Outcome of endoscopic transcortical intraventricular biopsy of isolated thickened pituitary stalk lesions in children

OBJECTIVE The purpose of this study was to investigate the efficacy and safety of endoscopic transcortical intraventricular biopsy in pediatric patients with isolated thickened pituitary stalk lesions. METHODS From 1994 to 2018, 16 pediatric patients (8 males and 8 females) underwent endoscopic transcortical intraventricular biopsy at a single institution to establish an accurate pathological diagnosis for appropriate treatment strategies. RESULTS Preoperatively, the median diameter of the pituitary stalks was 5.31 ± 1.67 mm (range 3.86–9.17 mm). Overall, the diagnostic yield at endoscopic intraventricular biopsy was 93.8%. Histopathological diagnosis included germinoma (n = 10, 62.5%), Langerhans cell histiocytosis (n = 4, 25%), pilocytic astrocytoma (n = 1, 6.3%), and pituicytoma (n = 1, 6.3%). Two patients developed new diabetes insipidus after the procedure, and 3 patients had new postoperative hypothyroidism. There were no postoperative neurological deficits in this series. CONCLUSIONS Neuroendoscopic biopsy via the transcortical intraventricular corridor was shown to be safe and to aid in a reliable histopathological diagnosis in the management of isolated pituitary stalk lesions in pediatric patients. It can be considered a minimally invasive alternative to open biopsy via transcranial or endonasal corridors.

GCT-38. RELAPSE PATTERNS OF INTRACRANIAL GERMINOMAS BEFORE AND AFTER ENDOSCOPIC ERA

PURPOSE We evaluated the relapse patterns of CNS germinomas before and after introducing neuroendoscopic biopsy in 2000. METHODS We retrospectively assessed the relapse patterns of 57 patients treated as pure germinoma or germinoma with STGC between 1980 and 2019 at University of Tsukuba, partially containing the patients of the previous report (Takano S et al., World Neurosurg, 2015). Median age was 15 y.o.(7y.o.~38y.o.), and men was 80.7%. Tumor locations were pineal 35, sellar 19, basal ganglia 3, others 11. Group A;1980~1999 was 20, and group B;2000~2019 was 37. From 1980 to 1994, whole brain irradiation(WB) 30.6 Gy plus whole ventricle irradiation(WV) 19.8 Gy. From 1995 to 1999, WV 26~30.6 Gy with Chemotherapy(Chem) or Chem alone. Since 2000, Chem for 3 kurr with WV 24~30.6 Gy, and 6–19.8 Gy as local boost to residual lesion. RESULTS Follow up periods were median 121 M(4.5M~386M; group A), and median 89 M(4 M~231 M; group B). Six patients(30%) recurred in the group A, as ex field 4(1;brain and extramedullary, 1;brain and paranasal sinus, 1;LV & third ventricle, 1;extramedullary), in field 1(LV). Chem only 1(LV & third ventricle). Two patients(5.4%) recurred in the group B, as ex field 2(1;intramedullary, 1;extramedullary). The group A showed CR;18, PR;1, Dead;1(Dissemination), and the group B showed CR;35, PR;1 Dead;1(Encephalopathy). CONCLUSION WV and Chem prevented extrafield recurrence keeping good quality of life. Neuroendscopy biopsy with ETV did not increase CSF seeding.

Is there variable neuronal susceptibility to compression?

A 12-year-old boy with suprasellar germinoma complicated by hydrocephalus was found to have dorsal midbrain syndrome and bilateral compressive optic neuropathy. Following a third ventricular neuroendoscopic biopsy and the initiation of chemotherapy, a follow-up magnetic resonance imaging scan of the brain showed significant regression of the tumor with resolution of hydrocephalus. On smooth pursuit, there was significant improvement in upgaze. However, light-near dissociation of his pupillary defect was persistent. Fundal examination showed persistent temporal pallor of the optic discs bilaterally, associated with a suboptimal best-corrected visual acuity of 20/40 and bilateral centrocecal scotoma.The differential recovery of neuronal function following relief of compression is poorly understood. In this case, both the optic nerve and pretectal axonal fibers responsible for pupillary reflex, with their neuronal cell bodies residing outside the direct compressive site at the midbrain, showed poor functional recovery. However, relief of pressure at the rostral interstitial medial longitudinal fasciculus and posterior commissure nuclear complexes resulted in significant clinical improvement in upgaze. This case suggests that, for neurons, axons are apparently more susceptible to pressure than cell bodies. The predominant transmission of nerve impulses takes place through the length of axons, and thus is more sensitive to pressure changes, with the associated microvascular compromise and demyelination.

A Case of Neurosarcoidosis-Induced Syndrome of Inappropriate Secretion of Antidiuretic Hormone Diagnosed with Neuroendoscopy

We treated a patient with neurosarcoidosis, which caused the syndrome of inappropriate secretion of antidiuretic hormone (SIADH), in whom diagnosis was performed using neuroendoscopy. The patient was a 56-year-old female who was hospitalized for hyponatremia and diagnosed with SIADH based on a detailed examination. During the course, she developed impaired consciousness due to acute hydrocephalus, which improved after ventricular drainage. Head magnetic resonance imaging (MRI) confirmed nodular lesions at the floor of the third ventricle and the cerebral aqueduct. Neuroendoscopic biopsy led to the diagnosis of neurosarcoidosis. Her hyponatremia improved after steroid therapy. Neurosarcoidosis can cause SIADH, and complication of hydrocephalus may lead to a poor prognosis. Neuroendoscopy appears to be effective for the diagnosis of neurosarcoidosis with hydrocephalus and helps in deciding the treatment modality.

Neuroendoscopic biopsy of brain lesions: accuracy and complications

OBJECT The authors conducted a study to analyze the accuracy of neuroendoscopic biopsies of ventricular and periventricular lesions and record any difficulties or complications of the neuroendoscopic biopsy procedure. METHODS A total of 50 patients with different diseases consecutively underwent endoscopic biopsy procedures. The biopsy result was considered diagnostic if the pathologist reported any specific finding on which clinicians could base decisions about treatment or observation. The biopsy result was referred to as accurate if the results matched results of a sample obtained later or if the treatment response and disease evolution were compatible with the diagnosis. The biopsy result was considered inaccurate if results showed any relevant differences from those of the later sample or if the patient's disease did not evolve as expected. Complications were recorded and compared with those found in a literature review. RESULTS For 2 patients, the procedure had to be terminated. The biopsy diagnostic rate was 89.6%, and the accuracy rate was 86%. Complications associated with the procedure were 3 hemorrhages (6%), 2 infections (4%), and 1 death (2%); no reoperations were needed. CONCLUSIONS Endoscopic biopsy seems to be an accurate procedure with acceptable morbidity and mortality rates.