Endoscopic surgery of the patients with idiopathic hydrocephalus due to extraventricular cisternal obstruction

The possibility of developing hydrocephalus due to extraventricular cisternal obstruction was discovered in the 20th century. The development of neuroimaging and endoscopic techniques has made it possible to plan and perform minimally invasive surgeries in a narrow anatomical corridor with a good results.

PURPOSE OF THE STUDY: to determine the effectiveness of endoscopic surgery for hydrocephalus due to idiopathic extraventricular cisternal obstruction of the CSF pathways.

MATERIALS AND METHODS. Sixty-five patients with hydrocephalus due to extraventricular obstruction was evaluated and operated at the Center of Neurosurgery from 2007 to 2020. Preoperative Kiefer scale rate was 6.8 + 3.3 (0–15) points, and Rankin scale rate — 2.2 + 1 (0–5) points. Endoscopic third ventriculocisternostomy was performed in 42 (64.6 %) patients. Shunt-surgery was performed in 17 (26.1 %) patients. Six (9.2 %) patients didn’t operate.

RESULTS. After endoscopic surgery, the condition of patients significantly improved (p < 0.001) after 2 and 12 months. Complete or partial regression of symptoms was noted in 85 % of patients 1 year after surgery. After shunt-surgery, the trend is comparable. The only position of the premamillary membrane and “flow void” have correlated with the condition of patients. Other characteristics of the CSF-pathways of the brain didn’t actually change. In all cases of the endoscopic surgery, an additional membrane conglomerate was found under the premamillary membrane that was the same to preoperative tomograms.

CONCLUSION. The high efficiency of endoscopic third ventriculocisternostomy allows to recommend using that as the primary one in patients with extraventricular obstruction of the CSF pathways. but not for cases of anatomy abnormalities of the third ventricular fundus area (short premamillary membrane in combination with a high standing bifurcation of the basilar artery) and cisterns of the posterior cranial fossa base (narrow cisterns, impossibility to move endoscope under the premamillary membrane).

1. Dandy WE. Experimental hydrocephalus. Annals of Surgery, 1919;70(2):129–42.

2. Rigamonti D. Adult Hydrocephalus. Cambridge University Press, 2014:344. https://doi.org/10.1017/CBO9781139382816

3. Ransohoff J, Shulman K, Fishman RA. Hydrocephalus: A review of etiology and treatment. Journal of pediatrics, 1960;56:499–511. DOI: 10.1016/s0022–3476(60)80193-x

4. Rekate HL. The definition and classification of hydrocephalus: a personal recommendation to stimulate debate. Cerebrospinal Fluid Research, 2008;22; 5:2. DOI: 10.1186/1743-8454-5-2.

5. Li J, McAllister JP 2nd, Shen Y, Wagshul ME, Miller JM, Egnor MR, Johnston MG, Haacke EM, Walker ML. Communicating hydrocephalus in adult rats with kaolin obstruction of the basal cisterns or the cortical subarachnoid space. Experimental Neurology, 2008;211(2):351–361. DOI: 10.1016/j.expneurol.2007.12.030.

6. Aleman J, Jokura H, Higano S, Akabane A, Shirane R, Yoshimoto T. Value of constructive interference in steady-state three-dimensional, Fourier transformation magnetic resonance imaging for the neuroendoscopic treatment of hydrocephalus and intracranial cysts. Neurosurgery, 2001;48(6):1291–5; discussion 1295–6. DOI: 10.1097/00006123-200106000-00021

7. Greitz D. Radiological assessment of hydrocephalus: new theories and implications for therapy. Neurosurgical Review, 2004;27(3):145–65; discussion 166–7. DOI: 10.1007/s10143-004-0326-9

8. Laitt RD, Mallucci CL, Jaspan T, McConachie NS, Vloeberghs M, Punt J. Constructive interference in steady-state 3d Fourier-transform MRI in the management of hydrocephalus and third ventriculostomy. Neuroradiology, 1999;41(2):117–23. DOI: 10.1007/s002340050715

9. Gavrilov GV, Cherebillo VYu, 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 Russ.).

10. Gavrilov GV, Cherebillo VYu, 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 Russ.).

11. Kehler U, Gliemroth J. Extraventricular intracisternal obstructive hydrocephalus — a hypothesis to explain successful 3rd ventriculostomy in communicating hydrocephalus. Pediatric Neurosurgery, 2003;38(2):98–101. DOI: 10.1159/000068053

12. Dlouhy 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;9(2):182–190. DOI: 10.3171/2011.11.PEDS11495.

13. Kageyama H, Miyajima M, Ogino I, Nakajima M, Shimoji K, Fukai R, Miyake N, Nishiyama K, Matsumoto N, Arai H. Panventriculomegaly with a wide foramen of Magendie and large cisterna magna. Journal of Neurosurgery, 2016;124(6):1858–1866. DOI: 10.3171/2015.6.JNS15162

14. Dincer A, Kohan S, Ozek MM. Is all “communicating” hydrocephalus really communicating? prospective study on the value of 3d-constructive interference in steady state sequence at 3T. American Journal of Neuroradiology, 2009;30(10):1898–906. DOI: 10.3174/ajnr.A1726.

15. Al-Hakim S, Schaumann A, Tietze A, Schulz M, Thomale U-W. Endoscopic third ventriculostomy in children with third ventricular pressure gradient and open ventricular outlets on MRI. Child’s Nervous System, 2019;35:2319–2326. DOI: 10.1007/s00381–019–04383-x.

16. Teo C, Kadrian D, Hayhurst C. Endoscopic management of complex hydrocephalus. world Neurosurgery, 2013;79(2): S 21.e1–7. DOI: 10.1016/j.wneu.2012.02.015.

17. Oertel J, Schroeder H, Gaab M. Third ventriculostomy for treatment of hydrocephalus: results of 271 procedures. Neurosurgery Quarterly, 2006;16(1):24–31. DOI: 10.1097/01.wnq.0000203022.31915.02.

18. Kehler U, Herzog J. Infratentorial intracisternal obstructive hydrocephalus (InfinOH): how often is this subtupe, which can be treated endoscopically, among idiopathic normal pressure hydrocephalus (iNPH)? IFNE Interim Meeting, Tokyo, dec 12–13, 2011.

19. Fritsch MJ, Kehler U, Meier U. Normal pressure hydrocephalus. Thieme, 2014: 344. DOI: 10.1055/b-0034–98124

20. Kandasamy J, Yousaf J, Mallucci C. Third ventriculostomy in normal pressure hydrocephalus. World Neurosurgery, 2013;79(2): S 22.e1–7. DOI: 10.1016/j.wneu.2012.02.008.

21. Chan D Y-C, Zhu C X–L, Chan D T-M, Poon W-S. Extraventricular intracisternal obstructive hydrocephalus: A differential diagnosis of ‘communicating hydrocephalus’ after a successful endoscopic third ventriculostomy. Surgical Practice, 2018;22(3):145–147. DOI:10.1111/1744–1633.12316

22. Hailong F, Guangfu H, Haibin T, Hong P, Yong C, Weidong L, Dongdong Z. Endoscopic third ventriculostomy in the management of communicating hydrocephalus: a preliminary study. Journal of Neurosurgery, 2008;109(5):923–30. DOI: 10.3171/JNS/2008/109/11/0923