Endoscopic treatment of complex multiloculated hydrocephalus in children, steps that may help to decrease revision rate

Background: Multiloculated hydrocephalus (MLH) is associated with increased intracranial pressure, with intraventricular septations, loculations, and isolation of parts of the ventricular system. Search continues for ideal surgical remedy capable of addressing the dimensions of the problem. We aimed to evaluate endoscopic septal fenestration and pellucidotomy combined with proximal shunt tube refashioning and further advancement into isolated loculations of the ventricular system containing choroid plexus. Methods: This retrospective study was conducted on 55 patients with symptomatic complex MLH who underwent endoscopic surgery. The collected data included patients’ age, gender, presenting manifestations, operative details, rate of remission of preoperative clinical and imaging signs, postoperative complications, redo surgery, or extra shunt hardware insertion. Patients were divided into Group A (underwent the standard technique of endoscopic multiseptal wide fenestration and final ventriculoperitoneal shunt insertion) and Group B (modified technique by adding extra side ports along the proximal shunt hardware). Results: Groups A and B included 25 and 30 patients, respectively. The percentage of patients showing improvement of almost all manifestations was higher in Group B compared to Group A, with no significant difference (P > 0.05). Group B had lower rate of complications (20% vs. 36%, P = 0.231), insertion of two shunts (16.7% vs. 20%, P = 1.000), and redo surgery (20% vs. 44%, P = 0.097). Conclusion: The modified technique was associated with better outcomes in terms of the use of single shunt and redo surgery. Launching randomized clinical trials to compare the two techniques are recommended to ascertain the efficacy of the modified technique.

Visual hallucination caused by multiloculated hydrocephalus in the frontal lobe: a case report

A 72-year-old man consulted our hospital for visual hallucination. His non-contrast computed tomography (CT) of head showed multiloculated hydrocephalus in the frontal lobe. Memantine treatment was started and his visual hallucination disappeared. This is a rare case of frontal lobe damage causing visual hallucination.

Neuroendoscopic surgery in neonates — indication and results over a 10-year practice

Purpose Neuroendoscopic procedures for treatment of term and preterm newborn infants, such as endoscopic lavage for posthemorrhagic hydrocephalus, are gaining popularity despite sparse data. This single-institution report compiles all neuroendoscopic surgical procedures performed in neonates during a 10-year period. Methods Charts and electronic records were reviewed of all consecutive newborns who underwent a neuroendoscopic procedure before reaching a postmenstrual age of 44 weeks between 09/2010 and 09/2020. Available documentation was reviewed regarding the performed neuroendoscopic procedure, course of disease, complications, and all re-operations throughout the first year of life. Results During the 10-year study period, 116 infants (median gestational age at birth: 29 1/7 weeks) underwent a total of 153 neuroendoscopic procedures (median postmenstrual age at surgery: 35 0/7 weeks). The most common indication at the time of the neuroendoscopic procedures (n = 153) was intraventricular hemorrhage (IVH, n = 119), intraventricular infection (n = 15), congenital malformation (n = 8), isolated 4th ventricle (n = 7), multiloculated hydrocephalus (n = 3), and tumor (n = 1). Thirty-eight of 116 children (32.8%) underwent 43 operative revisions after 153 neuroendoscopic procedure (28.1%). Observed complications requiring surgical revision were secondary infection (n = 11), CSF fistula (n = 9), shunt dysfunction (n = 8), failure of ETV (n = 6), among others. 72 children (62%) of 116 children required permanent CSF diversion via a shunt. The respective shunt rates per diagnosis were 47 of 80 (58.8%) for previously untreated IVH, 11 of 13 (84.6%) for intraventricular infection. Shunt survival rate for the first year of life was 74% for the whole cohort. Conclusion The experience with this large cohort of neonates demonstrates the feasibility of neuroendoscopic technique for the treatment of posthemorrhagic or postinfectious hydrocephalus. Rate and type of complications after neuroendoscopic procedures were within the expected range. Assessing the potential long-term benefits of neuroendoscopic techniques has to await results of ongoing studies.

Ventriculosubgaleal shunt and neuroendoscopic lavage: refining the treatment algorithm of neonatal post-hemorrhagic hydrocephalus

Background The optimal management of neonatal post-hemorrhagic hydrocephalus (PHH) is still debated, though several treatment options have been proposed. In the last years, ventriculosubgaleal shunt (VSgS) and neuroendosdcopic lavage (NEL) have been proposed to overcome the drawbacks of more traditional options, such as external ventricular drainage and ventricular access device. Methods We retrospectively reviewed neonates affected by PHH treated at our institution since September 2012 to September 2020. Until 2017 patients received VSgS as initial treatment. After the introduction of NEL, this treatment option was offered to patients with large intraventricular clots. After NEL, VSgS was always placed. Primary VSgS was reserved to patients without significant intraventricular clots and critically ill patients that could not be transferred to the operating room and undergo a longer surgery. Results We collected 63 babies (38 males and 25 females) with mean gestational age of 27.8 ± 3.8SD weeks (range 23–38.5 weeks) and mean birthweight of 1199.7 ± 690.6 SD grams (range 500–3320 g). In 6 patients, hemorrhage occurred in the third trimester of gestation, while in the remaining cases hemorrhage complicated prematurity. This group included 37 inborn and 26 outborn babies. Intraventricular hemorrhage was classified as low grade (I–II according to modified Papile grading scale) in 7 cases, while in the remaining cases the grade of hemorrhage was III to IV. Mean age at first neurosurgical procedure was 32.2 ± 3.6SD weeks (range 25.4–40 weeks). Death due to prematurity occurred in 5 patients. First-line treatment was VSgS in 49 patients and NEL in the remaining 14 cases. Mean longevity of VSgS was 30.3 days (range 10–97 days) in patients finally requiring an additional treatment of hydrocephalus. Thirty-two patients required one to three redo VSgS. Interval from initial treatment to permanent shunt ranged from 14 to 312 days (mean 70.9 days). CSF infection was observed in 5 patients (7.9%). Shunt dependency was observed in 51 out of 58 surviving patients, while 7 cases remained shunt-free at the last follow-up. Multiloculated hydrocephalus was observed in 14 cases. Among these, only one patient initially received NEL and was complicated by isolated trapped temporal horn. Conclusions VSgS and NEL are two effective treatment options in the management of PHH. Both procedures should be part of the neurosurgical armamentarium to deal with PHH, since they offer specific advantages in selected patients. A treatment algorithm combining these two options may reduce the infectious risk and the risk of multiloculated hydrocephalus.

Multiloculated Hydrocephalus: Surgical Techniques

Objective: Hydrocephalus shunt remains as the most common treatment choice for nonobstructive hydrocephalus, but in some cases multiloculated hydrocephalus (MH) remains a difficult neurosurgical disease despite of the different therapeutic options available. In children with MH multiple shunt procedures combined with neuroendoscopy may be required.(1) The rationale for neuroendoscopy in such complex cysts and multiloculated hydrocephalus is also to open several compartments to the normal fluid-filled spaces, minimize the number of isolated/loculated CSF spaces, and decrease shunt dependency and the number of proximal shunt catheters.(2) In such cases our major objective is keep the children with one or no one shunt and with one normal intracranial pressure (ICP). Most patients with multiloculated hydrocephalus are infants with a severe disability who present with high intracranial pressure. Multiple shunting was a routine practice so far to normalize the intracranial pressure, but in these cases shunt complications could be quite common including shunt infection, malposition and malfunction which needed more shunt revision surgeries.(1, 3) Neuroendoscopy has changed the treatment options for complex multiloculated hydrocephalus. The possibility to do several fenestrations and change multiples cysts in one simple cyst or ventricle was one important improvement in MH treatment.(4-6) In this review we will discuss aspects related to etiology, surgical techniques, and results in multiloculated hydrocephalus. Methods: The authors carried out a literature review on multiloculated hydrocephalus and evaluated a series of personal cases operated in the recent years. The keywords loculated hydrocephalus and surgical technique were used in Pubmed database website. Fifty-two articles were obtained and reviewed. From these publications we select the most relevant ones for the presentation. The articles were divided according to the main subject, with articles on etiology, surgical techniques and outcomes were selected. We also reviewed some difficult cases with MH from personal experience. In all of those cases endoscopy procedures were performed associated to shunt procedures in all cases. The authors described some different techniques of cyst fenestration and the association to shunt or not. Results/Discussion: Neuroendoscopy has changed the treatment in MH. This is a very difficult and interesting disease. Common risk factors for the development of MH include intraventricular hemorrhage, bacterial meningitis, shunt infection, and cerebrospinal fluid (CSF) overdrainage from shunt placement (rare). The magnetic resonance imaging (MRI) or computerized tomography (CT) scan with evidence of septations causing marked nonuniform compartmentalization and enlargement within the ventricular system are the most important ways to do the diagnosis of MH. Predisposing factors include low birth weight, prematurity, perinatal complications, and congenital malformation. Although the full pathogenesis of MLH remains unclear, it is known that inflammation leads to subependymal gliosis, which produces glial tufts and septations that occlude the normal ventricle system. Septations also develop via organization of intraventricular exudate and debris from ventriculitis. Despite os clinical history of poor outcome, head circuference increase and prior infection or brain bleeding, we need image to perform the diagnosis. Types of loculated hydrocephalus could be divided in: multiloculated and uniloculated. The most important classification was done by Spennato.(5) He divided in five types: 1) hydrocephalus with multiple intraventricular septations; 2) isolated lateral ventricle/unilateral hydrocephalus; 3) entrapped temporal horn; 4) isolated fourth ventricle; 5) expanding cavum septi pellucidi/cavum vergae Using the endoscope to treat MH has some advantages.(7, 8) This is a less invasiveness and this is very important in kids.(6) Avoidance of brain retraction, less blood loss, faster operation time, and shorter hospital stay. But endoscopy has some risk and possible complications. It also has several disadvantages. A subdural hematoma and/or hygroma may form, but the incidence of this is lower than with open craniotomy. The risk of ventriculitis, CSF leakage (subcutaneous CSF collection), and hemorrhage are reported to be like that with open craniotomy. Intraoperative bleeding can usually be easily managed by irrigation or coagulation. However, handling of significant intraoperative bleeding is not as easy in endoscopy as in open craniotomy.(9) Some new technologies could improve the outcome and avoid risk and complications.(10, 11) Navigation could be used in two forms: Navigation system is used to planning the entry point and the endoscopy trajectory Endoscopy guided and navigation during all surgical time. The evaluation of results is presented in different ways in the literature. The main outcomes observde for measuring results were: hydrocephalus control or not, number of surgery performed and number of catheters used.(4) Shunt Independence is rare. Conclusion: Multiloculated hydrocephalus is one difficult disease to treat.(4) Neuroendoscopy cyst fenestration was one great improvement in treatment of MH, but after this new procedure the clinical outcome still no so good. Endoscopy is important to decrease the number of shunts and surgeries.

Y-shaped Ventriculo-peritoneal Shunt for Adult Complicated Hydrocephalus: Report of 28 Illustrative Cases

ObjectiveTo investigate the effectiveness of Y-shaped ventriculo-peritoneal shunt (VPS) (one abdominal tip connected with double or triple ventricular tips by one or two Y-shaped connectors) in the treatment of adult complicated hydrocephalus, we analyzed the long-term outcome and reported some illustrative cases.MethodsAmong 1,100 VPS surgeries between 2012 and 2017 in neurosurgery of Beijing Tiantan Hospital, twenty-eight (2.5%) adult patients with multiloculated hydrocephalus treated with Y-shaped shunt were analyzed.ResultsNineteen patients underwent Y-shaped VPS (bilateral frontal horn shunt) before or without tumor resection/stereotactic biopsy, 7 patients underwent Y-shaped VPS after tumor resection (5 bilateral and 2 triple shunts), and the other 2 patients underwent sequential bilateral VPS (unilateral VPS with additional contralateral ventricular tip by Y-shaped connector 6 months later). The one-year and two-year hydrocephalus-free survival rate for was both 88.7%. The one-year and two-year overall survival rate was both 66.7%. Cox regression confirmed that the OS is correlated with tumor grades. ConclusionsY-shaped VPS strategy is an easy and reliable option for multiloculated hydrocephalus, which can be used as the first choice for some indications.

Role of intraoperative computed tomography scanner in modern neurosurgery – An early experience

Background: Intraoperative imaging addresses the limitations of frameless neuronavigation systems by providing real-time image updates. With the advent of new multidetector intraoperative computed tomography (CT), soft tissue can be visualized far better than before. We report the early departmental experience of our intraoperative CT scanner’s use in a wide range of technically challenging neurosurgical cases. Methods: We retrospectively analyzed the data of all patients in whom intraoperative CT scanner was utilized. Out of 31 patients, 24 (77.4%) were cranial and 8 (22.6%) spinal cases. There were 13 male (41.9%) and 18 (58.1%) female patients, age ranged from 1 to 83 years with a mean age of 34.29 years ±17.54 years. Seven patients underwent spinal surgery, 2 cases were of orbital tumors, and 16 intra-axial brain tumors, including 5 low- grade gliomas, 10 high-grade gliomas, and 1 colloid cyst. There were four sellar lesions and two multiloculated hydrocephalus. Results: The intraoperative CT scan guided us to correct screw placement and was crucial in managing four complex spinal instabilities. In intracranial lesions, 59% of cases were benefitted due to intraoperative CT scan. It helped in the precise placement of ventricular catheter in multiloculated hydrocephalus and external ventricular drain for a third ventricular colloid cyst. Conclusion: Intraoperative CT scan is safe and logistically and financially advantageous. It provides versatile benefits allowing for safe and maximal surgery, requiring minimum changes to an existing neurosurgical setup. Intraoperative CT scan provides clinical benefit in technically difficult cases and has a smooth workflow.