Dieter Hellwig

Endoscopic treatment of septated chronic subdural hematoma

BACKGROUNDnChronic subdural hematomas are well delineated collections of fluid (blood) between the dura mater and the arachnoid space. Two types of encapsulated chronic subdural hematoma can be distinguished: the nonseptated and the septated form. The nonseptated form can be treated easily using the burrhole-drainage method, whereas treatment of septated chronic subdural hematoma remains a therapeutical problem. The main problem is the division of the hematoma by neomembranes into compartments, which hinder the efflux of the hematoma fluid through one or two burrholes.nnnMETHODSnSince 1991 we have operated on 14 patients with septated subdural hematoma using flexible steerable endoscopes through a burrhole approach. The flexible endoscopes are fixed and guided with the help of the Marburg Neuroendoscopy Fixation and Guiding System. For resection of neomembranes small microscissors or microforceps were used. This technique avoids blunt rupture of the membranes which may cause bleeding. A closed drainage system is applied temporarily to guarantee the efflux of the remaining hematoma.nnnRESULTSnFrom January 1991 to May 1994, 14 patients with the septated variant of chronic subdural hematoma were operated on using the endoscopic technique. After the neuroendoscopic intervention 12 patients had a sufficient or complete hematoma evacuation. One patient had to be operated on a second time, and there was one postoperative subdural infection. Long term follow up of all patients shows no recurrence of the subdural hematoma.nnnCONCLUSIONnTreatment of membraneous septated CSH using an endoscopic operative technique combined with the application of a closed drainage system is a minimally invasive method and a therapeutic alternative to the craniostomy-membranectomy technique.

Unilateral deep brain stimulation of the internal globus pallidus alleviates tardive dyskinesia

We describe a patient with fluspirilene‐induced tardive dyskinesia of the choreiform oro‐facial‐laryngeal type resistant to various conservative approaches for 7 years who underwent deep brain stimulation of the internal pallidal globe. We found immediate and marked suppression of her perioral involuntary movements with unilateral stimulation at 60 Hz.

Stereotactic Endoscopic Interventions in Cystic Brain Lesions

Stereotactic endoscopic techniques are extremely helpful in diagnosis and therapy of cystic intracerebral space occupying lesions. Acute space occupying lesions can be managed effectively and without major tissue traumatization. Up to now we have operated on more than 70 cystic intracerebral space occupying lesions with a stereotactic endoscopic technique. The main diagnoses were colloid cysts, cystic craniopharyngeoma, arachnoidal and pineal cysts. In must be stressed that in cystic anaplastic astrocytomas and glioblastomas as well as metastases only an acute inner cerebral decompression can be achieved by neuroendoscopic techniques in combination with the application of reservoir systems. In benign parenchymal or intraventricular cysts neuroendoscopic intervention is performed for definitive treatment. The results are overall encouraging. There was no operative mortality and operative morbidity was below 3%. Postoperative follow-up in patients with benign cysts showed no evidence of recurrence.

Endoscopic Anatomy of the Third Ventricle

42 cadaver brains in situ were examined endoscopically to work out topographical anatomical landmarks for orientation. The endoscopic route from the chosen precoronal trepanation point to the defined ventricular landmarks has been measured in 22 cases. The identification and measurements of the anatomical landmarks are helpful for safe and atraumatic endoscopical navigation within the ventricular system. Furthermore this article describes and discusses cerebral lesions during ventriculoscopy.

Novel multipurpose bipolar instrument for endoscopic neurosurgery.

OBJECTIVE Hemorrhage control in endoscopic neurosurgery is critical because of the lack of suitable instruments for coagulation. One reason for this problem is that miniaturization of the instruments is still a technical problem. In this article, we present a solution: the use of bipolar microforceps with a small diameter of 1.5 mm. METHODS With the use of modern synthetic and metallic materials, the construction of the bipolar microforceps was designed without the use of mechanical joints. All movable elements are integrated within the instrument shaft. This design provides optimal visibility of the operating field because the sheath has a diameter of only 1.5 mm along its entire length. Therefore, this instrument is compatible with most working channels of neuroendoscopes. RESULTS The new, joint-free design of the forceps and the electric insulation of the branches were the technical innovations that led to the development of this novel, multipurpose instrument. CONCLUSION This new instrument may enhance endoscopic resection and shrinkage of cystic lesions and may offer new possibilities in endoscopic tumor resection and the treatment of hemorrhage.

Intracranial dislocation of a lumbo-peritoneal shunt-catheter: case report and review of the literature.

We report on the dislocation of the tip of a lumbo-peritoneal shunting catheter into the cerebral parenchyma 10 months after insertion. The progressive migration towards the deep structures of the brain, once the catheter had left the peritoneal cavity, might have been caused by CSF-flow. Such hypothesis is supported by modern MRI technology visualizing CSF-flow in a spino-cerebral direction.

Treatment of Central Deafferentation and Trigeminal Neuropathic Pain by Motor Cortex Stimulation: Report of a Series of 20 Patients.

OBJECTIVEnMotor cortex stimulation (MCS) is an alternative treatment modality for central neuropathic pain, if conservative treatment failed. Study aim was outcome assessment after MCS.nnnMATERIAL AND METHODSnThis study is a retrospective case series review of patients who had undergone MCS for central pain (n = 8), deafferentation pain (n = 3) and neuropathic trigeminal pain (n = 9) between April 2001 and May 2011. In all patients, four contact-paddle electrodes were placed in the epidural space overlying the motor cortex via burr hole trepanation under local anesthesia. The follow-up period was 6 months to 6 years. Pain control was assessed by the visual analog scale (VAS).nnnRESULTSnA total of 22 patients (11 men, 11 women) were treated; after trial stimulation two male patients were excluded for incompliance reasons. The mean patient age was 59.8 years (range: 31-79 years). In the central pain group, three patients reported complete, and four patients satisfactory pain control. In the trigeminal neuropathic pain group, seven patients reported complete, and two patients satisfactory pain control. In the deafferentation pain group, one patient reported complete, and two patients satisfactory pain control. None of the patients showed new neurologic deficits after the MCS.nnnCONCLUSIONSnMCS is an effective treatment modality for central neuropathic pain and trigeminal pain with low morbidity and mortality. Future studies are necessary to evaluate and optimize this treatment option in more detail.

Stereotactic-endoscopic Procedures on Processes of the Cranial Midline

The term midline tumour is defined partly from the topographic and from the pathogenetic point of view. Problems of modern imagegenerating procedures in establishing the diagnosis of cerebral midline lesions are described. The role of stereotactic diagnostic and therapeutic interventions is emphasized. Stereotactic brain tumour biopsy, installation of shunts and reservoirs under visual control are performed. Interstitial radiotherapy is carried out for low-grade gliomas. As an important innovation, stereotactic procedures are combined with endoscopic techniques. Particular diagnostic and therapeutic difficulties of typical midline tumours such as craniopharyngeoma, germinoma, glioma and primary cerebral lymphoma as a local extension are discussed. A reasonable concept in diagnosis and therapy of cerebral midline lesions is proposed.

Localization of precentral gyrus in image-guided surgery for motor cortex stimulation

According to recent clinical data, motor cortex stimulation (MCS) is an alternative treatment for central pain syndromes. We present our minimal invasive technique of image guidance for the placement of motor cortex stimulating electrode and assess the clinical usefulness of both neuronavigation and vacuum headrest. Neuronavigation was used for identification of precentral gyrus and accurate planning of the single burr-hole. The exact location was reconfirmed by intraoperative phase reversal of somatosensory evoked potential (SSEP) and clinical response after electrical stimulation test. Implementation of navigation technique facilitated localization of the precentral gyrus with a high degree of accuracy. Determination of stimulating electrode placement was possible in every case. Postoperative clinical and neuroradiological evaluations were performed in each patient. All patients experienced postoperative relief from pain. Our preliminary series may confirm image guidance as a useful tool for surgery of MCS. Additionally, minimal and safe exposure can be performed using a single burr-hole and vacuum head rest.

A cost-effectiveness analysis of endoscopic third ventriculostomy.

Study sample Power calculations to determine the sample size were not reported. Eligible children were identified from the British Columbia Childrens Hospital between 1989 and 1998. All patients (n=28) who underwent ETV were included in the study (intervention group). Those children were then matched for age, pathogenesis and the number of prior shunt procedures with patients treated with CFS (control group).