Endoscopic Third Ventriculostomy

Background: Endoscopic third ventriculostomy (ETV) and Choroid Plexus Cauterization (CPC) have been recommended as reliable surgical options in developing countries for childhood hydrocephalus owing to reported shunt failures in shunt dependency.

PURPOSE: This study aims to provide external validation of the "Endoscopic Third Ventriculostomy Success Score (ETVSS)" for both short-term and long-term predictive adequacy.

METHODS: Between 1998 and 2007, we collected clinical follow-up data (after 6 and 36 months) of all 104 hydrocephalic children (<18 years of age) treated by endoscopic third ventriculostomy (ETV) in our hospital. Predictive adequacy of ETVSS for 6- and 36-month periods was tested by means of an unpaired t test, Hosmer-Lemeshow "goodness-of- fit" test, and area under the receiver operating characteristic curve.

RESULTS: Mean follow-up was 73.4 months. For both the short-term (6 months) and the long-term (36 months) periods, the mean predicted probability of ETV for the patients with successful ETV treatment was significantly higher than in the patients with failed ETV treatment. The areas under the curve for the short- and long-term periods were, respectively, 0.82 (95% CI 0.71-0.92) and 0.73 (95% CI 0.62-0.84). For patients with moderate ETVSS (50-70), the median age at first ETV was significantly higher for patients with successful ETV for both short- and long-term periods.

CONCLUSION: In hydrocephalic children, the ETVSS is a useful tool for prediction of outcome after ETV treatment. The ETVSS is more adequate in predicting short-term than long-term success. In our population, it is suggested that success rate for patients with moderate ETVSS could be improved if more weight is attributed to age at first ETV.

Object The purpose of the present study is to assess the effectiveness of endoscopic third ventriculostomy (ETV) in children with hydrocephalus related to posterior fossa tumors. Methods Between September 1999 and December 2002, 63 children with posterior fossa tumors were treated at Santobono Hospital in Naples, Italy. Twenty-six patients had severe hydrocephalus. In order to relieve intracranial hypertension before tumor removal, 20 were treated with ETV, and 6 with ventriculo-peritoneal (VP) shunts. Twenty patients with mild hydrocephalus were treated with diuretics, corticosteroid agents, and early posterior fossa surgery, and 17 patients who did not have hydrocephalus were treated by elective posterior fossa surgery. Another 4 ETV were performed in the management of postoperative hydrocephalus. Results Preoperative ETV procedures were technically successful. One was complicated by intraventricular bleeding. The successful 19 preoperative ETV resolved intracranial hypertension before posterior fossa surgery in all cases. Three of these 19 patients developed postoperative hydrocephalus and were treated by VP shunt insertion after posterior fossa surgery. Out of the 4 ETV performed after posterior fossa surgery, only 2 were successful, both when the shunt malfunctioned. Conclusions Endoscopic third ventriculostomy should be considered as an alternative procedure to ventriculo-peritoneal shunting and external ventricular draining for the emergency control of severe hydrocephalus caused by posterior fossa tumors, since it can quickly eliminate symptoms, and hence, can delay surgery scheduling if required. Even though ETV does not prevent postoperative hydrocephalus in all cases, it does protect against acute postoperative hydrocephalus due to cerebellar swelling. In addition, it eliminates the risks of cerebrospinal fluid (CSF) infection related to external drainage and minimizes the risk of overdrainage because it provides more physiological CSF drainage than the other procedures. Since postoperative hydrocephalus is very often physically obstructive, ETV should always be considered a possible treatment procedure.

Background The significant technological improvement of endoscopic instrumentation has allowed, in the last 10 years, a widespread diffusion of neuroendoscopic procedures. Nevertheless, severe, sometimes life-threatening, complications may occur during neuroendoscopic surgery, and the incidence and age specificity of complications in children have been underdescribed so far. Materials and methods Complications recorded in a prospectively collected database of pediatric patients undergoing neuroendoscopic procedures were analysed; the medical histories of the patients and the surgical procedures were reviewed. Results Complications occurred in 32 out of 231 (13.8%) procedures performed for the management of obstructive hydrocephalus (137), multiloculated hydrocephalus (53), arachnoid cysts (29) and intraventricular tumors (12). Subdural hygroma occurred in 11 cases, seven requiring subdural shunting. In one of these cases, infection of the subdural space occurred and required a craniotomy. Cerebrospinal fluid (CSF) infection occurred in 11 cases. In one case, a frontal abscess developed and was managed with craniotomy. CSF leak occurred in nine cases, intraventricular haemorrhages in two, technical failures in seven, subcutaneous CSF collection (managed with lumbo-peritoneal shunt) in one, thalamic contusion and post-operative transient akinetic mutism in one. This patient suddenly died 6 months later, probably as a consequence of closure of the stoma. Two patients developed secondary compartmentalisation of the ventricles after complicated endoscopic third ventriculostomy. In nine cases, these complications were associated. Overall, no patient died after the procedure (operative mortality 0), one patient died 6 months after the procedure for unexplained events (sudden death rate 0.4%), and three patients presented permanent disability as a consequence of surgical complication (permanent morbidity 1.3%). Conclusions Complication rate of neuro-endoscopic procedures is not negligible even in experienced hands. The majority are minor complications which do not affect the final outcome, but sporadically major events may occur, leading to significant problems in surgical management and, occasionally, to permanent disabilities. Careful selection of patients on pre-operative imaging studies and intensive training of surgeons are mandatory to improve results.

Object The purpose of the present study is to assess the effectiveness of endoscopic third ventriculostomy (ETV) in children with hydrocephalus related to posterior fossa tumors. Methods Between September 1999 and December 2002, 63 children with posterior fossa tumors were treated at Santobono Hospital in Naples, Italy. Twenty-six patients had severe hydrocephalus. In order to relieve intracranial hypertension before tumor removal, 20 were treated with ETV, and 6 with ventriculo-peritoneal (VP) shunts. Twenty patients with mild hydrocephalus were treated with diuretics, corticosteroid agents, and early posterior fossa surgery, and 17 patients who did not have hydrocephalus were treated by elective posterior fossa surgery. Another 4 ETV were performed in the management of postoperative hydrocephalus. Results Preoperative ETV procedures were technically successful. One was complicated by intraventricular bleeding. The successful 19 preoperative ETV resolved intracranial hypertension before posterior fossa surgery in all cases. Three of these 19 patients developed postoperative hydrocephalus and were treated by VP shunt insertion after posterior fossa surgery. Out of the 4 ETV performed after posterior fossa surgery, only 2 were successful, both when the shunt malfunctioned. Conclusions Endoscopic third ventriculostomy should be considered as an alternative procedure to ventriculo-peritoneal shunting and external ventricular draining for the emergency control of severe hydrocephalus caused by posterior fossa tumors, since it can quickly eliminate symptoms, and hence, can delay surgery scheduling if required. Even though ETV does not prevent postoperative hydrocephalus in all cases, it does protect against acute postoperative hydrocephalus due to cerebellar swelling. In addition, it eliminates the risks of cerebrospinal fluid (CSF) infection related to external drainage and minimizes the risk of overdrainage because it provides more physiological CSF drainage than the other procedures. Since postoperative hydrocephalus is very often physically obstructive, ETV should always be considered a possible treatment procedure.

TECHNICAL FIELD - This application relates to the field of coatings that prevent fogging on solid surfaces without altering the characteristics of the covered surface. The coatings may be used on devices and equipment for sports and recreation, the medical field, military and industrial safety
applications. Such devices and equipment include windows and mirrors of automobiles, motorcycles, boats, airplanes, and trains. In industrial and instrumentation application: protective windows, domes, and lenses of gauges, dials, meters. In medical applications: intraocular lenses, endoscopic/laparoscopic lenses, protective eyewear, contact lenses for visual correction, medical implants, surfaces, and medical and surgical tools.
BACKGROUND
The problem of condensation with fogging: Hydrophobic versus hydrophilic surfaces. Protective eyewear, glasses, sunglasses, swimming goggles, diving goggles, helmet visors, windshields, intraocular lenses, medical scopes, and high-precision instrumentation are just several applications where visual distortion due to fogging with condensation poses a problem.
Control of fogging due to condensation on polymer and glass surfaces has seen development, testing and patenting of solutions for a broad spectrum of optical, vision, visor, goggle and lens materials, including optical glasses, borosilicate glass, polycarbonates, tinted thin film coatings, and other polymers for athletic visor and vision-wear. These can require optimization of the robustness and resiliency to create permanent anti-fog coatings, and optimization of adhesion on polycarbonates and surfaces with difficult geometries such as very high curvature. Therefore, anti-fog technologies and their applications have to be conceived and optimized by
adapting to a broad range of specifications for use, use duration, etc., and require working directly with a variety of end users to create such adaptability. End users for anti-fog technology include, but were not limited to: surgeons, professional athletes, recreational users, professional safety users, fire-workers, emergency personnel, biohazard handlers, medical and surgical personnel, and instrumentation dials and domes manufacturers.
Control of fogging should be tested using the specific conditions of condensation experienced by each group end users, such as body or outdoor temperatures, and water vapor pressures and various fluids present during use, such as bodily fluids, sweat, blood, skin oils and human tears or fluids produced from machinery. U.S. patent application Ser. No. No. 13/674,307 (hereinafter '307 application) describes an emulsion that physically changes the surface topography so that condensation behavior can be controlled. The result in the '307 application is a hydrophilic surface that manipulates water droplets so that the water droplets form a thin translucent film on the hydrophilic surface. The'307 application describes a  wet anti-fog technology, where the emulsion is applied when the
surface requires an antifogging coating and should not be dried on the surface. When the emulsion of the '307 application is dried, the polymers come out of the solution and precipitate so that the coated surface is no longer optically transparent and fails to maintain optical quality.
Specifically, the emulsion described in the '307 application is optimized for temporary application and for ease of application. The emulsion described in the '307 application was designed for medical applications, including but not limited to vitro-retinal surgery as well as endoscopic and laparoscopic procedures and surgeries. Thus the emulsion described in the '307
application does not permanently coat the surfaces with anti-fog technology. Accordingly, there is need for a dry permanent anti-fog technology that manipulates water so the water droplets form a thin translucent film on a surface rather than produce fogging on the surface while maintaining optical quality. First, the invention consists of permanent anti-fog coatings, including but not limited to their materials components, composition, adaptive formulation and several methods of fabrication.
The permanent anti-fog is referred to as “FogKnox™”. It includes but is not limited to very high quality optical transmission films that are distortion-free, and exhibit a very high degree of transparency. FogKnox™ includes but is not limited to dry, permanent and very highly uniform optical anti-fog coatings, which can be delivered in wet (fluid) or solid from. Both wet and solid form preserve and improve instantaneously visualization on edges of lenses, dials and surfaces and wide-angle lens. Only after drying is the anti-fog a permanent, non-removable solid film. In a separate embodiment, the anti-fog coatings can be made removable for applications where
lenses and devices on which they are applied need to be resurfaced, called KnoxFog™. The antifoam coatings can also be made semi-permanent, so it can be scrubbed, thus removable by scrubbing, detergent washing and/or sonication, for medical applications, and are then called
VitreOx™. Second, the invention includes, for all above mentioned anti-fog coatings, their method of application in large scale, medium scale or small scale manufacturing, via several possible coating processes, adaptive compositions, adjustments of physical properties and surface
preparation procedures, which are disclosed as the second part of the invention. Third, all the above coatings can also be applied on existing, already manufactured optical devices, tools, dials, goggles, vials, bottles and scopes, via the third element of the invention, specific delivery device and its cartridge of anti-fog coatings materials. The delivery device
includes a coating delivery and element to allow for quick drying element attachment to the metered delivery automated mechanism to apply the coating in a few seconds, and let it dry within minutes.

Object: The goal of this study was to evaluate the safety, efficacy, and indications for repeat endoscopic third ventriculostomies (ETV). Methods and results: We reviewed the records of 20 patients who had undergone repeat ETV from 1987 to 1999. Their ages ranged from 8 months to 53 years (mean 17 years). The primary etiologies of hydrocephalus were: primary aqueductal stenosis

PURPOSE:
This study aims to provide external validation of the "Endoscopic Third Ventriculostomy Success Score (ETVSS)" for both short-term and long-term predictive adequacy.

METHODS:
Between 1998 and 2007, we collected clinical follow-up data (after 6 and 36 months) of all 104 hydrocephalic children (<18 years of age) treated by endoscopic third ventriculostomy (ETV) in our hospital. Predictive adequacy of ETVSS for 6- and 36-month periods was tested by means of an unpaired t test, Hosmer-Lemeshow "goodness-of- fit" test, and area under the receiver operating characteristic curve.

RESULTS:
Mean follow-up was 73.4 months. For both the short-term (6 months) and the long-term (36 months) periods, the mean predicted probability of ETV for the patients with successful ETV treatment was significantly higher than in the patients with failed ETV treatment. The areas under the curve for the short- and long-term periods were, respectively, 0.82 (95% CI 0.71-0.92) and 0.73 (95% CI 0.62-0.84). For patients with moderate ETVSS (50-70), the median age at first ETV was significantly higher for patients with successful ETV for both short- and long-term periods.

CONCLUSION:
In hydrocephalic children, the ETVSS is a useful tool for prediction of outcome after ETV treatment. The ETVSS is more adequate in predicting short-term than long-term success. In our population, it is suggested that success rate for patients with moderate ETVSS could be improved if more weight is attributed to age at first ETV.

Objective We searched for factors that could predispose towards persistent hydrocephalus in children with posterior fossa (PF) tumors in order to determine the need for permanent cerebrospinal fluid (CSF) diversion. Methods The clinical records of 64 children who underwent surgery for PF tumors in the Pediatric Neurosurgery division of the Hospital of Clinics, Ribeirao Preto, Brazil, from 1990 to 2006, were retrospectively reviewed. The patients’ ages ranged from 3 months to 18 years. The factors evaluated included age at surgery, severity of hydrocephalus (ventricular index), tumor location, size of the tumor, extent of tumor resection, and histology. Results Ventricular index, measured from the initial neuroradiological image, age at surgery, and location of the tumor were significantly associated with definitive postoperative CSF diversion (shunt or endoscopic third ventriculostomy), which was necessary for 34% of the patients. Conclusions Young children with severe preoperative hydrocephalus and a midline tumor should be considered at risk when preoperative treatment decisions are made.

Various MR techniques have been used to assess CSF flow and to image the subarachnoid spaces and ventricles. Anecdotal reports describe the use of intrathecal and intraventricular gadolinium-based contrast agents in humans and animals. We sought to determine the clinical usefulness of gadolinium-enhanced MR ventriculography for assessing CSF flow in patients with various neurologic conditions. Five patients (three female and two male patients aged 6 months to 65 years) were included in the study. After performing sagittal, coronal, and axial T1-weighted MR imaging of the brain, 0.02-0.04 mmol of gadodiamide was injected into the lateral ventricle. Sagittal, coronal, and axial T1-weighted imaging was repeated soon after the injection. We were specifically looking for the site of obstruction to CSF flow in those patients with hydrocephalus, communication between cysts and ventricles, elucidation of suspicious intraventricular lesions, and patency of third ventriculostomies. MR ventric...

Endoscopic third ventriculostomy (ETV) is increasingly used as alternative treatment for obstructive hydrocephalus. The aim of this study was to determine the utility of quantitative and qualitative examinations with cine phase-contrast MR imaging to determine the efficacy of ventriculostomy across time and whether CSF pulsation is restored after ETV. Thirty-eight patients treated with ETV were evaluated with cine phase-contrast MR within 1 month after surgery. Follow-up studies were performed after 1 year in 25 patients and after 2 years in 12. We evaluated flow void changes in the floor of the third ventricle and quantified the stroke volume at the site of the ventriculostomy. We also recorded changes in ventricular size and clinical outcome. To determine the restoration of CSF pulsation, we compared the CSF waveform at the ventriculostomy with the CSF waveform at the aqueduct in a healthy control group. After ventriculostomy, restoration of pulsate motion characteristics of CSF c...

Background Cerebrospinal fluid (CSF) abdominal pseudocyst is an uncommon but important complication of ventriculoperitoneal shunts. From the collected series, several features about the etiology and management become apparent. Retrospective data were obtained from 12 children treated with cerebrospinal fluid abdominal pseudocyst defined an alternative approach for management of these patients. Methods There were eight girls and four boys who ranged in age from 12 days to 18 years old (mean 7.7 months). The most frequent etiology of the hydrocephalus was Chiari type II malformation in six cases. Initial presentation with shunt malfunction was detected in nine cases. Abdominal distention and/or pain were the most frequent finding in our series (10/12). In only one case, infection was detected for all cerebrospinal fluid abdominal pseudocysts (8.3%). Ventriculoperitoneal shunt (VPS) externalization, antibiotics, and cyst aspiration was performed in 8/12 cases as initial management of abdominal pseudocyst. Ventriculoperitoneal shunt reinsertion in abdominal cavity and/or endoscopic third ventriculostomy (ETV) was performed as final management in 9/12. Ventriculoatrial shunt was used only in three cases. Recurrence of the abdominal cyst was observed in two cases. Discussion Based on the success rate (75%) in our series submitted to this management, a ventriculoperitoneal shunt can be safely reinserted in the majority of the patients. Endoscopic third ventriculostomy could be performed in selected cases as an alternative approach. Although infection has been reported as responsible for pseudocyst formation, it was only exceptionally found in our series.

Resumen Introducción: El tercer ventrículo del cerebro humano proporciona continuidad luminal entre los dos ventrículos laterales y el acueducto cerebral. La mayoría de las lesiones que afectan al tercer ventrículo, incluidos tumores, quistes y malformaciones vasculares, pueden tratarse con éxito mediante técnicas microquirúrgicas y endoscópicas. Objetivos: Describir aspectos anatómicos fundamentales del tercer ventrículo y su aplicación neuroquirúrgica. Materiales y métodos: La información se obtuvo mediante la revisión de artículos en formato digital e impreso de publicación reciente. Resultados y discusión: Es una cavidad impar de la línea media, en forma de embudo estrecho. Se comunica en su margen anterosuperior con cada ventrículo lateral a través de los forámenes de Monro y posteriormente con el cuarto ventrículo a través del acueducto de Silvio. La literatura describe un techo, un piso y paredes anterior, posterior y dos laterales. Conclusiones: La cirugía del tercer ventrículo todavía se considera un desafío. A pesar de los grandes avances técnicos, la elección del mejor abordaje sigue siendo controvertida.

Neuro-endoscopic surgery is finding increasing application for various clinical conditions. We present our experience of 100 cases of diverse intracranial lesions, including infections, managed by neuro-endoscopy in a busy neurosurgical department in the developing world. One hundred patients treated from March 1996 to February 2002 formed the study group. Management of hydrocephalous by Endoscopic third ventriculostomy (ETV) was the aim in 75 patients with or without diagnostic biopsy. Excision or resection was attempted in 25 patients with juxtaventricular or intraventricular lesions. Endoscopic procedures included total tumour resection, partial resection, biopsy, stent placement, Monroplasty, septostomy and third ventriculostomy. Outcomes of endoscopic surgery were evaluated with respect to clinical and/or radiological improvement, complications and need for additional therapy. Endoscopy was the only surgical treatment in 59 patients. Intermittent lumbar drainage for cerebrospin...