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  • Novel Adaptation of the AxiEM Electromagnetic Neuronavigation System for Intraoperative Tracking of Neuroendoscope During Intraventricular Surgery

    Final Number:
    651

    Authors:
    Smit Prafulchandra Shah; Irene Say MD; Rachana Tyagi MD

    Study Design:
    Other

    Subject Category:

    Meeting: Congress of Neurological Surgeons 2018 Annual Meeting

    Introduction: Endoscopic third ventriculostomy (ETV) has emerged as a promising answer to the problem of hydrocephalus, whereby an alternative pathway of cerebrospinal fluid (CSF) flow is created through a fenestration in the floor of third ventricle. However, success with ETV and the neuroendoscope demands high technical skill given the acute, yet rare risks of catastrophic injury, including basilar artery injury, memory loss, and endocrine dysfunction. Advances in preoperative imaging have allowed for better patient selection and technical advances in neuroendoscopy have improved visualization of critical neuroanatomical structures.

    Methods: We performed a retrospective chart review of adult and pediatric patients treated with neuronavigation guided endoscopic third ventriculostomy (ETV) or intraventricular cyst fenestration for radiographically confirmed, clinically significant congenital or acquired hydrocephalus between 2012–2014; n = 21 patients. All patients underwent successful completion of this procedure without clinically significant acute or longterm complications.

    Results: Etiology of obstructive hydrocephalus in our patients ranged from myelomeningocele, recurrent optic nerve gliomas to aqueductal stenosis. Twenty patients were complication free postoperatively except one patient who had temporary diabetes insipidus. As compared to predicted average pre-operative ETVSS score of 59.04%, post operative score was 81%. At long-term follow-up of average 41 months, there was no observed incidence of basilar artery injury, infection, CSF leak or forniceal injury. As compared to published success rates for ETV of 73% shunt independence, our rate was 76% during average first postoperative follow-up of 4.76 months.

    Conclusions: Adapting frameless electromagnetic neuronavigation provides real-time, multi-planar orientation during neuroendoscopic intraventricular surgery and reduces the risk of injury to critical brain structures. Intraoperative navigation provides a safe corridor for neuroendoscopy and avoids many complications of skull fixation in both adult and pediatric patients. Adding image guidance to neuroendoscopy increases safety margins for targeting accuracy, especially for patients with challenging anatomic landmarks.

    Patient Care: Potentially, by increasing the use of Neuronavigation along with ETV, better patient outcomes can be expected by acquiring surgical precision. We believe such studies will add to the existing literature of ETV studies which can be potentially done on a larger scale with higher number of patients.

    Learning Objectives: By the conclusion of this session, participants should be able to (1) Understand the importance and advantages of incorporating Neuronavigation & image guidance to ETV surgeries (2) Understand Risk vs Benefits of ETVs and (3) Understand the importance of predicted vs actual ETVSS (ETV Success Score).

    References: 1. http://www.hydroassoc.org/complications-of-etvand-etvcpc/ 2. Schroeder HW, Wagner W, Tschiltschke W, Gaab MR. Frameless neuronavigation in intracranial endoscopic neurosurgery. J Neurosurg 2001 Jan;94(1):72–9. 3. Shannon CN, Simon TD, Reed GT, et al. The economic impact of ventriculoperitoneal shunt failure. J Neurosurg Pediatr 2011 Dec;8(6):593–9. 4. Guzman R, Pendharkar AV, Zerah M, Sainte-Rose C. Use of the NeuroBalloon catheter for endoscopic third ventriculostomy. J Neurosurg Pediatr 2013 Mar;11(3):302–6. 5. Hayhurst C, Byrne P, Eldridge PR, Mallucci CL. Application of electromagnetic technology to neuronavigation: A revolution in image-guided neurosurgery. J Neurosurg 2009 Dec;111(6):1179–84. 6. Oertel JM, Vulcu S, Schroeder HW, Konerding MA, Wagner W, Gaab MR. Endoscopic transventricular third ventriculostomy through the lamina terminalis. J Neurosurg 2010 Dec;113(6):1261–9. 7. Longatti P, Fiorindi A, Feletti A, Baratto V. Endoscopic opening of the foramen of magendie using transaqueductal navigation for membrane obstruction of the fourth ventricle outlets: Technical note. J Neurosurg 2006 Dec;105(6):924–7. 8. Tao C. Complications of endoscopic third ventriculostomy. [Available at: http://www.hydroassoc.org/wp-content/uploads/kbase/Complications-of-Endoscopic-Third-Ventriculostomy.pdf] 9. Rohde V, Behm T, Ludwig H, Wachter D. The role of neuronavigation in intracranial endoscopic procedures. Neurosurg Rev 2012 Jul;35(3):351–8. 10. Vogel TW, Bahuleyan B, Robinson S, Cohen AR. The role of endoscopic third ventriculostomy in the treatment of hydrocephalus. J Neurosurg Pediatr 2013 Jul;12(1):54–61. 11. Kulkarni AV, Drake JM, Mallucci CL, Sgouros S, Roth J, Constantini S. Endoscopic third ventriculostomy in the treatment of childhood hydrocephalus. J Pediatr 2009 Aug;155(2):254–9.e1. 12. Kulkarni AV, Riva-Cambrin J, Browd SR. Use of the ETV success score to explain the variation in reported endoscopic third ventriculostomy success rates among published case series of childhood hydrocephalus. J Neurosurg Pediatr 2011 Feb;7(2):143–6. 13. Wang Y, Gao J, Zhang D, Ding Q. Complications of endoscopic third ventriculostomy for hydrocephalus. Zhonghua Yi Xue Za Zhi 2015 May 5;95(17):1338–40. 14. Grand W, Leonardo J, Chamczuk AJ, Korus AJ. Endoscopic third ventriculostomy in 250 adults with hydrocephalus: Patient selection, outcomes, and complications. Neurosurgery 2016 Jan;78(1):109–19. 15. Beuriat PA, Szathmari A, Grassiot B, Plaisant F, Rousselle C, Mottolese C. Role of endoscopic third ventriculostomy in the management of myelomeningocele-related hydrocephalus: A retrospective study in a single french institution. World Neurosurg 2016 Mar;87:484–93.

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