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Department of Neurosurgery,
University Medical center Ljubljana

• Hydrocephalus means excess water in the

• Traditional treatment:
– Shunt insertion (ventriculo-peritoneal, ventriculo-
atrial, ventirulo-plavral)
• up to 20% of patients can develop
• Neuroendoscopy is now being used to
new passage is created between
venticular system and subarahnoidal
space -> an excessive amount of water can
be absorbed
• In obstructive hydrocephalus this is the
treatement of choice
• a bypass around aqueductus cerebri is

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• Less pain than traditional surgery • Only 2D image

• Faster recovery than traditional • Less space to perform surgery
surgery, shorter hospital stay and • Learning curve
quicker return to normal activities • Lack of appropriate endoscopic
• Minimal scarring instruments
• Small incision site and minimal
trauma to the brain or spinal cord
• In some instances, the surgery is
substantially shorter than traditional
surgical approaches

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• Neuroendoscopy is a surgical technique which usses small thin endoscopes

(around 5 mm in diameter) to approach deep structures of the brain and perform
surgical procedures there

• It is relatively new and rapidly developing concept

• Three basic prerequisities of doing neuroendoscopy:

1. Preformed space into which the endoscope can be passed

2. A sufficient light has to be delivered into the cavity to visualise the structures inside
3. We must be able to pass instruments into that spece to perform surgical procedures

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History (the beginning)

• 1910: L’Espinasse, a Chicago

urologist, perform the first
neurosurgical endoscopic procedure
(fulguration of choroid plexus in two
infants with hydrocephalus)

• 1923: Mixter, a neurosurgeon,

performed the first endoscopic
ventriculostomy in a child with
congenital obstructive hydrocephalus

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History (decline of neuroendoscopy)

• Treatement of hydrocephalus was

replaced by placement of
ventriculoperitoneal shunts
• The end of the initial era of
• The birth of microneurosurgery in the
1960s pushed endoscopy further into
the background
• The microscope allow neurosurgeons
to perform operations deep within
the brain and at the base of the skull
with both adequate illumination and

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History (extension of neuroendoscopy)

• Extension of the use of

neuroendoscopy to:
– intraventricular tumors
– skull base tumors
– Craniosynostosis
– degenerative spine disease
– intracranial cysts
– rare subtypes of hydrocephalus

• There is the vast potential of the

endoscope in neurosurgery

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Indications for intracranial endoscopic procedures

• The indications for neuroendoscopic operations have been standardized in the last
few years

• In general, neuroendoscopy is used for procedures in preexisting or pathologically

formed cavities in the central nervous system

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Indications for intracranial endoscopic procedures


1. Hydrocephalus • a very recent concept

– Third ventriculostomy • an endoscope is used along with the
– Aqueductoplasty microscope
– Compartmentalized hydrocephalus • a whole new world of possibilities
– Septum pellucidotomy • reduced size of the craniotomy and
– Multicompartment hydrocephalus minimally invasiveness
– Ventricular catheter placement
1. Pituitary tumor resection
2. Intraventricular Tumors
2. Skull base tumor biopsy
3. Arachnoid cysts
3. Cerebral aneurysms
– fenestracion
4. Microvascular decompression
4. Colloid Cysts
5. Acoustic neuromas

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Endoscopic third ventriculostomy

Third ventricle

A perforation of lamina
terminalis is made to bypass
the aquductal stenosis

Subarahnoidal space
(cisterna interpedunclularis)


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Endoscopic third ventriculostomy

• Our case:
– 8 months old child after postnatal
intraventricular bleeding -> the blood
cloth blocked the aqueductus cerebri
-> Head circumference started to

Aqueductal stenosis

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Endoscopic third ventriculostomy

Lamina terminalis • A view of the floor of the third


• Endoscope passed through the

foramen Monroe into the third

Choroid plexus Corpora mamilaria

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Endoscopic third ventriculostomy

A case from
our clinic

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Arachnoid cysts

• arachnoid cysts constitute 1% of all

intracranial mass lesions

• they are seen in 1% of the population

• thay can arise in any part of the central

nervous system where arachnoid is found
(typically within the arachnoid cysterns)

• ETIOLOGY: it is believed that most cases of

arachnoid cysts are developmental
malformations that arise from the
unexplained splitting or tearing of the
arachnoid membrane

• Neuroendoscopy prvides a simple

solution to these cysts simply by
fenestrating them in the depth so that
the extra water can be absorbed

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Arachnoid cysts (our experience)



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Arachnoid cysts (our experience)

• A cyst fenestration into the

ventricular system was

• With a help of a microsurgery,

cyst was resected and
obstruction was released

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Arachnoid cysts (our experience)

• Before the operation

• 7 months after the


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Intraventricular tumors

• These are deep seated brain tumors

which can arise from within or grow
into the ventricular symptoms
• It is now possible with
neuroendoscopy to take a biopsy or
remove these tumors under vision
and perform a ventriculostomy at the
same time
• This is usually followed by radiation
and/or chremo therapy

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Intraventricular tumors

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Intraventricular tumors

Low-grade astrocytoma in the posterior

portion of the third ventricle

(a) The T2-weighted preoperative MRI

scan shows that the tumor is
causing obstructive hydrocephalus

(b) Endoscopic biopsy of the tumor

a d (c) Immediately after biopsy, a third

ventriculostomy is performed to
treat the occlusive hydrocephalus

(d) The postoperative MRI shows a

prominent flow void at the floor of
the third ventricle, indicating flow
of CSF into the interpeduncular

b c

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Coloid cysts

• These are rare and small cysts located in a

crucial area of the ventricle where they
can block the flow of cerebrospinal fluid
(foramen Monroe)
• Although, microsurgery for these is quite
successful, endoscopic techniques have
been developed to excise these cysts
through an even smaller opening

Coloid cyst is blocking

aqueductus cerebri!!!

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Thank you for your attention

Questions and answers

University Medical center Ljubljana