ENDOSCOPIC PROCEDURES
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Endoscopic Procedures
These procedures are done with ENT specialists in following conditions.
A. CSF Rhinorrhea
Cerebrospinal fluid (CSF) leaks are one of the common complications after traumatic brain injuries (TBI). The risks of CSF leaks can be detrimental to the outcomes of the patients. Early diagnosis and proper management is imperative for it is strongly associated with a better long-term prognosis of the patients.
Traumatic CSF leak is reported to be approximately 10% to 30% of the skull base fractures in adults. More than half of these CSF leak is presented within 48 hours of the trauma while almost all CSF leaks occur within 3 months in delayed manner. The most common fracture sites leading to CSF leaks following TBI are the frontal sinus (30.8%), sphenoid sinus (11.4–30.8%), ethmoid (15.4–19.1%), cribriform plate (7.7%), frontoethmoid (7.7%) and sphenoethmoid (7.7%)
CT cisternography, though invasive, helps accurately identify the site of CSF leak, especially in the presence of multiple bony defects. Magnetic resonance imaging (MRI) accurately detects CSF leaks and associated complications such as the encephaloceles and meningoceles.
Following vehicular accident, this patient had nasal bleeding which later was replaced by CSF leak. This did not stop with conservative measures. The CT scan and MRI brain showed a defect in the cribriform and ethmoid sinuses. This defect was repaired by nasal endoscope using fat, septal flap and fibrin glue. These surgeries are performed in collaboration with ENT colleagues.
Some CSF leaks improve with bed rest alone. Other CSF leaks may need surgical treatment.
B. Endoscopic Pituitary Surgery
The pituitary gland is located at the bottom of your brain and above the inside of your nose. It is responsible for regulating most of your body’s hormones, the chemical messengers that travel through your blood.
Endoscopic surgery is performed through the nose to remove tumors from the pituitary gland and skull base. In this minimally invasive surgery, the surgeon works through the nostrils with a tiny endoscope camera and light to remove tumors with long instruments. It is the most common surgery used to remove pituitary tumors.
In many cases, an ear, nose, and throat specialist will work with a neurosurgeon.
CT Scan After Surgery showing Complete Removal Pituitary tumour
Ventriculoscopy
It is an examination of a ventricle of the brain by means of an endoscope. The endoscope is a tiny telescopic camera that is inserted into the ventricle through a small incision in the scalp and a small hole in the skull. It is a minimally invasive procedure. It can be used to treat hydrocephalus (where the surgeon then creates a hole in the membrane at the bottom of the ventricle avoiding the necessity of a shunt) or to remove tumours situated in the ventricles as shown below.
1. ETV
Endoscopic 3rd ventriculostomy for congenital hydrocephalus due to aqueduct stenosis.
This 10-year-old boy presented with persistent headaches. MRI brain showed large ventricles due to aqueduct stenosis. 3rd ventriculostomy was performed by the endoscope. The boy did well postoperatively.
2. Third Ventricular Colloid CYST Excision
Colloid cysts are benign unilocular cysts of neuroepithelial origin, consistently located in the anterior third ventricle. They represent 0.2 to 2.0% of all intracranial tumours. They can be removed microsurgically or endoscopically.
Colloid cysts are benign growths that are usually located either in the third ventricle or at or near the foramen of Monroe which is found at the anterior aspect of the third ventricle of the brain. The cysts are comprised of epithelial lining filled with gelatinous material that commonly contains mucin, old blood, cholesterol, and ions. Colloid cysts can cause a variety of symptoms including headaches, diplopia, memory problems, and vertigo. They most common symptoms are headaches, nausea, and vomiting secondary to obstructive hydrocephalus. The obstructive hydrocephalus is precipitated by blocking the egress of cerebrospinal fluid (CSF) from the lateral ventricles at the foramen of Monro, which connects the lateral and third ventricles
A third option to treat a colloid cyst is a stereotactic aspiration. Aspiration of a colloid cyst may not be achievable if the contents of the colloid cyst are particularly thick or if there is no safe corridor to the colloid cyst. Stereotactic aspiration of a colloid cyst has less relative surgical risk than an endoscopic or open resection of the colloid cyst but has the highest reoperation rate compared to the other two treatment modalities.
A colloid cyst can be removed with a craniotomy or endoscopically.
Endoscopic excision is a safe and effective, minimally invasive method for colloid cyst removal.
This 30-year-old gentleman had headaches and vomiting. The MRI brain showed a large colloid cyst blocking the foramen of Monroe causing hydrocephalus. The colloid cyst was punctured and then excised completely by endoscopy. The patient had an uneventful recovery.
Microscopic Surgery
3.Endoscopic Temporal Horn Fenestration
This patient had a fall from 20 feet tall chemical tank 10 years ago and had sustained a subdural hematoma, which was operated on. He was asymptomatic for almost 9 years when he started complaining of constant dull headaches at the site of surgery. MRI brain revealed entrapped temporal horn of the lateral ventricle. The CSF pressure of the temporal horn was high. The medial wall of the temporal horn was fenestrated by the endoscope, thereby communicating it with the basal cisterns. He was relieved of the headache completely.