World Neurosurg
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The technology and instrumentation for neuroendoscopy are described: endoscopes (principles, designs, applications), light sources, instruments, accessories, holders, and navigation. Procedures for cleaning, sterilizing, and storing are included. ⋯ Neuroendoscopic instrumentation is now an established technique in neurosurgical practice and is experiencing rapid development (stereoscopy, integrated operating room).
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Endoscopic third ventriculostomy (ETV) is increasingly prevalent among pediatric neurosurgeons as the initial treatment for hydrocephalus. The combination of ETV and choroid plexus cauterization (ETV/CPC) has improved the success rate among infants with hydrocephalus for whom ETV alone is much less successful. In parts of the developing world where there are economic and human resource constraints, this mode of treatment may be more appropriate than the routine use of shunts, which are prone to failures that require urgent surgical treatment. Here we review indications for the use of ETV or ETV/CPC as the primary treatment for hydrocephalus. ⋯ Primary treatment of hydrocephalus by ETV can avoid shunt-dependence and its complications for many patients. Optimal results depend upon proper patient selection and the use of combined ETV/CPC when treating infants.
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The management of hydrocephalus associated with a posterior fossa tumor is debated. Some authors emphasize the advantages of an immediate tumor removal that may normalize the cerebrospinal fluid (CSF) dynamics. However, in clinical practice, the mere excision of the lesion has been demonstrated to be accompanied by a persisting hydrocephalus in about one third of the cases. Preoperative endoscopic third ventriculostomy (ETV) offers several advantages. It may control the intracranial pressure (ICP), avoid the necessity of an emergency procedure, allow appropriate scheduling of the operation for tumor removal, and eliminate the risks related to the presence of an external drainage. The procedure also reduces the incidence of postoperative hydrocephalus. A final advantage, more difficult to weight, but obvious to the neurosurgeon, is the possibility to remove the lesion with a relaxed brain and normal ICP. In the postoperative phase, ETV can be used in case of persisting hydrocephalus, both in patients who underwent only the excision of the tumor and in those whose preoperative ETV failed as a consequence of intraventricular bleeding with secondary closure of the stoma (redoETV). The main advantage of postoperative ETV is that the procedure is carried out only in case of persisting hydrocephalus; its use is consequently more selective than preoperative ETV. The disadvantage consists in the common use of an external CSF drainage in the first few postoperative days, which is necessary to control the pressure and for ruling out those cases that reach a spontaneous cure of the hydrocephalus. ⋯ Preoperative ETV constitutes an effective procedure for controlling the hydrocephalus associated with posterior fossa tumors. It might lower the rate of persistent postoperative hydrocephalus and result in a short hospital stay. Low rates of patients requiring an extrathecal-CSF shunt device are also reported by authors who utilize ETV postoperatively. As, however, the assessment of the persistent hydrocephalus in these children is based on prolonged ICP monitoring through an external CSF drainage, their results are weighted by a major risk of infective complications and longer hospital stay.
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The management of complex hydrocephalus is challenging. There is no consensus of the best treatment for isolated fourth ventricles, arachnoid cysts, and multiloculated hydrocephalus, although the avoidance of multiple shunts is desirable. We reviewed our experience with the use of endoscopic techniques to simplify complex multicompartmental hydrocephalus to determine its efficacy and safety. ⋯ Endoscopic simplification of complex hydrocephalus enables dependence on only a single shunt in the majority of patients, and a significant proportion achieve shunt independence. Endoscopic management should be considered before the placement of a second shunt, and some cases require staged endoscopic procedures to adequately communicate multicompartmental hydrocephalus.
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Hydrocephalus, largely a disease of poverty in many developing regions such as Sub-Saharan Africa, becomes even more challenging to treat because of lack of trained neurosurgical personnel, inadequately equipped public health care facilities, meager resource allocation, high rates of neonatal infection, difficulty of access to tertiary care hospitals able to treat hydrocephalus, and high complication rates in patients who are able to access and receive shunting procedures. Furthermore, conventional methods of training of neurosurgeons and nursing staff to become proficient in neuroendoscopic procedures involve a lengthy period of training, often at specialized centers in Western or local Western-style institutions. ⋯ Neuroendoscopy is not only a priority surgical tool for East Africa. It offers a medical philosophy as an application that serves as an art and a science dedicated to the development of a complex surgical specialty: neurosurgery.