Endoscopic endonasal approach for cerebrospinal fluid fistulae

Different techniques have been proposed to repair cerebrospinal fluid rhinorrhea. Advances in nasal surgery led to a high success rate and low morbidity for the endonasal approach. It has become the favorite route for treating cerebrospinal fluid leaks of the anterior skull base. Better results have been obtained with the improvement of rigid endoscopes and intrathecal sodium fluorescein. in a prospective study, twenty-four patients with cerebrospinal fluid rhinorrhea were evaluated and treated by endoscopic endonasal surgery. in all cases intrathecal sodium fluorescein enabled a precise localization of the bone defect. the most common causes of CSF rhinorrhea were traumatic (8 cases, 33%), spontaneous (6 cases, 25%), and iatrogenic (5 cases, 20.8%). Preoperative radiological evaluations (plane CT, CT cisternogram and MRI) showed the exact site and size of the defect in all patients. the most common site of leakage was the ethmoidal roof-cribriform plate. Primary closure was achieved in all patients. There were no major operative or postoperative complications. the endoscopic endonasal approach can be considered the first choice in the treatment of cerebrospinal fluid rhinorrhea.Universidade Federal de São Paulo, Dept Neurosurg, São Paulo, BrazilUniversidade Federal de São Paulo, Dept ENT, São Paulo, BrazilUniversidade Federal de São Paulo, Dept Neurosurg, São Paulo, BrazilUniversidade Federal de São Paulo, Dept ENT, São Paulo, BrazilWeb of Scienc

Neuroendoscopic Training: Presentation of a New Real Simulator

Introduction: There are several models in use in surgical training such as cadaveric, synthetic and animal models as well as virtual reality simulators. Despite having different models for training, unfortunately, financial, technical and operational obstacles more often limit their application in developing countries. the authors have worked out a new synthetic model that could provide a reliable neuroendoscopic training method. the main goal of this study is to introduce the model and discuss relevant data regarding its use.Description of the model: the model is made from a synthetic thermo-retractile and thermo-sensible rubber called Neoderma (R). It can be used for neuroendoscopic, rhinological and endonasal skull base surgical training. Recorded videos showed a great similarity between the model and the human brain. Thirty-seven neurosurgeons were presented to the model. All of them considered it extremely useful. This model does not need any special techniques for maintenance or conservation. After training, it can be easily cleaned and stored. Furthermore, it is atoxic and easy to use.Discussion: A well-designed and realistic training model can help neurosurgeons to improve gradually their skills with no risks. Use of all instruments is strongly recommended. They also hope that, in the future, the model will become a standard simulator able to assist in the training of neurosurgeons.Universidade Federal de São Paulo, Dept Neurol & Neurosurg, Paulista Sch Med, BR-04037001 São Paulo, BrazilUniv Fed Pernambuco, Dept Gynecol, Recife, PE, BrazilUniversidade Federal de São Paulo, Dept Neurol & Neurosurg, Paulista Sch Med, BR-04037001 São Paulo, BrazilWeb of Scienc

Fetal hydrocephalus - prenatal treatment

Patients and methods: From January 1986 to January 2001, 85 cases of hydrocephalus were referred to the Pediatric Neurosurgery and Fetal Medicine Sections of the São Paulo Federal University and the Santa Joana Maternity Hospital in São Paulo, Brazil. Thirty-nine of these cases concerned fetuses ranging from 24 to 32 weeks' gestation, who underwent intrauterine treatment. the hydrocephalus etiologies consisted of: aqueduct stenosis (18 cases), intraventricular hemorrhage (8 cases), Dandy-Walker malformation (4 cases), Chiari type II (4 cases), and other diverse etiologies (5 cases). Twenty fetuses underwent repeated cephalocentesis: 18 received a ventriculo-amniotic shunt and in 1 case endoscopic third ventriculostomy was performed. the follow-up period varied between 1 and 14 years (median 5 years). Out of 39 patients, 26 have been considered as normal (IQ above 70), 6 have mild or moderate handicaps (IQ from 35 to 70), and 7 are severely handicapped (IQ below 35). After birth, 38 patients underwent ventriculoperitoneal shunting with low-pressure valves. Conclusion: in the absence of chromosomopathies, when the gestational age ranges between 24 and 32 weeks, progressive fetal hydrocephalus of a non-infectious origin can obtain benefit from intraventricular decompression performed during the fetal period. New methods of diagnosis and treatment should be developed, especially in those countries where interruption of gestation is not permitted by law, for the benefit of those families who, due to social or religious factors, do not accept abortion.Universidade Federal de São Paulo, Sect Pediat Neurosurg, BR-04023062 São Paulo, BrazilUniversidade Federal de São Paulo, Dept Obstet, BR-04023062 São Paulo, BrazilUniversidade Federal de São Paulo, Sect Pediat Neurosurg, BR-04023062 São Paulo, BrazilUniversidade Federal de São Paulo, Dept Obstet, BR-04023062 São Paulo, BrazilWeb of Scienc

Frameless Image-Guided Neuroendoscopy Training in Real Simulators

Background: Over the last decade, neuroendoscopy has re-emerged as an interesting option in the management of intraventricular lesions in both children and adults. Nonetheless, as it has become more difficult to use cadaveric specimens in training, the development of alternative methods was vital. the aim of this study was to analyze the performance of a real simulator, in association with image-guided navigation, as a teaching tool for the training of intraventricular endoscopic procedures.Methods: 3 real simulators were built using a special type of resin. 1 was designed to represent the abnormally enlarged ventricles, making it possible for a third ventriculostomy to be performed. the remaining 2 were designed to simulate a person's skull and brain bearing intraventricular lesions, which were placed as follows: in the foramen of Monro region, in the frontal and occipital horns of the lateral ventricles and within the third ventricle. in all models, MRI images were obtained for navigation guidance. Within the ventricles, the relevant anatomic structures and the lesions were identified through the endoscope and compared with the position given by the navigation device. the next step consisted of manipulating the lesions, using standard endoscopic techniques.Results: We observed that the models were MRI compatible, easy and safe to handle. They nicely reproduced the intraventricular anatomy and brain consistence, as well as simulated intraventricular lesions. the image-based navigation was efficient in guiding the surgeon through the endoscopic procedure, allowing the selection of the best approach as well as defining the relevant surgical landmarks for each ventricular compartment. Nonetheless, as expected, navigation inaccuracies occurred. After the training sessions the surgeons felt they had gained valued experience by dealing with intraventricular lesions employing endoscopic techniques.Conclusion: the use of real simulators in association with image-guided navigation proved to be an effective tool in training for neuroendoscopy.Universidade Federal de São Paulo, Paulista Sch Med, Dept Neurol & Neurosurg, BR-04037001 São Paulo, BrazilNeurologia Inst Curitiba, Dept Neurosurg, Curitiba, Parana, BrazilUniv Fed Pernambuco, Dept Gynecol, Recife, PE, BrazilUniversidade Federal de São Paulo, Paulista Sch Med, Dept Neurol & Neurosurg, BR-04037001 São Paulo, BrazilWeb of Scienc