1. Neuroendoscopy Department of Neurosurgery,
University Medical center Ljubljana

4. Hydrocephalus Hydrocephalus means excess water in the brain
Traditional treatment:
Shunt insertion (ventriculo-peritoneal, ventriculo-atrial, 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

5. 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 2D image
Less space to perform surgery
Learning curve
Lack of appropriate endoscopic instruments
Neuroendoscopy

6. 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:
Preformed space into which the endoscope can be passed
A sufficient light has to be delivered into the cavity to visualise the structures inside
We must be able to pass instruments into that spece to perform surgical procedures
Neuroendoscopy

7. 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

8. 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 1960s 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

9. 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

10. 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

11. Indications for intracranial endoscopic procedures
PURE ENDOSCOPIC PROCEDURE
ENDOSCOPIC ASSISTED MICROSURGERY
Hydrocephalus
Third ventriculostomy
Aqueductoplasty
Compartmentalized hydrocephalus
Septum pellucidotomy
Multicompartment hydrocephalus
Ventricular catheter placement
Intraventricular Tumors
Arachnoid cysts
fenestracion
Colloid Cysts
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
Pituitary tumor resection
Skull base tumor biopsy
Cerebral aneurysms
Microvascular decompression
Acoustic neuromas
Neuroendoscopy

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

13. 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

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

15. Endoscopic third ventriculostomy
A case from
our clinic
Neuroendoscopy

16. 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

17. Arachnoid cysts (our experience)
BRAIN PARENHYMA
Neuroendoscopy

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

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

20. 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

21. Intraventricular tumors
Neuroendoscopy

22. Intraventricular tumors
Low-grade astrocytoma in the posterior portion of the third ventricle
The T2-weighted preoperative MRI scan shows that the tumor is causing obstructive hydrocephalus
Endoscopic biopsy of the tumor
Immediately after biopsy, a third ventriculostomy is performed to treat the occlusive hydrocephalus
The postoperative MRI shows a prominent flow void at the floor of the third ventricle, indicating flow of CSF into the interpeduncular fossa. d a b c
Neuroendoscopy

23. Coloid cysts Coloid cyst is blocking aqueductus cerebri!!!
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

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