Childs Nerv Syst (2004) 20:816–820

DOI 10.1007/s00381-004-0936-0 ORIGINAL PAPER

Nobuhito Morota
Yoko Fujiyama
Endoscopic coagulation of choroid plexus
as treatment for hydrocephalus:
indication and surgical technique

Received: 30 December 2003 Abstract Object: Choroid plexus progressive, later required a VP
Published online: 19 June 2004 surgery, which had been discarded as shunt. Conclusion: Choroid plexus

Springer-Verlag 2004 a treatment for hydrocephalus, was surgery for hydrocephalus seems to
brought back into use with the de- be effective in some patients. Ad-
velopment of modern neuroendo- vanced modern technology has en-
scopic technology. The object of this abled the application of a neuroen-
article is to describe the author’s ex- doscope for this procedure. From our
Presented at the Second World Conference perience of the surgery with special limited experience, the key to the
of the International Study Group on emphasis on the surgical indication. success of endoscopic choroid plexus
Neuroendoscopy (ISGNE), Castel dell’Ovo, Methods: Three infants underwent coagulation is the selection of pa-
Naples, Italy, 11–13 September 2003
endoscopic choroid plexus coagula- tients. Favorable candidates for the
N. Morota ()) · Y. Fujiyama tion as a treatment for hydrocephalus. surgery seem to be those who suffer
Department of Neurosurgery, Standard procedure for the surgery from the slow progressive, severe
National Children’s Medical Center, was unilateral transparietal insertion form of hydrocephalus and who lack
National Center for Child Health of a flexible neuroendoscope and the septum pellucidum.
and Development, electrical coagulation of the choroid
2-10-1, Okura, Setagaya, Tokyo, 157-8535,
Japan plexus. The results showed the re- Keywords Hydrocephalus ·
e-mail: [email protected] lease of increased intracranial pres- Neuroendoscopy · Endoscopy ·
Tel.: +81-3-34160181 sure in two infants, while the other, Choroid plexus · Coagulation ·
Fax: +81-3-34162222 whose hydrocephalus was rather Children

Introduction children with hydroanencephalic hydrocephalus in 2002

[15].
The history of endoscopic neurosurgery dates back 1910 The author describes his personal experience of the
when hydrocephalus was treated by fulgurating the procedure utilizing neuroendoscopy for the treatment of
choroid plexus [3]. Dandy disseminated the procedure severely advanced forms of hydrocephalus in infants.
later [3, 14]. The results of choroid plexotomy were
ambiguous in terms of perioperative complications and
long-term results [1, 6–8, 11, 12]. As a result, the pro- Patients and methods
cedure was regarded as being outdated and faded away
from the arena of hydrocephalus treatment. Patients
Endoscopic neurosurgery has been resurfacing as a
Since the foundation of the National Center for Child Health and
new armament of modern neurosurgery since the intro- Development in March 2002, we have operated on 31 patients with
duction of modern technology [5]. The advent of flexible various types of hydrocephalus. The total number of procedures for
endoscopy enabled third ventriculostomy to be a safe hydrocephalus was 55, of which 17 entailed endoscopic surgery.
and shuntless treatment for the various forms of hydro- Endoscopic coagulation of the choroid plexus was performed in
three patients who had markedly dilated ventricles. Their septum
cephalus [5, 9, 10]. On the other hand, Wellons III et al. pellucidum was almost lost due to long-standing hydrocephalus. The
described a satisfactory outcome of microsurgical co- patients’ ages at surgery were 2, 5, and 8 months old . One patient
agulation of the choroid plexus in the treatment of had fetal intraventricular hemorrhage and the other two had this
 817

Fig. 1 Fetal hydrocephalus due

to intraventricular hemorrhage.
Fetal MRI taken at the gesta-
tional age of 33 weeks revealed
marked ventriculomegaly with
biparietal cortical agenesis. No
significant ventriculomegaly
was observed in the third and
fourth ventricles

during the neonatal period. The choroid plexus coagulation was the
first treatment for hydrocephalus in one of the patients, while another
had had a failed endoscopic third ventriculostomy 1 month before,
and the last one had bilateral reservoir placement for intermittent
drainage of the cerebrospinal fluid (CSF) soon after birth at another
hospital. All patients underwent enhanced CT or MRI to confirm the
presence and measure the size of the choroid plexus before surgery.

Surgical procedure

The patient is placed in a supine position with the head rotated to

the left side under general endotracheal anesthesia. The head is
elevated so that the right parietal region comes to the top of the
surgical field. A semi-circular skin incision is made near the mid-
line after skin preparation and draping. The periosteum is dissected
away in the same way as the skin incision. A small craniotomy is
made using either the sagittal or the lambdoid suture as a hinge.
The dura is opened and the pia-arachnoid membrane (when the
cortex is not present) is tucked up by 5–0 threads and fixed to the
periosteum to prevent the cortex from collapsing inside. Then, the
pia-arachnoid membrane is opened to insert a flexible endoscope.
Because the septum pellucidum is usually lost, bilateral choroid
plexus are confirmed to be lying on the atrophic thalamus. The
dilated trigone made possible the endoscopic approach to the
ventral part of the choroid plexus in the temporal horn. Using an
endoscopic monopolar coagulator, the bilateral choroid plexus are
cauterized carefully. Special attention is paid to preserving the
veins on the ventricular wall and avoiding thermal damage to
the thalamus. In general, the choroid plexus from the foramen of
Monro to the trigone are coagulated. No attempt is made to extract
the choroid plexus under endoscopy. After completion of the bi-
lateral coagulation, the ventricle is irrigated repeatedly to wash out
debris and air. The endoscope is then withdrawn, immaculate he-
mostasis is obtained, and the dura is closed. The bone flap is re-
placed and the periosteum is sutured to the original one. The skin is
approximated layer-by-layer.

Results
Endoscopic coagulation of the choroid plexus for severely
advanced hydrocephalus was effective in controlling the
progress of hydrocephalus in two patients. No further
intervention has been required in the postoperative fol- Fig. 2a, b Hydrocephalus due to fetal intraventricular hemorrhage.
low-up period of 1 year in one and 4 months in the other. a Postnatal MRI T1-weighted and b proton imaging. Subependymal
The third patient later required a VP shunt. This pa- linear low signal intensity (black arrows) depicted by proton im-
tient, who had developed hydrocephalus following neo- aging was suggestive of hemosiderin deposit due to fetal intra-
ventricular hemorrhage
818

Fig. 3 Chronological change of

head circumference after birth.
Head circumference stayed the
same size during the first
2 weeks and then became pro-
gressively enlarged. After en-
doscopic choroid plexus coag-
ulation at the age of 2 months,
head circumference showed
initial stabilization, slow pro-
gression, and again stabilized.
Currently, head circumference
falls within the upper limit of
the normal range of head cir-
cumference

natal intraventricular hemorrhage, needed frequent CSF

removal through a CSF reservoir preoperatively. The
brain mantle of this patient was thicker than the that of the
other two. In addition, the procedure was carried out
through a frontal burr hole and combined with endoscopic
third ventriculostomy.

Representative case
The patient was diagnosed with fetal ventriculomegaly at the ges-
tational age of 31 weeks (Fig. 1), and was born by cesarian section
at the gestational age of 34 weeks with a body weight of 2,379 g
and head circumference of 34.2 cm. A MRI taken after birth
showed marked ventriculomegaly, focal brain damage from the
right anterior horn to the frontal base, and biparietal agenesis of the Fig. 4 a Contrast-enhanced CT scan taken before surgery showed
brain mantle. Diagnosis of fetal intraventricular hemorrhage was the approximate volume and localization of the left choroid plexus.
made based on MRI imagings which revealed linear low-signal The right choroid plexus was not shown in this slice. b Contrast-
intensity along the ventricular wall caused by hemosiderin deposit enhanced CT scan taken 7 days after surgery demonstrated obscure
(Fig. 2). The head size remained stable during the first month but enhancement of the left choroid plexus
gradually increased (Fig. 3). Since the increase in head size was
slow and ventriculomegaly was prominent, he underwent endo-
scopic coagulation of the choroid plexus at the age of 2 months
(Fig. 4). The surgery as described above confirmed hemosiderin Discussion
deposit on the ventricular wall. The visible part of the bilateral
atrophic choroid plexus was coagulated utilizing a flexible endo- Treatment of hydrocephalus without shunting has been
scope (Fig. 5). Postoperatively, the head size remained stable. Sleep a dream for neurosurgeons as well as patients with hy-
study showed the decreased frequency of oxygen desaturation and drocephalus. Recent technological advancement of neu-
the patient started to show psychomotor development after surgery.
Currently, 1 year after surgery, the patient has reached the normal roendoscopes has turned the dream into reality. Nowa-
range for head circumference (Fig. 3). The major fontanel is con- days, endoscopic third ventriculostomy has become a
caved and low but steady psychomotor development has been re- standard treatment for obstructive hydrocephalus, such as
ported despite severe retardation. that caused by aqueduct stenosis [5, 10]. Although the
 819

Fig. 5 Intraoperative pho-

tographs of the choroid plexus
(arrowhead) before and after
coagulation

surgical result in the pediatric population seems less fa- cation for those children who have the slow progressive
vorable [2, 3], endoscopic surgery has been applied for form of severely advanced hydrocephalus with a small
various types of hydrocephalus [9]. amount of the choroid plexus left in the ventricle.
Endoscopic coagulation of the choroid plexus is the From a technical viewpoint, endoscopic coagulation of
revival of an old idea using modern neuroendoscopic the choroid plexus is not complicated, but some special
technology. The history of endoscopic neurosurgery start- attention is required. We used the parietal approach for
ed by fulgurating the choroid plexus in 1910 [4]. Dandy better observation of the bilateral choroid plexus, as de-
later attempted to apply the ventriculoscope in choroid scribed by Wellons III et al. [15]. A semi-circular skin
plexectomy surgery [4, 14]. Reflecting the result of chor- incision was relatively large as an endoscopic procedure
oid plexus surgery for the treatment of hydrocephalus, the to make the dural opening large enough. It enabled wa-
reason why choroid plexus surgery was unable to remain tertight dural closure later. The craniotomy was hinged at
a reliable procedure seemed to stem from its uncertain the lambdoid or sagittal suture. The dural opening was
long-term results [1, 7, 8], unpredictable outcome, and made in a different direction from the craniotomy. These
relatively high morbidity [11, 12]. procedures are intended to lower the risk of CSF leakage
The goal of surgery is not the complete coagulation of postoperatively. When the brain was thin or brain pa-
the choroid plexus but to restore the balance of CSF renchyma was not present in the case of hydroanen-
production and absorption in the central nervous system. cephaly [13], the pia-arachnoid membrane was tucked up
Since endoscopic access is limited to the choroid plexus before its opening in order to insert an endoscope. This
located from the foramen of Monro to the trigone, only procedure helps to prevent postoperative subdural fluid
partial coagulation of the choroid plexus is allowed during collection and the collapse of thin brain parenchyma.
surgery. It means that the residual choroid plexus in the Coagulation of the choroid plexus using an endoscopic
temporal horn would keep producing CSF. If the volume monopolar probe is straightforward but skilled hands are
of residual choroid plexus remains large, it could com- required in order not to damage the thalamus and the
pensate for the CSF production lost by coagulation. Thus, choroidal artery. Although we have never encountered
the smaller the total volume of the choroid plexus, the significant bleeding from the choroid plexus, we always
more the surgery would be warranted. It is also estimated prepare an operative microscope for emergency use.
that if the slow progress of hydrocephalus suggests the Endoscopic choroid plexus coagulation has its own
limited function of the choroid plexus, choroid plexus limitations and the possibility of future VP shunts would
surgery could have more chance of success. not be completely precluded. Long-term watchful follow-
Indications for choroid plexus surgery need to be dis- up is mandatory after surgery. Endoscopic choroid plexus
cussed. It seems that candidates for choroid plexus sur- coagulation seems to be worth trying, considering the
gery in the most of the previous reports were chosen relatively high rate of complications after VP shunting, in
nonselectively, meaning all types of hydrocephalus were those children with severe forms of hydrocephalus [13].
involved in the surgery [11, 12]. Wellons III et al. re- Delayed timing of VP shunting following endoscopic
ported satisfactory results from microscopic choroid choroid plexus coagulation would be meaningful for those
plexotomy in children with hydroanencephalic hydro- children with a high risk of complications.
cephalus [15]. Large ventricles often associated with de-
fects in the septum pellucidum enable the endoscopic
access to the bilateral choroid plexus. Based on my lim-
ited experience, I strongly recommend the surgical indi-
820

Conclusion important factor for success is patient selection. Favorable

candidates for the surgery seem to be:
Our limited experience suggests that endoscopic coagu-
lation of the choroid plexus could be the surgical proce- 1. Severely advanced hydrocephalus like hydroanen-
dure of choice for severe forms of hydrocephalus, like cephalic hydrocephalus
hydroanencephalic hydrocephalus. The surgical proce- 2. Slow progressive hydrocephalus
dure is relatively straightforward for experienced neuro- 3. Lack of or thinned out septum pellucidum to make the
surgeons, but special attention should be paid to avoid the bilateral endoscopic access possible
collapse of the brain cortex and CSF leakage due to the
thin brain parenchyma (if present). Probably, the most

References
1. Albright L (1981) Percutaneous choroid 6. Lapras C, Mertens P, Guilburd JN, 11. Putnam TJ (1934) Treatment of hydro-
plexus coagulation in hydroanen- Lapras C Jr, Pialat J, Patet JD (1988) cephalus by endoscopic coagulation of
cephaly. Childs Brain 8:134–137 Choroid plexectomy for the treatment choroid plexuses: description of new
2. Buxton N, Macarthur D, Mallucci C, of chronic infected hydrocephalus. instrument. N Engl J Med 210:1373–
Punt J, Woeberghs M (1998) Neuroen- Childs Nerv Syst 4:139–143 1376
doscopic third ventriculostomy in pa- 7. Milhorat TH (1974) Failure of choroid 12. Scarff JE (1970) The treatment of
tients less than 1 year old. Pediatr plexectomy as a treatment for hydro- nonobstructive (communicating) hy-
Neurosurg 29:73–76 cephalus. Surg Gynecol Obstet drocephalus by endoscopic cauteriza-
3. Cinalli G, Sainte-Rose C, Chumas P, 139:505–508 tion of the choroid plexuses. J Neuro-
Zerah M, Brunelle F, Lot G, Pierre- 8. Milhorat TH, Hammock MK, Chien T, surg 33:1–12
Kahn A, Renier D (1999) Failure of Davis DA (1976) Normal rate of cere- 13. Sutton LN, Bruce DA, Schut L (1980)
third ventriculostomy in the treatment brospinal fluid formation five years af- Hydranencephaly versus maximal hy-
of aqueductal stenosis in children. ter bilateral choroid plexectomy. drocephalus: an important clinical dis-
J Neurosurg 90:448–454 J Neurosurg 44:735–739 tinction. Neurosurgery 6:35–38
4. Cohen AR (1992) The history of neu- 9. Oi S, Hidaka M, Honda Y, Togo K, 14. Walker ML, MacDonald J, Wright LC
roendoscopy. In: Manwaring KH, Shinoda M, Shimoda M, Tsugane R, (1992) The history of ventriculoscopy:
Crone KR (eds) Neuroendoscopy 1. Sato O (1999) Neuroendoscopic surgery where do we go from here? Pediatr
Mary Ann Liebert, New York, pp 3–8 for specific forms of hydrocephalus. Neurosurg 18:218–223
5. Jones RFC, Steining WA, Brydon M Childs Nerv Syst 15:56–68 15. Wellons JC III, Tubbs RS, Leveque
(1990) Endoscopic third ventriculosto- 10. Oka K, Yamamoto M, Ikeda K, JCA, Blount JP, Oakes WJ (2002)
my. Neurosurgery 26:86–92 Tomonaga M (1993) Flexible en- Choroid plexectomy reduced neurosur-
doneurosurgical therapy for aqueductal gical intervention in patients with hy-
stenosis. Neurosurgery 33:236–243 droanencephaly. Pediatr Neurosurg
36:148–152