Hannes Haberl

Navigated endoscopic surgery for multiloculated hydrocephalus in children

OBJECT Multiloculated hydrocephalus remains a challenging condition to treat in the pediatric hydrocephalic population. In a retrospective study, the authors reviewed their experience with navigated endoscopy to treat multiloculated hydrocephalus in children. METHODS Between April 2004 and September 2008, navigated endoscopic procedures were performed in 16 children with multiloculated hydrocephalus (median age 8 months, mean age 16.1 +/- 23.3 months). In all patients preoperative MR imaging was used for planning entry sites and trajectories of the endoscopic approach for cyst perforation and catheter positioning. Intraoperatively, a rigid endoscope was tracked by the navigation system. For all children the total number of operative procedures, navigated endoscopic procedures, implanted ventricular catheters, and drained compartments were recorded. In addition, postoperative complications and radiological follow-up data were analyzed. RESULTS In 16 children, a total of 91 procedures were performed to treat multiloculated hydrocephalus, including 29 navigated endoscopic surgeries. Finally, 21 navigated procedures involved 1 ventricular catheter and 8 involved 2 catheters for CSF diversion via the shunt. The average number of drained compartments in a shunt was 3.6 +/- 1.7 (range 2-9 compartments). In 9 patients (56%) a navigated endoscopic procedure constituted the last procedure within the follow-up period. One additional surgery was necessary in 3 patients (19%) after navigated endoscopy, and in 4 patients (25%) 2 further procedures were necessary after navigated endoscopy. Serial follow-up MR imaging demonstrated evidence of sufficient CSF diversion in all patients. CONCLUSIONS Navigated endoscopic surgery is a safe and effective treatment option for multiloculated hydrocephalus. The combination of the endoscopic approach and neuronavigation further refines preoperative planning and intraoperative orientation. The aim of treatment is to drain as many compartments as possible and as soon as possible, thereby establishing sufficient CSF drainage with few ventricular catheters in single shunt systems. Close clinical and radiological follow-up is mandatory because multiple revisions are likely.

Endoscopic treatment of isolated fourth ventricle: clinical and radiological outcome.

BACKGROUND: Treatment of an isolated fourth ventricle should be considered when clinical symptoms or a significant mass effect occur. OBJECTIVE: To report clinical and radiographic outcomes after endoscopic transaqueductal or transcisternal stent placement into the fourth ventricle. METHODS: In 19 patients (age, 34th week of gestation-20 years; median age, 17.5 months), 22 endoscopic procedures were performed. Either an aqueductoplasty or, in cases with a supratentorially extended fourth ventricular component, an interventricular fenestration was performed. In all patients, a stent connected to the cerebrospinal fluid--diverting shunt was placed through the fenestration. Surgical complications and radiological and clinical outcomes are reported. RESULTS: All 19 patients had a mean follow-up of 26.9 ± 18.2 months. No persisting neurological complications were observed; 27.3% of patients experienced complete resolution of presenting symptoms, whereas 68.3% demonstrated partial resolution. Symptoms with short duration (< 4 weeks) resolved completely, whereas long-standing symptoms partially improved. Short-term shunt complications (n = 2; insufficient catheter placement and subdural hygroma) and a need for long-term stent revisions (n = 3; stent retraction and shunt revision for other causes) were observed. The mean fourth ventricular volume was reduced after surgery (44.2 ± 25.8 to 23.1 ± 21.9 mL; P < .01). Pontine diameter increased from 0.9 ± 0.3 to 1.2 ± 0.3 cm (P < .01) after surgery. Both effects were still demonstrated on later radiological follow-up of 24.4 ± 14.2 months (fourth ventricular size, 24.7 ± 28.1 mL; P < .01; pontine diameter, 1.3 ± 0.3 cm; P < .01). CONCLUSION: The clinical and radiological outcomes after endoscopic aqueductoplasty and interventriculostomy in children with an isolated fourth ventricle indicate that this procedure is feasible, effective, and safe.

Neuroendoscopic lavage for the treatment of intraventricular hemorrhage and hydrocephalus in neonates

Object Neonatal intraventricular hemorrhage (IVH) may evolve into posthemorrhagic hydrocephalus and cause neurodevelopmental impairment. In this study, an endoscopic surgical approach directed toward the removal of intraventricular hematoma was evaluated for its safety and efficacy. Methods Between August 2010 and December 2012 (29 months), 19 neonates with posthemorrhagic hydrocephalus underwent neuro endoscopic lavage for removal of intraventricular blood remnants. During a similar length of time (29 months) from March 2008 to July 2010, 10 neonates were treated conventionally, initially using temporary CSF diversion via lumbar punctures, a ventricular access device, or an external ventricular drain. Complications and shunt dependency rates were evaluated retrospectively. Results The patient groups did not differ regarding gestational age and birth weight. In the endoscopy group, no relevant procedure-related complications were observed. After the endoscopic lavage, 11 (58%) of 19 patients required a later shunt insertion, as compared with 100% of infants treated conventionally (p < 0.05). Endoscopic lavage was associated with fewer numbers of overall necessary procedures (median 2 vs 3.5 per patient, respectively; p = 0.08), significantly fewer infections (2 vs 5 patients, respectively; p < 0.05), and supratentorial multiloculated hydrocephalus (0 vs 4 patients, respectively; p < 0.01) [corrected].Conclusions Within the presented setup the authors could demonstrate the feasibility and safety of neuro endoscopic lavage for the treatment of posthemorrhagic hydrocephalus in neonates with IVH. The nominally improved results warrant further verification in a multicenter, prospective study.

Feasibility of telemetric ICP-guided valve adjustments for complex shunt therapy

ObjectThe advances in shunt valve technology towards modern adjustable differential pressure (DP) valves and adjustable gravitational assisted valves result in an increasing complexity of therapeutical options. Modern telemetric intracranial pressure (ICP) sensors may be helpful in their application for diagnostic purposes in shunt therapy. We present our first experiences on telemetric ICP-guided valve adjustments in cases with the combination of an adjustable DP valve and adjustable gravitational unit.MethodsFour consecutive cases were evaluated in a retrospective review who had received a proGAV adjustable, gravitational assisted DP valve with secondary in-line implantation of an adjustable shunt assistant (proSA), together with a telemetric ICP sensor (Neurovent-P-tel) between December 2010 and June 2012 in our institution. The measured ICP values and the corresponding valve adjustments were analyzed in correlation with the clinical course and the cranial imaging of the patients.ResultsNo surgery-related complications were observed after implantation of the proSA and the telemetric ICP sensor additional to the proGAV. ICP values could actively be influenced by adjustments of the respective valve units. An increase of the position depending resistance of the proSA resulted in significant attenuated negative ICP values for the standing position, while adjustments of the proGAV could be detected not only in a supine position but also in a standing position. A clinical improvement could be achieved in all cases.ConclusionThe combination of adjustability in the differential pressure valve and the gravitational unit reveals a complex combination which may be difficult to adapt only according to clinical information. Telemetric ICP-guided valve adjustments seem to be a promising tool as an objective measure according to different body positions. Further investigations are needed to select the patients for these costly implants.

Frame-based cranial reconstruction

The authors report on the first experiences with the prototype of a surgical tool for cranial remodeling. The device enables the surgeon to transfer statistical information, represented in a model, into the disfigured bone. The model is derived from a currently evolving databank of normal head shapes. Ultimately, the databank will provide a set of standard models covering the statistical range of normal head shapes, thus providing the required template for any standard remodeling procedure as well as customized models for intended overcorrection. To date, this technique has been used in the surgical treatment of 14 infants (age range 6-12 months) with craniosynostosis. In all 14 cases, the designated esthetic result, embodied by the selected model, has been achieved, without morbidity or mortality. Frame-based reconstruction provides the required tools to precisely realize the surgical reproduction of the model shape. It enables the establishment of a self-referring system, feeding back postoperative growth patterns, recorded by 3D follow-up, into the model design.

Culture meets surgery

Berlin treasures a very specific sentiment. In contrast to other old but traditionally wealthy German cities like Munich or Hamburg, Berlin never settled and never have the city’s claims been staked. Although its importance ever increased, Berlin looks back to a rather checkered history of rise and fall, of unification, separation, and reunification. A flourishing trading city in the Middle Ages after merging the market towns Berlin and Coelln, it has experienced a first division and loss of independence in 1442. After reunification in 1470, Berlin until these days lived through an exhausting succession of political and economic crises causing repeated periods of substantial impoverishment and suppression, answered by organized resistance, civil unrest, and uprisings. A basic flavor of depression and desperation remained alive at all times and may very well be experienced today in the somewhat harsh and gruffy sense of humor of native Berliners, which at most encourages to take eventual blows of faith relaxed and with composure. Somewhat unaffected by adverse events and as if shrugging off the misery, Berlin continuously developed. It became an electoral residence, royal city, and imperial capital. Under Frederick the Great Berlin was the intellectual and cultural center of enlightenment. In 1909, the first German motor airport opened. In the golden 20s, personalities like the architect Walter Gropius; the physicist Albert Einstein; the painter George Grosz; writers like Arnold Zweig, Berthold Brecht, and Kurt Tucholsky, and actors and directors like Marlene Dietrich, Friedrich Wilhelm Murnau, and Fritz Lang turned Berlin into the cultural capital of Europe. The nightlife of that period found its most famous description in the film Cabaret. Four million inhabitants celebrated the opening of the first Autobahn in 1921. In 1924, the airport Tempelhof was opened, and the first public television was introduced in 1935. All this sounds very much like a success story if there had not happened the war of 30 years, halving the population, the occupation by Napoleon causing a sinister period of regression, followed by the first world war, bringing hunger and poverty, theWeimar Republic with harsh internal political hassles, followed by a galloping inflation and—after recovery by help of the allies—the word economic crisis, preparing the ground for national socialism and the second world war. Mutating into the capital of national socialism, Berlin experienced the horror of anti-Semitism, hardly suppressed during the Olympic Games of 1936. The city finally was destructed for the greater part between June 1940 and February 1945 by the most numerous allied bombing raids ever flown over a German City during the second world war. After a long period of vegetative survival, broken into pieces, and on the drip feed of the world powers, Berlin recovered slowly and only after the reunification in 1989 developed again into the current vibrant capital. This time, the traces of the past remained visible. The grounds of the former Berlin Wall, an only very tentatively built on fallow land, cut through the very city center, marking a virtually and very symbolic “broken heart”. Thus, the city center from the palace of tears down to Checkpoint Charly breathes a strange mix of bitter and sweet memories, loading the place with sentimentality. Alive but deeply marked by the fundamental crises of the past, Berlin continues its never ending journey towards a very distant and radiant goal. Berlin keeps on walking or rather strolling, admired, and accursed for this eternal status of a tramp poor but confident. Particularly in summer, drowsily drifting along in the sun, this very emotional city seems to just dream away, aimlessly self-absorbed in its narcissism. It is this specific mind setting which attracts—on the axis from Paris to Moscow—the shady world of glamour, illusion, gamble, fast wealth, and mass parties for any reason—be it the soccer world championship or the one mile high heels catwalk race—but as well creative potential, arts, and multiple scientific disciplines. Against this sparkling background, Culture meets Surgery was the title of the opening conference of the transdisciplinary research project‚ SchadelBasisWissen, directed by Sigrid Weigel and Hannes Haberl.