Endoscopic fenestration of intraventricular cerebrospinal fluid cysts: the contralateral approach

Abstract

OBJECT The endoscopic fenestration of intraventricular CSF cysts has evolved into a well-accepted treatment modality. However, definition of the optimal trajectory for endoscopic fenestration may be difficult. Distorted ventricular anatomy and poor visibility within the cyst due to its contents can make endoscopic fenestration challenging if approached from the ipsilateral side. In addition, transcortical approaches can theoretically cause injury to eloquent cortex, particularly in patients with dominant-sided lesions. The aim of this study was to examine the value of the contralateral transcortical transventricular approach in patients with dominant-sided ventricular cysts. METHODS During a 5-year period between 2007 and 2011, 31 patients with intraventricular CSF cysts underwent surgery by the senior author (R.R.). Fourteen of these patients had cysts located on the dominant side. An image-guided endoscopic cyst fenestration via the contralateral transcortical transventricular approach was performed in 11 patients. A retrospective chart review was performed in all these patients to extract data on clinical presentation, operative technique, and surgical outcome. RESULTS The most common presenting symptom was headache, followed by memory deficits and cognitive deterioration. In all cases CSF cysts were space occupying, with associated obstructive hydrocephalus in 8 patients. Image-guided endoscopic fenestration was successfully performed in all cases, with septum pellucidotomy necessary in 6 cases, and endoscopic third ventriculostomy in 1 case for additional aqueductal occlusion. Postoperative clinical outcome was excellent, with no associated permanent neurological or neuropsychological morbidity. No recurrent cysts were observed over a mean follow-up period of 2 years and 3 months. CONCLUSIONS The contralateral approach to ventricular cysts can achieve excellent surgical outcomes while minimizing approach-related trauma to the dominant hemisphere. Careful case selection is essential to ensure that the contralateral endoscopic trajectory is the best possible exposure for sufficient cyst fenestration and restoration of CSF circulation.

Neurocognitive Complications after Ventricular Neuroendoscopy: A Systematic Review

“…In 25 studies, a rigid endoscope was used; in four studies, a flexible endoscope was used; and in six studies, both flexible and rigid endoscopes were used, while in 6 studies, the type of endoscope used was not described (Table 1). Table 1 presents the 40 included series describing neurocognitive complications, of which 8 assess for neurocognitive outcome through specific neuropsychological test batteries [3,4,10,[12][13][14][15][16]. Transient and permanent neurocognitive complications in 2804 ventricular neuroendoscopic procedures occurred in 2.0% (n = 55) and 1.04% (n = 28) of the patients, respectively.…”

“…Additionally, they state that patients presenting with chronic obstructive hydrocephalus and history of progressive cognitive dysfunction alone may profit from ETV [13]. Hugelshofer et al assessed 11 right-handed patients with space-occupying intraventricular cysts on their dominant side, who underwent Behavioural Neurology endoscopic fenestration through a contralateral (nondominant) approach [3]. Preoperative neuropsychological assessment in 10 patients revealed cognitive impairment in eight patients, while all eight patients showed postoperative cognitive improvement after neuropsychological testing.…”

“…No permanent cognitive complications were seen. They conclude that a nondominant approach for dominant-hemispheric ventricular cysts is associated with very low approach-related morbidity [3]. Ten out of 22 patients undergoing CC resection underwent neuropsychological testing in a series published in 2016 by Birski et al [10].…”

“…Ventricular neuroendoscopy, for the treatment of occlusive, and also nonocclusive, hydrocephalus, colloid cysts (CC), intraventricular cysts, fourth ventricle outlet obstruction (FVOO), and intraventricular tumors has become increasingly popular over the last two decades [1][2][3][4]. Various ventricular endoscopic procedures, such as third ventriculostomy (ETV), CC resection or aspiration, tumor biopsy or resection, septum pellucidotomy, and foraminoplasty or stenting, have been described.…”

“…In addition, endoscopic treatment of hydrocephalus is considered preferable to the placement of ventriculoperitoneal shunt (VPS) in patients above the age of six months, since it is at least as efficient and it avoids a lifetime shunt dependency and associated complications, occurring sometimes years after VPS placement [1,7]. Despite the growing preference of neuroendoscopic procedures for the treatment of hydrocephalus and intraventricular lesions, only few studies analyze variables such as cognitive and emotional deficits following these procedures [3,4,[8][9][10][11][12][13][14][15][16]. In addition, the very few studies assessing for neurocognition in a systematic manner do not focus on neurocognitive decline caused by the surgery itself, but rather on improvement in neurocognitive outcome.…”