Endoscopy in Neurosurgery

Moderator - Presentor –
Dr Manish Agrawal Dr Vijendra Bijarnia
Dr Jitendra Singh Shekhawat
Dr Manmohan Singh
Dr Surendra Saini
 Introduction
• An Endoscope is a device using fiber optics and powerful
lens systems to provide lighting and visualization of the
interior of body.
• There have been four major stages in the development of
neuroendoscopy –
– The urologist Victor D L’Espinasse
– The next stage when Walter Dandy (father of neuroendoscopy)
and Mixter attempted endoscopic fenestration of the third
ventricle
– The third significant leap came in the early 1970s. Gerard Guiot
performed the first endoscopic approach to pituitary tumor in
1962
– The current application of endoscopy in neurosurgery as
• endoscopic third ventriculostomy
• Sellar-suprasellar and clinoidal & paraclinoidal region
• Intraventricular tumors
• Endoscopic spine surgery for degenerative disc diseases
• Posterior Cranial Fossa Pathology
• Trigeminal Neuralgia
 PRINCIPLE
• Based on the science of optics
– Based on TIR (Total Internal
Reflection) in Flexible Endoscope
Systems
– Based On Relay Lens System In Rigid
Endoscope Systems
• Illumination relies on TIR
 Components
• Endoscope
• Fiberoptic cable
• Light source
• Camera
• Monitor
• Video recording system
 Endoscopes

Rod-lens Fiberoptic
endoscopes endoscopes

Flexible Steerable
Always rigid
fiberscopes fiberoscope
Flexible Steerable Rigid fiberoscope
fiberoscope fiberoscope

Smallest Diameter Tip can be bent in

varying degree

No working Working channel Working channel

channel present present

For visualizing Targets can be used

catheter placement only on a straight
and ensuring an line from the burr
intraventricular hole
position
 Rod-lens endoscope
• Superior quality of images
• Viewing angles available are 0-, 30-, 45-, 70-, and 120-degree.
• The 0- and 30-degree endoscopes are the most widely used.
• Objective lens - for image formation
• Relay lens system - for image transport- also called as Image
Reversal System
• Ocular lens - for image magnification
FLEXIBLE ENDOSCOPE
 FLEXIBLE ENDOSCOPE
• Also called as Ventriculoscope
• To navigate in the ventricular system and around corners when
used as an assist-device during microsurgical operations.
• 1-15 mm outer diameter (depending on number of fibers)
 DISADVANTAGES OF FLEXIBLE ENDOSCOPE

• Optics are worse than those of rigid endoscopes.

• Cannot be autoclaved, must be gas sterilized so
limits their longetivity
• Frequent use can damage the fiber bundle, which
further decreases the image resolution
 LIGHT SOURCE
• Tungsten- Halogen Light Source
• Mercury Vapour
• Xenon light source – preferred for documentation
• Basic (Xenon)Unit Advanced Unit with digital
display and standby feature
 CAMERA
• Attach to eye piece
Basic camera with a Focusing Advanced models with Focus
Ring & zoom functions
MONITOR
• Monitors need to be positioned
such that the surgeon, the
assistant and OR personnel can
all view them
• Xenon light sources provides the best illumination for
neuroendoscopy.
• A monitor with highest possible quality should be selected but
the resolution should be less than camera.
Operation Theatre Setup
 Advantages
• Wide-angle view
• Visualization at the site of surgery
• Ability to look around corners with angled endoscopes
• Increased area of visualization at the site of surgery
• Less pain
• Faster recovery ,shorter hospital stay and quicker return to
normal activities
• Minimal scarring
• Small incision site and minimal trauma
• Better definition
• Minimization of retraction.
• Assessing adequacy of tumor removal or
aneurysm clip placement
• In addition to benefiting the patient
– the endoscope is an excellent teaching tool
• The anatomical definition
• unique angles of view available with the endoscope.
 Disadvantages
• Lack of binocular vision with current technology
• Occupying space in surgical corridor
• Necessity of assistant or holder for endoscope
to perform bimanual surgery
• Lack of instrumentation to work through
operative channel
• Barrel effect
• Lack of depth perception
• Learning curve
Indications for intracranial endoscopic procedures
1. Hydrocephalus
– Third ventriculostomy
– Aqueductoplasty
– Septum pellucidotomy
– Multicompartment hydrocephalus
– Ventricular catheter placement
– Stent placement
2. Intraventricular tumors
3. Arachnoid cysts
– Fenestracion
4. Colloid cysts
5. Skull base
6. Endoscopic assisted microsurgery
 Endoscopy and Hydrocephalus
• Cranial endoscopy was first used in the setting
of hydrocephalus before the advent of shunt
systems, when the condition was commonly
fatal.
• Interest in the endoscopy has resumed because
– Of the high rate of long-term morbidity associated
with the use of shunts, most commonly shunt
malfunctions and infections.
 ETV
• The first attempted endoscopic third ventriculostomy
(ETV) was undertaken in 1923.
• ETV technique was “rediscovered” in the 1970s and
1980s.
• considered a safe and effective treatment for
obstructive hydrocephalus
• Numerous potential benefits over shunt, which
possesses its own set of inherent risks and
complications
– Infection
– slit ventricle syndrome
– mechanical malfunction
 Prerequisite for ETV
• Symptomatic non-communicating hydrocephalus
• ETV candidates must have patent subarachnoid spaces
• Suitable anatomy to permit safe fenestration of the floor of the
third ventricle
– The size of the third ventricle
– the thickness of its floor
– the position of the basilar artery, and
– the prepontine interval between the basilar artery and clivus
Space Should be sufficient between dorsum sellae and
basilar artery
If space between artery and dorsum sellae
is less perforate on dorsum sellae
 Schematic illustration of the Liliequist
membrane in the sagittal plane.
D = diencephalic segment Liliequist membrane is a distinct
M = mesencephalic segment
S = sellar segment arachnoid structure within the basal
cistern and consists of double or even
triple folds of arachnoid mater.
Location –
𝑀 • Posterior to pituitary stalk
• Anterior to interpeduncular cistern of
midbrain
𝐷𝑆
• Inferior to third ventricular floor
• Superior to prepontine cistern
• Medial to the tip of uncus at the
tentorial edge.
• Conventionally a length of 5 mm along the floor of
the third ventricle and adequate prepontine space to
pass an instrument are preferred for safe pursuit of
an ETV.
• In experienced hands, however, narrower corridors,
including a prepontine interval of less than 1 mm,
may still permit endoscopic fenestration of the floor
of the third ventricle.
 Fenestration techniques
• Passage of a Fogarty balloon catheter with repeated inflation
and deflation
• Blunt penetration of the floor with a Bugbee wire or rigid
probe
• Electrocoagulation
• Laser coagulation
• Water jet fenestration.
 Procedure
Step 1: Patient positioning
• The patient is positioned supine with the head
slightly flexed.
Step 2: Burr hole.
• A coronal burr hole is performed with the
optimal entry position at 3 cm lateral to the
midline and 1 cm anterior to the coronal suture
• An incision is made so that the burr hole is 3 cm lateral
to the midline on the right-hand side. A curved incision
is prepared so that a shunt/reservoir can be inserted if
endoscopic third ventriculostomy is unsuccessful
Step 3: Entry into the lateral ventricle
• The endoscope is advanced into the lateral ventricle
with or without stereotactic assistance
Step 4: Entry into the third ventricle.
• Under direct vision, the endoscope is passed through
the foramen of Monro into the third ventricle
Step 5: Ventriculostomy
• The ventriculostomy is placed just posterior to the
infundibular recess of the pituitary stalk, anterior to
the mamillary bodies. Perforation is either blunt,
using the endoscope, or with an instrument followed
by balloon catheter dilatation
• Both the ependyma and underlying arachnoid are
opened
Step 6: Inspection and hemostasis.
• Fluctuation of the margins of the fenestration indicates
CSF flow.
• Entry into the prepontine cistern is performed with
caution so as to avoid injury to the basilar apex and
perforating vessels.
• Bleeding from the edges of the opening can be
tamponaded by keeping the balloon inflated for a
slightly longer period.
• Hemostasis with irrigation is achieved until a clear
operative field is visualized
• Etiologies of obstructive hydrocephalus for
which ETV has been performed
– aqueductal stenosis
• Aqueductal stenosis is the most common and is the
most favorable etiology for durable benefit following an
ETV
– Tumor
– infection, and
– intracerebral hemorrhage.
 Outcome of ETV
• Success following an ETV is defined by amelioration of
the signs and symptoms of elevated intracranial
pressure (ICP) – Best assessor
• Factors that influence the outcome
– The etiology of hydrocephalus
– Anatomic factors, and
– Patient selection – Specifically
• young age and prior history of communicating
hydrocephalus or shunt are associated with worse
outcomes whereas
• preoperative thinning and inferior bowing of the third
ventricle floor is associated with ETV success
ETV SS
 Failure of ETV
• Early failure
– Bleeding around the fenestration site,
– Unnoticed additional arachnoid membranes occluding the flow of
CSF, and
– An inadequate size of the fenestration
• Late failure
– subsequent closure of the fenestration by gliotic tissue or arachnoid
membrane.
 Complications
• The reported complication rates range from 1% to 18%, with a
mortality rate of less than 1%.
• intraoperative, early postoperative, and late postoperative.
• Intraoperative complications
– Neurovascular injury
– bradycardia with cardiac arrest.
– Venous or arterial bleeding (Massive subarachnoid bleeding from
perforation of the basilar artery or its branches has also been
reported rarely)
• Early postoperative complications
– neurological and endocrinologic dysfunction
– subdural hematoma
– CSF leak
– infection.
– direct trauma can result in transient
• oculomotor or other cranial nerve palsy
• midbrain injury
• hypothalamic dysfunction
• Hemiparesis
• Seizure
• transient memory loss
– Electrolyte and endocrinologic abnormalities
• Late postoperative complications - mainly of
delayed failure resulting from
– closure of the ETV stoma
 Endoscopic Aqueductoplasty
• Hydrocephalus caused by membranous occlusion
or short-segment stenosis of the aqueduct of
Sylvius
• First performed by Walter Dandy in 1920
• with and without stenting
• Stenting of the aqueduct is considered for
– patients at high risk for aqueductal restenosis
– patients with a trapped fourth ventricle
• Potential advantages compared with ETV
– Aqueductoplasty restores the physiologic CSF pathway
– imparts no risk for basilar artery injury
– avoids hypothalamic injury and
– negates consideration of any arachnoidal adhesions
• The bur hole for endoscopic aqueductoplasty is placed
more anteriorly than for standard ETV.
• A flexible endoscope may be useful for perforating
membranous obstruction, especially if the obstruction is in
the distal aqueduct
• Shunted patients with a trapped fourth ventricle - often have
slit-like lateral ventricles
– poor candidates for the standard endoscopic aqueductoplasty
– a suboccipital approach for retrograde aqueductoplasty and stenting.
 complications
• Especially in long-segment stenoses
– midbrain injury
– Parinaud’s syndrome, and
– cranial nerve palsies.
• long-segment aqueductal stenoses
– ETV may be a more appropriate procedure.
• Stent migration and local tissue reactions
• On the whole, although aqueductoplasty is conceptually attractive,
ETV remains the preferred technique for endoscopic CSF diversion.
 COMPLEX HYDROCEPHALUS
• Patients with shunt infections or intraventricular
hemorrhage
– compartmentalization of the ventricles
– often requiring multiple shunt placements.
• Multiple shunts are not ideal, and are associated
– high failure rates
– subsequent infections.
• Endoscopy offers a simple means of communicating
isolated CSF spaces and ventricles by membrane
fenestration
 Septostomy and Foraminoplasty
• Isolated lateral ventricular hydrocephalus
• Slightly lateral entry point may enhance face-on
visualization of the septum.
• Fenestration of potentially scarred, multilayered septum
– mechanically, through “saline torch” dissection,
– with laser coagulation,
– with sharp extirpation.
• An avascular region should be targeted, with care to avoid
the usually asymmetrical septal veins.
– middle septal region, at the level of the foramen of Monro, poses
a relatively safe area for septostomy.
• Septostomy frequently occurs in conjunction with another
procedure,
– cyst fenestration
– ETV,
– foraminotomy.
• The risk for closure from foraminoplasty is high.
 Ventricular Tumors and Cysts
• Neuroendoscopy is increasingly used for
• biopsy of ventricular tumors and
• fenestration of a variety of intracranial cysts.
• The advantages
– improved visualization of intraventricular pathology
– refined management of tumor-related hydrocephalus
– safer biopsies
– minimally invasive removal of intraventricular tumors.
• For example pineal region tumors, tissue and
cerebrospinal fluid can be sampled concurrently.
 – an ETV or a ventricular shunt under endoscopic guidance can be
performed in the same setting.
– Septostomy is also readily accomplished to prevent unilateral
trapping of a lateral ventricle.
• The ability to remove tumors endoscopically depends on
tumor consistency, vascularity, and location
• Not all intraventricular tumors should be approached
endoscopically.
• The ideal tumor for endoscopic consideration has the following
characteristics
– moderate to low vascularity;
– soft consistency;
– less than 2 cm in diameter
– associated secondary hydrocephalus;
– histologically low grade
 Colloid Cysts
• Colloid cysts are benign tumors of neuroectodermal origin that
constitute 0.5% to 1% of all brain tumors
• They arise from the anterior aspect of the velum interpositum
or the choroid plexus of the third ventricle, in close proximity
to the foramen of Monro
• Symptomatic colloid cysts are usually accompanied by
hydrocephalus secondary to obstruction of both foramina of
Monro
• Dandy - first surgical resection of a colloid cyst in 1921
– posterior transcallosal approach and
– later developed the anterior transcortical-transventricular approach.
• Resection - when possible
 Complications
• Associated with resection of colloid cyst
– memory dysfunction
– venous infarction
– intraventricular hemorrhage
– Hemiparesis
– Meningitis
– seizures, and
– even death.
– Release of cyst contents can provoke aseptic meningitis
 Arachnoid Cysts
• most commonly arise from
– the middle fossa or retrocerebellar space
– discovered as incidental imaging findings
– Sellar and suprasellar arachnoid cysts are more likely to present with
symptoms
• The majority of asymptomatic cysts can be safely observed
• Arachnoid cysts are postulated to arise from splitting of the
arachnoid membrane in early development,
• Enlarges because of
– an osmotic pressure gradient
– active secretion by the cyst wall lining or ectopic choroid-like
structures,
– CSF movement through a communication between the subarachnoid
space and the cyst during venous or arterial pulsations.
• Traditional management
– craniotomy for cyst fenestration
– marsupialization, or resection, as well as adjunctive cystoperitoneal
or ventriculoperitoneal shunting.
• Endoscopic ventriculocystostomy offers an effective and less
invasiveness
ENDOSCOPIC TRANSSPHENOIDAL
SURGERY
Relevant anatomy
 Anatomical Structures Involved in the
Endonasal Approach to the Sella
Endoscopic Nasal Exploration
• Endoscopic Sphenoid Sinus Exploration
Sphenoid stage
 Approaches and anatomic relationship to skull base
• All approaches are initiated with a wide sphenoid sinus
exposure
• For all endonasal cranial base procedures, the sphenoid sinus
represents a vestibule –
– an entryway providing access for all expanded approaches.
 Approaches for Endonasal Skull Base Procedures

• Transsellar Approach
• Transplanum Approach
• Transcribriform Approach
• Transclival Approach
• Transodontoid Approach
Transsellar Approach
Transplanum Approach
• Suprasellar
Craniopharyngiomas
• Tuberculum
Meningiomas
Transcribriform Approach
• Sinonasal Malignancies
• Olfactory Groove
Meningiomas
Transclival Approach
• Clival Chordomas and
Chondrosarcomas
Transodontoid Approach
• Foramen Magnum
malignancy
• Basilar Invagination
 Endoscopic Spine Surgery
• Endoscopic Discectomy
• Endoscopic Foraminotomy
• Endoscopic Lateral Recess Decompression
• Endoscopic Laminotomy for Bilateral Decompression
Thank You