Manu Rastogi

Role of neuroendoscopy in the management of patients with tuberculous meningitis hydrocephalus

The role of neuroendoscopy in patients of tuberculous meningitis with hydrocephalus (TBMH) is not yet established. We present details of endoscopic morphology, and analyze outcome of Neuroendoscopy performed in 28 patients (15 males and 13 females, average age 23 years) of TBMH in last 2.5 years. Endoscopic procedures performed included endoscopic third ventriculostomy (ETV) alone (n=19), ETV with monroplasty (n=2), and septostomy (n=2), ETV with decompression/biopsy of tuberculoma (n=2) and with abscess drainage (n=1). Outcome was assessed on the basis of clinico-radiological improvement, need for external shunt and complications. Outcome was satisfactory in 14 (50%), acceptable in five (18%) and unsatisfactory in nine (32%) patients. Overall, 19 (68%) patients benefited from endoscopic intervention. Cerebrospinal fluid (CSF) leak (n=2) and per-operative bleeding (n=1) were the only complications encountered. Endoscopy appears to be helpful in a considerable number of patients with TBMH, and should be considered as the first surgical option for CSF diversion surgery in these patients. External shunt should be reserved for those who fail the endoscopic CSF diversion.

Role of endoscopic third ventriculostomy in patients with communicating hydrocephalus: an evaluation by MR ventriculography

Post-tubercular meningitic hydrocephalus (TBMH) and post-traumatic hydrocephalus (PTH) is often considered a contraindication for endoscopic third ventriculostomy (ETV), as it is mostly of communicating type in these cases. The aim of the present study was to define the role of ETV in patients with communicating hydrocephalus. Ten consecutive patients of TBMH, PTH and postneurocysticercus (NCC) hydrocephalus were formed the study group. Diagnosis of communicating hydrocephalus was made using magnetic resonance ventriculography (MRV). If contrast was seen coming out from the ventricular system into the basal cisterns, it was considered as communicating hydrocephalus. Patients with clinical and imaging evidence of raised intracranial pressure and failed medical treatment were taken up for ETV. All patients were studied by preoperative and postoperative MRV. Success of the procedure was assessed by the improvement in clinical and imaging parameters on postprocedure follow-up in all these cases. Technically successful ETV was performed in all 10 patients. Overall success rate of ETV in communicating hydrocephalus was 70% (n = 7). The shunt surgery was performed in the remaining three patients with ETV failure. One patient developed complication following postoperative MRV and was managed conservatively. We conclude that ETV is effective in post-TBM, post-traumatic communicating and post-NCC communicating hydrocephalus and should be considered as initial surgical option for cerebrospinal fluid diversion in these patients. MRV is a relatively safe technique to ascertain the patency of subarachnoid space as well as ETV stoma.

Neuro-endoscopic management of intraventricular neurocysticercosis (NCC).

SummaryObjective. Various approaches including endoscopy have been used for the treatment of intraventricular and cisternal NCC. We present our technique of Neuro-endoscopic management of intraventricular NCC.Methods. Twenty-one cases, 13 females and 8 males (age range 12–50 years; mean, 25.7 years), of intraventricular NCC [lateral (n = 6), third (n = 6), fourth (n = 10) ventricles including a patient with both lateral and third ventricular cysts] producing obstructive hydrocephalus formed the group of study. Gaab Universal Endoscope System along with 4 mm 0° and 30° rigid telescopes were used through a frontal burr-hole for removal of intraventricular including intra-fourth ventricular (n = 10) NCC. Endoscopic third ventriculostomy (ETV) was done for internal cerebrospinal fluid (CSF) diversion. Average follow up was 18 months.Results. Complete (n = 18) or partial (n = 2) removal of NCC was done in 20 patients, while a cyst located at foramen of Monro slipped and migrated to occipital or temporal horn in 1 patient. Thirty-degree 4-mm rigid telescope provided excellent image quality with ability to address even intra-fourth ventricular NCC through the dilated aqueduct using a curved tip catheter. No patient required further surgery for their hydrocephalus. There was no operative complication and post-operative ventriculitis was not seen in any case despite partial removal of NCC.Conclusion. Neuro-endoscopic surgery is an effective treatment modality for patients with intraventricular NCC. It effectively restores CSF flow and is capable of removing cysts completely or partially from accessible locations causing mass effect. Partial removal or rupture of the cyst does not affect the clinical outcome of the patients.

Surgical outcome of tuberculous meningitis hydrocephalus treated by endoscopic third ventriculostomy: prognostic factors and postoperative neuroimaging for functional assessment of ventriculostomy

OBJECT Endoscopic third ventriculostomy (ETV) is increasingly being used as an alternative treatment for post-tuberculous meningitis (TBM) hydrocephalus. The aim of this study was to affirm the role of ETV in patients with TBM hydrocephalus and also to study the usefulness of cine phase-contrast MR imaging (cine MR imaging) for functional assessment of the ETV stoma. An additional goal was to identify factors that influence the outcome of ETV, so as to define patients with TBM hydrocephalus in whom ETV is warranted. METHODS Twenty-six patients with TBM hydrocephalus treated with ETV were evaluated clinically and with cine MR imaging postoperatively. The duration of follow-up ranged from 1 to 15 months. The authors evaluated flow void changes in the floor of the third ventricle and analyzed parameters from the preoperative data, which they then used as a basis for comparison between endoscopically successful and endoscopically unsuccessful cases. RESULTS The overall success rate of ETV in TBM hydrocephalus was 73.1% in this case series. Cine MR imaging showed a sensitivity of 94.73% and specificity of 71.42% for the functional assessment of third ventriculostomy in these patients, with the efficacy being maintained during follow-up. The outcome of ETV showed a statistically significant correlation with the stage of illness and presence of intraoperative cisternal exudates. Although duration of symptoms and duration of preoperative antituberculous therapy (ATT) appeared to influence the outcome, their correlation with outcome was not statistically significant. CONCLUSIONS Endoscopic third ventriculostomy should be considered as the first surgical option for CSF diversion (that is, before shunt surgery) in patients with TBM hydrocephalus. Cine MR imaging is a highly effective noninvasive tool for the postoperative functional assessment of stomata. Patients who presented with a history of longer duration and those who were administered preoperative ATT for a longer period had a better outcome of endoscopic treatment. Outcome was poorer in patients who presented with higher stages of illness and in those in whom cisternal exudates were observed intraoperatively.

Endoscopic transaqueductal removal of fourth ventricular neurocysticercosis with an angiographic catheter.

OBJECTIVE Fourth ventricular neurocysticercosis (FVNCC) usually presents with obstructive hydrocephalus. Available treatment options are medical, external cerebrospinal fluid diversion, microsurgical, or endoscopic removal alone or in combination. We present our experience of transaqueductal removal of FVNCC by angiographic catheter with endoscopic third ventriculostomy with a rigid endoscope. METHODS Ten patients (five male and five female patients; age range, 12–45 yr; mean, 23.2 years) with FVNCC with obstructive hydrocephalus underwent endoscopic removal along with endoscopic third ventriculostomy in a single sitting, through a frontal precoronal burr hole. Diagnosis was established on imaging and confirmed on histology in all of the cases. The Gaab Universal Endoscope System along with 4-mm, 30-degree rigid telescopes was used to enter the third ventricle, and a cut length of angiographic catheter was negotiated through the aqueduct for removal of FVNCC. RESULTS Removal of the cyst was performed in all cases. A 30-degree rigid telescope provided excellent image quality, with the ability to address intra-FVNCC through the dilated aqueduct with a curved-tip catheter. None of these patients required any further surgery. There were no significant operative or postoperative complications in any of the cases. All of the patients were asymptomatic, with an average follow-up of 18 months. CONCLUSION Transaqueductal removal of an intra-fourth ventricular cyst along with endoscopic third ventriculostomy with a rigid endoscope and catheter is an effective treatment and obviates the need for posterior cranial fossa exploration.

Relative cerebral blood volume is a measure of angiogenesis in brain tuberculoma.

Objective: The aim of this study was to correlate the perfusion indices with magnetic resonance imaging-derived cellular and necrotic fraction of the tuberculoma and angiogenesis metrics on histopathology. Methods: We performed dynamic contrast-enhanced magnetic resonance imaging in 13 excised brain tuberculoma patients. Microvascular density and vascular endothelial growth factor (VEGF)-expressing cells were quantified from the excised tuberculoma. The cellular and necrotic fractions of the tuberculomas were quantified on a postcontrast T1-weighted imaging. Results: Relative cerebral blood volume of cellular portion significantly correlated with cellular fraction volume (r = 0.882, P < 0.001), microvascular density (r = 0.900, P < 0.001), and VEGF (r = 0.886, P < 0.001) of the 13 excised tuberculomas. Microvascular density also correlated significantly with VEGF (r = 0.919, P < 0.001). Conclusions: Relative cerebral blood volume is a measure of angiogenesis in the cellular fraction of the brain tuberculoma. This information may be of value in predicting the therapeutic response in future.

Unilateral hydrocephalus: atypical presentation of intracranial tuberculoma.

A 43-year-old male presented with 3-month history of low-grade fever and headache. Radiological investigations revealed unilateral hydrocephalus. Unilateral obstruction of the foramen of Monro due to chronic tubercular ependymal inflammation was suspected and endoscopic septostomy was planned. Though ventriculo-peritoneal shunt is a simple method to treat hydrocephalus, complications related to this procedure are numerous. Neuroendoscopy is a safe method to treat hydrocephalus in selected cases, and also provides access to biopsy the lesion in question. An isolated tuberculoma obstructing the foramen of Monro was seen during endoscopy. Presentation and management of this unusual tuberculoma is reported along with a review of the pertinent literature.

Endoscopic Third Ventriculostomy through the Interfornicial Space

Endoscopic third ventriculostomy (ETV) is the most common cranial endoscopic surgery being done worldwide for a variety of conditions resulting in hydrocephalus. We report ETV in a case of congenital hydrocephalus with deficient third ventricular roof and wide interfornicial space.A 6-month-old male child presented with gradual progressive head enlargement and signs of raised intracranial pressure. Computed tomography of the head showed aqueductal stenosis with enlargement of third and lateral ventricles. The patient was operated under general anesthesia with endotracheal intubation. A right coronal burr hole and free-hand entry were made into the right lateral ventricle. The anterior part of the septum and the third ventricular roof were deficient with a narrow Monro’s foramen and the third ventricular floor was visible through the space between both fornices. ETV was done in standard fashion. Postoperatively the patient showed uneventful recovery clinicoradiologically. We review the literature and discuss the findings and technique of ETV in this rare entity.

Cerebral edema spontaneously elevating a compound depressed fracture

172 J. Neurosurg.: Pediatrics / Volume 1 / February 2008 This 4-year-boy presented after sustaining a head injury when he fell down a well with postresuscitation Glasgow Coma Scale (GCS) score of 10 and right hemiparesis. He had a lacerated wound over the left temporoparietal region through which brain matter herniated. Computed tomography (CT) scanning revealed a left frontotemporoparietal depressed fracture with underlying contusion and local mass effect (Fig. 1A and B). Hematological parameters indicated severe anemia and a grossly deranged coagulation profile. After correcting these parameters, prior to taking the patient for surgery, repeated CT scanning revealed cerebral edema, spontaneous elevation of a depressed fracture, increased soft-tissue scalp swelling, and no midline shift (Fig. 1C and D). We performed a left frontotemporoparietal decompressive crainectomy, evacuated the underlying contusion, and undertook a duraplasty using autologous graft. Postoperative recovery was good, and the patient was discharged with a GCS score of 12 and residual right hemiparesis on the 10th day. Trauma is the most common cause of death in children. Pediatric head injury constitutes 25–30% of all head injuries. The overall mortality rate in children ranges from 20–50%. Falls from heights account for 80% of cases in this age group.1,3 There are certain differences in the way a child’s brain responds to injury compared with that of an adult. In children, the cerebral edema is intractable, the brain volume increases rapidly, and the condition is termed “malignant brain edema.”2 We reported this case because we believe that the breach in the cranial vault was lifesaving, despite the development of malignant brain edema, which led to the spontaneous elevation of the depressed fractured segment. (DOI: 10.3171/PED/2008/1/2/172)

Contralateral motor deficit in extradural hematoma: Analysis of 35 patients

We work at one of the busiest trauma centers of the country and deal with more than 200 cases of extradural hematomas per year. The striking frequency of the association of motor deficits with extradural hematomas prompted us to take up this study and delineate the factors that could lessen the morbidity by decreasing the convalescence of the affected patients. We primarily found that the association between EDH and motor deficits was common, and early intervention resulted in faster recovery of motor power, (70% in patients operated within 24 hours of trauma, and 53.3% in patients operated after 24 hours of trauma. recovered complete power within 4 weeks.) We concluded a clinically significant association of extradural hematomas and concurrent motor deficits, and found that timely intervention in patients presenting with mild head injury enabled us to achieve complete recovery of motor power. Contributing factors included the concurrence of signs of herniation and associated parenchymal injuries.