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NEUROENDOSCOPY  

   

 Department  of  Neurosurgery,  University  Medical  center  Ljubljana    

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Hydrocephalus  

•  Hydrocephalus  means  excess  water  in  the  brain  

•  TradiHonal  treatment:  –  Shunt  inserHon  (ventriculo-­‐peritoneal,  ventriculo-­‐

atrial,  venHrulo-­‐plavral)  

•  up  to  20%  of  paHents  can  develop  complicaHons  

•  Neuroendoscopy  is  now  being  used  to  perform  a  THIRD  VENTRICULOSTOMY  -­‐  a  new  passage  is  created  between  venHcular  system  and  subarahnoidal  space  -­‐>  an  excessive  amount  of  water  can  be  absorbed  

•  In  obstruc(ve  hydrocephalus  this  is  the  treatement  of  choice  

•  a  bypass  around  aqueductus  cerebri  is  made  

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ApplicaHon  

ADVANTAGES  

•  Less  pain  than  tradiHonal  surgery  •  Faster  recovery  than  tradiHonal  

surgery,  shorter  hospital  stay  and  quicker  return  to  normal  acHviHes  

•  Minimal  scarring  •  Small  incision  site  and  minimal  

trauma  to  the  brain  or  spinal  cord  •  In  some  instances,  the  surgery  is  

substanHally  shorter  than  tradiHonal  surgical  approaches    

DISADVANTAGES  

•  Only  2D  image  •  Less  space  to  perform  surgery  •  Learning  curve  •  Lack  of  appropriate  endoscopic  

instruments    

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Neuroendoscopy  

•  Neuroendoscopy  is  a  surgical  technique  which  usses  small  thin  endoscopes  (around  5  mm  in  diameter)  to  approach  deep  structures  of  the  brain  and  perform  surgical  procedures  there  

•  It  is  relaHvely  new  and  rapidly  developing  concept    

•  Three  basic  prerequisiHes  of  doing  neuroendoscopy:  

1.  Preformed  space  into  which  the  endoscope  can  be  passed  2.  A  sufficient  light  has  to  be  delivered  into  the  cavity  to  visualise  the  structures  inside  3.  We  must  be  able  to  pass  instruments  into  that  spece  to  perform  surgical  procedures  

 

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History  (the  beginning)  

•  1910:  L’Espinasse,  a  Chicago  urologist,  perform  the  first  neurosurgical  endoscopic  procedure  (fulguraHon  of  choroid  plexus  in  two  infants  with  hydrocephalus)  

•  1923:  Mixter,  a  neurosurgeon,  performed  the  first  endoscopic  ventriculostomy  in  a  child  with  congenital  obstrucHve  hydrocephalus  

 

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History  (decline  of  neuroendoscopy)  

•  Treatement  of  hydrocephalus  was  replaced  by  placement  of  ventriculoperitoneal  shunts  

•  The  end  of  the  iniHal  era  of  neuroendoscopy  

•  The  birth  of  microneurosurgery  in  the  1960s  pushed  endoscopy  further  into  the  background  

•  The  microscope    allow  neurosurgeons  to  perform  operaHons  deep  within  the  brain  and  at  the  base  of  the  skull  with  both  adequate  illuminaHon  and  magnificaHon  

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History  (extension  of  neuroendoscopy)  

•  Extension  of  the  use  of  neuroendoscopy  to:    

–  intraventricular  tumors  –  skull  base  tumors  –  Craniosynostosis  –  degeneraHve  spine  disease  –  intracranial  cysts  –  rare  subtypes  of  hydrocephalus  

•  There  is  the  vast  potenHal  of  the  endoscope  in  neurosurgery  

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IndicaHons  for  intracranial  endoscopic  procedures  

•  The  indicaHons  for  neuroendoscopic  operaHons  have  been  standardized  in  the  last  few  years  

•  In  general,  neuroendoscopy  is  used  for  procedures  in  preexis(ng  or  pathologically  formed  cavi(es  in  the  central  nervous  system  

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IndicaHons  for  intracranial  endoscopic  procedures  

PURE  ENDOSCOPIC  PROCEDURE  

1.   Hydrocephalus  –  Third  ventriculostomy    –  Aqueductoplasty    –  Compartmentalized  hydrocephalus    –  Septum  pellucidotomy    –  MulHcompartment  hydrocephalus    –  Ventricular  catheter  placement  

2.   Intraventricular  Tumors  3.   Arachnoid  cysts  

–  fenestracion  

4.   Colloid  Cysts  

   

ENDOSCOPIC  ASSISTED  MICROSURGERY  

•  a  very  recent  concept    •  an  endoscope  is  used  along  with  the  

microscope  •  a  whole  new  world  of  possibiliHes  •  reduced  size  of  the  craniotomy  and  

minimally  invasiveness  

1.   Pituitary  tumor  resec(on    2.   Skull  base  tumor  biopsy    3.   Cerebral  aneurysms    4.   Microvascular  decompression    5.   Acous(c  neuromas  

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Endoscopic  third  ventriculostomy  

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Aquductus cerebri

Subarahnoidal space (cisterna interpedunclularis)

Third ventricle

A perforation of lamina terminalis is made to bypass the aquductal stenosis

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Endoscopic  third  ventriculostomy  

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•  Our  case:  –  8  months  old  child  acer  postnatal  

intraventricular  bleeding  -­‐>  the  blood  cloth  blocked  the  aqueductus  cerebri  -­‐>  Head  circumference  started  to  increase  

Aqueductal stenosis

Endoscopic  third  ventriculostomy  

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•  A  view  of  the  floor  of  the  third  ventricle  –  LAMINA  TERMINALIS  

•  Endoscope  passed  through  the  foramen  Monroe  into  the  third  ventricle  

Choroid plexus Corpora mamilaria

Lamina terminalis

Endoscopic  third  ventriculostomy  

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A case from our clinic

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Arachnoid  cysts  

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•  arachnoid  cysts  consHtute  1%  of  all  intracranial  mass  lesions    

•  they  are  seen  in  1%  of  the  populaHon  

•  thay  can  arise  in  any  part  of  the  central  nervous  system  where  arachnoid  is  found  (typically  within  the  arachnoid  cysterns)  

 •  ETIOLOGY:  it  is  believed  that  most  cases  

of  arachnoid  cysts  are  developmental  malformaHons  that  arise  from  the  unexplained  spligng  or  tearing  of  the  arachnoid  membrane    

•  Neuroendoscopy  prvides  a  simple  solu(on  to  these  cysts  simply  by  fenestra(ng  them  in  the  depth  so  that  the  extra  water  can  be  absorbed  internally  

Arachnoid  cysts  (our  experience)  

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CYST  

BRAIN  PARENHYMA  

Arachnoid  cysts  (our  experience)  

•  A  cyst  fenestraHon  into  the  ventricular  system  was  performed  

 •  With  a  help  of  a  microsurgery,  

cyst  was  resected  and  obstrucHon  was  released  

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Arachnoid  cysts  (our  experience)  

•  Before  the  operaHon  

•  7  months  acer  the  operaHon  

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Intraventricular  tumors  

•  These  are  deep  seated  brain  tumors  which  can  arise  from  within  or  grow  into  the  ventricular  symptoms  

•  It  is  now  possible  with  neuroendoscopy  to  take  a  biopsy  or  remove  these  tumors  under  vision  and  perform  a  ventriculostomy  at  the  same  Hme    

•  This  is  usually  followed  by  radiaHon  and/or  chremo  therapy  

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Intraventricular  tumors  

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Intraventricular  tumors  

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Low-­‐grade  astrocytoma  in  the  posterior  porHon  of  the  third  ventricle    (a)  The  T2-­‐weighted  preoperaHve  MRI  

scan  shows  that  the  tumor  is  causing  obstrucHve  hydrocephalus  

(b)  Endoscopic  biopsy  of  the  tumor  

(c)  Immediately  acer  biopsy,  a  third  ventriculostomy  is  performed  to  treat  the  occlusive  hydrocephalus  

(d)  The  postoperaHve  MRI  shows  a  prominent  flow  void  at  the  floor  of  the  third  ventricle,  indicaHng  flow  of  CSF  into  the  interpeduncular  fossa.  

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Coloid  cysts  

•  These  are  rare  and  small  cysts  located  in  a  crucial  area  of  the  ventricle  where  they  can  block  the  flow  of  cerebrospinal  fluid  (foramen  Monroe)    

•  Although,  microsurgery  for  these  is  quite  successful,  endoscopic  techniques  have  been  developed  to  excise  these  cysts  through  an  even  smaller  opening  

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Coloid cyst is blocking aqueductus cerebri!!!

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Thank you for your attention

Questions and answers

University Medical center Ljubljana