endoscopic third ventriculostomy for the management of chiari

8/3/2019 Endoscopic Third Ventriculostomy for the Management of Chiari

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oleh

Yagatheeswaran Ketheeswaran

0702005216

Pembimbing

dr.Wayan Niryana,Sp.BS


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Chiari type I malformation Hydroceplalus

Syringomyelia

Endoscopic third ventriculostomy


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also known as the Arnold-Chiari malformation is a relatively common syndrome caused by

displacement of the cerebellar tonsils belowthe level of the foramen magnum


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sometimes causing non-communicatinghydrocephalus as a result of obstruction of

cerebrospinal fluid (CSF) outflow The cerebrospinal fluid outflow is caused by

phase difference in outflow and influx ofblood in the vasculature of the brain.


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Headaches Tinnitus (ringing in the ears) Dizziness and vertigo Nausea Nystagmus (irregular eye movements) Facial pain Muscle weakness Impaired gag reflex Restless Leg Syndrome Sleep Apnea Dysphagia (difficulty swallowing)

Impaired coordination intercranial pressure pupillary dilatation Dysautonomia: tachycardia (rapid heart), syncope (fainting),

polydipsia (extreme thirst), chronic fatigue


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Combination of:- Patient history

- Neurological examination

- Magnetic Resonance Imaging (MRI). Radiographic criteria for diagnosing a

congenital Chiari I Malformation downwardherniation of the cerebellar tonsils greater

than 5 mm below the foramen magnum.


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Once symptomatic onset occurs, a commontreatment is decompression surgery

differs dependent on the type ofmalformation (type I, II, III, or IV)

Type I is generally adult-onset and, while notcurable, is treatable and rarely fatal.


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The term is derived from the Greek words "hydro"meaning water and "cephalus" meaning head.

Primary characteristic is excessive

accumulation of fluid in the brain.

The "water" is actually cerebrospinal fluid (CSF) aclear fluid that surrounds the brain and spinalcord.

The excessive accumulation of CSF results in an

abnormal widening of spaces in the brain calledventricles which creates potentially harmfulpressure on the tissues of the brain.


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The signs and symptoms of hydrocephalus vary generally byage of onset:

Infants An unusually large head

A rapid increase in the size of the head A bulging or tense soft spot (fontanel) on the top of the head Vomiting Sleepiness Irritability Poor feeding Seizures Eyes fixed downward (sunsetting of the eyes) Deficits in muscle tone and strength, responsiveness to

touch, and expected growth


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Toddlers and older children Abnormal enlargement of a toddler's head Headache Nausea or vomiting

Fever Delays in walking or talking Problems with previously acquired skills, such as walking or

talking Blurred or double vision Unstable balance Poor coordination Irritability Change in personality Problems with attention Decline in school performance Poor appetite Seizures Sleepiness Difficulty remaining awake or waking up


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Types of hydrocephalus There are three main types of hydrocephalus:

hydrocephalus that's present at birth(congenital hydrocephalus)

hydrocephalus that develops after birth

(acquired hydrocephalus) hydrocephalus that usually only develops in

older people (normal pressure hydrocephalusor NPH)


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The goal of treatment reduce or prevent braindamage by improving the flow of CSF.

Hydrocephalus treatment is surgical, generally creatingvarious types of cerebral shunts.

It involves the placement of a ventricular catheter intothe cerebral ventricles to bypass the flowobstruction/malfunctioning arachnoidal granulationsand drain the excess fluid into other body cavities,from where it can be resorbed.

An alternative treatment for obstructive hydrocephalusin selected patients endoscopic thirdventriculostomy (ETV), whereby a surgically createdopening in the floor of the third ventricle allows theCSF to flow directly to the basal cisterns.


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A disorder in which a cyst forms within the spinalcord called a syrinx

It expands and elongates over time, destroyingthe center of the cord and may result in pain,

weakness, and stiffness in the back, shoulders,arms or legs.

Other symptoms headaches ,loss of the abilityto feel extremes of hot or cold, especially in the

hands and disruption in body temperature. SMmay also adversely affect sweating, sexualfunction and bladder and bowel control.


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Trauma to the spinal cord or congenital

developmental problems of the brain and/orspinal cord may result in SM.

Spinal cord trauma such as a car accident orserious fall may manifest years later as SM.

Congenital developmental problems,sometimes undetectable may result insyringomyelia.


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MRI leadingdiagnostic tool used indetermining SM.

Analgesia

Surgery


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Endoscopic third ventriculostomy is a

technique to treat obstructive hydrocephalus Involves making a hole in the floor of the third

ventricle to bypass the aqueductal obstruction

Involves using an endoscope, singleport,multiport, rigid or flexible

Considered minimally invasive neurosurgicalprocedure


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General Anatomy Endoscopic Anatomy

Tools

Technique


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Lateral Walls: anterior 2/3 of the thalamus andhypothlamus. These are joined together by the massaintermedia.

Posterior anatomy: pineal body, habenularcommisure, posterior commisure, and the cerebralaqueduct

Anterior anatomy: In the AP direction Optic Recess Optic Chiasm Infundibulum

Infundibular recess Tuber Cinereum Mamillary Bodies


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Working instruments1. Grasping forceps

2. Biopsy forceps

3. Scissors4. Bipolar coagulation

5. Cutting probe


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Determine entry point and enter ventricularsystem

Finding and entering the Foramen of Munro

Inspecting the floor of the third ventricle

Perforating the floor of the third ventricle

Enlarging the perforation (approx 5 mm)

Inspecting the pre-pontine cistern


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The procedure is performed through a smallincision (approximately 1 inch) behind the hairline.From this site, the endoscope is inserted into theventricular compartment of the brain and thennavigated into the third ventricle. The floor of thiscompartment is then fenestrated, or opened. Theendoscope is then removed and the wound is

closed. The procedure is performed inapproximately 30 minutes and patients can returnhome the following day.


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BACKGROUND

Hydrocephalus affects 7% to 10% of patients

with Chiari I malformation(CIM). It can be successfully treated by endoscopic

third ventriculostomy (ETV), possibly

improving related CIM and syringomyelia.


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OBJECTIVE

To confirm the effectiveness of ETV in themanagement of Chiari-related hydrocephalusand symptoms

estimate the posterior cranial fossa volume(PCFV)to find the possible reasons for thesuccess or failure of ETV.


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METHODS

Fifteen patients (11 children and 4 adults)underwent ETV for hydrocephalus associatedwith CIM (syringomyelia was present in 6patients).

Preoperative PCFV,posterior fossa brainvolume (PFBV), and PFBV/PCFV ratio werecalculated in the last 12 patients in the seriesby a magnetic resonance imagingbased

computerized method.


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RESULTS All patients had symptomatic hydrocephalus (mean

third ventricle diameter,14.1 mm). Mean tonsillarectopia was 12.7 mm. Postoperatively, hydrocephalus symptoms

improved in all cases (mean third ventriclediameter, 8.3 mm); signs and symptoms of CIM

and syringomyelia resolved or improved in allpatients, although the malformation remainedradiologically stable in half of the patients(postoperative mean tonsillar ectopia, 8.8 mm).

There were no remarkable differences between

cases and controls with regard to PCFV and PFBV. The PFBV/PCFV ratio was comparable in pediatriccases and controls but not among adult patients,suggesting a PCF overcrowding in the controls.


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CONCLUSION ETV is an effective treatment fo

hydrocephalus associated with CIM.

It is successful in improving CIM andsyringomyelia in patients with no

overcrowding (mainly in children) or withreversible overcrowding of the PCF (mainly inadults).


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endoscopic third ventriculostomy for the management of chiari

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