Transcortical Transventricular Endoscopic Approach and Ommaya Reservoir Placement for Cystic Craniopharyngioma Dhaval Shukla Department of Neurosurgery, NIMHANS, Bangalore, India.
Transcortical Transventricular Endoscopic Approach and
Ommaya Reservoir Placement for Cystic Craniopharyngioma
Dhaval ShuklaDepartment of Neurosurgery, NIMHANS, Bangalore, India.
Cystic Craniopharyngiomas
• Cyst accounts for major tumor bulk • Complete resection of cystic craniopharyngiomas is
desirable • Hindered by functional preservation
• Regrow after partial resection or cyst puncture• Ommaya reservoir for repeated aspiration
• Reservoir is generally placed after partial surgical resection, or stereotactically
• Malposition of reservoir is not uncommon• A simple technique of endoscopic approach and
reservoir placement for cystic craniopharyngiomasMori RJ, et al. J Neurol Surg A. 2014.
Pettorini BL, et al. J Neurosurg Pediatr. 2009.
Video
https://www.youtube.com/watch?v=DnBTEjO_RNs
Data
• Five Cases – 3 children• Presented with raised ICP, no endocrinopathy• Purely or predominantly cystic tumors• Post op RT• F/u – 12 -17 months • No recurrence• No reaspiration• No dislodgement of catheter• No adverse effect related to procedure
Treatment Paradigm
• Traditional algorithms (gross total resection vs. subtotal resection +/- radiation therapy) are often not employed• Alternative algorithms including intracystic therapies,
progression-contingent RT, and SRS
• Survey of members of AANS • 36% recommended observation or RT for in absence of
diagnosis
• This change in treatment paradigm calls for minimally invasive technique for treatment • Innovative treatment strategies are warranted to
improve QoL
Hankinson TC, et al. Pediatr Neurosurg. 2013.Muller HL. Horm Res. 2008.
Why Reservoir?
• Our previous series • 52.5% partial excision• Complication rate 19.1%• GTR - 29.2% • PR - 10.4% • Pediatric 35.7% • Adult 4.3%
• PR preferred but recurrence is high• Repeated aspiration • Injection of chemotherapeutic agents
Patel A. NIMHANS 2005.
Why Endoscopy?
• Improper placement of the catheter with other techniques• 7% to 16%
• Endoscopy results in accurate catheter placement• Biopsy under direct vision can be done• Hydrocephalus can be take care of• Not associated with any morbidity
• Early RT after surgery can be given
• Another procedure may not be required• 73% did not require reaspiration
Mori RJ, et al. J Neurol Surg A. 2014.Moussa AH, et al. Br J Neurosurg. 2013
Limitations
• Large defect in cyst wall can predispose to leakage if intracystic therapies are employed• 16.3% children had misplacement or leakage of the
catheter (not endoscopic)
• Can be difficult in case of multiloculated cystic • Possible to fenestrate multiple loculation, and convert
all of them into a single cyst
• Excision cannot be done• Not a goal of this procedure
Zanon N, et al. Surg Neurol. 2008.Pettorini BL, J Neurosurg Pediatr. 2009.
Conclusion
Transcortical transventricular endoscopic approach and
Ommaya reservoir placement for cystic craniopharyngioma
is a minimally invasive, safe, accurate, and effective method.
Shukla D. Transcortical Transventricular Endoscopic Approach and Ommaya
Reservoir Placement for Cystic Craniopharyngioma.
Pediatric Neurosurgery 2015. DOI: 10.1159/000433605