NEUROENDOSCOPY Department of Neurosurgery University Medical center Ljubljana

NEUROENDOSCOPY Department of Neurosurgery, University Medical center Ljubljana

Hydrocephalus • • Hydrocephalus means excess water in the brain Traditional treatment: – • • Shunt insertion (ventriculo-peritoneal, ventriculoatrial, ventirulo-plavral) up to 20% of patients can develop complications Neuroendoscopy is now being used to perform a THIRD VENTRICULOSTOMY - a new passage is created between venticular system and subarahnoidal space -> an excessive amount of water can be absorbed In obstructive hydrocephalus this is the treatement of choice a bypass around aqueductus cerebri is made Neuroendoscopy 4

Application ADVANTAGES • • • DISADVANTAGES Less pain than traditional surgery Faster recovery than traditional surgery, shorter hospital stay and quicker return to normal activities Minimal scarring Small incision site and minimal trauma to the brain or spinal cord In some instances, the surgery is substantially shorter than traditional surgical approaches • • Only 2 D image Less space to perform surgery Learning curve Lack of appropriate endoscopic instruments Neuroendoscopy 5

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 relatively new and rapidly developing concept • Three basic prerequisities 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 Neuroendoscopy 6

History (the beginning) • 1910: L’Espinasse, a Chicago urologist, perform the first neurosurgical endoscopic procedure (fulguration of choroid plexus in two infants with hydrocephalus) • 1923: Mixter, a neurosurgeon, performed the first endoscopic ventriculostomy in a child with congenital obstructive hydrocephalus Neuroendoscopy 7

History (decline of neuroendoscopy) • • Treatement of hydrocephalus was replaced by placement of ventriculoperitoneal shunts The end of the initial era of neuroendoscopy The birth of microneurosurgery in the 1960 s pushed endoscopy further into the background The microscope allow neurosurgeons to perform operations deep within the brain and at the base of the skull with both adequate illumination and magnification Neuroendoscopy 8

History (extension of neuroendoscopy) • Extension of the use of neuroendoscopy to: – – – • intraventricular tumors skull base tumors Craniosynostosis degenerative spine disease intracranial cysts rare subtypes of hydrocephalus There is the vast potential of the endoscope in neurosurgery Neuroendoscopy 9

Indications for intracranial endoscopic procedures • The indications for neuroendoscopic operations have been standardized in the last few years • In general, neuroendoscopy is used for procedures in preexisting or pathologically formed cavities in the central nervous system Neuroendoscopy 10

Indications for intracranial endoscopic procedures PURE ENDOSCOPIC PROCEDURE 1. Hydrocephalus – – – Third ventriculostomy Aqueductoplasty Compartmentalized hydrocephalus Septum pellucidotomy Multicompartment hydrocephalus Ventricular catheter placement ENDOSCOPIC ASSISTED MICROSURGERY • • a very recent concept an endoscope is used along with the microscope a whole new world of possibilities reduced size of the craniotomy and minimally invasiveness 1. 2. 3. 4. 5. 2. Intraventricular Tumors 3. Arachnoid cysts – fenestracion 4. Colloid Cysts Neuroendoscopy Pituitary tumor resection Skull base tumor biopsy Cerebral aneurysms Microvascular decompression Acoustic neuromas 11

Endoscopic third ventriculostomy Third ventricle A perforation of lamina terminalis is made to bypass the aquductal stenosis Subarahnoidal space (cisterna interpedunclularis) Aquductus cerebri Neuroendoscopy 12

Endoscopic third ventriculostomy • Our case: – 8 months old child after postnatal intraventricular bleeding -> the blood cloth blocked the aqueductus cerebri -> Head circumference started to increase Aqueductal stenosis Neuroendoscopy 13

Endoscopic third ventriculostomy Choroid plexus • A view of the floor of the third ventricle – LAMINA TERMINALIS • Lamina terminalis Endoscope passed through the foramen Monroe into the third ventricle Corpora mamilaria Neuroendoscopy 14

Endoscopic third ventriculostomy A case from our clinic Neuroendoscopy 15

Arachnoid cysts • arachnoid cysts constitute 1% of all intracranial mass lesions • they are seen in 1% of the population • 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 malformations that arise from the unexplained splitting or tearing of the arachnoid membrane • Neuroendoscopy prvides a simple solution to these cysts simply by fenestrating them in the depth so that the extra water can be absorbed internally Neuroendoscopy 16

Arachnoid cysts (our experience) CYST BRAIN PARENHYMA Neuroendoscopy 17

Arachnoid cysts (our experience) • • Neuroendoscopy A cyst fenestration into the ventricular system was performed With a help of a microsurgery, cyst was resected and obstruction was released 18

Arachnoid cysts (our experience) • • Neuroendoscopy Before the operation 7 months after the operation 19

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 time This is usually followed by radiation and/or chremo therapy Neuroendoscopy 20

Intraventricular tumors Neuroendoscopy 21

Intraventricular tumors Low-grade astrocytoma in the posterior portion of the third ventricle (a) The T 2 -weighted preoperative MRI scan shows that the tumor is causing obstructive hydrocephalus (b) Endoscopic biopsy of the tumor a d (c) Immediately after biopsy, a third ventriculostomy is performed to treat the occlusive hydrocephalus (d) The postoperative MRI shows a prominent flow void at the floor of the third ventricle, indicating flow of CSF into the interpeduncular fossa. b c Neuroendoscopy 22

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 Coloid cyst is blocking aqueductus cerebri!!! Neuroendoscopy 23

Thank you for your attention Questions and answers University Medical center Ljubljana