gms | German Medical Science

Objective: Neuroendoscopic techniques have advanced significantly during the past decade. Endoscopic treatment of hydrocephalus is also technically possible and, somewhat promising, in small children. However, more data is needed to adequately apply these techniques to patients. The goal of endoscopy is to prevent or, at least delay shunt insertion.

Method: We report our experience with neuroendoscopic techniques, either as stand-alone or in combination with shunts in five recently treated infants. All patients had progressive increase of head circumference due to hydrocephalus. In all patients magnetic resonance imaging (MRI) of the head was performed before the treatment decision was made. Treatment options included removal of ventricular blood residues (brain washing, suction, removal of clots with forceps), perforating techniques (endoscopic third ventriculostomy, septostomy, aqueductoplasty, and cystostomy), stenting (aqueductal stenting), Rickham reservoir insertion and ventriculo-peritoneal shunt implantation.

Results: At the time of surgery, patients were at the ages of 2 weeks to 10 months. (A) 2 patients had massive intraventricular bleeding remnants which were removed by endoscopic irrigation, suction and forceps. A Rickham reservoir was placed, endoscopic third ventriculostomy (ETV) was performed as well as further fenestrations if necessary for communication of the supratentorial ventricles. 1/2 children was re-admitted 2 months after endoscopic operation for shunt insertion. (B) One child underwent ETV 10 months after subependymal hemorrhage when progression of head circumference was stopped. (C) One child had massive hydrocephalus with complex brain dysrhaphia and arachnoidal cyst which was fenestrated in addition to ETV. A Rickham reservoir was inserted requiring only temporary tapping. (D) One child with subependymal bleeding associated with hydrocephalus was suspected of having obstructive component according to MRI. During operation, an obstructive component was ruled out by endoscopy and subsequently, a shunt was inserted.

Conclusions: Treatment of hydrocephalus in small children is still challenging. Endoscopic procedures including blood removal and perforating techniques, either as stand-alone or in combination with shunt insertion have the potential to prevent or at least delay shunt insertion.