Neuro-endoscopy

Beyond E3V
Intra-ventricular lesions
 
K.K Bansal,
 Professor of Neurosurgery,
HIHT University
Himalayan institute of Medical Sciences,
 Dehradoon,
 
18th Dec. 2010, Jaipur  
Introduction………..
Intraventricular tumors and cysts are ideal
lesions for the application of neuroendoscopy.
Good visualization is possible due
to their location inside the cerebrospinal fluid
(CSF)-filled ventricular system;
The often-associated
obstruction of the CSF pathway and ventricular
enlargement offer the possibility of
working in large spaces
Introduction………History..
In 1963, Guiot et al. reported the use of ventriculoscopy in a
patient with a colloid cyst.
In 1973, Fukushima et al. provided the first modern
description of an endoscopic biopsy with the introduction of
the ventriculo-fiberscope.
The evolution of endoscopic techniques and improvement in
adequacy of diagnosis have allowed us to dramatically change
the prognosis and therapeutic regimen in pineal region
tumors;
Today…….
Neuroendoscopy is the preferred technique to
achieve minimally invasive management of these
lesions.
The great advantages of neuroendoscopy over other
biopsy techniques are that it allows visualization of
ependymal surfaces to diagnose unsuspected
metastases.
It is possible to manage associated hydrocephalus
via the same minimally invasive approach.
Third ventriculostomies, septostomies, and stent
placement, it is possible to re-establish patency of
CSF pathways.
Ideal tumor for endoscopic Mx
The ideal tumor for endoscopic resection should have the
following characteristics:
1. Moderate vascularity,

2. Soft consistency or cystic,

3. Small diameter (2–3 cm),

4. Associated hydrocephalus,

5. Low histological grade, and

6. Location inside the lateral ventricle.

Patient Selection
Endoscopic Biopsy of Intraventricular and
Paraventricular Tumors.
Endoscopy permits the simultaneous treatment of
associated hydrocephalus by means of a third
ventriculostomy E3V or septostomy.
In patients with small ventricles, endoscopy can be
associated with neuronavigation or, eventually, with
stereotaxy.
Paraventricular parenchymal tumors (i.e.,
thalamomesencephalic or basal ganglia), an
endoscopic biopsy can be performed if there is an
intraventricular extension of the lesion.
Endoscopic Technique
Anterior two-thirds of the lateral and third ventricle can
be approached through a frontal pre-coronal burr hole.
For the pineal region, a steerable endoscope prefered
through a coronal burr hole to assure safer maneuvers for
biopsy and ETV.
In case of trigonal tumor transoccipital approach used.
When an ETV is necessary, biopsy should be performed
first to prevent blood from reaching the interpeduncular
cistern.
The burr hole must be large enough to accommodate a
wand-like motion of the scope.
Endoscopic Technique
Usually an 8.9-mm cannula used for tumor
resection. This permits the use of a scope with a 4-
mm viewing port and an instrument port large
enough to accommodate the insertion of 2-mm
diameter instruments.

If one needed to work in the third ventricle, then a

smaller-diameter cannula with smaller instruments
would be used to avoid injury to the fornix, unless
the foramen of Monro is unusually large.
Endoscopic Technique
A solid tumor should not exceed 2 cm in diameter
Cystic lesions may be treated even if they are large.
 The endoscopic removal may become time-
consuming and ineffective if the tumor is too large
and too firm.
General principle is interruption of the blood supply
to the tumor and subsequent tumor debulking.
In general, a piecemeal resection is performed.
Lesions….
Neoplastic
Colloid cysts
Cystic Craniopharyngioma Projecting in lat vent
SEGA
Septal Glioma
Beningn Intraventricular cysts
Non-Neoplastic
NCC
Septate hydrocephalus
Colloid cysts
Colloid cysts are, in fact, the intra-ventricular lesions
that have been most often managed by using
endoscopic treatments.
The advantage of endoscopic surgery compared with
microsurgery should be lower morbidity, shorter
operative time, and shorter hospital stay.
This has been documented only in cases of colloid
cysts, whereas this observation is anecdotal for other
tumors as a result of the low number of cases
Colloid cyst
Colloid cyst
Cystic Cranio-pharyngioma Projecting in
lateral ventricle
Septal Glioma
Pineal- Germ cell tumor
Giant Pineal cyst
Intraventricular Nontumoral Lesions:
Neurocysticercosis
NCC…..Lat vent
Video…NCC
Post-op MRI
NCC ………..4th vent
 Patients Profile & Results
Name/Age/sex Diagnosis Procedure Histology

Mohsin/10/m 3rd Ventr Craniopharyngioma Endoscopic Aspiration/ Craniopharyngioma

decompression

Sanskriti/13/f Rec. cystic Endoscopic Aspiration/ Craniopharyngioma

Craniopharyngioma decompression (twice)

Rohit/5/m Rt Lat. Intraventricular giant Multiple fenestration/ Choroid plexus cyst

cyst septostomy

Ruchi/33/f Intra3rd ventricular multiple Endoscopic Aspiration/ Biopsy-Post radiation simple cyst
giant cysts decompression

Rahul/23/m Lt Lat Ventricular NCC Endoscopic removal NCC

Ravinder/16/m Colloid cyst Endoscopic decompression Colloid cyst

Atar singh55/m Septal Glioma/hydrocephalus ETV & biopsy Inconclusive

Anand swaroop/50/m hydrocephalus E3V & 4th vent cyst 2 NCC from 4th vent

Ram singh/45/m Colloid cyst Aspiration & removal Colloid cyst 

Deepak/15/m Post 3rd vent tumor Hydro Biopsy/ E3V GCT

Take home SMS…
Cystic Lesions are best treated even if you are a
Beginner.
Cystic lesions treated have good recovery even when
patient is in Low GCS
Tumor biopsy along with CSF diversion doing E3V
give best results.
With improvement of experience, it is possible to
remove selected tumors completely with a purely
endoscopic technique