Ventriculoscopy

The brain is the most complex organ in the human body. It consists of more than a trillion cells that differ in structure and function, but at the same time are a single whole. The brain regulates the activity of all systems and organs, as well as hearing, vision, speech, attention, memory and all those moments that we include in the concept of the human soul. Therefore, methods for diagnosing pathologies of the central nervous system should always be as safe and informative as possible.

Ventriculoscopy or cerebral endoscopy is a minimally invasive neurosurgical procedure for examining the lateral and third ventricles of the brain, an intraventricular endoscopy using a ventriculoscope that provides access to the deepest parts of the brain and is used for both diagnostic and therapeutic purposes. This method is used in neurosurgery and neurology to examine the cerebrospinal fluid system, treat hydrocephalus and other pathologies.

In recent decades, the endoscope has become increasingly important in the development of neurosurgery. In pediatrics in particular, intraventricular endoscopy has become a routine part of neurosurgical practice and training. Improving image quality, device ergonomics, neuronavigation, and many other technical factors have contributed to an ever-expanding range of indications for endoscopic treatment of intraventricular pathology.

Based on the success of the treatment of hydrocephalus, many countries have increased the use of endoscopic treatment of this disease. In hydrocephalus of non-tumor origin, ventriculoscopy allows, as a rule, to determine the origin of dropsy and its nature. The diagnosis of a brain tumor of intraventricular or paraventricular localization, as well as a tumor growing into the lumen of the cerebral ventricle, is made on the basis of direct and indirect signs detected during a visual examination. The histological nature of the process can be determined by biopsy of the pathological tissue collected during ventriculoscopy.

The consequence of all innovations is the expansion of neurosurgeon’s knowledge in the use of the endoscope and the increase in the level of complexity and accuracy of technologies for more complex interventions, in particular resection of intraventricular tumors. However, there are several important factors that must be considered for successful intraventricular neuroendoscopy.

What is needed for the procedure

Today, modern ventriculoscopes minimally injure tissues and quickly diagnose pathological areas.

This requires the presence of:

• ventriculoscope – an optical device with two channels: working and irrigation-aspiration for removing cerebrospinal fluid in excess, washing the cavities of the ventricles;
• a camera with digital recording and a light source at the end of the tube;
• additional tools, such as: an electrocoagulator for a possible stop of bleeding and a soft tissue incision; nippers and forceps to obtain biopsy material.

The endoscope itself is of two types: rigid (fibroventriculoscope) or flexible (rigid).

Indications for ventriculoscopy

Ventriculoscopy or endoscopy of the brain can be both diagnostic and therapeutic. As a method of treatment, it is used to stop bleeding, to remove tumors and cysts, to coagulate pathological vessels or dissect adhesions. This type of diagnosis and treatment should be carried out in the presence of conditions that are accompanied by hydrocephalus of the brain, namely:

• severe traumatic brain injury with increased intracranial pressure;
• hemorrhage in the ventricles of the brain;
• the presence of cysts and tumors;
• occlusive dropsy of the brain (when there is a narrowing of the holes and there is a violation of the outflow of cerebrospinal fluid);
• congenital malformations of the cerebrospinal fluid system;
• with an inflammatory complication in the membrane that lines the ventricles of the brain and the spinal canal inside, the so-called ventriculitis.

Contraindications for ventriculoscopy

For successful manipulation, prevention of the development of serious consequences, and given the fact that brain structures are highly vulnerable to changes in conditions, one should not forget about the following contraindications:

1. Coagulopathy is a bleeding disorder. There is a high risk of bleeding that is difficult to stop by conventional means.
2. The patient has meningoencephalitis and purulent meningitis. It is forbidden to conduct ventriculoscopy, since the purulent process can spread to uninfected areas of the brain.
3. The presence of concomitant severe somatic conditions not associated with brain pathologies. For example, liver or kidney failure, severely weakened immunity, and many others.
4. A present allergic reaction to drugs that anesthesiologists use to perform general anesthesia.
5. Lack of necessary expensive equipment and trained neurosurgeons in the hospital.

Therapeutic endoscopy of the brain

The brain contains cavities called ventricles. They produce a clear, watery cerebrospinal fluid that surrounds both the brain and spinal cord. It performs many important functions:

• cushions, protecting the brain from injury;
• supplies nutrients;
• removes waste products from tissues;
• regulates pressure in the brain.

Fluid normally circulates through the ventricular systems, then reabsorbed back into the bloodstream. Sometimes the passage of cerebrospinal fluid is blocked due to a tumor or cyst, head injury, birth defect, or infection. When this happens, CSF builds up inside the ventricles and puts pressure on nearby brain tissue. This condition is known as obstructive hydrocephalus.

The pressure of excess cerebrospinal fluid on the brain can be very dangerous, so surgery is usually required either to remove the obstruction or to divert the flow of this fluid into another passage. For many years, the best way to redirect CSF was to insert a shunt, a permanent plastic tube system to drain CSF to another part of the body. Recently, neurosurgeons have developed a new method that does not require the insertion of a permanent shunt. Instead, tiny surgical instruments called endoscopes are used to view the ventricles and create a new hole in the membrane that will allow the cerebrospinal fluid to circulate again. This modern procedure is called ventriculoscopy.

How does a ventriculoscope work?

New technologies have made the diagnostic procedure much more informative, as endoscopic equipment and modern imaging techniques such as MRI (magnetic resonance imaging) have allowed surgeons to view the structure of the brain before and during the procedure.

The endoscope is a metal probe of small diameter (4-6 mm) 18 cm long with a tiny telescopic camera and a light source at its end. It is inserted into the ventricle through a small incision in the skin and wide tendon (aponeurosis) 2 cm long in the scalp and a small opening in the skull. This allows the surgeon to view the channels through which the CSF circulates, and the reasons that prevent this.

The surgeon then creates a hole in the membrane at the bottom of the ventricle and enlarges it using a catheter (small tube) with an inflatable balloon. This is a bypass for the cerebrospinal fluid so that it can bypass obstructions and be reabsorbed into the rest of the brain. The patient at this time is in a supine horizontal position with a slightly raised head end under general anesthesia.

The main feature of the study is the ability to conduct a biopsy of a tumor and other suspicious formation for diagnosis, minor surgical operations, for example, the complete removal of the same tumor. The place of insertion of the endoscope depends on the presumptive or previously identified localizations of pathological processes.

If the pathology is in the upper parts of the brain, then the probe is inserted through a small hole in the skull bone. When the disorders are located in the lower sections, then access to the central nervous system is through the nasal passage. When the procedure is over, the neurosurgeon sutures the dura mater and skin, applies an aseptic dressing.

Advantages, risks and disadvantages of this manipulation

Ventriculoscopy has many advantages. It is a minimally invasive procedure with success rates of 50% to 80% in adults and children over the age of two. It is also possible for children up to two years of age. If the fontanel is not yet closed, then the manipulation is carried out through it, but before ventriculoscopy, an ultrasound examination of the brain (neurosonography) is mandatory. With this method of treatment and diagnosis, complications are less common.

Ventriculoscopy has a large number of advantages over other methods of research and treatment.

The most important of them:

1. Carrying out not only the diagnosis of possible pathologies, but also the ability to immediately treat them.
2. Hospitalization of the patient in the shortest possible time, which contributes to rapid rehabilitation and recovery.
3. A relatively minimal level of trauma to the human body, a slight effect on the soft tissues of the brain.
4. Rare complications after such a procedure, often local bleeding from the suture area.

However, there are some drawbacks that must be taken into account when performing ventriculoscopy: an incomplete overview of their actions, since the neurosurgeon cannot get direct access to the operating site, but can only see it on screens. To carry out this type of diagnosis or treatment, expensive equipment and trained specialists are required.

Possible complications of the procedure include general weakness, fever, intracranial hemorrhage or intraventricular bleeding, temporary short-term memory loss, or hormonal dysfunction. Ventriculoscopy is not usually recommended for children under two years of age due to a higher failure rate.

Sometimes the first hole in the membrane closes over time and the procedure has to be repeated, and a shunt may need to be implanted. The procedure is also more complex than traditional bypass surgery.

What you need to know before having a ventriculoscopy

Before the operation, a complete medical examination is carried out, an anamnesis of life and disease is taken, blood tests, an ECG are performed, and an anesthesiologist is consulted. It is not allowed to eat or drink anything after midnight on the eve of the operation. The hair should be washed with a special antibacterial soap and a small amount of hair may need to be shaved in the area where the access will be made.

The manipulation itself takes about two hours, and the patient is under general anesthesia. Therefore, the patient should spend at least a day under the supervision of medical personnel in the hospital. If you follow the recommendations of your doctor, this will help to significantly reduce the negative consequences and complications and increase the effectiveness of this study.

Subsequently, a slight headache may occur. If at the incision site there are redness, pain, swelling, or subfebrile temperature is observed during the first 6 months after the operation, excessive drowsiness and irritability, nausea and vomiting, recurrent headaches, loss of appetite, blurred vision, impaired coordination, then you must definitely contact doctor for advice to avoid possible complications.

Ventriculoscopy has many advantages for the patient, but do not forget that it is, first of all, an operative intervention. The appointment and conduct of this manipulation should be carried out by an experienced neurosurgeon and according to his clear indications.