Pineal region tumors: Long-term results of endoscopic third ventriculostomy and concurrent tumor biopsy with a single entry approach in a series of 64 cases

Object Simultaneous endoscopic third ventriculostomy (ETV) and tumor biopsy is a widely accepted therapeutic and diagnostic procedure for patients with noncommunicating hydrocephalus secondary to a pineal region tumor. Multiple approaches have been advocated, including the use of a steerable fiberoptic or rigid lens endoscope via 1 or 2 trajectories. However, the optimal approach has not been established based on the individual anatomical characteristics of the patient. Methods A retrospective review of patients undergoing simultaneous ETV and tumor biopsy was undertaken. Preoperative MR images were examined to measure the width of the anterior third ventricle and maximal diameters of the tumor, Monro foramen (right), and massa intermedia. The distances between the tumor and massa intermedia, tumor and anterior commissure, midbrain and massa intermedia, and the dorsum sella and anterior commissure were also recorded. Single and dual trajectory approaches were compared using paired t-tests for each parameter. Results Over an 8-year interval, 15 patients underwent simultaneous ETV and tumor management. These patients ranged from 6 to 71 years of age (mean 36.7 years); 5 were younger than 18 years of age. Seven were treated using a dual trajectory approach, and 8 were treated using a single trajectory approach. All cases were completed without complications or the need for an additional CSF diversionary procedure within 6 months. The diagnostic yield at biopsy was 86.7%. There were no statistically significant differences between the single and dual trajectory groups for the measured parameters. However, the dual trajectory group demonstrated a larger anterior third ventricular diameter (1.43 vs 1.21 cm, p = 0.29). The single trajectory group trended toward a smaller tumor–anterior commissure interval (2.23 vs 2.51 cm, p = 0.24) and a larger dorsum sella–anterior commissure distance (1.67 vs 1.49 cm, p = 0.28). Conclusions These data confirm the safety and diagnostic efficacy of simultaneous ETV and biopsy for tumors of the pineal region. Although no statistically significant differences were seen in the authors' recorded measurements, several trends suggest a role for a tailored approach to selecting a single or dual trajectory approach when using a rigid endoscope.

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Pineal Region Tumors: Simultaneous Endoscopic Third Ventriculostomy and Tumor Biopsy

World Neurosurgery ◽

10.1016/j.wneu.2012.02.020 ◽

2013 ◽

Vol 79 (2) ◽

pp. S18.e9-S18.e13 ◽

Cited By ~ 34

Author(s):

Peter F. Morgenstern ◽

Mark M. Souweidane

Keyword(s):

Endoscopic Third Ventriculostomy ◽

Pineal Region ◽

Third Ventriculostomy ◽

Tumor Biopsy ◽

Pineal Region Tumors

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Combined endoscopic third ventriculostomy and tumor biopsy in the management of pineal region tumors, safety considerations

Egyptian Journal of Neurosurgery ◽

10.1186/s41984-018-0022-7 ◽

2018 ◽

Vol 33 (1) ◽

Author(s):

Mohamed Amer Ibrahim Amer ◽

Hytham Ibrahim Shokry Elatrozy

Keyword(s):

Endoscopic Third Ventriculostomy ◽

Pineal Region ◽

Third Ventriculostomy ◽

Tumor Biopsy ◽

Pineal Region Tumors ◽

Safety Considerations

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One- vs Two-Burr-Hole Technique for Combined Endoscopic Third Ventriculostomy and Pineal Region Biopsy: Volumetric Analysis of Brain at Risk

Operative Neurosurgery ◽

10.1093/ons/opaa010 ◽

2020 ◽

Vol 19 (2) ◽

pp. 175-180

Author(s):

Brandon D Liebelt ◽

Fangxiang Chen ◽

Antonio Biroli ◽

Xiaochun Zhao ◽

Peter Nakaji

Keyword(s):

At Risk ◽

Endoscopic Third Ventriculostomy ◽

Brain Parenchyma ◽

Pineal Region ◽

Burr Hole ◽

Third Ventriculostomy ◽

Tumor Biopsy ◽

Burr Holes ◽

The Brain ◽

The Ideal

Abstract BACKGROUND Pineal region tumors are associated with the ventricular system. Endoscopic third ventriculostomy (ETV) is often performed at the same time as tumor biopsy. OBJECTIVE To investigate the volume of brain possibly undergoing injury and forniceal stretching during ETV and tumor biopsy. METHODS We performed a retrospective review of preoperative magnetic resonance imagings (MRIs) and computed tomography (CTs) of patients with pineal region masses and used volumetric image-guided navigation to simulate a 1-burr-hole vs a 2-burr-hole approach through the brain parenchyma. We compared the volumes of parenchyma and fornix at the risk of injury. RESULTS The ideal entry point for ETV using 2 burr holes was a mean ± standard deviation (SD) of 25.8 ± 6 mm from the midline and 11.4 ± 9 mm behind the coronal suture. The ideal entry point using 2 burr holes for tumor biopsy was 25.7 ± 8 mm from the midline and 53.7 ± 14 mm anterior to the coronal suture. With 1 burr hole, the mean ± SD volume of brain parenchyma at risk was 852 ± 440 mm3. The volume of brain parenchyma at risk with 2 burr holes was 2159 ± 474 mm3 (P < .001; paired t-test). The use of 1 burr hole predisposed the fornix to 14 ± 3 mm of possible stretch, which was minimized with the 2-burr-hole approach. CONCLUSION Using 1 burr hole for both the ETV and tumor biopsy is less likely to traumatize the brain parenchyma than using 2 burr holes. However, 1 burr hole predisposes the fornix to stretch injury. We recommend tailoring the entry to each patient according to their anatomy rather than using a 1-size-fits-all approach.

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Three-Dimensional Simulation of Collision-Free Paths for Combined Endoscopic Third Ventriculostomy and Pineal Region Tumor Biopsy: Implications for the Design Specifications of Future Flexible Endoscopic Instruments

Operative Neurosurgery ◽

10.1227/neu.0000000000001177 ◽

2015 ◽

Vol 12 (3) ◽

pp. 231-238 ◽

Cited By ~ 5

Author(s):

Kyle W Eastwood ◽

Vivek P Bodani ◽

James M Drake

Keyword(s):

Software Package ◽

Endoscopic Third Ventriculostomy ◽

Third Ventricle ◽

Three Dimensional ◽

Pineal Region ◽

Third Ventriculostomy ◽

Tumor Biopsy ◽

Foramen Of Monro ◽

Tumor Margin ◽

Pineal Region Tumor

Abstract BACKGROUND Recent innovations to expand the scope of intraventricular neuroendoscopy have focused on transitioning multiple-incision procedures into single-corridor approaches. However, the successful adoption of these combined procedures requires minimizing the unwanted torques applied to surrounding healthy structures. OBJECTIVE To define the geometry of relevant anatomical structures in endoscopic third ventriculostomy (ETV) and pineal region tumor biopsy (ETB). Second, to determine the optimal instrument shaft path required for collision-free single burr hole combined ETV/ETB. METHODS Magnetic resonance and computed tomography data from 15 pediatric patients who underwent both ETV and ETB procedures between 2006 and 2014 was segmented by using the 3DSlicer software package to create virtual 3-D patient models. Anatomical regions of interest were measured including the foramen of Monro, the massa intermedia, the floor of the third ventricle, and the tumor margin. Utilizing the MATLAB software package, virtual dexterous instruments were inserted into the models and optimal dimensions were calculated. RESULTS The diameters of the foramen of Monro, massa intermedia (anterior-posterior, superior-inferior), anterior third ventricle, and tumor margin are 6.85, 4.01, 5.05, 14.2, and 28.5 mm, respectively. The average optimal burr placement was determined to be 22.5 mm anterior to the coronal and 30 mm lateral to the sagittal sutures. Optimal flexible instrument geometries for novel instruments were calculated. CONCLUSION We have established a platform for estimating the shape of novel curved dexterous instruments for collision-free targeting of multiple intraventricular points, which is both patient and tool specific and can be integrated with image guidance. These data will aid in developing novel dexterous instruments.

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Hydrocephalus in achondroplasia: efficacy of endoscopic third ventriculostomy

Journal of Neurosurgery Pediatrics ◽

10.3171/2021.9.peds21242 ◽

2021 ◽

pp. 1-8

Keyword(s):

Surgical Complications ◽

Medical Records ◽

Endoscopic Third Ventriculostomy ◽

Ventricular Volume ◽

Long Term Results ◽

Third Ventriculostomy ◽

Historical Comparison ◽

Number Of Patients ◽

Significant Difference

OBJECTIVE Ventriculoperitoneal shunts (VPSs) for hydrocephalus in patients with achondroplasia are known to have a higher failure rate than in other hydrocephalus populations. However, the etiology of hydrocephalus in this group is considered “communicating,” and, therefore, potentially not amenable to endoscopic third ventriculostomy (ETV). ETV has, nonetheless, been reported to be successful in a small number of patients with achondroplasia. The authors aimed to investigate the long-term results of ETV in this population. METHODS Patients with achondroplasia who had undergone surgical treatment for hydrocephalus (ETV or VPS placement) were identified. In patients who had undergone ETV, medical records and neuroimages were reviewed to determine ventricular volumes and frontal and occipital horn ratios (FOHRs) pre- and postoperatively, as well as the incidence of surgical complications and reoperation. Patients who underwent VPS placement were included for historical comparison, and their medical records were reviewed for basic demographic information as well as the incidence of surgical complications and reoperation. RESULTS Of 114 pediatric patients with achondroplasia referred for neurosurgical consultation, 19 (17%) were treated for hydrocephalus; 10 patients underwent ETV only, 7 patients underwent VPS placement only, and 2 patients had a VPS placed followed by ETV. In patients treated with ETV, ventricular volume and FOHRs were normal, if measured at birth, and increased significantly until the time of the ETV. After ETV, all patients demonstrated significant and sustained decreases in ventricular measurements with surveillance up to 15 years. There was a statistically significant difference in rates of repeat CSF surgery between the ETV and VPS cohorts (0/12 vs 7/9, p < 0.001). CONCLUSIONS ETV was efficacious, safe, and durable in the treatment of hydrocephalus in patients with achondroplasia. Although many studies have indicated that hydrocephalus in these patients is “communicating,” a subset may develop an “obstructive” component that is progressive and responsive to ETV.

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LONG-TERM RESULTS OF A SECOND ENDOSCOPIC THIRD VENTRICULOSTOMY IN CHILDREN

Neurosurgery ◽

10.1227/01.neu.0000350228.08523.d1 ◽

2009 ◽

Vol 65 (3) ◽

pp. 539-547 ◽

Cited By ~ 38

Author(s):

Paola Peretta ◽

Giuseppe Cinalli ◽

Pietro Spennato ◽

Paola Ragazzi ◽

Claudio Ruggiero ◽

...

Keyword(s):

Endoscopic Third Ventriculostomy ◽

Imaging Study ◽

Pediatric Neurosurgery ◽

Long Term Results ◽

Preoperative Imaging ◽

Third Ventriculostomy ◽

Prepontine Cistern ◽

Operative Findings ◽

Second Procedure

Abstract OBJECTIVE To evaluate retrospectively the operative findings and long-term results of a repeat endoscopic third ventriculostomy (ETV) in pediatric hydrocephalic patients readmitted after the first procedure with symptoms and/or signs of intracranial hypertension and/or radiological evidence of increased ventricular dilation and/or occluded stoma on follow-up radiological examinations. METHODS We analyzed a series of 482 ETVs in pediatric patients from 2 Italian departments of pediatric neurosurgery. The clinical charts of 40 patients undergoing a second ETV were selected and reviewed retrospectively. The pre- and postoperative radiological findings and operative films were analyzed retrospectively. RESULTS Forty patients underwent a total of 82 ETVs. Thirty-eight patients were operated on twice and 2 were operated on 3 times. During the second procedure, the stoma was found to be closed in 28 patients without underlying adhesions, to be open but with significant arachnoid adhesions in the prepontine cistern in 8 patients, to be open without adhesions in 2 patients, to have a pinhole orifice in 1 patient, and to be closed with underlying adhesions in 1 patient. The second procedure allowed reopening of the stoma or lysis of the arachnoid adhesions in 35 patients and was abandoned in 3 patients because of extensive arachnoid adhesions or because the stoma was found to be wide open (2 patients). In 30 patients (75%), the second ETV was effective, and the 2 patients who underwent a third ETV remained shunt free. In 10 patients (25%), a ventriculoperitoneal shunt was eventually placed. Age younger than 2 years at the time of the first procedure and arachnoid adhesions in the subarachnoid cisterns observed during the second procedure are the main negative prognostic factors for the success of a second ETV. CONCLUSION A second ETV can be performed with a reasonable chance of restoring patency of the stoma and avoiding placement of an extrathecal shunt. Every effort should be made to detect subarachnoid adhesions in the cistern on preoperative imaging study to select potential candidates and avoid unnecessary procedures.

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The Role of Neuroendoscopy in the Treatment of Pineal Region Tumors

JBNC - JORNAL BRASILEIRO DE NEUROCIRURGIA ◽

10.22290/jbnc.v22i2.953 ◽

2018 ◽

Vol 22 (2) ◽

pp. 21-25

Author(s):

Flávio Ramalho Romero ◽

Eduardo De Freitas Bertolini ◽

Adalberto Sestari ◽

Sérgio Soares Guerrero ◽

Ramon Barbalha Guerrero ◽

...

Keyword(s):

Diagnostic Yield ◽

Pineal Region ◽

Endoscopic Biopsy ◽

Third Ventriculostomy ◽

Tumor Biopsy ◽

Pineal Tumors ◽

Pineal Region Tumors ◽

Therapeutic Outcomes ◽

Initial Procedure

Object. The authors report their experience in six patients presenting with pineal tumors and associated hydrocephalus who underwent an endoscopic biopsy procedure and third ventriculostomy (ETV) in a single setting. The purpose of this report is to discuss the role of neuroendoscopic procedures in the management of pineal region tumors. Methods. A retrospective review of patients undergoing simultaneous ETV and tumor biopsy was ndertaken. Neuroendoscopic surgery was first applied for tumor debulking with tissue diagnosis and gross morphological analysis of the tumor and the intraventricular structures, followed by third ventriculostomy. Subsequent procedures were determined on the basis of verified individual tumors. Results. Over a 2-year interval, 6 patients underwent simultaneous ETV and tumor management. These patients ranged from 6 to 54 years of age (mean 24.3 years). All cases were completed without complications or the need for an additional CSF diversionary procedure within 6 months. The diagnostic yield of the biopsy was 100%. Favorable therapeutic outcomes were obtained in all cases of germinoma and pineoblastoma, with follow-up periods ranging from 6 to 24 months. Conclusion. The majority of our patients with dilated ventricles were treated satisfactorily with effective neuroendoscopic procedures as the initial procedure, avoiding unnecessary craniotomy and promising excellent therapeutic outcomes.

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