Alberto Delitala

Application of neuroendoscopy to intraventricular lesions.

We present an overview of the history, development, technological advancements, current application, and future trends of cranial endoscopy. Neuroendoscopy provides a safe and effective management modality for the treatment of a variety of intracranial disorders, either tumoral or non-tumoral, congenital, developmental, and degenerative, and its knowledge, indications, and limits are fundamental for the armamentarium of the modern neurosurgeon.

Recent experience in the management of meningeal hemangiopericytomas.

Although the histogenesis of meningeal hemangiopericytomas (HMP) remains controversial, both biological and clinical evidence seems to identify these neoplasms as a separate entity with respect to meningiomas. In order to assess the current prognosis of HMP we reviewed our personal experience limited to the last decade (1986-1995): during this period 7 patients (4M, 3F) were treated by surgery alone or surgery combined with postoperative radiotherapy. In spite of meticulous attempts at radical resection, the tumors recurred in all but two cases with a mean interval of 85 months, and a total of 18 operations were performed (2.57/patient; range 1-4). Massive intratumoral hemorrhage determined acute deterioration and required emergency surgery in two cases while in one patient diffuse visceral metastases were discovered at autopsy. Five patients are still alive at follow-up but only 2 of them are in good neurological conditions and without evidence of disease. These results are similar to those reported in other series. In view of our results we conclude that intracranial hemangiopericytomas still have a dismal prognosis. Advances in neuroimaging, neuroanesthesia, microneurosurgery and adjuvant therapy do not seem to have significantly affected the recurrence rate, quality of life and mortality.

Draining Techniques for Cystic Craniopharyngiomas

Microsurgical total removal still remains the gold standard in the treatment of primary craniopharyngiomas with the best long-term prognosis. Excellent results have been achieved in particularly skilled and experienced hands [1, 2]. However, the intimate relationship with delicate neurovascular structures, the frequent absence of clear-cut cleavage, and the biologically benign nature of the tumor often suggest a less aggressive attitude [3]. This is particularly true in recurrent cases and in very young or very old patients, who are more prone to devastating intra- and postoperative complications. Only 10 % of craniopharyngiomas are totally solid, while more than half are purely or predominantly cystic [1, 4, 5]. In such cases, control of mass effect, often caused by enlargement of the cystic component, may represent a suitable alternative to resection and several techniques have been proposed [4–10]. In this chapter we are going to describe two techniques for the treatment of cystic craniopharyngiomas:

Supraorbital endoscopic approach to colloid cysts.

BACKGROUND Surgical approaches to colloid cysts of the third ventricle have evolved over time. In recent years, endoscopy has been recognized as an effective alternative to open surgery. The disadvantage of endoscopic treatment is the difficulty in controlling the adhesion of the cyst to the roof of the third ventricle and in obtaining complete removal of the cyst. OBJECTIVE To design and carry out a supraorbital approach to obtain a better viewing angle of the cyst and better control of the adhesion of the cyst to the roof of the third ventricle. METHODS From September 2005 to February 2008, we operated on 7 consecutive patients with colloid cysts in the third ventricle. All procedures were performed with the endoscopic supraorbital approach. The endoscopic procedure was performed with a rigid STORZ endoscope with 3 working channels. In 4 patients, the surgical supraorbital trajectory was planned with the help of a navigator. RESULTS The procedures lasted between 60 and 110 minutes, including the registration on the navigation system. Near-total removal of the cyst was achieved in 6 patients. All patients were discharged within 6 days. CONCLUSION Endoscopic treatment may be an effective and safe alternative to open surgical craniotomy. Our series shows that the endoscopic supraorbital endoscopic resection is a valuable approach to colloid cysts of the third ventricle.

Acromegaly and pituitary tumors: early anatomoclinical observations.

The elucidation of pituitary physiopathology has been a major challenge for physicians since early ages. Due to the unawareness of the endocrine system, acromegaly, the most striking pituitary disorder, was commonly regarded as an intrinsic bone disease. Andrea Verga and Vincenzo Brigidi, Italian authors of the 19th century, reported the first macroscopic and microscopic descriptions of pituitary adenomas in acromegalic patients. Although far from providing a correct pathogenetic interpretation of the disease, they opened the way to forthcoming observations and discoveries. A short history of acromegaly and pituitary physiopathology is drawn.

Neuroendoscopic options in the treatment of mesencephalic expanding cysts: Report of four cases and review of the literature

OBJECTIVE Mesencephalic expanding cysts, also called lacunae, are rare intraparenchymal, multilobulated cavities of variable diameter mostly localized in the thalamo-mesencephalic region. In symptomatic cases, usually presenting with hydrocephalus or midbrain syndrome, surgical treatment is required and, considering their position, a minimally invasive approach should be preferred. METHODS Four cases of expanding mesencephalic cysts endoscopically treated in three different Italian centers are described. Other possible causes of intracerebral cyst were excluded in all cases by complete neuroimaging and laboratory screening. All patients presented with signs and symptoms of midbrain compression and a slight to moderate ventricular dilation was present in three cases. RESULTS All patients underwent endoscopic cyst fenestration into the ventricle, associated with endoscopic third-ventriculostomy (ETV) in two cases and with cyst wall biopsy in one case. One patient suffered from transient worsening of her hemiparesis due to intraoperative bleeding. All patients showed clinical improvement and a reduction in cyst size on follow-up magnetic resonance images (MRI). CONCLUSION Neuroendoscopy appears to be an effective, probably definitive surgical option in the treatment of symptomatic mesencephalic expanding cysts. Associating ETV with cyst fenestration seems to offer more complete treatment. Deep intracystic navigation and cyst wall biopsy should be avoided.

Endoscopic Approaches to Intraventricular Lesions.

BACKGROUND Endoscopy is becoming increasingly popular for the neurosurgical management of intraventricular lesions and has recently been accepted as an effective alternative approach to open surgery. The deep location of intraventricular lesions makes the microsurgical approach difficult. Moreover, many intraventricular tumors do not require aggressive neurosurgical treatment. Some of these lesions are even associated with hydrocephalus or an enlarged ventricular system. METHODS We collected the data of 32 patients affected by purely intraventricular lesions in the lateral or third ventricles who underwent 33 endoscopic intraventricular procedures from 2006 to 2011. We classified the lesions according to their location within the ventricles so as to plan the best endoscopic trajectory. We approached the lesions using rigid and flexible endoscopes through precoronal or supraorbital trajectories according to their localization and the presence of hydrocephalus. In many procedures we used neuronavigation. RESULTS Thirty-three endoscopic intraventricular procedures were performed in 32 patients; 27 procedures were performed via the precoronal, and 6 procedures via the supraorbital frontopolar approach. A complete excision of the lesion was obtained in only three cases. In all other cases, a biopsy was taken. CONCLUSIONS Our series shows that an endoscopic approach to intraventricular lesions should be tailored according to localization of the lesion and ventricular size. The complete excision of intraventricular lesions is often impossible with the endoscope, but biopsies allow diagnoses to be obtained in almost all cases.