Endoscopic Aqueductoplasty with and without Stent
Makaleler > Tam Makale · 2006
Yazarlar: Y. Erşahin
min - Minimally Invasive Neurosurgery, Uluslararası, Wos, 2006, cilt 49, ss 124-125
Özet
Sir, I read with interest the article on endoscopic aqueductoplasty (EAP) by Miki et al. [ 1 ]. They performed EAP in 6 patients with aqueduct stenosis (AS) by using a flexible neuroendoscope. They have achieved good results in all patients and have not encountered restenosis. However they did not mention the follow-up period. In 1999, Schroeder and Gaab [ 2 ] reported that EAP is an effective alternative to third ventriculostomy for the treatment of hydrocephalus caused by a short AS. In 2004, Schroeder et al. [ 3 ] reported the long-term results of their patients in whom EAP had been performed. Their patients' mean follow-up period was 40 months. EAP was performed in 39 patients and endoscopic third ventriculostomy (ETV) was also performed simultaneously in 13 patients. They observed restenosis of the aqueduct in 7 patients, after an average of 25 months, ranging from 14 days to 97 months. Fritsch et al. [ 4 ] retrospectively analyzed the outcome of 27 patients who underwent EAP or interventriculostomy with or without stent placement. They concluded that in patients with membranous distal AS, EAP alone is sufficient enough at 2 years follow-up to provide clinical and radiographic sufficiency and in patients with tumor-associated AS, EAP alone will not suffice. If there is an indication for EAP, a stent needs to be placed. In patients with isolated fourth ventricle and a history positive for intraventricular haemorrhage or meningitis, it is very unlikely that an EAP alone will stay open. The high revision rate in this group has led to a change in treatment strategy toward initial stent placement [ 4 ]. We have performed aqueductoplasty only in 8, aqueductoplasty with ETV in 11, aqueductoplasty with stent in 5 and aqueductoplasty with stent and ETV in 7 patients. It is not possible to figure out which procedure would be effective when aqueductoplasty and ETV are done simultaneously. Therefore aqueductoplasties with or without stent should be analyzed to find out the need of stenting the aqueduct. Of the 6 adult patients with primary AS, only one needed a second endoscopic procedure following EAP. Restenosis developed 5 months after the first EAP. The patient's symptoms and signs completely improved after ETV. Aqueductoplasty failed in 2 children. A 7-month-old boy with AS and shunt infection underwent EAP at the time of shunt malfunction. He was shunted one week after aqueductoplasty. The other patient was a 5-year-old boy with isolated fourth ventricle. Unfortunately isolated fourth ventricle on MRI and ataxia and dysphagia persisted in the follow-up. MRI in the constructive, steady-state sequences disclosed a web in the aqueduct (Table [ 1 ]). Of the 6 patients in whom aqueductoplasty with stent had been performed, 4 patients had primary AS, one patient had a tectal glioma and one had a pineal tumor. In two patients with secondary AS, the brain stem was pushed toward the clivus and there was no space between the brain stem and clivus for a safe ETV. This is why EAP and stenting of the aqueduct were done in both patients. Endoscopic subtotal tumor removal was done prior to EAP with stent in the patient with a pineal tumor. The stent migrated into the third ventricle 3 months later. Aqueductoplasty with stent was performed again and he has been symptom-free for one year. Bilateral subdural fluid collection developed following aqueductoplasty with stent in two infants with marked hydrocephalus. A subdural-peritoneal shunt was implanted in both patients (Table [ 2 ]). Table 1