmarks such as frontal and occipital pole, anterior commissure, lamina terminalis, and highest point on parietal pole and width of different parts of corpus callosum and height were measured. Results were analysed statistically. The results showed positive correlation between the longitudinal dimension of brain and all other parameters. Morphometric variation in size and its relation to nearby structures are seen in many neurological and psychiatric conditions such as Alzheimer's disease, Schizophrenia and bipolar disorders. Hence the present study can be used as reference by neurologist, neurosurgeons and psychiatrists.

Endoscope-assisted Trans-lamina Terminalis Resection of Chordoid Glioma at the Third Ventricle: A Case Report

As per the 2021 World Health Organization (WHO) Classification of Tumors of the Central Nervous System, chordoid glioma (CG) is defined as a slow-growing glial neoplasm categorized as grade II tumor. This tumor is primarily located in the anterior part of the third ventricle, often adheres to important surrounding structures, and is hemorrhagic in nature. Therefore, dissecting this tumor is extremely difficult. In this study, we present the case of a 44-year-old man who initially complained of mild headache and was diagnosed with a homogeneous gadolinium-enhanced lesion in the third ventricle via magnetic resonance imaging. The pathological diagnosis based on his biopsy at the previous hospital was CG. The patient demonstrated no neurological deficit at that time, but the tumor had gradually grown, hydrocephalus appeared 2 years after the tumor was detected, and the patient developed short memory disorder and daytime sleepiness. We resected the tumor via the anterior interhemispheric trans-lamina terminalis approach using a microscope and an endoscope. The residual tumor at the blind spot of the microscopic view was resected under an angled rigid endoscopic view using dedicated tools for transsphenoidal surgery. The tumor was grossly resected, and the histopathological diagnosis was CG. Postoperative neurological findings included slight memory disorder and hypothalamic adrenal dysfunction. No tumor recurrence was reported 3 years post resection. The endoscope-assisted anterior interhemispheric trans-lamina terminalis approach was determined useful for CG resection with minimal surgical complications and without tumor recurrence.

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.

Cisternostomy as a Surgical Treatment for Traumatic Brain Injury-Related Prolonged and Delayed Intracranial Pressure Elevation: A Case Report

Traumatic brain injury (TBI) can be classified into primary, due to the effect of the initial trauma, or secondary, due to increased intracranial pressure (ICP). Increased ICP may cause brain herniation and also decreases cerebral blood perfusion leading to ischemia. Recently, a few studies showed that cisternostomy with decompressive craniectomy (DC) has better outcomes than DC alone in patients with TBI. This can be explained by the recent advances indicating that cisternal cerebrospinal fluid (CSF) communicates with cerebral interstitial fluid (IF) through Virchow-Robin spaces. Theoretically, opening cisterns to atmospheric pressure may induce IF drainage and subsequently decrease ICP. A 55-year-old man presented to the emergency department with subdural hematomas, hemorrhagic contusions, and subarachnoid hemorrhage after falling off a moving truck. ICP elevation was refractory despite increased sedation, initiation of paralysis with Cisatracurium, esophageal cooling, multiple doses of 23.4 % saline and mannitol, and DC. Lumbar drain (LD) placement was performed with beneficial results. Unfortunately, the LD stopped functioning multiple times and each time this occurred, he developed increased ventricular size with elevated ICP. The patient underwent cisternostomy and lamina terminalis fenestration. No further increased ICPs were observed after cisternostomy at a one-month follow-up. Cisternostomy is a potential surgical treatment for patients with TBI-related prolonged ICP elevation.

Cisternotomy and Liliequist's Membrane Fenestration as a Surgical Treatment for Idiopathic Intracranial Hypertension (Pseudotumor Cerebri): A Case Report

Subarachnoid basal cistern opening (cisternotomy) is used during many microsurgical operations to relax the brain by removing or diverting cerebrospinal fluid (CSF). Recently, cisternotomy has been used in patients with traumatic brain injury to improve outcomes due to its ability to decrease intracranial pressure (ICP) and brain edema by diverting CSF. Theoretically, another condition that can benefit from cisternotomy is idiopathic intracranial hypertension (IIH) as it presents with manifestations of increased ICP, such as headache, vomiting, and papilledema. Here, we discuss the case of a 39-year-old woman with IIH who presented with headache, nausea, and papilledema in the setting of maximally tolerated medical management after five months of shunt removal due to infection. The patient did not want to proceed with the replacement of her shunt and therefore underwent a right eyebrow craniotomy for cisternotomy, lamina terminals fenestration, and Liliequist's membrane opening. Postoperatively, her symptoms improved completely. She was off acetazolamide altogether at the three-month follow-up and no longer had pseudotumor cerebri headaches. This case report demonstrates the use of cisternotomy to relieve the manifestations of increased ICP and its potential as a surgical option for patients with IIH.

ANG II and Aldosterone Acting Centrally Participate in the Enhanced Sodium Intake in Water-Deprived Renovascular Hypertensive Rats

Renovascular hypertension is a type of secondary hypertension caused by renal artery stenosis, leading to an increase in the renin–angiotensin–aldosterone system (RAAS). Two-kidney, 1-clip (2K1C) is a model of renovascular hypertension in which rats have an increased sodium intake induced by water deprivation (WD), a common situation found in the nature. In addition, a high-sodium diet in 2K1C rats induces glomerular lesion. Therefore, the purpose of this study was to investigate whether angiotensin II (ANG II) and/or aldosterone participates in the increased sodium intake in 2K1C rats under WD. In addition, we also verified if central AT1 and mineralocorticoid receptor blockade would change the high levels of arterial pressure in water-replete (WR) and WD 2K1C rats, because blood pressure changes can facilitate or inhibit water and sodium intake. Finally, possible central areas activated during WD or WD followed by partial rehydration (PR) in 2K1C rats were also investigated. Male Holtzman rats (150–180 g) received a silver clip around the left renal artery to induce renovascular hypertension. Six weeks after renal surgery, a stainless-steel cannula was implanted in the lateral ventricle, followed by 5–7 days of recovery before starting tests. Losartan (AT1 receptor antagonist) injected intracerebroventricularly attenuated water intake during the thirst test. Either icv losartan or RU28318 (mineralocorticoid receptor antagonist) reduced 0.3 M NaCl intake, whereas the combination of losartan and RU28318 icv totally blocked 0.3 M NaCl intake induced by WD in 2K1C rats. Losartan and RU28318 icv did not change hypertension levels of normohydrated 2K1C rats, but reduced the increase in mean arterial pressure (MAP) produced by WD. c-Fos expression increased in the lamina terminalis and in the NTS in WD condition, and increased even more after WD-PR. These results suggest the participation of ANG II and aldosterone acting centrally in the enhanced sodium intake in WD 2K1C rats, and not in the maintenance of hypertension in satiated and fluid-replete 2K1C rats.

Enhancing access to the suprasellar region: the transcallosal translamina terminalis approach

Craniopharyngioma represents one of the most challenging brain tumors to treat. Surgery may be the definitive treatment, and multiple surgical approaches have been described, each based on different anatomical considerations. Some approaches require working through narrow corridors that do not often provide a sufficient view of the critical anatomical structures around the tumor. The choice of the right approach is key for optimizing resection and minimizing risk. In this paper, the author presents the case of a pediatric patient with a large suprasellar craniopharyngioma who underwent complete resection of the tumor through a novel approach: a transcallosal translamina terminalis corridor. This particular transcallosal corridor, behind the anterior communicating artery, allows the optimal opening of the lamina terminalis extending up to the anterior commissure. This novel variation of the traditional operation provides a wider exposure of the tumor compared with the classic approaches through the lamina terminalis. This technique has not been sufficiently described in the pediatric literature. The author describes it here as an alternative method for treating patients with sellar and suprasellar tumors.

The Iatrogenic Development of an Anterior Cerebral Artery Pseudoaneurysm during Lamina Terminalis Fenestration-Genesis, Diagnosis and Therapy: Lessons Learned

Intracranial pseudoaneurysms (PSA) are scarcely presented in the literature. We describe the case of an intracranial PSA on the right anterior cerebral artery, which developed during the complicated surgical treatment of a ruptured right middle cerebral aneurysm. The pseudoaneurysm grew over time and was co-incidentally diagnosed 3 months after the original surgery. The PSA was successfully treated by coiling. In cases of vascular injuries during complicated brain surgery, the timely and careful radiological diagnosis of such a lesion is necessary to allow its fast and proper treatment and thus prevent the patient from potential risks.

Regulation of Thirst and Vasopressin Release

Recent experiments using optogenetic tools facilitate the identification and functional analysis of thirst neurons and vasopressin-producing neurons. Four major advances provide a detailed anatomy and physiology of thirst, taste for water, and arginine-vasopressin (AVP) release: ( a) Thirst and AVP release are regulated by the classical homeostatic, interosensory plasma osmolality negative feedback as well as by novel, exterosensory, anticipatory signals. These anticipatory signals for thirst and vasopressin release concentrate on the same homeostatic neurons and circumventricular organs that monitor the composition of blood. ( b) Acid-sensing taste receptor cells (TRCs) expressing otopetrin 1 on type III presynaptic TRCs on the tongue, which were previously suggested as the sour taste sensors, also mediate taste responses to water. ( c) Dehydration is aversive, and median preoptic nucleus (MnPO) neuron activity is proportional to the intensity of this aversive state. ( d) MnPO^GLP1R neurons serve as a central detector that discriminates fluid ingestion from solid ingestion, which promotes acute satiation of thirst through the subfornical organ and other downstream targets.

Amphetamine-induced sensitization of hypertension and lamina terminalis neuroinflammation

Psychomotor stimulants are prescribed for many medical conditions, including obesity, sleep disorders, and attention-deficit/hyperactivity disorder. However, despite their acknowledged therapeutic utility, these stimulants are frequently abused, and their use can have both short- and long-term negative consequences. Although stimulants such as amphetamines acutely elevate blood pressure, it is unclear whether they cause any long-term effects on cardiovascular function after use has been discontinued. Previous work in our laboratory has demonstrated that physiological and psychosocial stressors will produce sensitization of the hypertensive response, a heightened pressor response to a hypertensinogenic stimulus delivered after stressor exposure. Here, we tested whether pretreatment with amphetamine for 1 wk can sensitize the hypertensive response in rats. We found that repeated amphetamine administration induced and maintained sensitization of the pressor response to angiotensin II following a 7-day delay after amphetamine injections were terminated. We also found that amphetamine pretreatment altered mRNA expression for molecular markers associated with neuroinflammation and renin-angiotensin-aldosterone system (RAAS) activation in the lamina terminalis, a brain region implicated in the control of sympathetic nervous system tone and blood pressure. The results indicated amphetamine upregulated mRNA expression underlying neuroinflammation and, to a lesser degree, message for components of the RAAS in the lamina terminalis. However, we found no changes in mRNA expression in the paraventricular nucleus. These results suggest that a history of stimulant use may predispose individuals to developing hypertension by promoting neuroinflammation and upregulating activity of the RAAS in the lamina terminalis.

The Forebrain Thirst Circuit Drives Drinking through Negative Reinforcement

The brain transforms the need for water into the desire to drink, but how this transformation is performed remains unknown. Here we describe the motivational mechanism by which the forebrain thirst circuit drives drinking. We show that thirst-promoting subfornical organ neurons are negatively reinforcing and that this negative-valence signal is transmitted along projections to the organum vasculosum of the lamina terminalis (OVLT) and median preoptic nucleus (MnPO). We then identify molecularly defined cell types within the OVLT and MnPO that are activated by fluid imbalance and show that stimulation of these neurons is sufficient to drive drinking, cardiovascular responses, and negative reinforcement. Finally, we demonstrate that the thirst signal exits these regions through at least three parallel pathways and show that these projections dissociate the cardiovascular and behavioral responses to fluid imbalance. These findings reveal a distributed thirst circuit that motivates drinking by the common mechanism of drive reduction.

The spiking and secretory activity of oxytocin neurones in response to osmotic stimulation: a computational model

KEY POINTS

A quantitative model of oxytocin neurones that combines a spiking model, a model of stimulus-secretion coupling and a model of plasma clearance of oxytocin was tested. To test the model, a variety of sources of published data were used that relate either the electrical activity of oxytocin cells or the secretion of oxytocin to experimentally induced changes in plasma osmotic pressure. To use these data to test the model, the experimental challenges involved were computationally simulated. The model predictions closely matched the reported outcomes of the different experiments.

ABSTRACT

Magnocellular vasopressin and oxytocin neurones in the rat hypothalamus project to the posterior pituitary, where they secrete their products into the bloodstream. In rodents, both vasopressin and oxytocin magnocellular neurones are osmoresponsive, and their increased spiking activity is mainly a consequence of an increased synaptic input from osmoresponsive neurons in regions adjacent to the anterior wall of the third ventricle. Osmotically stimulated vasopressin secretion promotes antidiuresis while oxytocin secretion promotes natriuresis. In this work we tested a previously published computational model of the spiking and secretion activity of oxytocin cells against published evidence of changes in spiking activity and plasma oxytocin concentration in response to different osmotic challenges. We show that integrating this oxytocin model with a simple model of the osmoresponsive inputs to oxytocin cells achieves a strikingly close match to diverse sources of data. Comparing model predictions with published data using bicuculline to block inhibitory GABA inputs supports the conclusion that inhibitory inputs and excitatory inputs are co-activated by osmotic stimuli. Finally, we studied how the gain of osmotically stimulated oxytocin release changes in the presence of a hypovolaemic stimulus, showing that this is best explained by an inhibition of an osmotically regulated inhibitory drive to the magnocellular neurones.

17β-Estradiol attenuates p38MAPK activity but not PKCα induced by angiotensin II in the brain

17β-Estradiol (E2) has been shown to modulate the renin-angiotensin system in hydromineral and blood pressure homeostasis mainly by attenuating angiotensin II (ANGII) actions. However, the cellular mechanisms of the interaction between E2 and angiotensin II (ANGII) and its physiological role are largely unknown. The present experiments were performed to better understand the interaction between ANGII and E2 in body fluid control in female ovariectomized (OVX) rats. The present results are the first to demonstrate that PKC/p38 MAPK signaling is involved in ANGII-induced water and sodium intake and oxytocin (OT) secretion in OVX rats. In addition, previous data from our group revealed that the ANGII-induced vasopressin (AVP) secretion requires ERK1/2 signaling. Therefore, taken together, the present observations support a novel concept that distinct intracellular ANGII signaling gives rise to distinct neurohypophyseal hormone release. Furthermore, the results show that E2 attenuates p38 MAPK phosphorylation in response to ANGII but not PKC activity in the hypothalamus and the lamina terminalis, suggesting that E2 modulates ANGII effects through the attenuation of the MAPK pathway. In conclusion, this work contributes to the further understanding of the interaction between E2 and ANGII signaling in hydromineral homeostasis, as well as it contributes to further elucidate the physiological relevance of PKC/p38 MAPK signaling on the fluid intake and neurohypophyseal release induced by ANGII.

Combined Interhemispheric and Transsylvian Approach for Resection of Craniopharyngioma

We present a 37-year-old male case of cystic suprasellar huge craniopharyngioma, who presented with significant memory disturbance due to obstructive hydrocephalus. Combined interhemispheric and pterional approach was chosen to resect huge suprasellar tumor. Interhemispheric trans-lamina terminalis approach was quite effective to resect third ventricular tumor, while pterional approach was useful to dissect tumor out of basilar perforators and stalk.

The link to the video can be found at: https://youtu.be/BoYIPa96kdo .

Reciprocal Control of Drinking Behavior by Median Preoptic Neurons in Mice

Stimulation of glutamatergic neurons in the subfornical organ drives drinking behavior, but the brain targets that mediate this response are not known. The densest target of subfornical axons is the anterior tip of the third ventricle, containing the median preoptic nucleus (MnPO) and organum vasculosum of the lamina terminalis (OVLT), a region that has also been implicated in fluid and electrolyte management. The neurochemical composition of this region is complex, containing both GABAergic and glutamatergic neurons, but the possible roles of these neurons in drinking responses have not been addressed. In mice, we show that optogenetic stimulation of glutamatergic neurons in MnPO/OVLT drives voracious water consumption, and that optogenetic stimulation of GABAergic neurons in the same region selectively reduces water consumption. Both populations of neurons have extensive projections to overlapping regions of the thalamus, hypothalamus, and hindbrain that are much more extensive than those from the subfornical organ, suggesting that the MnPO/OVLT serves as a key link in regulating drinking responses.

SIGNIFICANCE STATEMENT

Neurons in the median preoptic nucleus (MnPO) and organum vasculosum of the lamina terminalis (OVLT) are known to regulate fluid/electrolyte homeostasis, but few studies have examined this issue with an appreciation for the neurochemical heterogeneity of these nuclei. Using Cre-Lox genetic targeting of Channelrhodospin-2 in transgenic mice, we demonstrate that glutamate and GABA neurons in the MnPO/OVLT reciprocally regulate water consumption. Stimulating glutamatergic MnPO/OVLT neurons induced water consumption, whereas stimulating GABAergic MnPO neurons caused a sustained and specific reduction in water consumption in dehydrated mice, the latter highlighting a heretofore unappreciated role of GABAergic MnPO neurons in thirst regulation. These observations represent an important advance in our understanding of the neural circuits involved in the regulation of fluid/electrolyte homeostasis.

Chordoid Glioma of Third Ventricle With an Epidermoid Cyst: Coexistence or Common Histogenesis?

Chordoid glioma (CG) is a World Health Organization classified grade II tumor located exclusively in the region of anterior third ventricle. Association of CG with other lesions is extremely rare. We report a case of CG in a 45-year-old male coexisting with an epidermoid cyst in the third ventricle. Ultrastructural examination of the CG revealed microvilli, junctional complexes, and intermediate filaments within the cytoplasm suggesting origin from specialized ependyma. The association of the 2 lesions appears coincidental as convincing evidence for a common histogenesis was not found.

Subfrontal trans-lamina terminalis approach to a third ventricular craniopharyngioma

Craniopharyngiomas are benign, partly cystic epithelial tumors that can rarely occur in a retrochiasmatic location with involvement of the third ventricle. The lamina terminalis is an important neurosurgical corridor to these craniopharyngiomas in the anterior portion of the third ventricle. We present a video case of a large midline suprasellar and third ventricular craniopharyngioma in a 32-year-old male with visual disturbances. The tumor was approached with a subfrontal translamina terminalis exposure, and a gross-total resection of the tumor was achieved. This surgery involved working through a lamina terminalis fenestration around the optic nerve, optic chiasm, optic tracts, and the anterior communicating artery complex. This video illustrates the techniques employed in performing a transbasal anterior skull base approach to the third ventricle and demonstrates vivid surgical anatomy of neurovascular structures around the lamina terminalis. The video can be found here: https://youtu.be/fCYMgx8SnKs .

Contralateral approach for clipping of bilateral anterior circulation aneurysms

Patients with bilateral anterior circulation aneurysms present a management challenge. These lesions may be treated in a staged manner or alternatively, for select patients, a contralateral approach may be utilized to treat bilateral aneurysms with a single surgery. In this narrated video illustration, we present the case of a 57-year-old woman with incidentally discovered bilateral aneurysms (left middle cerebral artery [MCA], left anterior choroidal artery and right MCA). A contralateral approach through a left pterional craniotomy was performed formicrosurgical clipping of all three aneurysms. The techniques of pterional craniotomy, contralateral approach, microsurgical clipping and intraoperative angiography are reviewed. The authors are grateful to Wuyang Yang, M.D. for his assistance. The video can be found here: http://youtu.be/MlPIu3hQZkg.

Suprachiasmatic translamina terminalis corridor used in endoscopic endonasal approach for resecting third ventricular craniopharyngioma

OBJECT

The translamina terminalis corridor was used in the transcranial anterior route to treat third ventricular craniopharyngioma (TVC), which presents a challenge to neurosurgeons. The endoscopic endonasal approach (EEA) has recently been used to treat craniopharyngiomas. However, there are few reports of the EEA being used to treat TVC. The authors' novel surgical approach of treating selected TVC by the endoscopic endonasal route via the suprachiasmatic translamina terminalis (STLT) corridor is described.

METHODS

In this single-center study, the EEA via the STLT corridor was used to resect TVC with great upper and anterior extension causing bulged lamina terminalis, and TVC with a residual upper compartment, after routine infrachiasmatic transmetastalk corridor resection.

RESULTS

The STLT corridor was used in 3 patients. Gross-total resection was achieved in all cases. One patient achieved visual improvement, and the other 2 patients showed partial visual improvement. Leakage of CSF occurred in 1 patient. Postoperative hormone replacement therapy was required in all patients.

CONCLUSIONS

The STLT corridor is a complementary minimally invasive corridor used in the EEA for treating selected TVC. The STLT alone or combined with infrachiasmatic transmetastalk corridors should be selected depending on the size of suprachiasmatic and infrachiasmatic space.

Renal responses produced by microinjection of the kappa opioid receptor agonist, U50-488H, into sites within the rat lamina terminalis

Activation of central kappa opioid receptors (KOR) has been demonstrated to produce marked free water diuresis with a concurrent increase in renal sympathetic nerve activity (RSNA). This study investigated the cardiovascular (CV) and renal effects evoked by central activation of KOR in two lamina terminalis sites, the median preoptic area (MPA) and anterolateral division of the bed nuclei of the stria terminalis (BST). Rats anesthetized with urethane alpha-chloralose were instrumented to record mean arterial pressure, heart rate, RSNA, and urine output (V). Rats were infused with isotonic saline (25 μL/min) and urine samples were collected during two 10-min control periods and six consecutive 10-min experimental periods following microinjection of vehicle, U50-448H (U50, KOR agonist) alone or norbinaltorphimine (nor-BNI, KOR antagonist) plus U50. Microinjection of U50 into the BST increased V (peak at 30 min, 84.8 ± 12.9 μL/min) as compared to its respective control, vehicle, or nor-BNI plus U50. This diuretic effect occurred without any significant changes in CV parameters, RSNA, or urinary sodium excretion. In contrast, U50 injection into the MPA significantly increased RSNA (peak at 20 mins: 129 ± 9.9) without increasing the other parameters. This study demonstrated novel sites through which activation of KOR selectively increases V and RSNA. The ability of U50 to increase V without affecting sodium excretion and RSNA raises the possibility that LT neurons could be an important substrate through which drugs targeting KOR could selectively facilitate water excretion in sodium-retaining diseases such as congestive heart failure.

Interhemispheric Endoscopic Fenestration of the Lamina Terminalis through a Single Frontal Burr Hole

Objective We evaluate the feasibility and safety of performing a novel interhemispheric endoscopic fenestration of the lamina terminalis (IEFLT) through a single frontal burr hole immediately lateral to the superior sagittal sinus. Methods Five cadaveric heads underwent IEFLT. Sequential burr holes were made beginning above the glabella and progressed cranially to caudally until the frontal sinus. An endoscope was inserted, and interhemispheric dissection of the arachnoid membranes was completed with endoscopic instruments in a straight direction from the point of entry to the lamina terminalis (LT). Angled optics (0 and 30 degrees) were used to study the neurovascular structures and surgical landmarks. Results The IEFLTs were successfully completed in all specimens and allowed for good visualization of the inferior portion of the LT. The arachnoid dissections were achieved uneventfully. The endoscope provided good surface control of the LT and excellent stereoscopic visualization of the neurovascular complexes. Improved circumferential visualization of the superior part of the anterior portion of the third ventricle was attained. Conclusion IEFLT is a potential alternative to the classic endoscopic third ventriculostomy and a simpler alternative to the subfrontal EFLT, although surgical maneuverability is still limited due to the size of the probe in relation to the narrow surgical corridor.

ENaC γ-expressing astrocytes in the circumventricular organs, white matter, and ventral medullary surface: sites for Na+ regulation by glial cells

Using a double immunofluorescence procedure, we report the discovery of a novel group of fibrous astrocytes that co-express epithelial sodium channel (ENaC) γ-subunit protein along with glial acidic fibrillary protein (GFAP). These cells are concentrated along the borders of the sensory circumventricular organs (CVOs), embedded in the white matter (e.g., optic nerve/chiasm, anterior commissure, corpus callosum, pyramidal tract) and are components of the pia mater. In the CVOs, a compact collection of ENaC γ-immunoreactive glial fibers form the lamina terminalis immediately rostral to the organum vasculosum of the lamina terminalis (OVLT). Astrocyte processes can be traced into the median preoptic nucleus - a region implicated in regulation of sodium homeostasis. In the subfornical organ (SFO), ENaC γ-GFAP astrocytes lie in its lateral border, but not in the ventromedial core. In the area postrema (AP), a dense ENaC γ-GFAP glial fibers form the interface between the AP and nucleus tractus solitarius; this area is termed the subpostremal region. Antibodies against the ENaC α- or β-subunit proteins do not immunostain these regions. In contrast, the antibodies against the ENaC γ-subunit protein react weakly with neuronal cell bodies in the CVOs. Besides affecting glial-neural functions in the CVOs, the astrocytes found in the white matter may affect saltatory nerve conduction, serving as a sodium buffer. The ENaC γ-expressing astrocytes of the ventral medulla send processes into the raphe pallidus which intermingle with the serotoninergic (5-HT) neurons found in this region as well as with the other nearby 5-HT neurons distributed along ventral medullary surface.

Microsurgical third ventriculocisternostomy as an alternative to ETV: report of two cases

OBJECTIVE

To describe a microsurgical alternative to endoscopic third ventriculocisternostomy.

METHODS

Two children with shunt-dependent hydrocephalus and multiple shunt revisions were considered candidates for third ventriculocisternostomy (TVS). Because of slit ventricles, an endoscopic approach was not possible and, therefore, both patients received a microsurgical TVS by a supraorbital approach.

RESULTS

In both cases, microsurgical TVS was successful and the patients became shunt free.

CONCLUSION

Microsurgical TVS by a supraorbital craniotomy is a viable alternative to endoscopic TVS in selected cases.

Influence of lamina terminalis fenestration on the occurrence of the shunt-dependent hydrocephalus in anterior communicating artery aneurysmal subarachnoid hemorrhage

Recently, it was reported that fenestration of the lamina terminalis (LT) may reduce the incidence of shunt-dependent hydrocephalus in aneurysmal subarachnoid hemorrhage (SAH). The authors investigated the efficacy of the LT opening on the incidence of shunt-dependent hydrocephalus in the ruptured anterior communicating artery (ACoA) aneurysms. The data of 71-ruptured ACoA aneurysm patients who underwent aneurysmal clipping in acute stage were reviewed retrospectively. Group I (n=36) included the patients with microsurgical fenestration of LT during surgery, Group II (n=35) consisted of patients in whom fenestration of LT was not feasible. The rate of shunt-dependent hydrocephalus was compared between two groups by logistic regression to control for confounding factors. Ventriculo-peritoneal shunts were performed after aneurysmal obliteration in 18 patients (25.4%). The conversion rates from acute hydrocephalus on admission to chronic hydrocephalus in each group were 29.6% (Group I) and 58.8% (Group II), respectively. However, there was no significant correlation between the microsurgical fenestration and the rate of occurrence of shunt-dependent hydrocephalus (p>0.05). Surgeons should carefully decide the concomitant use of LT fenestration during surgery for the ruptured ACoA aneurysms because of the microsurgical fenestration of LT can play a negative role in reducing the incidence of chronic hydrocephalus.