Elsevier

World Neurosurgery

Volume 108, December 2017, Pages 817-825
World Neurosurgery

Original Article
Results of Combined Intraventricular Neuroendoscopic Procedures in 130 Cases with Special Focus on Fornix Contusions

Portions of this work were presented in abstract form at the annual meeting of the Deutschen Gesellschaft für Neurochirurgie, June 8–10, 2015, in Karlsruhe, Germany.
https://doi.org/10.1016/j.wneu.2017.09.045Get rights and content

Objective

Increasing experience with intraventricular neuroendoscopic procedures shows good results in the combination of endoscopic third ventriculostomy (ETV) and tumor biopsy. Other possible combinations are mainly presented in subgroups in the literature. Here, we present our experience with combined intraventricular procedures within 1 setting over the last 2 decades.

Methods

This study retrospectively analyzes data from neuroendoscopic intraventricular procedures between 1993 and 2015 in 3 different departments of neurosurgery. Inclusion criteria were a combination of at least 2 intraventricular endoscopic procedures (e.g. third ventriculostomy, cyst fenestration, tumor surgery or aqueductoplasty) within 1 setting.

Results

One-hundred and thirty cases with more than 300 procedures fulfilled the inclusion criteria. The most frequent combinations were ETV and tumor biopsy (n = 36), ETV and aqueductoplasty/stenting (n = 30), and ETV and cyst fenestration (n = 18). The complication rate was 16.9% with an overall morbidity of 1.6% and mortality of 0.8%. Fornix contusion was one of the most frequent intraoperative complications (16.4%). Shunt independency was achieved in 82.9% of cases with hydrocephalic symptoms.

Conclusions

A combination of different intraventricular endoscopic procedures is safe and reliable, bearing similar risks of morbidities and mortality to single neuroendoscopic procedures. This study is one of the largest series in the literature and has similar low complication rates to others. Fornix contusion is the most frequent intraoperative complication in these patients. However, obvious clinical correlation is rare.

Introduction

Neuroendoscopic procedures have been under constant evaluation and debate since the first steps in the early twentieth century by Walter Dandy.1 The introduction of new instruments including rod lens and high-resolution cameras helped to overcome the high morbidity and mortality, resulting in an increase of neuroendoscopic procedures.2, 3 The development of new techniques over recent decades has enabled a wide range of possible intraventricular procedures.

The most common procedure is endoscopic third ventriculostomy (ETV). This procedure has proved its value as the gold standard for treatment of obstructive hydrocephalus because of the high success rate and minimal complication rates.4, 5 Techniques for the treatment of aqueductal stenosis or isolated fourth ventricle were developed successfully.6, 7, 8, 9 Alternatives to ETV for the treatment of obstructive hydrocephalus have also been introduced successfully, using the fenestration of the lamina terminalis10, 11 as well as fenestration of the septum.12 Furthermore, different options for the treatment of intraventricular cyst by fenestration or resection have been successfully established.13, 14 Of course, it is possible that a combination of those procedures is necessary in clinical cases. Endoscopic tumor biopsy and simultaneous ETV is the most common combined procedure described in the literature. A recent meta-analysis of nearly 2100 endoscopic biopsies in 1513 cases showed a combination with other neuroendoscopic procedures, mainly ETV, in 82.7% of the cases.15 However, particular combinations can be found as small subgroups in studies of intraventricular procedures.14, 16, 17 There is a lack of information concerning particular risks of combined procedures, and therefore, this study focus on a retrospective analysis of our database, focusing on the outcome and complication rate strictly in combined procedures. Detailed reports of potential intraoperative lesions through endoscopic intraventricular procedures are rare in the literature.18, 19 Because the combination of 2 procedures may increase stress at the foramen of Monro,20 particular reference was given to the intraoperative extent of fornix contusion.

Section snippets

Methods

This report includes all patients who underwent combined endoscopic procedures from the Department of Neurosurgery, Ernst Moritz Arndt University, Greifswald, Germany between January 1993 and March 2003; from the Department of Neurosurgery, Hannover Nordstadt Hospital between April 2003 and September 2008; and from the Department of Neurosurgery, Saarland Medical School, Germany between December 2010 and April 2015.

Patients with combined procedures were defined as cases in which at least 2

Results

Overall, 130 patients (72 male; 59 female) were included. The age ranged from 4 months to 82 years. Twenty-nine patients were younger than 15 years and 10 patients were younger than 19 years at the time of surgery. The mean follow-up was 16 months. The main presenting symptoms were headache (62%), nausea/vomiting (33%), and ataxia/coordination problems (26%). A decrease of consciousness was observed in 24%. Signs of paresis occurred in 11% of cases.

The single procedures represented were 101

Discussion

Neuroendoscopy for the treatment of intraventricular lesions has become standard in many neurosurgical departments. The presented overall morbidity of 1.6% and mortality of 0.8% is comparable to our reports on single neuroendoscopic procedures, with 1.4% morbidity and 0.6% mortality.25

The most frequently described combination is a combination of ETV and tumor biopsy. Intraventricular or paraventricular tumors are often associated with CSF disorders and it is favorable to combine tumor biopsies

Conclusions

We show in this study of combined intraventricular neuroendoscopic procedures a morbidity and mortality that are similarly low to earlier studies on single procedures. We are convinced that with careful preoperative planning and experience in several techniques, a combination is feasible and safe. However, minor fornix contusions are frequently seen but usually remain clinically asymptomatic.

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    Conflict of interest statement: J.B. Oertel, H. W. S. Schroeder, and M. R. Gaab are consultants for Karl Storz Company.

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