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ORIGINAL ARTICLE
Year : 2021  |  Volume : 69  |  Issue : 6  |  Page : 1571-1578

Neuroendoscopy in the Surgical Management of Lateral and Third Ventricular Tumors: Looking Beyond Microneurosurgery


Department of Neurosurgery, Bombay Hospital Institute of Medical Sciences, Mumbai, Maharashtra, India

Date of Submission19-Feb-2020
Date of Decision12-Apr-2021
Date of Acceptance05-May-2021
Date of Web Publication23-Dec-2021

Correspondence Address:
Chandrashekhar E Deopujari
Room No 114, MRC building, Bombay Hospital, 12, Marine Lines, Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.333458

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 » Abstract 


Background: Intraventricular tumors pose a surgical challenge because of the difficulty in reaching their deep location through safe corridors and their adherence or proximity to vital neurovascular structures. Although microneurosurgery is the mainstay of surgical management, neuroendoscopy aided by adjuncts, namely, navigation and ultrasonic aspirators, has made a great contribution to improving surgical results.
Objective: This article reviews the experience of a neurosurgical unit with endoscopic procedures for intraventricular tumors. The current indications, benefits, and complications of neuroendoscopy are described.
Materials and Methods: This is a retrospective, observational study of lateral and third ventricular tumors tackled either purely with an endoscope or with its assistance over 19 years in a single unit at Bombay Hospital Institute of Medical Sciences, Mumbai.
Results: Of a total of 247 operated patients with intraventricular tumors, 85 cases operated using an endoscope were included. The majority of the patients had a tumor in the third ventricle (n = 62), whereas 23 patients had tumor in the lateral ventricle. The most common pathologies were colloid cyst and arachnoid cyst (n = 18). An endoscope was used for microsurgical assisted excision of tumors in 31 cases, biopsy in 24, cyst fenestration in 23, and pure endoscopic excision in seven cases.
Conclusion: Microsurgery remains the gold standard for the removal of giant, vascular intraventricular tumors. However, endoscopic fenestration or excision of cysts and biopsy have become better alternatives in many cases. Endoscope-assisted microsurgery affords safety and helps in achieving a more complete excision.


Keywords: Intraventricular tumors, lateral ventricle, microneurosurgery, neuroendoscopy, third ventricle, ventricular endoscopy
Key Message: Surgical techniques for intraventricular tumors have evolved with endoscopy, which is now an established method for cystic lesions and biopsies of solid tumors. Although microsurgery remains the mainstay for surgery of complex tumors, it may be complemented with endoscopy for better results.


How to cite this article:
Deopujari CE, Karmarkar VS, Shaikh ST, Mohanty CB, Sharma V, Tadghare J, Thareja V. Neuroendoscopy in the Surgical Management of Lateral and Third Ventricular Tumors: Looking Beyond Microneurosurgery. Neurol India 2021;69:1571-8

How to cite this URL:
Deopujari CE, Karmarkar VS, Shaikh ST, Mohanty CB, Sharma V, Tadghare J, Thareja V. Neuroendoscopy in the Surgical Management of Lateral and Third Ventricular Tumors: Looking Beyond Microneurosurgery. Neurol India [serial online] 2021 [cited 2022 Jan 19];69:1571-8. Available from: https://www.neurologyindia.com/text.asp?2021/69/6/1571/333458




Intraventricular tumors comprise less than 1% of all central nervous system tumors, with the majority of them benign and slow growing in nature.[1] They frequently occur in younger age-group,[2] and may manifest with either subtle clinical presentations or with symptoms of raised intracranial pressure (ICP). They were long considered inoperable because of their location, challenges in approaching them, and the grim outlook when they finally presented in a neurologically decompensated patient. However, with improvements in our understanding of microneurosurgical anatomy, pathobiology of these tumors, earlier detection (imaging techniques, CT [computed tomography], MRI [magnetic resonance imaging]), and the maturing of microneurosurgical techniques, the outlook has improved significantly.[3]

Treatment primarily aims to relieve the hydrocephalus along with complete excision of the lesion, wherever possible. The presence of concomitant hydrocephalus is an important factor for the introduction of the endoscope, and it may be used safely not only for cerebrospinal fluid (CSF) diversion but also for biopsy or excision of solid and cystic tumors.


 » Materials and Methods Top


This surgical series is a retrospective, observational study of endoscope utilization for lateral and third ventricular tumors over 19 years (2000–2019). All patients were operated by the senior author, and the data was collected from the patient record database registers from the department of neurosurgery. The cases were analyzed for age of presentation, location of the tumor, role of endoscope in its objective, and associated complications. Extraventricular tumors with intraventricular extension and fourth ventricular tumors were excluded from this study. A ventricular access device was left in situ in patients with residual lesion, which could still obstruct the ventricular system or when a large raw area of the ventricular surface resulted from tumor removal for possible postoperative oozing. Concurrent endoscopic third ventriculostomy and/or septostomy was performed in cases of obstructive hydrocephalus when feasible. Postoperative management protocol included a CT scan on postoperative Day 1 followed by MRI at 3 months. Patients were followed up after a year with MRI, and further follow-up imaging was advised according to disease status. The follow-up period ranged from 6 months to 19 years.


 » Results Top


Of a total of 247 patients [Table 1] with intraventricular tumors operated over 19 years, 85 cases wherein the endoscope was used intraoperatively were analyzed. The follow-up period ranged from a minimum of 6 months to 19 years (mean 7.5 years). There were 26 patients ≤18 years of age (<4 years = 7; 4–18 years = 19), 29 patients were between 18 and 40 years, and 30 patients were above 40 years of age. Males constituted 50 of the 85 cases. Third ventricular tumors made up 62 cases with majority in the anterior third ventricle (n = 35), whereas 23 patients had tumors in the lateral ventricle with majority in the frontal horn and trigone (n = 6 each) [Table 2]a. The most common lesion operated were colloid cyst and arachnoid cyst (n = 18 each), followed by low-grade glial/astrocytic tumors (n = 17), pineal tumors (n = 9), craniopharyngioma (n = 5), neurocytoma (n = 4), and epidermoid cysts (n = 3). There were two cases each of hypothalamic hamartoma, meningioma, and choroid plexus papilloma and one case each of an ependymoma, glioneural tumor, ganglioglioma, neurocysticercosis, and germ cell tumor. The common presenting complaints were raised intracranial pressure (n = 36), headache (n = 19), and visual blurring (n = 9).
Table 1: Total cases of intraventricular tumors (Primary and Secondary) operated over 19 years

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The endoscope's assistance was taken for microsurgical excision in 31 cases, which predominantly consisted of colloid cysts, neurocytomas, and epidermoid cysts [Table 2]b. The endoscope was used in such cases either for whole duration of surgery (n = 3) or at the beginning of the surgery for biopsy, devascularization, and decompression of cyst (n = 16) prior to conversion into microsurgery, and for assessment of tumor bed after excision (n = 12). Endoscopic biopsy was done in 24 cases of predominantly posterior third ventricular lesions [Table 2]b. Endoscopic fenestration was performed in 23 cases for arachnoid cysts, intraventricular craniopharyngiomas [Figure 1], and pineal cysts [Table 2]b. Seven tumors could be completely excised by endoscopy alone [Table 2]b, and this included three cases of colloid cysts [Figure 2], three cases of low-grade glioma (one in septum, one in frontal horn, and one in third ventricle) [Figure 3] and one case of neurocysticercosis [Figure 4]. There were a total of nine cases with malignant pathology, namely, high-grade glioma, pineoblastoma, and anaplastic astrocytoma. All these patients underwent endoscopic biopsy followed by adjuvant radiotherapy (RT) or chemotherapy treatment.
Figure 1: (a) MRI brain (T2 axial, postcontrast coronal and postcontrast sagittal) (Left to Right) images of a 49-year-old female with a recurrent cystic intraventricular craniopharyngioma operated by pterional approach 9 years ago. The thick cyst wall was now decompressed via an endoscope transcranially followed by an Ommaya reservoir insertion. Further subtotal resection was achieved by frontal transcortical approach. (b) MRI brain (postcontrast axial and coronal) (Left to Right) images after the second surgery showing small solid residue for which adjuvant radiation treatment was given

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Figure 2: (a) MRI brain contrast images of a 49-year-old male who presented with drop attacks with imaging showing a third ventricle colloid cyst. (b) The cyst was excised endoscopically after decompressing its contents initially with suction. The cyst was then removed with the help of a grasper after dissecting it all around. (c) Postoperative MRI brain contrast images showing complete removal of the cyst

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Figure 3: (a) MRI brain images of an intraventricular solid cystic lesion in the third ventricle (orange arrow), hyperintense on fluid-attenuated inversion recovery (FLAIR) images and nonenhancing on postcontrast images. (b) Endoscopic third ventriculostomy showing the basilar artery (black arrow). (c) Tumor initially excised with help of grasping forceps (green arrow). (d) Complete resection achieved with the help of endoscopic CUSA (blue arrow). (e) Postoperative CT scan of the patient. Histopathology was suggestive of an astrocytoma

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Figure 4: (a) MRI brain (Contrast) images of a 45-year-old male showing a small lobulated enhancing lesion in the foramen of Monro causing obstructive hydrocephalus. Features were suggestive of a neurocysticercus lesion. (b) The patient underwent endoscopic excision of the lesion alongwith septostomy to relieve the hydrocephalus. Intraoperative view of the lesion. (c) Lesion was excised using grasping forceps. (d) View of the lesion bed after removal and achieving haemostasis. (e) Postoperative MRI brain (T1W) images showing complete excision

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Among the cases where radical resection was attempted (n = 37), a gross total resection could be done in 33 cases and subtotal resection (STR) was done in four cases. Two cases had a stable residue (neurocytoma and ganglioglioma), whereas two cases were given adjuvant RT (solid craniopharyngioma and Grade II ependymoma). At follow-up, three patients with recurrent tumor required transcranial microsurgery, which included two cases of craniopharyngioma and one case of neurocytoma.

CSF access device (Ommaya reservoir) was inserted in 13 cases during the procedure and left in situ for possible CSF drainage postoperatively. A total of 46 patients required treatment for concurrent hydrocephalus. Whereas simultaneous endoscopic third ventriculostomy (ETV) was done in 39, ventriculoperitoneal (VP) shunt was required for seven patients. The seven cases of shunts included those in whom ETV was not feasible, shunt was done at another center before referral, one case of ETV failure, and three cases with delayed shunting postsurgery. Other complications included three cases of meningitis and two cases with transient diabetes insipidus [Table 3]. There was no mortality in our case series.
Table 3: Complications seen among the 85 cases

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 » Discussion Top


Intraventricular tumors can be classified as primary and secondary. Primary tumors originate from ependyma, subependymal glia, and the choroid plexus and include colloid cyst, subependymal giant cell astrocytoma (SEGA), ependymoma, subependymoma, choroid plexus tumors, central neurocytoma, meningioma, and so on.[4],[5] Paraventricular (secondary) tumors originate from the parenchyma, with more than two thirds of its volume bulging into the ventricle[4] and include astrocytomas, meningiomas, gliomas, arachnoid cysts, and so on.

Location of the lesion in the ventricles when corroborated with age of the patients helps in predicting the possible pathology.[6] In the pediatric age-group, intraventricular tumors most commonly occur in the lateral ventricle, namely, ependymoma, astrocytoma, and CPP.[7] Low-grade gliomas such as pilocytic astrocytoma, ependymoma, and SEGA occur frequently in the young adults.[8] The incidence of lateral ventricular tumors is around 43% in the frontal horn, 22% in the body and septum, 20% in atrium, 9% in the temporal, and 6% in the occipital horn.[9] In our series of endoscopic cases, 26% of lateral ventricular tumors were in the frontal horn, 29% in the body/trigone, 19% in the septum, 17% in the temporal horn, and 9% in the occipital horn [Table 2]a.

Neuroendoscopy for intraventricular tumors

Walter Dandy first used the term ventriculoscopy after using an endoscope to treat two cases of hydrocephalus in 1922.[10] Endoscope use was first reported for intraventricular tumors in 1963 by Guiot et al.[11] Majority of the early procedures were biopsies.[12] Today, the scope of endoscope use has enlarged because of technological advances such as improved optics, navigation, and better instrumentation as well as endoscopic cavitron ultrasonic aspirator (CUSA). In larger tumors, endoscope assistance can be utilized to access the hidden angles inside the ventricles.[13] This can also allow us in coagulation or clipping of vascular pedicle of the tumor and LASER-assisted hemostasis.

Endoscopic biopsy was done for three lateral ventricular tumors in our series that were high grade in pathology and not amenable for radical excision. It was predominantly used for mid- and posterior third ventricle lesions in 21 of our cases. For tumors with hydrocephalus, ETV can be performed concomitantly with biopsy. This can be done either through the same burr hole or by making two separate ones depending on the location and size of the lesion, the extent of ventriculomegaly, the size of the foramen of Monro, and the goal of surgery.[14] It is preferable to do ETV first and biopsy later to avoid the risk of blood spillage after biopsy that may obscure the view to perform a safe ETV.[15]

Neuroendoscopy has increased the rate of obtaining pathological diagnosis by more than 90%.[16],[17] Endoscopic biopsies in our series too had a positive predictive value of 96% with only one patient having a false diagnosis of pilocytic astrocytoma, which turned out to be on molecular study a diffuse midline glioma (H3K27M positive) arising from ventricular wall, possibly from posterior thalamus. Endoscopic biopsy additionally provides adequate sample under vision, feasibility to assess pathologically specimens from many quadrants, and the possibility to control bleeding, if any, from the biopsy site. A complete resection may also be attempted if feasible.

Tumors can present with compartmentalized hydrocephalus by obstructing one of the foramen of Monro. In such cases with unilateral hydrocephalus, we have performed an endoscopic septostomy to enable CSF diversion. This can be combined with a unilateral VP shunt rather than two shunts if ETV cannot be performed [Figure 5].
Figure 5: (a) MRI brain (FLAIR [fluid-attenuated inversion recovery] axial, T2 coronal, and postcontrast axial) (Left to Right) images of a 23 year-old female with a solitary intraventricular lesion at the foramen of Monro causing obstructive hydrocephalus and presenting with features of raised intracranial pressure. The patient underwent endoscopic biopsy with septostomy and a ventriculoperitoneal shunt insertion following which her papilledema resolved. Pathology report was suggestive of a hypothalamic hamartoma. (b) Postoperative CT scan showing resolution of the hydrocephalus. The lesion has remained stable in size for 13 years

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In 23 tumors with cystic components such as craniopharyngiomas, arachnoid cysts, and low-grade gliomas, cysts were fenestrated with or without concomitant tumor resection or reservoir insertion.[18] Although we have usually preferred bipolar or unipolar cautery for these fenestrations, thulium LASER also seems to be a promising technique and was recently used by us in the case of an arachnoid cyst with a tough capsule.

Colloid cysts are the most common space-occupying lesion treated endoscopically because of their suitable consistency, avascular nature, and accessible location.[19],[20] In our series, three colloid cysts were completely excised with an endoscope, whereas in 15 cases of colloid cysts, endoscopic-assisted microsurgery was performed. The procedure was converted into microsurgery because of poor visualization of the cyst in four cases, thick cyst content in three cases, and the possibility of fornix injury in one case. Other tumors that can be excised by this route include exophytic low-grade gliomas, SEGAs, neurocytomas, small choroid plexus lesions, and pure intraventricular craniopharyngiomas (n = 5 in this series).[21] Complete tumor removal is possible in small (≤2 cm), well-circumscribed, and cystic tumors.[22],[23],[24] Endoscopic CUSA is a viable and safe tool for resection[25] and has been used more recently by us for aiding radical excision in four of these patients. Arachnoid cysts and neurocysticercosis are also quite amenable for transcortical endoscopic surgery (n = 19 in this series).[26] Surgical planning must include the possibility of converting to open microneurosurgery.[27] Another advantage of endoscopy is the visualization of seeding, which can be missed on prior MRI imaging as was seen in our two cases of germinoma, one of pineal parenchymal tumor, and one rare case of seeding in a pilocytic astrocytoma. This helps in proper staging of the disease, making the choice of treatment more precise.

Complications common to all approaches are ventriculitis, hemorrhage, subdural hygroma [Figure 6], and venous infarct. Ventricular wall collapse in acute hydrocephalus can be prevented by placing cottonoid balls around the tumor site and by continuous irrigation into the ventricle while keeping a close watch on vital parameters. Tumor bleeding and intraventricular hemorrhage are known complications of endoscopic tumor surgery, with an occurrence rate of about 3.5%.[28] Usually, the bleeding stops with warm ringers lactate (RL) irrigation. If persistent, then bipolar cautery and balloon tamponade can be used. In our series, we had two cases of intraventricular bleeding (2.35%) from the posterior third ventricle in cases with a biopsy done of high-grade glioma. In both the patients, hemostasis was achieved with warm RL irrigation, and an Ommaya device was inserted, which was connected to an external scalp vein for ventricular drainage (EVD) [Figure 7]. In one child with a very vascular lesion, thulium LASER was very useful for hemostasis from the tumor bed. Misguided trajectories and manipulation of the endoscope while in the ventricular compartment can cause vascular injury or infarction. Aspiration of CSF leading to a dry field can lead to better visualization of the bleeding vessels to coagulate them and achieve hemostasis.[13] We have frequently used endoscope after microsurgical resection to inspect for bleeding points and any hidden residual tumor. In two cases of epidermoid cysts, the endoscope helped show a residual tumor in angles that was missed in microsurgery.
Figure 6: (a) MRI brain postcontrast axial images showing a giant trigonal intraventricular meningioma in a 12 year-old boy. (b) Postoperative MRI brain postcontrast images after endoscopic assisted microsurgical excision of the lesion. (c) CT scan showing the presence of a right-sided subdural hygroma with pseudomeningocele that required evacuation

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Figure 7: (a) MRI brain axial (T2 and postcontrast images) showing a heterogenous, solid cystic intraventricular neurocytoma that was incompletely resected at a peripheral center due to intraoperative tumoral bleeding. The patient underwent endoscopic-assisted microsurgical resection at our center through the frontal transcortical approach. Endoscope assistance was taken to visualize the third ventricle and occipital horn. (b) Postoperative CT showing intraventricular hemorrhage that was managed with an external ventricular drain. (c) Follow-up MRI brain axial images after 6 months showing absence of recurrence

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The presence of hydrocephalus is not imperative for endoscopy after the introduction of navigation.[29] However, we have not routinely used endoscopy in cases with very small ventricles. Navigation is useful in intraventricular tumor surgery, more so in smaller ventricles, for localization of cortical entry point, trajectory of the operative corridor, and access points so that the chances of endoscope manipulation injury are minimized.[30] Pure endoscopic resection of solid intraventricular tumors has been described in the literature by Souweidane and Luther[31] and Rocque.[32] In our case series, we have excised three solid tumors with the help of endoscopic CUSA (Söring GmbH, Germany), which were low-grade, glial tumors. Apart from the usual adjuncts, innovative techniques such as the use of endotracheal suction catheter and urological basket retriever have also been described in the literature to aid in the resection of tumors[31],[33] The tumors reported feasible for pure endoscopic resection include SEGA, neurocytoma, and germ cell tumors. Use of ports to help in deep access have been described after tract dilatation.[34] In our experience, we have used them for a few of our initial cases but did not find them to be necessary thereafter.

The limitations of the current article are the highly variable follow-up duration with a wide variety of pathological entities. However, this wide pathological spectrum of tumors in the current study also proves the versatility of the endoscope. It should also be kept in mind that there has been significant improvement in the optics and ergonomics of the endoscope in the study period, that is, 19 years. Moreover, our experience has shown that endoscopic management of intraventricular tumors has shown excellent short- and long-term outcomes in well-selected cases. Our experience with other endoscopic adjuncts such as CUSA and LASER is limited. More experience with these should help in expanding the indications of endoscopic resections in our hands. There is a definite learning curve with the use of the endoscope. Models simulating endoscopic intraventricular procedures and techniques[35] are proven to be an effective tool for training young neurosurgeons in endoscopic anatomy and help achieve better and safer surgical results.


 » Conclusion Top


The endoscope has proved to be an essential tool in the armamentarium of the surgeon during the excision of the intraventricular tumors. It is useful for CSF diversion, biopsy of lesions, and excision of cystic, small, solid intraventricular tumors. Although microsurgery remains important for radical removal of large, complex, and vascular tumors, endoscopic assistance has improved the results by reducing postoperative complications such as hemorrhage and also the need for prolonged postoperative ventricular drainage or shunting in our experience.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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35.
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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