We present an overview of the history, development, technological advancements, current application, and future trends of cranial endoscopy. Neuroendoscopy provides a safe and effective management modality for the treatment of a variety of intracranial disorders, either tumoral or non-tumoral, congenital, developmental, and degenerative, and its knowledge, indications, and limits are fundamental for the armamentarium of the modern neurosurgeon.
The authors report on 125 patients who underwent endoscopic third ventriculostomy for obstructive hydrocephalus in three Italian Neurosurgical Centers. The series includes 77 cases of primary aqueductal stenosis, 33 with triventricular hydrocephalus due to external tumor compression, and 15 with tetraventricular hydrocephalus. The operations were carried out mainly under general anesthesia, using a flexible endoscope. Decrease of size of the third ventricle and the presence of a signal void at the level of the fenestration are the main postoperative MRI findings. Signs of intracranial hypertension, increased head circumference and Parinaud syndrome respond more frequently to the endoscopic treatment. The overall rate of good results (shunt-independent patients) in this series is 86.4%; primary aqueductal stenosis (93.5%) and triventricular hydrocephalus due to external compression (84.8%) are associated to the higher rate of good postoperative results than tetraventricular hydrocephalus (53.3%). Because of the very low invasivity of this technique, the absence of postoperative mortality and the scarce and usually transient postoperative complications, the authors advise to enlarge the indications for endoscopic third ventriculostomy to all patients with obstructive hydrocephalus when the third ventricle is large enough and there are no alterations of the CSF resorption.
ETV results in a relatively high rate of clinical improvement and a low complication rate in patients with idiopathic normal pressure hydrocephalus. Therefore, it may be easily performed with the same approach used for intracranial pressure monitoring with low morbidity. However, our data must be confirmed by additional studies.
In patients with INPH showing short duration of symptoms, prevalence of gait disturbance, and slight mental impairment, ETV provides similar results to those of shunting. We suggest performing ETV in these patients and reserving shunting only for those who do not improve after ETV, despite the presence of cerebrospinal fluid flow through the ventriculostomy on MRI flow studies. The good results after ETV in our series indirectly confirm that the cerebrospinal fluid absorption is good or at least sufficient in selected patients with INPH.
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