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.

External view of cyst Inner view of cyst

Placement of Catheter Reservoir

Video

https://www.youtube.com/watch?v=DnBTEjO_RNs

Case 1

Case 2

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