- Division of Neurosurgery, Beth Israel Deaconess Medical Center, USA
- Department of Neurosurgery, University of Chicago Medical Center, USA
Clark C. Chen
Department of Neurosurgery, University of Chicago Medical Center, USA
DOI:10.4103/2152-7806.82083Copyright: © 2011 Chen CC. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited
How to cite this article: Chen CC, Kasper E, Warnke P. Palliative stereotactic-endoscopic third ventriculostomy for the treatment of obstructive hydrocephalus from cerebral metastasis. Surg Neurol Int 15-Jun-2011;2:76
How to cite this URL: Chen CC, Kasper E, Warnke P. Palliative stereotactic-endoscopic third ventriculostomy for the treatment of obstructive hydrocephalus from cerebral metastasis. Surg Neurol Int 15-Jun-2011;2:76. Available from: http://sni.wpengine.com/surgicalint_articles/palliative-stereotactic-endoscopic-third-ventriculostomy-for-the-treatment-of-obstructive-hydrocephalus-from-cerebral-metastasis/
Background:Endoscopic third ventriculostomy (ETV) is increasingly used in the treatment of obstructive hydrocephalus. The literature supporting its use in the setting of metastatic disease, however, remains limited.
Methods:Between 2005 and 2010, 16 patients underwent ETV for treatment of obstructive hydrocephalus secondary to cerebral metastasis. Efficacy of symptomatic palliation and associated complications were reviewed. The results were compared to reported data for ventriculoperitoneal shunt placement in adult brain tumor patients. Patient selection criteria for ETV are reviewed.
Results:Eleven of the 16 patients experienced symptomatic improvement after ETV (69%). Patients who presented with headache associated with nausea, vomiting, or lethargy were more likely to respond to treatment relative to patients presenting with headache alone. Of the 16 ETV patients, one suffered a wound infection and another underwent external ventricular drainage for assessment of intracranial pressure, yielding an overall complication rate of 12.5%.
Conclusions:In select patients with obstructive hydrocephalus related to cerebral metastasis, ETV constitutes a minimally invasive palliative option. The efficacy of ETV in this population is comparable to those reported for obstructive hydrocephalus secondary to primary cerebral neoplasm or other non-neoplastic causes. Patients receiving chemotherapy close to the time of ETV may be at increased risk for infection.
Keywords: Cerebral metastasis, endoscopic third ventriculostomy, palliation
Cerebral metastases constitute an ongoing therapeutic challenge in neuro-oncology. It is estimated that approximately 20%–40% of patients afflicted with cancer will eventually develop cerebral metastases.[
The prognosis of patients afflicted with cerebral metastases is poor.[
Given the inherent poor prognosis associated with cerebral metastases, management from a surgical perspective requires judicious considerations—factoring the potential benefit, efficacy of competing and less invasive modalities (such as radiosurgery[
For patients with multiple cerebral metastases, poor RPA class, or medical condition prohibitive of general anesthesia, the major goal for surgical intervention is palliation. In this setting, oncologic neurosurgeons are sometimes faced with management of obstructive hydrocephalus secondary to cerebral metastasis. Historically, these patients have been treated with standard ventriculoperitoneal shunting (VPS).[
Patient selection and outcome evaluation. Clinical information was obtained after Institutional Review Board approval. We reviewed the records of surgical cases performed at our institution between the years of 2005 and 2010 and identified 56 third ventriculostomy procedures. The medical records from these patients were reviewed to identify patients that 1) presented with cerebral metastasis and 2) underwent third ventriculostomy for palliation of hydrocephalus related to cerebral metastasis. Sixteen such patients were identified. This constitutes less than 2% of BIDMC patients who underwent surgery for symptoms related to cerebral metastasis during the 5 year period. Prior to surgery, the indications for performing the third ventriculostomy were reviewed by two independent neurosurgeons (CC and PW). Assessment of outcome was determined by review of medical record documenting neurologic and functional status. Success of ETV was defined as partial or complete relief of symptoms. Failure was defined as no change or deterioration in condition. Outcome was assessed in the immediate postoperative period after ETV, and, when possible, at 1-month follow-up. Patients who complained of persistent symptoms at this time were further evaluated by CINE phase contrast magnetic resonance imaging (MRI) for patency of the ventriculostomy site.[
Surgical technique. To be successful, ETV requires an intact CSF resorption capacity. To ensure such capacity, patients with the following history or radiographic findings were excluded in terms of consideration for ETV: previous history of ventricular hemorrhage, hemorrhagic metastasis, meninigitis, leptomeningeal metastasis, and radiographic findings of dilated subarachnoid space.
With one exception, all ETVs were performed under general anesthesia with endotracheal intubation. One procedure was performed under Monitored Anesthesia Care (MAC) because the patient was riddled with extensive pulmonary metastases and was at risk for failure of extubation.[
All third ventriculostomies were performed under image-guidance employing frame-based stereotaxy. After induction of anesthesia, a Riechert/Mundinger stereotactic head frame (Inomed GmbH, Emmendingen, Germany) was secured onto the patient's cranium. A 1.25 mm slice-thickness contrast-enhanced computed tomography (CT) imaging of the head was subsequently acquired using an intraoperative scanner (Ceretom, Neurologica, MA, USA). CT images were processed to yield three-dimensional reconstructions using software by Inomed (STP3, Germany). Using these reconstructions, an optimal trajectory through the Foramen of Monroe, offering an en-face view of the floor of the third ventricle, was planned. The basilar tip was identified, and a target position was selected to avoid contact with the basilar tip. Care was also taken to avoid trajectory intersection with any visualized vessels. The aiming bow was then mounted onto the stereotactic head frame. A burr hole was then placed as the entry point based on the planned trajectory. A 4.0 mm introducer sheath was inserted along the trajectory into the lateral ventricle under guidance of the rigid frame. Entry into the lateral ventricle was verified by the withdrawal of CSF. An oval Oi HandyPro endoscope (4.0 × 2.6 mm, Storz, Tuttlingen, Germany) equipped with three channels for instrument, suction, and irrigation was then advanced into the lateral ventricle with stereotactic guidance. Under direct vision, the neuroendoscope was then further advanced into the third ventricle. A disconnected monopolar electrode was used to perforate the thinnest portion of the floor of the third ventricle, just anterior to the two mammillary bodies. The perforation was enlarged using a Fogarty No. 4 balloon catheter inflated to a diameter of approximately 5 mm. Pertinent illustrations of surgical techniques are as shown in
(a) Intraoperative head computed tomography for stereotactic planning of endoscopic third ventriculostomy (ETV) trajectory. (b) ETV performed under stereotactic guidance using the Riechert/Mundinger frame. (c) Stereotactic trajectory with en-face view of the floor of the third ventricle. (d) Completion of ETV
In one patient, ETV was done prior to an endoscopic pineal biopsy of a lung metastasis. Two distinct trajectories were used to perform the ETV and the endoscopic biopsy.
Patient population. Between 2005 and 2010, we treated 16 patients with palliative ETV for symptomatic obstructive hydrocephalus secondary to cerebral metastases. Patient characteristics are as shown in
Indications and outcomes. All 16 patients complained of either isolated headache or headache with various other symptoms, including, nausea, vomiting, and lethargy. All patients had imaging workup demonstrating obstruction of CSF flow tract by cerebral metastases, ventriculomegaly, and no evidence of leptomeningeal disease. Symptomatic improvement was observed after palliative ETV in 11 of 16 patients (69%). A breakdown of the specific symptoms is as shown in
Overall, patients who presented with headache associated with nausea, vomiting, or lethargy were more likely to benefit from ETV. Seven of eight such patients experienced relief of symptoms after ETV (87.5%). Four of the eight patients with headache without such associated symptoms experienced resolution of symptoms after ETV (50%). The difference between these groups was significant by Student's t test (P = 0.037). The likelihood of symptomatic improvement did not correlate to the ventricular size. We also attempted to correlate the likelihood of symptomatic improvement to the opening pressure observed during surgery. However, the opening pressure was not consistently reported in the operative note. Thus, there was insufficient data point for this analysis.
Complications. Of the patients whose symptoms did not improve after ETV, CINE phase contrast MRI was performed to assess patency of the ventriculostomy site.[
We recognized the possibility that a subset of patients may benefit from VPS despite a patent ventriculostomy if it was insufficient to restore normal CSF dynamics.[
One patient of this series suffered an infection of the incision site requiring debridement. Of note, this patient was likely immune-compromised from chemotherapeutic agents administered approximately 1 week prior to surgery. While the white blood count (WBC) was acceptable at the time of ETV (9.1 × 109 cells/L), the count dropped precipitously to the range of 2–3 × 109 cells/L approximately 3 days after the procedure, and the patient presented with a wound infection 1 week after the procedure.
The inherent prognosis of most patients afflicted with cerebral metastasis is poor and mostly unaffected by excision. Thus, the risk of surgical intervention needs to be carefully weighed against the potential harm.[
Along the line of comfort and palliation, it seems reasonable to raise the question of whether any surgical intervention is warranted in this population—particularly in light of the observation that a quarter of our patient population failed to survive a month after ETV. We believe that surgical intervention can be justified on two fronts. First, based on our clinical experience, headache related to hydrocephalus is severe, incapacitating, and extremely resistant to medical management. If symptomatic relief and improved quality of life is achievable with a minimally invasive surgery, we believe this to be justified—even if it is for a brief period. Second, while there are long-term survivors of cerebral metastasis, it is currently impossible to accurately identify them given the current prognostic tools. Treatment of hydrocephalus in the acute setting may thus yield meaningful survival gain for some patients.
In terms of surgical intervention, VPS is the most commonly used modality for the treatment of obstructive hydrocephalus secondary to cerebral metastases in poor surgical candidates. Overall, VPS is a good option for this indication. Modern series of palliative VPS for elevated ICP in the adult metastatic population yield a complication rate of 10%–30%. Approximately 70%–80% of the patients demonstrated symptomatic improvement postprocedure.[
The clinical efficacy of palliative ETV in our experience compares favorably to those reported for VPS. Overall, 69% of the patients experienced symptom relief after the procedure (compared to approximately 70% for palliative VPS). Therapeutic success seemed less likely for patients who presented with isolated headache or headache associated with neurologic deficits relative to those that presented headache without nausea and vomiting. The complication rate of ETV in our series (13%) is also comparable to those reported for VPS (10%). In our opinion, the major advantages of ETV over VPS for palliation in the metastatic population are fourfold: (1) the procedure obviated the risk and discomfort associated with subcutaneous tunneling and surgical manipulation of the abdomen; (2) palliative ETV can be performed under MAC in patients with tenuous pulmonary function.[
In addition to VPS and ETV, another palliative option in the treatment of obstructive hydrocephalus involves the insertion of an Ommaya reservoir followed by serial CSF removal. This last approach is limited by the risk of infection from repeatedly accessing the reservoir. Furthermore, discharge from hospital is difficult since nonphysicians are typically unfamiliar with the appropriate technique for Ommaya reservoir access. Finally, the amount of CSF and the periodicity of CSF removal through the Ommaya is unlikely physiologic. As such, the palliative effect will be limited. For these reasons, we do not favor Ommaya reservoir placement unless the patient is not a candidate for ETV or VPS.
It is important to note that the patients included in this ETV series were highly selected. All patients reported here exhibit anatomy amenable to ETV (classic triventricular hydrocephalus with sufficient dilatation of the third ventricle for surgical access). Patients with history of ventricular hemorrhage, hemorrhagic metastasis, meningitis, and leptomeningeal metastasis were excluded for consideration of ETV because of concern for decreased CSF resorption capacity.[
Another major limitation of this study involves the small sample size and mixed patient population. Because of our stringent selection criteria, utilization of ETV constituted <2% of our metastatic patients who underwent surgical treatment during the five-year period. Realizing the small sample size, we nevertheless performed an analysis in hopes of assessing efficacy and safety of this practice in the metastatic population.
In our case series, all ETV were performed under stereotactic guidance. In doing so, we believe that we maximize the precision of our trajectory to the third ventricle and minimize manipulation of the cerebral parenchyma. Planning the trajectory to avoid contact of existing venous and arterial structures (including the basilar tip) also minimizes the risk of vascular injury.
The literature for ETV in metastatic patients is extremely limited. While studies of ETV have been reported for primary brain tumors[
A review of the one case of wound infection raises an issue pertinent to patients afflicted with metastatic disease. Many of these patients may suffer cerebral metastases and related hydrocephalus while receiving chemotherapy that compromises the immune system.[
Since proof-of-principle series by Nguyen et al.,[
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