Michael Vloeberghs

Neuroendoscopic Third Ventriculostomy in Patients Less than 1 Year Old

A series of neuroendoscopic third ventriculostomies in children less than 1 year old is reported. Twenty-seven patients underwent the procedure with 21 (77%) failing within a mean of 1.36 months of the procedure. Nineteen were subsequently shunted. The presence or absence of flow through the ventriculostomy and the size of the lateral ventricles on post-operative imaging were not an indicator of success or failure. Only 4 (15%) had a complication of the procedure. Although the majority fail, approximately 1/3 are spared the added morbidity and mortality of having a shunt. With such a low morbidity and zero mortality the procedure has many benefits over shunting. Consequently, neuroendoscopic third ventriculostomy is used in this institution, where possible, rather than a shunt.

Neuroendoscopic third ventriculostomy for hydrocephalus in adults: report of a single unit’s experience with 63 cases

BACKGROUND Neuroendoscopic third ventriculostomy (NTV) is becoming a first line treatment for hydrocephalus in this center. Its use in a consecutive series of adults is reported. METHOD Initially a retrospective data collection after 7 months becoming prospective studying all patients who underwent NTV in this center. The adults (17 years or older) have been studied. RESULTS Sixty-three patients met the criteria for inclusion: 38 male, 25 female. Mean age at first NTV 37.5 years. There was an 80% success rate (i.e., no further therapy for the hydrocephalus required). Follow-up was for a mean of 3.1 years. The largest subgroup were patients with third ventricular tumours (35%), of whom 86% were successfully treated. Mean time to failure for the whole series was 8.5 months (range immediate--30 months). Complications occurred in 17.5%; those deemed serious in 11%. There were three deaths (4.7%) within 30 days of the procedure. There were six other deaths during follow-up, five because of tumour progression and one because of pneumonia. CONCLUSIONS This procedure lends itself to the treatment of hydrocephalus in adults and appears to be more successful than in young children. It is efficacious in both previously shunted and non shunted patients. It is now the first-line treatment for noncommunicating hydrocephalus in this center and also for patients with shunt failure who are anatomically suitable, having cerebrospinal fluid spaces large enough to admit the endoscope. The complication and mortality rates compare favorably with those for shunts.

The role of neuroendoscopy in the management of brain tumours

Neuroendoscopy is increasingly used in the management of brain tumours and tumour related hydrocephalus and this study reviews the efficacy of neuroendoscopic interventions in this unit in patients with brain tumours. A series of 87 neuroendoscopic operations carried out in 77 patients with brain tumours over a 6-year period is reported. The age range of the patients was from 5 months to 70 years (median 13 years). In 56 cases (64%) presentation was with a newly-diagnosed tumour and hydrocephalus. The majority of the remaining patients had var ying degrees of worsening hydrocephalus on the background of a previously diagnosed tumour. Neuroendoscopic third ventriculostomy (NTV) was successful in relieving hydrocephalus in the short term in 63/66 cases (95%) and in the longer term in 55/66 cases (83%). Neuroendoscopic tumour biopsies were successful in providing a tissue diagnosis in 17/28 cases (61%) and four extensive and three partial resections of tumour were carried out. There were two deaths within 30 days of the procedure with only one of these, secondary to intraventricular haemorrhage, directly related to neuroendoscopy. Few significant complications were noted otherwise. For selected intraventricular and paraventricular tumours neuroendoscopy offers the opportunity to combine relief of hydrocephalus with tumour biopsy and sampling of CSF in a single procedure.

Neuroendoscopy in the premature population

Abstract The population born prematurely is particularly prone to hydrocephalus. Shunting techniques, whilst still the gold standard, have considerable failure rates and contribute significant morbidity and mortality. The role of neuroendoscopic techniques in the treatment of such patients is explored, and a series of 19 patients born prematurely and operated on neuroendoscopically before their 1st birthdays is described.

A virtual reality surgery simulation of cutting and retraction in neurosurgery with force-feedback

A virtual-reality surgical simulator aimed at neurosurgery is presented. The simulator utilises boundary element (BE) technology to develop real-time realistic deformable models of the brain. The simulator incorporates the simulation of surgical prodding, pulling and cutting. Advanced features include the separation the cut surfaces by retractors and post-cutting deformations. The experience of virtual surgery is enhanced by implementing 3D stereo-vision and the use of two hand-held force-feedback devices.

Liliequist's membrane in minimally invasive endoscopic neurosurgery

Liliequists membrane, an arachnoid condensation extending from the upper border of the dorsum sellae to the anterior edge of the mammillary bodies and formerly a relatively insignificant structure, has been found to be extremely important in the neuroendoscopic management of hydrocephalus. Failure to open this membrane can lead to the failure of third ventriculostomies. Clin. Anat. 11:187–190, 1998.

Flexible neuroendoscopic treatment of suprasellar arachnoid cysts

Endoscopic treatment of suprasellar arachnoid cysts is now the treatment of choice. By marsupializing the roof of the cyst the condition can be cured. The perceived necessity to open both the roof and the floor is called into question by this paper. Three cases of suprasellar arachnoid cyst are described all of which have had successful marsupialisation of the cysts by flexible neuroendoscopy Flexible neuroendoscopic marsupialization of the cyst by widely opening the cyst roof only is described. This is compared with the other techniques, and also the endoscopic technique involving opening both the roof and the floor of the cyst, a more difficult and potentially dangerous method. Successful treatment of this condition is achieved by marsupialization of only the roof of the cyst. This is a much safer procedure, and has resulted in a resolution of signs and symptoms in the cases described followed-up between 24 and 28 months from the procedure.

Consensus on the appropriate use of intrathecal baclofen (ITB) therapy in paediatric spasticity.

Among features of motor disorders in children, spasticity is associated with considerable morbidity and problems in care, particularly in severely affected patients. Intrathecal baclofen (ITB) has been increasingly used as a relatively specific treatment modality for spasticity. To date, most of the evidence for its use in paediatric patients has come from retrospective and uncontrolled studies, although randomised, controlled trials of screening ITB and ITB therapy itself have recently been published. This consensus statement on the use of ITB in paediatric patients with spasticity was developed on the basis of currently available evidence, with the aim of providing information for clinicians, promoting an expert opinion and a consistent approach to the management of these patients and emphasising the need for further prospective, large-scale studies.

Constructive interference in steady-state 3D Fourier-transform MRI in the management of hydrocephalus and third ventriculostomy

Abstract We describe the use of three-dimensional Fourier transform constructive imaging in the steady state (CISS) MRI in the assessment of patients with hydrocephalus. We have found it of value both as a diagnostic investigation and in the follow-up of patients treated by third ventriculostomy.

The role of intrathecal baclofen in the management of primary and secondary dystonia in children

Intrathecal baclofen (ITB) is a well-established method of treating spasticity in children with cerebral palsy. In our series, eight children with primary or dystonia secondary to cerebral palsy have benefited from ITB. The observations in this paper are subjective and based on the carers impressions, but have confirmed the role of ITB in dystonia. Children with dystonia secondary to cerebral palsy benefited most and ITB can be used in these as a single treatment modality. The approach is different in dystonia secondary to cerebral palsy, where ITB can be used to palliate the spastic component, but other methods are necessary to treat the primary disease. We currently have three children in our series, where ITB in conjunction with deep brain stimulation (DBS) was used with satisfactory results.