Minimallyr lnvasive Neu rosurgery
Editor in'Chief A. Perneczky, Mainz, Germany
Advisory Board
Honorary Advisory Board
H. Bertalanffy, Marburg, Cermany
A. Basso, Buenos Aires, Argentina M. Brock, Berlin, Cermany A. Crockard, London, United Kingdom W. Th. Koos, Vienna, Austria
Caemaert, Cent, Belgium R. DelValle-Robles, Mexico City, Mexico A. De Salles, Los Angeles, USA T. Dticzi, Pecs, Hungary W. Ehrfeld, Mainz, Cermany J.
Chief Editors A. Cohen, Cleveland, USA B. George, Paris, France T. Kanno, Toyoake, Japan
E. Ferrer, Barcelona, Spain C. Fries, Mainz, Cermany M. Fukui, Fukuoka, Japan T. Fukushima, Pittsburgh, USA C. Ciorgi, Baltimore, USA
K. Sano, Tokyo, Japan R. F. Spetzler, Phoenix, USA
M. C. Yasargil, Zririch,
Switzerland
A. Crotenhuis, Nijmegen, Netherland R. von Hanwehr, Washington D.C., USA R. T. Higashida, San Francisco, USA Y. Kato, Toyoake, Aichi, Japan
M. Khayata, Phoenix, USA N. D. Kitchen, London, United Kingdom E. Knosp, Vienna, Austria P. Lasjaunias, Le Kremlin-Bic6tre, France K. Manwaring, Phoenix, USA W. Menz, Karlsruhe, Cermany W. Mrlller-Forell, Mainz, Cermany T. Ohira, Tokyo, Japan K. Oka, Fukuoka, Japan B. Richling, Vienna, Austria R. J. Sclabassi, Pittsburgh, USA M. Taneda, Osaka, Japan M. Tschabitscher, Vienna, Austria A. Valavanis, Zririch, Switzerland L.
Zamorano, Detroit, USA
Volume
45
2002
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Thieme Verlag
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Stuttgart. New York
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Ventricular Failure as a Cause of Unsuccessful Endoscopic Third Ventriculostomy
W. R. Murshid
Abstract
Introduction
Introduction: In spite of extensive studies on cerebrospinal fluid (CSF)dynamics, the mechanism of its circulation is still obscure.
The pathophysiology of hydrocephalus has been attributed to three classical mechanisms; over-production of cerebrospinal fluid (CSF), increased resistance to CSF flow and increased ve-
The aim of this study is to evaluate the effect of an insult to the brain tissue on the success or failure of an endoscopic procedure. Methods: During the period from May 1995 to December 1998 we studied 21 children, ages from 2 to 48 months (mean 15 months) with non-communicating hydrocephalus. The intracranial pressure was measured at the time of endoscopic surgery. The follow-up period was from 2 - 5 years. They were divided into 2 groups. Group I were 8 patients with no history of brain insult. Group II (13 cases) had a previous brain insult (infective and/or vascular). Endoscopic third ventriculostomy (ETV) was done in 17 cases; 5 in Group I and 12 in Group II. Fenestration of cyst/s was done in all of Group I and in 9 cases of Group II. Failure was considered whenever shunt implantation was required.
Results: The mean intracranial pressure in Group I was 13.0 mmHg as compared to 9.7 mmHg in Group ll (p = 0.015). The failure rate of the endoscopic procedure/s was 25% and54% in Groups I and II, respectively. Discussion: The success of ETV and/or fenestration of cyst/s depends on a sufficient pressure gradient. The pressure gradient is
generated by a normal or compensated ventricular function. Conclusion: Brain tissue damage can result in ventricular failure. The quality of ventricular wall function has a significant role on the success ofETV.
nous sinus pressure [11. However, as shown by cine-magnatic resonance studies, the CSF flow is a complex bidirectional phenomenon (i.e., antegrade and retrograde). This pulsatile flow is dependent on the cardiac pulse and the subsequent central nervous system (CNS) displacement [2l.The role of insults on the CNS has not been studied in the pathophysiolory of hydrocephalus. These factors might contribute to the resistance or failure of treatment
of hydrocephalus to a single conventional method, i.e., endoscopic third ventricolostomy (ETV) or shunt implants.
With the introduction of neuroendoscopy in general and ETV in particular as relatively physiological methods for the treatment of hydrocephalus, the simple concept of the three classical causes of hydrocephalus is likely to change. The aim of this study is to evaluate the effect of an insult to the brain on the success or failure of neuroendoscopic procedures. This was done by comparing 2 groups of patients with non-communicating hydrocepalus. The first group were patients with arachnoid cysts, who did not suffer any brain insult and did not have any congenital brain malformation. These were considered to have a relatively normal ventricular function (as many reports
[3,4] have shown a slit-valve mechanism to maintain I(ey words Endoscopic Third Ventriculostomy . Hydrocephalus . Intracranial Pressure . Slit Ventricle Syndrome . Normal Pressure Hydroce-
phalus . Pseudotumor Cerebri
Affiliation Division of Neurosurgery, Department of Surgery King Khalid University Hospital, Riyadh, Saudi Arabia Comespondence Dr. W. R. Murshid, FRCSEd (SN), FACS, Associate Professor and Consultant Neurosurgeon
.
Division of Neurosurgery . Department of Surgery (37)' King Khalid University Hospital . P.O. Box 7805'Riyadh17472.Kingdom of Saudi tuabia. Phone: +966-1-467-0011 Fax: +966- 1 - 467 -9493' E-mail :
[email protected]
Bibliography Minim Invas Neurosurg2oo2;45:65-77
@
these
arachnoid cysts) and were used as a control. The second group were cases who sustained a brain insult in the form of pre-natal or post-natal infections or vascular injuries.
Georg Thieme Verlag Stuttgart . New York. ISSN 0946-7211
Table Cose No.
1
Features and outcome ofcases of non-communicating hydrocephalus due to arachnoid cyst
Age
(months)
Locotion
of
Previous
Sex
orochnoid cyst
implontls
shunt Endoscopic procedure CSF (no.) ETV Fenestrotion protein
Glucose
Post
8
VP
endoscopic Outcome
shunt
implont
(see text)
good
7F
Sylvian
24F
Suprasellar and CPA
+
9
successful
3
8M
Suprasellar
I
15
successful
4
24F
Suprasellar and CPA
* (2)
5
6F
Bitemporaland
6
18
7
28M
Suprasellar
8
5F
Temporal
F
Temporaland
PF
PF
+
2.85
ICP mmHg
z
1
0.43
with no historyofbraln insult (c.oup l)
0.09
2.96
17
successful
+ (2) (vP & cP)
0.06
4.5
20
successful
+ (2)
0.8
2.2
12
successful
+(1).
0.1
2.54
12
0.7
1.7
11
- Cercbello-pontine angle; PF = Poste of fossa; VP = Ventriculo-peritoneal shunt cP = Cysto-peritoneal shunt; fection; ETV = Endoscopic third ventriculostomy. CPA
Patients and Methods Patient population We studied 21 children (11 females and 10 males) diagnosed to have non-communicating hydrocephalus. They were referred to and treated by the author between May 1995 to December 1998 at King Khalid University Hospital, Riyadh, Saudi Arabia. Their follow-up period was from 2 to 5 years. Ages ranged from 2 months to 48 months (mean 15 months). The indication for an endocopic procedure was a non-communicating hydrocephalus diagnosed by brain CT scan. Five cases had in addition to the brain CT scan, a CT with intraventricular contrast to evaluate communication of the cyst or compartmentalization of the ven-
successful CP
*
good
= Developed staphalococcal shunt in-
tricules. Patients were divided into 2 groups. Group I (Table 1) were 8 patients with arachnoid cysts of different locations with no history of an insult to the brain, Fig.l illustrates the second case. Cases of Dandy Walker malformation or variant were excluded to rule out any effect of cerebellar malformations on ventricular function. The location of the arachnoid cysts were as follows: 4 supratentorial and 4 both supra- and infratentorial. Group II (Table 2) were 13 patients who had a previous insult to the brain (pre-natal and or post-natal). some patients had more than one insult. Case number 4 is shown as an example of Group II in Fig. 2. The majority (11 cases) had post-natal infection mainly in the form of meningitis and/or ventriculitis. Seven cases had recurrent infections. As cases were referred from other hospitals,
1
Fig. a, b Pre-operative CT scan. c, d Post-operative CT scan of the same patient, done after 5 months. Note: The marked improvement of the ventricle size and the CSF in the subarachnoid spaces. E = vl
d €
? E
= =,
!o,
t c
o q,
0,,
n OJ
cIA
'D
; =.
=
o
z .D
c
o
c rct
N
o o
JY
E !+
o ul I
Table
2
Features and outcome of cases of non-communicating hydrocephalus with a history of brain insult (Croup ll)
Original couse Cose Age No. (months) of hydrocepholus
ICP CSF Previous Endoscopic mmHg procedure shunt implontls (no.) ETV Fenestrstion Protein Glucose
Brsin insult
Sex
Post endos- Outcome copic shunt (see text)
implont
7
18 M
Neonatal meningitis
1 . Birth asphyxia 2. Meningitis 3. Shunt Infection
* (4)
2 3
l1M
MMC
Ventriculitis
* (1)
4F
IVH-
1. Hypoxia
EVD
2. Ventriculitis @
* (3) * (2)
9
VP
good
()\
9
VP
good
@
4
4M
Suprasellar arachnoid cyst
Ventriculitis
5
24F
Aqueduct stenosis
1. Birth asphyxia 2. Ventriculitis
+
6
48F
Aqueduct stenosis
Ventriculitis
* (1)
@
0.61
2.5
1
1.9
14
1.58
4.02
successful
12
good
VP
successful
14
died after
12
3
WKS
7 I 9 10
36M
Aqueduct stenosis
Ventriculitis
sF
Aqueduct stenosis
TORCH
13M
MMC
Ventriculitis
3M
Aqueduct stenosis
1. TORCH
* (1)
0.33 0.76 1.43 1.15
+ +
* (3) * (1)
+
+
+
2.12
7
0.12
8
successful
1.93
8
successful
2.18
8
successful
l
successful
good
VP
2. Ventriculitis
11 12
12M 2F
MMC
Ventriculitis
Aqueduct stenosis
1. MCA Infraction 2. TORCH
13
24M
Meningitis
1. Meningitis 2. Ventriculitis
* (3)
* (3)
-
0.88
1.86
9
0.08
3.22
9
died after months VP+CP
3
good
-
IVMC = Myelomeningoc€l€: '32 wk pretem; MCA Middle cerebralartery; VP = Ventriculo-peritoneal shunt; CP Cysto pe toneal sh untj TORCH = Congenital toxoplasmosis, rubella, cytomeqalovirus, herpes; IVH = Intravent cular hemorrhage; EVD Externe I ventricular drain;@ = Documented to be a Cram-nega tive infection: ETV = EndoscoDic third ventriculostomv.
-
Fig.2 a Pre-operative
CTscan.
b Post-operative (ETV and fenestration of cyst) CT of the same patient. Note: The minimal imorovement of CSF in the subarachnoid spaces. This patient eventually required a shunt.
d € ? |D F
=.
d a qJ
= o
q, qJ
o
=
='
=
o
only in 3 cases was the infection documented to be Gram-negartive. Three had periventricular calcification due to congenital c5'tomegalovirus or toxoplasmosis. Three sLlstained birth asphyxi,r. One had pre-natal infarction in the left middle cerebral artery
pupillary line. Warmed normal saline was used for irrigation when required. Fenestration of cyst walls and the floor of the third ventricle was done using the tip of the scope.
territory. The original causes of non-communicating
At the time of the endoscopic procedure the intracranial pressure (lCP)was measured and the CSF was studied for glucose and protein. The ICP was evaluated as previously reported [5] using a pressure transducer (Hewlett Packard 12901s, USA) attached at one end to the scope and the other end to the Hewlett Packard monitor. The pressure recorded was taken from the frontal horn of the laterial ventricle.
l-rydrocet-
phalus in Croup Il are shown in Table 2.
z .D
o ro
c)
o
IY
5 (Jl
o!
t/l I
Endoscopic procedures were performed as previously reported using a rigid pediatric nephroscope [5,6]. The scope was introduced through the anterior fontanel or a burr hole (according to the patient's age)just anterior to the coronal suture in the micl-
None of the cases had concurrent infection at the time of the en-
doscopic procedure/s.
3
c tt
d €
? @
= =.
g o
3
Fig. An eleven-months-old infant managed in accordance with the study (not included) with repeated attacks of shunt infection. This patient was treated with septostomies and a poste or fossa cysto-peritoneal shunt. Radiological studies were done seven months apart, ar b Axial FIAIR sequence MRl, pre- and post-operative, respectively. Note: The small third ventricle and the widespread c),sti€ leucomalacia.
