Endoscopic transaqueductal stent placement for tumors-related aqueductal compression in pediatric patients. Surgical consideration, technique, and results

Abstract

Purpose: Endoscopic transaqueductal stenting has become a well-accepted treatment option for a selected small subset of aqueductal stenosis-related obstructive hydrocephalus. However, transaqueductal stenting poses unique challenges and risks which requires critical consideration. This report discusses the clinical experiences with tranaqueductal stenting for periaqueductal tumor-related aqueductal stenosis focusing on pediatric patients. Methods: A retrospective analysis of all patients undergoing endoscopic TAS from 01/1993–01/2022 in the author’s departments was performed. Demographic, clinical, radiological, and intraoperative endoscopic data were evaluated. All patients with AS-related occlusive hydrocephalus that was treated with TAS were analyzed and prospectively followed. Special attention has been given to providing insights into indications, surgical technique, and limitations. Results: Out of 28 endoscopic transaqueductal endoscopis stenting procedures, five procedures were performed on periaqueductal tumor-related obstructive hydrocephalus, two children and three adult patients. CSF pathway was obstructed by tumor located in the aqueduct in 2, by tumor in the thalamus/mesencephalon in 1, by a tumor within the third ventricle in 1 and by a tumor of the lamina tecti in 1. Simultaneously with transaqueductal stenting, 2 endoscopic third ventriculostomies (ETV), 3 tumor biopsies, 1 tumor resection were performed. Postoperative complications included; CSF fistula (1 case), and asymptomatic fornix contusion (1 case). A working aqueductal stent was achieved in all cases based on clinical follow up evaluation. Postoperatively, all patients showed improvement or resolution of their symptoms. The mean follow-up period was 25,2 months (range, 1–108 months). One patient died due to tumor progression during early follow up. No stent migration was seen. Conclusion: Endoscopic third ventriculostomy remains the gold standard for treatment of CSF circulation obstrctions with lesions in the posterior third ventricle and aqueduct. Transaqueductal stenting for periaqueductal tumors-related aqueductal compression is technically feasible. However, because of the potential high risks and subtle advantages compared with ETV transaqueductal stenting might be indicated in a small subset of well-selected patients if alternative treatment options are not at hand.