Endoscopic Exploration of the IV^thVentricle

Abstract

Regarding to the upcoming techniques in neuroendoscopy the IVth ventricle was examined. First in a series of 30 fresh and fixed anatomical specimens-the vessels injected with LATEX-the fourth ventricle was investigated endoscopically. There are three possibilities to reach the IVth ventricle: coming from the IIIrd ventricle via the aqueductus cerebri, using the basal cisterns through the apertura lateralis Luschkae and coming via the cerebellomedullar cistern through the foramen of Magendi. Using different kinds of endoscopes (rigid, flexible and steerable flexible)-diameter ranging from 5 to 9 french-with different optical systems (0 degree, 5 degrees, 30 degrees, 75 degrees) and different light sources (Halogen, Xenon) the anatomical details seen under the endoscope and the topographical landmarks of the approaches were investigated, presented and discussed. Based on the experience at the end of the cadaver work a short comment on which kind of equipment seems the best was given. A series of 14 clinical cases was presented as the second part of the study (7 cases with a tumor in the IVth ventricle-2 metastasis, 3 gliotic tumors, 1 ependymoma, 1 medulloblastoma, 3 patients with an occluded aqueduct because of meningo-ventriculitis and 4 patients with cystic malformations). The neuroendoscopic approaches, the neuroanatomical details relevant for surgery and the clinical data will be given and discussed. In general no intraoperative or postoperative complications were seen. In conclusion our experience from the theoretical neuroanatomical and the clinical part as well as the advantages and disadvantages from the different kind of endoscopes and approaches are discussed.

Clinical Features in Patients Requiring Reoperation after Failed Endoscopic Procedures for Hydrocephalus

“…Loculated hydrocephalus, which often occurs after an episode of neonatal meningitis or germinal matrix hemorrhage, has been treated with fenestration of the septum pellucidum or cyst fenestration [9,12,15,18,19]. The isolated fourth ventricle has been treated with fourth ventriculostomy or foraminoplasty [21].…”

Endoscopic telovelar approach to the fourth ventricle: anatomic study

“…1c and 2b-d). A preliminary inspection of the fourth ventricle can be performed by means of the classic medial transcysternal route [30,33]; the introduction of the endoscope into the foramen of Magendie gives a wide panoramic view of the fourth ventricle (Fig. 1e, f).…”

“…In the 1990s, the first reports detailing endoscopic caudal exploration of the fourth ventricle and the aqueduct were published [3,15,30,33,39]. Subsequently, other surgical or anatomical reports were published detailing the anatomy of the fourth ventricle as visualized by the endoscope using a transaqueductal approach [10,13,22,23,38,41].…”

“…From the first anatomic reports that the fourth ventricle and aqueduct could be approached endoscopically, not only from the third ventricle but also through a tailored craniocervical approach [30,33], other applications of this surgical approach were investigated. In some selected cases, this endoscopic approach has been used in the management of obstructive hydrocephalus due to aqueduct obstruction, reestablishing the free communication between the third and fourth ventricle [4,14,41].…”

“…1d). After inspection of the cisterna magna, the arachnoid was removed to approach the fourth ventricle via a medial transcysternal route [30,33] (Fig. 1e, f).…”