Neurosurgery has advanced in leaps and bounds in recent years and diseases that were considered untreatable a few decades ago are treated routinely with a good outcome. In this ongoing evolution, a new modality Of treatment Of neurosurgical problems is the introduction Or more accurately, re-introduction of the endoscope to treat neurosurgical problems.
What is it?
Neuroendoscopy is an exciting and rapidly evolving branch Of neurosurgery that is opening up new vistas in the treatment of brain disorders. It involves the insertion of an endoscope into the brain through a small opening (about 1.5 cm) made in the skull (burr hole) and performing brain surgery through this opening (minimally-invasive approach)
The first Neuroendoscopy was done in 1 910 for hydrocephalus. It had very sparing use due to technological limitations. Over the years and especially in the last 2 decades, technology has improved tremendously enabling a variety Of brain disorders to be treated endoscopically. The modern endoscope is a rigid rod about 6 mm in diameter and length Of about 10 inches with a series Of lenses that give an excellent image. The light is provided by a Xenon or halogen / LED light source. The Neuroendoscope shown in the picture is a state Of the art instrument that has 4 portals for suction, irrigation, light, and operating instruments.
Where is Neuroendoscopy useful?
Neuroendoscopy is useful in the treatment of the following conditions:-
1.Hydrocephalus: Congenital hydrocephalus (aqueduct- stenosis)
This is the most common and widely-used indication for the endoscope. Normally, the brain secretes a water-like fluid called Cerebrospinal fluid (CSF)which circulates in and around the brain and is then drained out through the blood. Hydrocephalus is a condition of the brain were due to blockage of the normal pathway, CSF accumulates in the spaces called Ventricles, Previously the standard treatment for hydrocephalus was to insert a silicone tube (Ventriculoperitoneal or VP shunt) from the brain to the abdomen to drain the excess fluid in the brain. With the use of the endoscope, the block is bypassed by opening up an alternate pathway for the fluid to drain into a different area Of the brain itself. It eliminates the use of a shunt thereby removing all the problems Of a shunt i.e. blockage and infection which is a patient’s (and surgeon’s) nightmare. It can be done safely in children above the age of 9 months.
2.Hydrocephalus: Congenital hydrocephalus (aqueduct- stenosis)
3.Loculated hydrocephalus: Due to a tumor
4.Other diseases of the brain that can be treated endoscopically are:
- Hematomas or blood clots
- Cysts or fluid collections in the brain.
- Tumors like Colloid Cysts, Pineal region tumors, and Pituitary Adenomas.
- Abscess or pus collections.
Neuroendoscopy is very useful as an adjunct in Micro neurosurgical procedures especially in Cerebral aneurysm surgery to see if the clip is properly applied and avoid clipping small but important blood vessels (perforators) or other vessels situated behind the aneurysm on the far side of the surgeon.
Third Ventriculostomy: How is it done?
Under General anesthesia, a frontal burr hole is done and the dura is opened. The endoscope is inserted into the enlarged ventricle and then depending on the nature Of the lesion the particular specific procedure is done.
The most common procedure done is that of Illrd Ventriculostomy for Obstructive hydrocephalus where the block is bypassed to drain the ventricles.
Similarly, for posterior fossa ischemic strokes, bleeds, or tumors, the need for shunting is also avoided.