Clinical and radiological sings of efficiency of endoscopic third ventriculostomy in idiopathic aqueductal stenosis

Aqueductal stenosis is the most common form of obstructive hydrocephalus. About 75 % of cases the cause of occlusion is unknown. Endoscopic third ventriculostomy is a highly effective minimally invasive surgical technique. In practice, the assessment of the effectiveness of the surgery performed often causes difficulties due to the discrepancy between dynamics of the clinical symptoms and radiological picture.

PURPOSE OF THE STUDY: to assess the clinical and radiological results of treatment of patients with idiopathic obstruction of the aqueduct of cerebri and to identify the relationship between the dynamics of neurological symptoms and changes of radiological characteristics in the postoperative period.

MATERIALS AND METHODS. From October 2011 to March 2021 at the Burdenko neurosurgical Institute 290 patients were operated. They met the criteria for adult idiopathic hydrocephalus: the onset of symptoms in adulthood and no indications for the etiology of hydrocephalus, as well as congenital hydrocephalus. In 113 (40 %) cases aqueductal stesosis was identify. The age of patients ranged from 18 to 77 years, averaged 42 + 16.7 years, there were slightly more men (50.5 %). The main symptoms of the disease were headaches (76 %), gait disturbance (64 %), memory loss (56 %), dizziness (33 %), urinary incontinence (33 %) and nausea (22 %). The condition of patients before surgery was evaluated by the Kiefer and Rankin scales and amounted to 6.43 + 3.2 (0–19) points and 2.26 + 0.88 (0–5) points, respectively. Brain MRI of all patients was analyzed for the size of the cerebral ventricles, the condition of the cerebral aqueduct, convexital and basal cerebrospinal fluid spaces, periventricular edema, the size of the sella turcica and the position of the cerebellar tonsils.

RESULTS . The ventral dislocation of the premamillary membrane, compression of the convexital subarachnoid spaces, and hyperintensive periventricular signal are significantly associated with a more severe condition of patients (p < 0.05). In 88.5 % cases endoscopic triventriculostomy was performed, other 11.5 % cases — ventriculoperitoneal shunting. In 70 % of patients after endoscopic surgery the symptoms completely regressed, in 25 % cases a significant improvement in the condition was noted. The average meaning of the Kiefer and Rankin scales after surgery was 0.96 + 1.82 (0–13) and 0.52 + 0.76 (0–4) points, respectively. After shunt-surgery 50 % patients had a complete regression of symptoms and 50 % had a significant improvement in their condition. Approximately 60 % of cases after surgery had a decrease in the size of the ventricles of the brain. The improvement in the condition of patients was significantly associated with a decrease in the size of the ventricles, an increase of the convexital subarachnoid spaces, and normal position of the premamillary membrane (p < 0.05). Reposition of the cerebellar tonsils into the cranial cavity occurred in 62.5% of patients.

CONCLUSION . Decrease of the size of the ventricles after surgery significantly associated with an improvement of the condition of the patients, but is not observed in all cases. The elimination of the pressure gradient and an increase of convexital subarachnoid spaces are the most important factors for the patients. Each of them individually and collectively leads to a regression of the symptoms of hydrocephalus.

1. M ori E, Ishikawa M, Kato T, Kazui H, Miyake H, Miyajima M, Nakajima M, Hashimoto M, Kuriyama N, Tokuda T, Ishii K, Kaijima M , Hirata Y, Saito M, Arai H; Japanese Society of Normal Pressure Hydrocephalus. Guidelines for management of idiopathic normal pressure hydrocephalus: second edition. Neurologia Medico Chirurgica (Tokyo). 2012;52(11):775–809. PubMed PM ID: 23183074. DOI: 10.2176/nmc.52.775

2. M ori K, Shimada J, Kurisaka M, Sato K, Watanabe K. Classification of hydrocephalus and outcome of treatment. Brain and Development. 1995 Sep-Oct;17(5):338–48. DO I: 10.1016/0387–7604(95)00070-r

3. Cinalli G, Spennato P, Nastro A, Allberti F, Trischitta V , Ruggiero C, Mirone G, Cianciulli E. Hydrocephalus in aqueductal stenosis. Child’s Nervous System. 2011:27:1621–1642. DOI: 10.1007/s00381‑011‑1546‑2

4. Gavrilov GV , Cherebillo VY u, Legzdain MA, Svistov DV . Treatment of obstructive hydrocephalus. Russian Journal of Neurosurgery 2010(2):52–57. (In R uss.).

5. J ellinger G. Anatomopathology of nontumoral aqueductal stenosis. Journal of Neurosurgical Sciences. 1986:30:1–16.

6. Cinalli G, Spennato P, Del Basso De Caro ML , Buonocore MC (2004) Hydrocephalus and Dandy–Walker malformation. In: Cinalli C, Maixner WJ, Sainte-Rose C. P ediatric hydrocephalus. Springer, Milan. 2004:259–277.

7. Bateman GA (2007) Magnetic resonance imaging quantification of compliance and collateral flow in late-onset idiopathic aqueductal stenosis: venous pathophysiology revisited. J Neurosurg. 2007:107:951–958.

8. V ulcu S, Eickele L, Cinalli G, Wagner W, Oertel J. L ong-term results of endoscopic third ventriculostomy: an outcome analysis. J Neurosurg 2015:123:1456–1462.

9. Gavrilov GV , Cherebillo VY u, Legzdain MA, Svistov DV . [Results of treatment of obstructive hydrocephalus by endoscopic third ventriculostomy]. Neirokhirurgiya I nevrologiya detskogo vozrasta. 2009:19(1);19–29. (In R uss.).

10. Brunelle F. M odern imaging of hydrocephalus. Pediatric hydrocephalus. 2004:79–93.

11. M cConachie. The CISS sequenze in the pre-operative assessment of neuroendoscopic third ventriculostomy. Pediatric hydrocephalus. 2004:405–410.

12. Brockmeyer D, Abtin K, Carey L, Walker M. E ndoscopic third ventriculostomy: an outcome analysis. Pediatric Neurosurgery. 1998:28:236–240. DOI: 10.1159/000028657

13. Cinalli G, Sainte-Rose C, Simon I, Lot G, Sgouros S. Sylvian aqueduct syndrome and global rostral midbrain dysfunction associated to shunt malfunction. Journal of Neurosurgery. 1999:90:227–236. DOI: 10.3171/jns.1999.90.2.0227

14. Cinalli G, Sainte-Rose C, Chumas P, Zerah M, Brunelle F, Lot G, Pierre-Kahn A, Renier D. Failure of third ventriculostomy in the treatment of aqueductal stenosis in children. Journal of Neurosurgery. 1999:90:448–454/ DOI: 10.3171/jns.1999.90.3.0448

15. G oumnerova LC, Frim D. Treatment of hydrocephalus with third ventriculostomy: outcome and CSF flow patterns. Pediatric Neurosurgery. 1997:27:149–152. DOI: 10.1159/000121242

16. Hellwig D, Grotenhuis JA, Tirakotai W, Riegel T, Schulte DM , Bauer BL, Bertalanffy H. E ndoscopic third ventriculostomy for obstructive hydrocephalus. Neurosurgical Review. 2005:28:1–34. DOI: 10.1007/s10143‑004‑0365‑2

17. Hopf NJ, Grunert P, Fries G, Resch KD, Perneczky A. E ndoscopic third ventriculostomy: outcome analysis of 100 consecutive procedures. Neurosurgery. 1999:44:795–804. DOI: 10.1097/00006123‑199904000‑00062

18. Teo C. Third ventriculostomy in the treatment of hydrocephalus: experience with more than 120 cases. Minimally invasive techniques for neurosurgery. 1998:73–76. DOI: 10.1007/978‑3‑642‑58731‑3_11

19. Tisell M, Almstrom O, Stephensen H, Tullberg M, Wikkelsö C. How effective is endoscopic third ventriculostomy in treating adult hydrocephalus caused by primary aqueductal stenosis? Neurosurgery. 2000;46(1):104–10; discussion 10–11.

20. Gavrilov GV , Cherebillo VY u, Legzdain MA, Svistov DV . Comparative analysis of treatment of obstructive hydrocephalus. Rossiiskii neirokhirurgicheskii zhurnal imeni professora A L Polenova, 2009:1(3);50–60. (In R uss.).

21. Cinalli G, Cappabianca P, de Falco R, Spennato P, Cianciulli E, Cavallo LM , Esposito F, Ruggiero C, Maggi G, de Divitiis E. Current state and future development of intracranial neuroendoscopic surgery. Expert Review of Medical Devices. 2005:2:351–373.

22. Kim S-K, Wang K-C, Cho B-K. Surgical outcome of pediatric hydrocephalus treated by endoscopic III ventriculostomy: prognostic factors and interpretation of postoperative neuroimaging. Child’s Nervous System. 2000:16:161–169. DOI: 10.1007/s003810050485

23. Tisell M, Edsbagge M, Stephenson H, Czosnyka M, Wikkelso. Elastance correlates with outcome after endoscopic third ventriculostomy in adults with hydrocephalus caused by primary aqueductal stenosis. Neurosurgery. 2002:50:70–77. DOI: 10.1097/00006123‑200201000‑00013

24. O ’Hayon BB, Drake JM , Ossip MG , Tuli S, Clarke M. Frontal and occipital horn ratio: A linear estimate of ventricular size for multiple imaging modalities in pediatric hydrocephalus. Pediatric Neurosurgery. 1998 Nov;29(5):245–9. DO I: 10.1159/000028730

25. R ussell DS. Observations on the pathology of hydrocephalus. Ulster Medical Journal. 1949 May;18(1):107–108

26. Turnbull IM, Drake CG. Membranous occlusion of the aqueduct of Sylvius. Journal of Neurosurgery: 1966:24:24–33.

27. Shevchenko KV, Shimansky V N, Tanyashin SV, Kolycheva MV , Poshataev VK, Karnaukhov VV , Solozhentseva KD, Afandiev RM . Adult idiopathic hydrocephalus: current state of the problem. Siberian Medical Review. 2021;(1):20–33. DO I: 10.20333/2500136‑2021‑1‑20‑33. (In R uss.).

28. D louhy BJ, Capuano AW, Madhavan K, Torner JC, Greenlee JD . Preoperative third ventricular bowing as a predictor of endoscopic third ventriculostomy success. Journal of Neurosurgery: Pediatrics. 2012 Feb;9(2):182–90. DOI: 10.3171/2011.11.PEDS11495.

29. D i Rocco C, Cinalli G, Massimi L, Spennato P, Cianciulli E, Tamburrini G. E ndoscopic third ventriculostomy in the treatment of hydrocephalus in pediatric patients. Advances and Technical Standards in Neurosurgery. 2006:31:119–219. DOI: 10.1007/3–211–32234–5_4

30. Korshunov AE, Shakhnovich AR, Melikian AG, Arutiunov NV, Kudriavtsev IIu.[Cerebrospinal fluid dynamics in chronic obstructive hydrocephalus before and after successful endoscopic third ventriculostomy]. Zhurnal Voprosy Neirokhirurgii Imeni N N Burdenko. 2008 Oct-Dec;(4):17–23.(In R uss.).