Tag: ventriculocisternostomy

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Pineal cyst surgery beyond morphology: a critical evaluation of a consecutive surgical series

Acta Neurochirurgica (2026) 168:85

This study evaluates surgical management of symptomatic pineal cysts in a consecutive single-center cohort, comparing microsurgical, endoscopic, and stereotactic techniques. Radiological measures — notably aqueduct diameter and predominant cyst expansion — were analyzed alongside clinical outcomes using the Chicago Chiari Outcome Scale, showing durable benefit when surgery is guided by clinicoradiological criteria.

Findings indicate aqueduct narrowing and anterior expansion better predict positive postoperative outcomes than cyst size alone. Each surgical approach demonstrated specific indications: microsurgery for suspicious lesions, endoscopy for hydrocephalus/anterior compression, and stereotactic drainage for deep or high-risk cases, with overall high rates of sustained improvement.

Clinical problem: Surgical management of pineal cysts is especially controversial in non-hydrocephalic symptomatic patients because clinical–radiological correlations are inconsistent and many studies rely mainly on size/morphology for decisions.

Study design: Retrospective single-center cohort of 46 symptomatic pineal cyst patients (2008–2024), comparing surgical (n=18) vs non-surgical (n=28) groups and analyzing radiological markers (e.g., cyst dimensions, aqueduct diameter, predominant expansion) alongside outcomes measured by CCOS over time.

Key differentiators for surgery: Compared with non-surgical patients, surgical patients had larger cysts, narrower aqueducts (0.9 vs 1.6 mm, p<0.001), and much more frequent predominant anterior expansion (67% vs 7%, p<0.001).

Overall outcomes: After surgery, 94% achieved good/excellent CCOS (≥12) at 12 months, and 93% maintained good/excellent outcomes at long-term follow-up (mean 62 months).

Predictors: Aqueduct diameter was more closely associated with outcome than pineal cyst size; neither cyst volume nor hydrocephalus consistently predicted postoperative outcome.

Technique comparison: Microsurgical resection (n=12) had favorable long-term outcomes (mean CCOS 14.9) but the highest complication rate (3 patients) and the highest recurrence of headache despite total excision.

Endoscopic approach: Endoscopic fenestration + ventriculostomy (n=3) produced the best long-term outcomes (mean CCOS 15.7) with no recurrences reported.

Stereotactic option: Stereotactic drainage + Rickham reservoir (n=3) achieved stable decompression but lower long-term CCOS (mean 13.0) than other approaches.

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Hydrocephalus in vein of Galen malformation: etiologies and therapeutic management implications

Hydrocephalus in vein of Galen malformation

Acta Neurochir (2016) 158:1279–1284

Up to now, only little is known about hydrocephalus (HC) in vein of Galen malformation (VGM).We want to present the different etiologies and our long-term experience (1992–2015) in the management of HC.

Methods Out of 44 treated children with VGM, we retrospectively reviewed all cases with HC.We analyzed the etiologies, our treatment results and complications.

Results Twenty-one children (48 %) presented either with HC or developed it over time. In 21% of those cases, high venous pressure was presumably the sole cause. Until 2009, seven of them received ventriculoperitoneal (VP) shunting; six of those resulted in severe postoperative complications. The remaining children have been treated successfully by endovascular embolization. Five out of the 44 children (11 %) developed HC after intraventricular hemorrhage. In four cases, those children were treated with positive results by using transient external ventricular drainages. In one case a VP shunt with highest valve pressure was inserted. Another four children (9 %) presented with aqueductal stenosis-related HC caused by either dilated venous outflow or space-occupying coil masses after embolization. The latter case was successfully treated by ventriculocisternostomy, whereas endovascular treatment decreased the venous outflow in size and thus resolved the HC in the other cases. In the remaining cases (7 %), atrophy due to melting brain syndrome led to HC ex vacuo.

Conclusions HC in VGM is a common phenomenon with several etiologies requiring different treatments. In most cases, embolization of the VGM as sole treatment is completely sufficient in order to decrease high venous pressure. However, certain other causes of HC should be treated in an interdisciplinary setting by specialized neurosurgeons.

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Fenestration of the lamina terminalis during aneurysm surgery

Lamina terminalis fenestration

J Neurosurg 119:629–633, 2013

Fenestration of the lamina terminalis (FLT) during aneurysm surgery for subarachnoid hemorrhage can, in theory, improve CSF circulation from the lateral and third ventricles to the cortical subarachnoid space, which may, in turn, decrease the incidence of hydrocephalus and vasospasm. However, the actual effects of FLT on CSF circulation have been difficult to determine, due to confounding factors. In addition, it is unclear whether the lamina terminalis remains functionally patent when the brain resumes its normal position. The goal of this study was to assess the functional patency of the fenestrated lamina terminalis in patients who underwent surgery for ruptured aneurysms.

Methods. This prospective study included 15 patients who underwent surgical clipping of ruptured anterior circulation aneurysms, with FLT performed during surgery. On postoperative Day 1, the external ventricular drain of each patient was closed, and 1 ml of Omnipaque 300, an iodine-based contrast agent, was injected intraventricularly, accompanied by cranial maneuvering designed to position the contrast agent adjacent to the lamina terminalis. Three to 5 minutes after cranial maneuvering, the flow of contrast agent into the basal cisterns was assessed with CT imaging. Flow was verified by an increase in Hounsfield units in a prespecified “region of interest” within the basal cisterns on the CT scan. This procedure was performed using a standardized protocol designed in consultation with the Department of Radiology and approved by the institutional review board. One patient who underwent endoscopic third ventriculostomy was recruited as a positive control to validate the technique, and 1 patient who underwent aneurysm clipping but not FLT was recruited as a negative control.

Results. Seventeen patients consented to study participation. In the 15 patients who underwent aneurysm clipping and FLT, and the negative control patient who underwent aneurysm clipping but not FLT, the contrast agent followed the normal ventricular pathway from the lateral ventricles into the fourth ventricle, and did not appear in the basal cisterns. In the positive control patient, the contrast agent robustly and immediately filled the basal cisterns.

Conclusions. Fenestration of the lamina terminalis did not result in functional patency of the lamina terminalis when performed as part of surgical clipping for ruptured aneurysms.

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