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Idiopathic intracranial hypertension (IIH) remains a poorly understood condition with no standardized treatment. Treatment is therefore generally individualized. Recent isolated reports have begun to describe the use of third ventriculostomy (open or closed) for the treatment of IIH. This review aims to communicate the current evidence for the use of third ventriculostomy in IIH. A systemic review, using PubMed, was performed of studies describing the use of third ventriculostomy, either open or closed, for the treatment of idiopathic intracranial hypertension. Only 3 studies for a total of 3 patients were found in which a third ventriculostomy was performed for the treatment of IIH. Despite very plausible proposed mechanisms of action, there is currently a paucity of both studies and, therefore, evidence for the use of either endoscopic or open third ventriculostomy for the treatment of IIH. The studies done to date do strongly suggest that further consideration is warranted. [ABSTRACT FROM AUTHOR]

Third ventriculostomy is the preferred treatment for obstructive hydrocephalus, but the biomechanics of brain tissue damage caused by fiber endoscopes remains unclear. In this study, brain tissue material parameters were tested based on the Ogden model to simulate needle puncture mechanics, and replicated the entire fiber endoscope advancement process during third ventriculostomy. It was found that a smaller diameter fiber endoscope, a perpendicular puncture angle, and a faster puncture speed would decrease the damage of brain tissue caused by the fiber endoscope. This study provides valuable insights for optimizing the instrumentation and surgical process of third ventriculostomy. [ABSTRACT FROM AUTHOR]

Purpose: Pediatric hydrocephalus is the most common cause of surgically treatable neurological disease in children. Controversies exist whether endoscopic third ventriculostomy (ETV) or cerebrospinal fluid (CSF) shunt placement is the most appropriate treatment for pediatric hydrocephalus. This study aimed to compare the risk of re-operation and death between the two procedures. Methods: We performed a retrospective population-based cohort study and included patients younger than 20-years-old who underwent CSF shunt or ETV for hydrocephalus from the Taiwan National Health Insurance Research Database. Results: A total of 3,555 pediatric patients from 2004 to 2017 were selected, including 2,340 (65.8%) patients that received CSF shunt placement and 1215 (34.2%) patients that underwent ETV. The incidence of all-cause death was 3.31 per 100 person-year for CSF shunt group and 2.52 per 100 person-year for ETV group, with an adjusted hazard ratio (HR) of 0.79 (95% confidence interval [CI] = 0.66–0.94, p = 0.009). The cumulative incidence competing risk for reoperation was 31.2% for the CSF shunt group and 26.4% for the ETV group, with an adjusted subdistribution HR of 0.82 (95% CI = 0.70–0.96, p = 0.015). Subgroup analysis showed that ETV was beneficial for hydrocephalus coexisting with brain or spinal tumor, central nervous system infection, and intracranial hemorrhage. Conclusion: Our data indicates ETV is a better operative procedure for pediatric hydrocephalus when advanced surgical techniques and instruments are available. [ABSTRACT FROM AUTHOR]

Background: Although generally a safe procedure, serious postoperative complications after endoscopic third ventriculostomy (ETV) for obstructive hydrocephaly have been rarely reported, such as delayed obstruction of the stoma at the third ventricle floor. Case description: A 20-year-old male was referred to our department because of severe headache and diplopia. A pineal tumour and obstructive hydrocephaly were detected in preoperative imaging. After tumour biopsy and ETV, the reduction of ventricle size and improvement of headaches were immediately observed. On the seventh day, however, he developed a rapidly progressing consciousness disturbance due to severe hydrocephalus leading to urgent secondary ETV. The original ventriculostomy stoma at the third ventricle floor was completely occluded by scar adhesion. The patient recovered well as previously and received additional treatment. Conclusion: Although very rare, occlusion of the ventriculostomy stoma can postoperatively occur in the subacute period. Patients undergoing ETV for obstructive hydrocephalus due to a pineal tumour should be carefully monitored to avoid serious consequences. [ABSTRACT FROM AUTHOR]

Idiopathic obstruction of the outlets of the fourth ventricle (FVOO) is a rare cause of hydrocephalus, which can be misdiagnosed as communicating hydrocephalus due to the enlargement of all four ventricles. Different surgical approaches are discussed in the literature. We present a case report of a 25-year-old male admitted with headache, vertigo, and nystagmus. The MRI scan showed a tetraventricular hydrocephalus with a patent aqueduct. After endoscopic third ventriculostomy (ETV), symptoms resolved. We performed a systematic review of the literature, covering 26 years, with the aim to investigate the symptoms, therapy, and outcome of primary FVOO, according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines. We found 9 case reports and 2 case series and could extract a total of 34 cases. After ETV all symptoms resolved in 10 of 23 cases (43.5%), and in 13 of 23 cases (56.5%) symptoms improved partially. Seven cases (30.4%) required additional surgery. A decrease in ventricular volume occurred in most cases. In the 10 patients who were operated via fenestration, all symptoms resolved in 6 cases. ETV seems to be an effective treatment option for patients with idiopathic FVOO in a majority of cases. In special cases, fenestration of the foramen of Magendie may be suitable.

Idiopathic obstruction of the outlets of the fourth ventricle (FVOO) is a rare cause of hydrocephalus, which can be misdiagnosed as communicating hydrocephalus due to the enlargement of all four ventricles. Different surgical approaches are discussed in the literature. We present a case report of a 25-year-old male admitted with headache, vertigo, and nystagmus. The MRI scan showed a tetraventricular hydrocephalus with a patent aqueduct. After endoscopic third ventriculostomy (ETV), symptoms resolved. We performed a systematic review of the literature, covering 26 years, with the aim to investigate the symptoms, therapy, and outcome of primary FVOO, according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines. We found 9 case reports and 2 case series and could extract a total of 34 cases. After ETV all symptoms resolved in 10 of 23 cases (43.5%), and in 13 of 23 cases (56.5%) symptoms improved partially. Seven cases (30.4%) required additional surgery. A decrease in ventricular volume occurred in most cases. In the 10 patients who were operated via fenestration, all symptoms resolved in 6 cases. ETV seems to be an effective treatment option for patients with idiopathic FVOO in a majority of cases. In special cases, fenestration of the foramen of Magendie may be suitable. [ABSTRACT FROM AUTHOR]

Background: Although controversial, endoscopic third ventriculostomy (ETV) in the management of Myelomeningocele and Chiari type II malformation-related hydrocephalous is gaining wider popularity and use. With variable success rates, it can be proposed as a first or second option after shunt malfunction. ETV in postinfectious hydrocephalus may also be considered as an alternative to shunting. With reported success rates of 50-60%, failure is attributed to anatomical reasons and/or to pathological subarachnoid space scarring that may result from infectious processes. Similarly, ETV in repeated shunt malfunctions is an acceptable option that may offer shunt independency. In all situations, case-by-case selection and discussion are to be considered. Case Description: A 5-year-old boy with a history of surgically treated lumbosacral myelomeningocele and ventriculoperitoneal shunting at six months of age is presented. During the course following the initial surgery, he experienced multiple shunt malfunctions, with two episodes of meningitis, leading to 7 shunt revision surgeries. Lately, the patient presented a large peritoneal cyst formation that needed regular evacuations. With a magnetic resonance imaging (MRI)-scan showing a large bi-ventricular hydrocephalus and a trapped third ventricle with multiple septations, surgical options included either ventriculoatrial shunting or third ventriculostomy. The latter option, offering shunt independency, was chosen after family consent and risk explanation. The expected success rate of the procedure was discussed and evaluated to 40-60% on the ETV success score. The video describes a step-by-step procedure with detailed radiological and correlated anatomical annotations of a completely distorted anatomy of a multifactorial hydrocephalous. No scarring at the prepontine cistern was observed. Shunt independency was achieved. However, the patient died from late postoperative status epilepticus and pulmonary complications. Whether these postoperative events are directly related to the procedure is unclear, although technically and clinically successful in the short term. Conclusion: We believe that ETV should be carefully indicated in selected patients with Chiari II, post-infectious hydrocephalus, by experienced hands, as the surgical anatomy can be extremely complex and misleading. [ABSTRACT FROM AUTHOR]

Introduction: Pineal region tumours (PRTs) are more common in children and represent a wide variety of lesions. The practise of a radiation test dose is obsolete and a biochemical/histological diagnosis is recommended before further therapy. Many patients present with hydrocephalus. Advances in neuroendoscopic techniques have allowed safe and effective management of this obstructive hydrocephalus with an opportunity to sample cerebrospinal fluid (CSF) and obtain tissue for histopathology. Definitive surgery is required in less than a third. Endoscopic visualisation and assistance is increasingly used for radical resection, where indicated. Methodology: Our experience of endoscopic surgery for paediatric PRTs from 2002 to 2021 is presented. All patients underwent MRI with contrast. Serum tumour markers were checked. If negative, endoscopic biopsy and endoscopic third ventriculostomy (ETV) were performed; and CSF collected for tumour markers and abnormal cells. For radical surgery, endoscope-assisted microsurgery procedures were performed to minimise retraction, visualise the extent of resection and confirm haemostasis. Results: M:F ratio was 2:1. The median age of presentation was 11 years. Raised ICP (88.88%) was the commonest mode of presentation. Nineteen patients had pineal tumours, one had a suprasellar and pineal tumour, one had disseminated disease, while six had tectal tumours. The ETB diagnosis rate was 95.45%, accuracy rate was 83.3% and ETV success rate was 86.96%. Conclusion: Neuroendoscopy has revolutionised the management of paediatric PRTs. It is a safe and effective procedure with good diagnostic yield and allows successful concurrent CSF diversion, thereby avoiding major surgeries and shunt implantation. It is also helpful in radical resection of lesions, where indicated. [ABSTRACT FROM AUTHOR]

Introduction: The management of refractory obstructive hydrocephalus is a paramount neurosurgical challenge. The endoscopic third ventriculostomy (ETV) has been accepted as the procedure of choice for obstructive hydrocephalus, depending on the presence of certain risk factors, such as intracranial infections, young age, previous shunt failure and distorted anatomy of the ventricular floor, that predispose occlusion or obstruction of the CSF outflow through the stoma. Case Report: A 20-year-old man with obstructive hydrocephalus due to primary aqueductal stenosis performed several neurosurgical procedures, including two previous ETV, without long term resolution. We performed another ETV, with stent placement at the stoma to prevent occlusion. After 25 months of asymptomatic follow-up, the patient presented with an enlarged fourth ventricle, and a new neuroendoscopic procedure showed a patent stoma and a well-placed stent. Discussion: Stent placement on the third ventricular floor was already reported 19 times in the literature. Its success rate is about 94,7%, and complications happened in 2 cases, with functional impaired in only one of them. Conclusion: Third ventriculostomy with floor stenting proved to be an effective procedure in our case of complex hydrocephalus. It is a viable option in cases where there is a greater chance of stoma occlusion. [ABSTRACT FROM AUTHOR]

Introduction: A vein of Galen aneurysmal malformation (VGAM) is a high-flow arteriovenous malformation that typically presents in early childhood. Complications associated with this condition include heart failure and hydrodynamic disorders resulting from high blood flow. Hydrocephalus is one of the hydrodynamic disorders. It can present in a chronic form due to a defect in the absorption of cerebrospinal fluid (CSF) resulting from venous hypertension or in an acute/subacute form due to obstruction of normal circulation routes caused by the mass effect of the VGAM. Currently, endovascular closure of the lesion is considered the treatment of choice. However, in acute/subacute presentations of obstructive hydrocephalus, progression may occur despite endovascular treatment, necessitating a cerebrospinal fluid diversion procedure. Prior to the advent of endoscopic treatment, ventricular shunts were utilized, but outcomes were poor due to the pathological hydrodynamic parameters associated with the malformation. The role of endoscopic third ventriculostomy as a treatment option in these situations remains unclear, and there is limited literature available. Therefore, we present the case of a patient with a vein of Galen aneurysmal malformation and obstructive hydrocephalus, which was treated via ETV. Furthermore, a literature review was conducted. Case description: We present a 5-month-old infant who was diagnosed at birth with VGAM. At 2 months of age, a partial closure of the malformation was performed via endovascular. Subsequently, the patient presented at the emergency department with symptoms of irritability, lethargy, vomiting, feeding refusal, and "setting sun" sign of several days' duration due to obstructive hydrocephalus. The patient was successfully treated via ETV. Following this, a new arteriography was performed and revealed occlusion of the VGAM. The child clinically improved and currently exhibits mild psychomotor impairment after 1-year follow-up. Conclusion: In the literature, there are a limited number of reports on the treatment of obstructive hydrocephalus associated with VGAM via ETV. These reports have demonstrated good outcomes with minimal surgical complications. Our patient also exhibited good results. As such, ETV is a viable and safe option for the treatment of obstructive hydrocephalus associated with VGAM in pediatric patients. However, more research is needed to establish the effectiveness of ETV in comparison to other treatment options and to understand the long-term outcomes. [ABSTRACT FROM AUTHOR]

Introduction: Loculated hydrocephalus is a complex condition in which different non-communicating compartments form within the ventricular system due to different etiology, mainly intraventricular hemorrhage and infection. Since the end of the twentieth century, neuroendoscopy has been explored as a therapeutic option for loculated hydrocephalus with non-univocal results. Methods: We performed a retrospective analysis of 90 patients who underwent endoscopic treatment for loculated hydrocephalus from January 1997 to January 2021 (mean age: 2 years, range 7–21). We included 37 (41.1%) children with multiloculated hydrocephalus, 37 (41.1%) with isolated lateral ventricle, 13 (14.4%) with excluded temporal horn, and 3 (3.3%) with isolated fourth ventricle. We compared our results with those available in literature. Results: A mean of 1.91 endoscopic procedure/patient were performed (only one endoscopy in 42.2% of cases). Complications of neuroendoscopy and of shunt surgeries were recorded in 17 (18.9%) and 52 (57.8%) children, respectively. Twenty-six (28.9%) children were shunt-free at the last follow-up, 47.8% have only one shunt. Discussion: The first goal of neuroendoscopy is to increase the rate of shunt-free patients but, when it is not possible, it aims at simplifying shunt system and reducing the number of surgical procedures. In our series, neuroendoscopy was able to achieve both these goals with an acceptable complication rate. Thus, our results confirmed neuroendoscopy as a valid tool in the long-term management of loculated hydrocephalus. Neuronavigation and intraoperative ultrasound could increase the success rate in cases with distorted anatomy. [ABSTRACT FROM AUTHOR]

Background and Aim: Optic pathway glioma (OPG) is a chronic condition that needs a multi-disciplinary management strategy. Most of these tumors are observed in the pediatric population and the tumor tends to stabilize after the child's growth. This benign course can be observed mostly in neurofibromatosis 1 (NF1) patients, which are about half of the pediatric patients. Methods and Materials/Patients: The current literature in PubMed and Scopus databases was searched. The recent data regarding OPG and treatment options were reviewed to design this narrative mini-review. Results: The brief data extracted from 17 articles, cited in the reference list, were included in the study. Conclusion: Chemotherapy is the first and best treatment modality for patients with OPG. It is more useful at younger ages because it has lower rates of complications and cancer in the future compared with radiotherapy, the treatment of choice in previous decades for these patients. However, in recent practice, it has been substituted by chemotherapy because of its serious adverse effects on the pediatric population. Neurosurgical treatments for OPG are used for three main purposes, third ventricle obstruction-related hydrocephalus, biopsy, and tissue diagnosis for cases with an uncertain diagnosis, and tumor decompression due to mass effect on vital structures. Surgical decompression is not considered the first-line treatment in OPG. It can be used for patients with progressive exophthalmos with ipsilateral blindness or patients with refractory pain after adjuvant treatment. This short review discusses the main aspects of OPG treatment modalities. [ABSTRACT FROM AUTHOR]

Background and Aim: Optic pathway glioma (OPG) is a chronic condition that needs a multidisciplinary management strategy. Most of these tumors are observed in the pediatric population and the tumor tends to stabilize after the child’s growth. This benign course can be observed mostly in neurofibromatosis 1 (NF1) patients, which are about half of the pediatric patients. Methods and Materials/Patients: The current literature in PubMed and Scopus databases was searched. The recent data regarding OPG and treatment options were reviewed to design this narrative mini-review. Results: The brief data extracted from 17 articles, cited in the reference list, were included in the study. Conclusion: Chemotherapy is the first and best treatment modality for patients with OPG. It is more useful at younger ages because it has lower rates of complications and cancer in the future compared with radiotherapy, the treatment of choice in previous decades for these patients. However, in recent practice, it has been substituted by chemotherapy because of its serious adverse effects on the pediatric population. Neurosurgical treatments for OPG are used for three main purposes, third ventricle obstruction-related hydrocephalus, biopsy, and tissue diagnosis for cases with an uncertain diagnosis, and tumor decompression due to mass effect on vital structures. Surgical decompression is not considered the first-line treatment in OPG. It can be used for patients with progressive exophthalmos with ipsilateral blindness or patients with refractory pain after adjuvant treatment. This short review discusses the main aspects of OPG treatment modalities.

We report a patient with racemose neurocysticercosis, highlighting the diagnostic and management issues. A 37-year-old male had headaches, fever, and seizures for 8 months. He had a positive tuberculin test, cerebrospinal fluid pleocytosis, and hydrocephalus and exudates on MRI. His symptoms rapidly resolved following antitubercular and prednisolone treatment. After 2 months, he was readmitted with headache and vomiting, and his brain MRI revealed communicating hydrocephalus with a cyst in the lateral ventricle and subarachnoid space, which was confirmed as neurocysticercosis on the third ventriculostomy. The patient was managed with dexamethasone and a ventriculoperitoneal shunt. This case highlights that meningitis symptoms, CSF pleocytosis, and positive tuberculin tests may not always suggest tubercular etiology. [ABSTRACT FROM AUTHOR]

Objective: To evaluate and discuss the outcomes of a combination of ventriculocystostomy (VC) and endoscopic third ventriculostomy (ETV) for obstructive hydrocephalus (HCP) due to ventricular/cisternal arachnoid cysts, and only ETV for obstructive HCP due to different etiologies. Methods: We retrospectively reviewed all 40 symptomatic patients (aged 4 months – 61 years) of obstructive HCP treated by ETV or VC+ETV during October 2014 – April 2019. VC+ETV was performed in 7 patients with intraventricular/cisternal arachnoid cyst and obstructive HCP. Only ETV was performed in 33 patients with obstructive HCP due to other etiologies. Results: Successful ETV or VC+ETV surgery was performed in 35 patients. The procedure failed in 5 patients aged < 1 year; all these 5 patients had a head circumference (HC) of > 90 percentile at the time of surgery. Another 5 patients aged < 1 year showed successful ETV, with a HC of 75–90 percentiles. Conclusion: ETV is a successful alternative treatment for obstructive HCP. The ventricular size may not demonstrate a remarkable reduction post-ETV than post-shunting. Accordingly, increased intracranial pressure may not effectively decrease during the early period post-ETV than post-shunting. Therefore, the success rates of VC and/or ETV are low in very young patients with very high HCs (> 90 percentile).

The Liliequist membrane is a radiologically neglected structure, with routine evaluation only carried out in pre-operative and post-operative cases of third ventriculostomy. We report two cases of Chiari III malformation in two unrelated females with similar findings on magnetic resonance imaging study including occipital and low cervical encephalocele, hydrocephalus, and segmentation anomalies in cervical spine. Along with these findings, we report a flow void on T2-weighted images observed in both cases across the site of Liliequist membrane between interpeduncular and chiasmatic cistern. Our findings of CSF flow across the Liliequist membrane may represent spontaneous third ventriculostomy or another congenital defect in the myriad of anomalies seen in cases of Chiari III malformation. [ABSTRACT FROM AUTHOR]

The endoscopic third ventriculostomy (ETV) success score (ETVSS) was developed to predict the success rate of ETV at 6 months. In this study, the authors assessed the performance of this score for > 6 months, i.e., at 12 months, and provided external validation in Brazilian children. All children undergoing first ETV (without choroid plexus cauterization) at a Brazilian single institution for > 20 years were included in the study. The ETVSS was retrospectively calculated for each patient and compared with the actual success of the procedure observed at 6 and 12 months after the procedure. A total of 313 eligible children underwent initial ETV, 34.18% of whom had undergone shunt placement before ETV. The most common etiologies were aqueductal stenosis (45%) and non-tectal brain tumors (20.8%). ETV was successful at 6 months in 229 patients (73.16%) compared with the 61.3% predicted by the ETVSS. The overall actual success rate observed at 1 year after ETV was 65.1% (204 patients). The area under the receiver operating characteristic curve was 0.660 at 6 months and 0.668 at 1 year, which suggested a tendency for the ETVSS to underestimate the actual success rate of ETV at both timepoints. The ETVSS showed good success prediction in accordance with the actual ETV success rate and proved to be useful during the decision-making process of ETV. [ABSTRACT FROM AUTHOR]

Background: Dengue is the leading cause of mosquito-borne viral infection. It is responsible for high morbidity and mortality in children living in endemic areas. Nowadays, neurological complications are progressively referred to and include a broad spectrum of symptoms. It can be secondary to metabolic alterations, direct invasion by the virus, and enhanced autoimmune response. Case presentation: Here, we report a rare case of hydrocephalus secondary to dengue encephalitis. A 13-day-old boy was diagnosed with dengue. He evolved with seizures and impaired consciousness being diagnosed with encephalitis. After clinical treatment, he was discharged fully recovered. Three months later, he presented with signs and symptoms of intracranial hypertension. Brain MRI revealed hydrocephalus secondary to acquired aqueduct stenosis. The patient underwent an endoscopic third ventriculocisternostomy. Conclusion: Dengue infection is a differential diagnosis for acute febrile neurological impairment in children from endemic areas. Follow-up should be offered after dengue encephalitis to detect possible late-onset complications, as hydrocephalus. [ABSTRACT FROM AUTHOR]

Patients diagnosed with low-pressure hydrocephalus typically present with enlarged ventricles and unusually low intracranial pressure, often measuring below 5 cmH 2 O or even below atmospheric pressure. This atypical presentation often leads to low recognition and diagnostic rates. The development of low-pressure hydrocephalus is believed to be associated with a decrease in the viscoelasticity of brain tissue or separation between the ventricular and subarachnoid spaces. Risk factors for low-pressure hydrocephalus include subarachnoid hemorrhage, aqueduct stenosis, prior cranial radiotherapy， ventricular shunting, and cerebrospinal fluid leaks. For potential low-pressure hydrocephalus, diagnostic criteria include neurological symptoms related to hydrocephalus, an Evans index >0.3 on imaging, ICP ≤ 5 cm H 2 O, symptom improvement with negative pressure drainage, and exclusion of ventriculomegaly caused by neurodegenerative diseases. The pathogenesis and pathophysiological features of low-pressure hydrocephalus differ significantly from other types of hydrocephalus, making it challenging to restore normal ventricular morphology through conventional drainage methods. The primary treatment options for low-pressure hydrocephalus involve negative pressure drainage and third ventriculostomy. With appropriate treatment, most patients can regain their previous neurological function. However, in most cases, permanent shunt surgery is still necessary. Low-pressure hydrocephalus is a rare condition with a high rate of underdiagnosis and mortality. Early identification and appropriate intervention are crucial in reducing complications and improving prognosis. • In this review, we discussed the underlying mecnanism contributing to the development of LPH • We shed light on the distinctive pathophysiological features of LPH that differentiate it from other types of hydrocephalus • We outlined the primary treatments for LPH, including negative pressure drainage and third ventriculostomy. [ABSTRACT FROM AUTHOR]

The neuroendoscopy is supported by three pivotal pillars: training, planning, and prudence. The training consists of attending practical courses with synthetic head models for immersion in the intricate ventricular anatomy and practice in handling the neuroendoscope. The planning begins with the choice of the entry point, usually performed at the Kocher's point, and measurement of this to the ventricle. Neuroendoscopy in intraventricular hemorrhage or ventriculitis is always challenging due to low visibility, thus, copious irrigation with a heated solution at 37°C, like plasma type, is mandatory, often reaching 6L of solution. Narrow spaces between the clivus and basilar artery can be very dangerous, therefore we prefer a "Sputnik" fórceps rather than blunt instruments to open the floor of the III ventricle and subsequently widen it with Fogarty n°3. Sometimes it is necessary to mechanically remove the larger clots that do not come off the ventricle walls only with irrigation; in these cases, we aspirate them through the neuroendoscope until we see the structures that allow us to perform ETV and guarantee its patency. Navigating inside the ventricle when the complex anatomy is distorted, such as cases of myelomeningoceles with large interthalamic masses, can be very difficult; for these cases, we use the optics inversion technique to access different locations with the same field of view. The innovation in neuroendoscope models allowed us to associate techniques, such as the concomitant use of an ultrasonic aspirator to remove intraventricular lesions. Another field of great development was fetal surgery for hydrocephalus; initially with cephalocenteses passing through the ventriculo-aminiotic shunt until the fetal ETV. For complex cases of the second look of ETV, we can still associate techniques such as aqueductoplasty and implantation of stents in the third ventricular floor and cerebral aqueduct to keep them patent. Last but not least, we have the pillar of prudence. Any neuroendoscopy, regardless of the surgeon's experience or the apparent simplicity of the case, must be done with the utmost caution, avoiding minimal bleeding, avoiding touching structures that are not vital to the procedure, and be objective.

Background: We describe the technical report and results of the first image-guided, linear accelerator, frameless radiosurgical third ventriculostomy. Methods: We report a 20 years old man, with diplopia, balance disturbances, and limitation for gaze supraversion. Magnetic resonance imaging resonance imaging of the brain and cranial computed tomography showed showed a left thalamic-midbrain lesion that caused partial compression of the Silvio aqueduct and mild ventricular dilatation. The biopsy revealed the diagnosis of pleomorphic xanthoastrocytoma. Before radical treatment of the tumor with fractionated stereotactic radiotherapy, the patient underwent to frameless radiosurgical third ventriculostomy, on the TrueBeam STX® platform with the ExacTrac localization system. The target used was the one defined on the floor of the third ventricle, at the midpoint between the mammillary bodies and the infundibular recess. The prescription dose was 120 Gy, given using a monoisocentric technique of multiple noncoplanar circular arches. The geometric arrangement of the plan consisted of 15 arches, with a 4 mm cone, distributed over a 110° table. Results: There was symptomatic and image improvement two days after radiosurgery. On CT, a reduction in ventricular dilation was observed with a reduction in the Evans index from 0.39 (initial CT) to 0.29 (CT at 15 days). In 3.0T magnetic resonance image at 3 months, we showed the third ventriculostomy. There have been no treatment failures or complications. Conclusion: It is possible to effectively perform the frameless radiosurgical third ventriculostomy without associated morbidity in the short term. [ABSTRACT FROM AUTHOR]

Background: Pineal region tumors often present with hydrocephalus. Endoscopic third ventriculostomy (ETV) and simultaneous tumor biopsy remain a minimally invasive procedure offering both diagnostic and therapeutic advantages in the management of these tumors. However, different operative techniques have been described in the literature. Aim: The aim is to study the ETV success rate, diagnostic rate of simultaneous tumor biopsy, complications, and follow‑up of patients of pineal region tumors managed with ETV and simultaneous tumor biopsy using the single burr hole technique. Methods: The study was performed by retrospectively reviewing the records of patients of pineal region tumors managed by simultaneous ETV and tumor biopsy using a “single burr hole” technique from January 2012 to December 2019. Results: Thirty‑four patients (22 males and 12 females) with a mean age of 28.7 years were analyzed. ETV was successful in relieving hydrocephalus in 29 (87.8%) patients. Three patients needed a ventriculoperitoneal shunt, and one required Ommaya reservoir placement for persistent hydrocephalus. Histological diagnosis was successfully established in 26 (78.8%) patients. There were two procedure‑related mortalities. Two patients underwent craniotomy and tumor excision subsequently. Radiotherapy was given to 11 patients, and 9 patients were managed by observation alone. The mean follow‑up of our study was 15.8 months. Conclusions: Simultaneous ETV and tumor biopsy using a single burr hole technique is a safe, minimally invasive procedure for the management of pineal region tumors. [ABSTRACT FROM AUTHOR]

Three-dimensional (3-D) endoscopes have been widely used for a large variety of approaches in neurosurgical practice. However, in the last decade, 3-D scopes were barely used for ventricular surgery. In this study, we illustrated our preliminary experience with a 3-D endoscope for third ventriculostomy using new dedicated endoscopic equipment. Over a 12-month period, a high-definition 3-D endoscopic third ventriculostomy (ETV) was performed in 14 patients with obstructive hydrocephalus. Patients were followed prospectively and compared retrospectively with a matched group of 16 similar patients who underwent ETV with a standard 2-dimensional (2-D) endoscope. Surgical outcome and intra- and postoperative course were retrospectively reviewed. 3-D ETV provided excellent surgical results, and no significant difference was shown in terms of outcome, complication, and length of hospitalization between the 2 groups. Moreover, operative time (minutes) was significantly shorter in the 3-D group than the 2-D ETV group (19.9 ± 4.8 vs. 22.9 ± 1.4, respectively; P < 0.05), and the use of the 3-D endoscope provided subjective improvements of depth perception, hand-eye coordination, and surgeon comfort. Our preliminary study clearly demonstrated the effectiveness of 3-D ETV and provided a significant reduction of operative time. Depth information from the 3-D scope appears to facilitate rapid and stable ETV maneuvers, representing a critical development that may become a valuable tool for neuroendoscopy. [ABSTRACT FROM AUTHOR]

Background: Modern technical capabilities have made minimally invasive surgery increasingly popular. Small incisions can reduce surgical duration and the degree of tissue trauma, which reduces the risk of complications. Burr hole microsurgery is a relatively new minimally invasive technique used in neurosurgery. The objective of this study was to assess the feasibility and outcomes of using burr hole microsurgery for the management of intracranial lesions. Methods: Forty-four adults were treated with burr hole microsurgery. Patients were divided into groups according to the presence of (1) brain tumors (n = 20); (2) congenital brain cysts (n = 16); (3) cavernous angiomas (n = 3); and (4) neurovascular conflicts of the 5th cranial nerve (n = 5). All surgical interventions were performed using the "MARI" device. Results: The transcortical approach was used to remove 16 brain tumors, and 2 brain tumors were biopsied. In the two tumor biopsy cases, the parasagittal interhemispheric route was used. Gross total resection was achieved in 10 cases (62.5%) when tumor size reached up to 4 cm, subtotal resection was achieved in four cases (25%) in large tumors, and partial resection in two cases (12.5%). In patients with congenital cysts, cavernous angiomas, trigeminal neuralgia, and symptomatic regression were noted the postoperative period. The surgical duration was 30-180 min (median, 75 min). A hemorrhagic complication was observed in one case. Significant postoperative complications and mortality were not observed. Conclusion: Burr hole microsurgery can treat different intracranial lesions effectively. Despite a smaller craniotomy diameter of 11-14 mm compared with keyhole approaches, surgery was successful. [ABSTRACT FROM AUTHOR]

Background: Simulation-based training has been considered as the most promising curriculum for neurosurgical education to finally improve surgical skills with the greatest efficiency and safety. However, most of the simulators including physical models and virtual reality systems are relatively expensive, which limits their promotion. In this study, the authors tried to develop a realistic, low-cost, and reusable simulator for endoscopic third ventriculostomy (ETV) and evaluate its validity. Methods: A 3D-printed rigid skull with the ventricular system originated from a de-identified patient with obstructive hydrocephalus was constructed. The third ventricular floor was designed as a replaceable module. Thirty-nine neurosurgeons tested the simulator and a rating system was established to assess their performance. All participants filled out questionnaires to evaluate the simulator after training. Five neurosurgical students were recruited to finish the whole training for ten times in order to explore the learning curve of ETV. Results: We found that (1) the more experienced surgeons performed obviously better than the rather inexperienced surgeons which verified that our model could reflect the ability of the trainees; (2) as the training progressed, the scores of the post-graduates increased and the fifth training average score was obviously higher than their first training average score. The feedback questionnaires showed the average scores for value of the simulator as a training tool and global rating were 3.15 and 3.54 (on a 4-point scale). Conclusion: Our model was practical for ETV training. The results of our program showed that our model could precisely reflect the operators' ability to perform ETV and could make it more efficient to master basic skills. [ABSTRACT FROM AUTHOR]

A 42-year-old male presented with diplopia, headache, and nausea. Magnetic resonance imaging (MRI) of the brain showed pineal tumor, and chest computed tomography (CT) demonstrated a lung tumor. Disorientation developed, with occurrence of hydrocephalus, and we performed neuroendoscopic surgery for biopsy of the pineal tumor and third ventriculostomy. The lung tumor was biopsied under bronchoscopic and CT guidance, and based on the pathological results, we diagnosed pineal metastasis of pulmonary sarcomatoid carcinoma (cT3N1M1b Stage IVA). Stereotactic radiotherapy for the metastatic pineal tumor and systemic chemotherapy (carboplatin + pemetrexed) were pursued, but hemorrhage of the tumor occurred, hydrocephalus worsened, and neoplastic meningitis was diagnosed by MRI. Therapy was switched to nivolumab, but without effect, and the patient succumbed. Even among lung tumors, sarcomatoid carcinoma is rare. There are also few reports of lung tumors metastasized to the pineal gland. Our case report of pineal tumor regarded as metastasis of pulmonary sarcomatoid carcinoma also includes a discussion of the literature. [ABSTRACT FROM AUTHOR]

Bibliometric analysis shows that neuroendoscopy (NE) overcame its pioneering phase in the late 1980s, and became a significant technological and clinical innovation in the early 1990s. During those years the charge-coupled device digital video cameras were introduced and videoendoscopy had its decisive breakthrough, laying the foundation for NE take-off. NE can be considered an early product of artificial intelligence, as much as neuroimaging and neuronavigation. In Italy, cerebral NE started in 1993 and, despite a couple of years of relative delay, gained ground rapidly thanks also to the personal contribution of Michelangelo Gangemi (1949–2017), to whose memory this article is dedicated. In this paper we try to re-create the history of Italian NE through original documents and other testimonials, in the context of the general worldwide development of NE. The modality of its rapid diffusion throughout our peninsula seems a good paradigm of how cooperation without unnecessary competition can be rewarding and constructive. [ABSTRACT FROM AUTHOR]

Background: In a combined endoscopic third ventriculostomy (ETV) and endoscopic tumor biopsy (ETB) procedure, an optimal tool trajectory is mandatory to minimize trauma to surrounding cerebral tissue. Objective: This paper presents wire-driven multi-section robot with push-pull wire. The robot is tested to attain follow-the-leader (FTL) motion to place surgical instruments through narrow passages while minimizing the trauma to tissues. Methods: A wire-driven continuum robot with six sub-sections was developed and its kinematic model was proposed to achieve FTL motion. An accuracy test to assess the robot's ability to attain FTL motion along a set of elementary curved trajectory was performed. We also used hydrocephalus ventricular model created from human subject data to generate five ETV/ETB trajectories and conducted a study assessing the accuracy of the FTL motion along these clinically desirable trajectories. Results: In the test with elementary curved paths, the maximal deviation of the robot was increased from 0.47 mm at 30 $^\circ$ turn to 1.78 mm at 180 $^\circ$ in a simple C-shaped curve. S-shaped FTL motion had lesser deviation ranging from 0.16 to 0.18 mm. In the phantom study, the greatest tip deviation was 1.45 mm, and the greatest path deviation was 1.23 mm. Conclusion: We present the application of a continuum robot with FTL motion to perform a combined ETV/ETB procedure. The validation study using human subject data indicated that the accuracy of FTL motion is relatively high. The study indicated that FTL motion may be useful tool for combined ETV and ETB. [ABSTRACT FROM AUTHOR]

Objective: The Hydrocephalus Clinical Research Network (HCRN) conducted a prospective study 1) to determine if a new, better-performing version of the Endoscopic Third Ventriculostomy Success Score (ETVSS) could be developed, 2) to explore the performance characteristics of the original ETVSS in a modern endoscopic third ventriculostomy (ETV) cohort, and 3) to determine if the addition of radiological variables to the ETVSS improved its predictive abilities., Methods: From April 2008 to August 2019, children (corrected age ≤ 17.5 years) who underwent a first-time ETV for hydrocephalus were included in a prospective multicenter HCRN study. All children had at least 6 months of clinical follow-up and were followed since the index ETV in the HCRN Core Data Registry. Children who underwent choroid plexus cauterization were excluded. Outcome (ETV success) was defined as the lack of ETV failure within 6 months of the index procedure. Kaplan-Meier curves were constructed to evaluate time-dependent variables. Multivariable binary logistic models were built to evaluate predictors of ETV success. Model performance was evaluated with Hosmer-Lemeshow and Harrell's C statistics., Results: Seven hundred sixty-one children underwent a first-time ETV. The rate of 6-month ETV success was 76%. The Hosmer-Lemeshow and Harrell's C statistics of the logistic model containing more granular age and etiology categorizations did not differ significantly from a model containing the ETVSS categories. In children ≥ 12 months of age with ETVSSs of 50 or 60, the original ETVSS underestimated success, but this analysis was limited by a small sample size. Fronto-occipital horn ratio (p = 0.37), maximum width of the third ventricle (p = 0.39), and downward concavity of the floor of the third ventricle (p = 0.63) did not predict ETV success. A possible association between the degree of prepontine adhesions on preoperative MRI and ETV success was detected, but this did not reach statistical significance., Conclusions: This modern, multicenter study of ETV success shows that the original ETVSS continues to demonstrate good predictive ability, which was not substantially improved with a new success score. There might be an association between preoperative prepontine adhesions and ETV success, and this needs to be evaluated in a future large prospective study.