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Neuroendoscopy: Challenges in a developing country and future perspectives. A single centre experience in Angola

Sérgio Neto

Neurosurgery Service, Neuroscience Department, Girassol Clinic, Luanda-Angola

E-mail : bhuvaneswari.bibleraaj@uhsm.nhs.uk

Ernesto Piedade

Neurosurgery Service, Neuroscience Department, Girassol Clinic, Luanda-Angola

Albano Eugénio

Intensive care unit, Medical Department, Girassol Clinic, Luanda-Angola

António Miguel

Intensive care unit, Medical Department, Girassol Clinic, Luanda-Angola

Nilton Rosa

Surgical Oncology Service, Surgical Department, Angolan Institute for Cancer Care, Luanda-Angola

DOI: 10.15761/NNS.1000135

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Abstract

Background: Neuroendoscopy is considered a renewed tool brought to the neurosurgical practice armamentarium after a first failed phase in 1910. Technology advances and contributions from many authors enabled and established it as a feasible technique. In many African countries due to lack of logistics and trained neurosurgeons in MIS or Neuroendoscopy, result in many neurological diseases (such as hydrocephalus; stroke or ventricular tumors), going by untreated or treated using classic techniques with well-known complications.

Nowadays neuroendoscopy is currently used for all types of neurosurgically treatable diseases such as intracranial cysts, intraventricular tumors, hypothalamic hamartoma (HH), cerebellar haemorrhagic stroke (CHS), intraventricular hemorrhage (IVH), skull base tumors, craniosynostosis, degenerative spine disease, and rare subtypes of hydrocephalus. Authors share their experience in a private centre as the first and main reference in the country for neuroendoscopy techniques and multiple applications in many neurological diseases.

Methods: A case series of 50 patients submitted to neuroendoscopic procedures, performed by the author from April 2017 to October 2019. Authors assessed and discuss patient´s baseline, group of procedures, length of stay and prognosis at 30 days and 90 days after the intervention.

Results: Of the 51 cranial neuroendoscopic interventions (corresponds to 15% of the overall cases operated at our service) during the study period. Major challenges experienced were patient dependent in 30 ± 3.0 patients (95% CL), learning curve related in 15 ± 1 patients, and poor endoscopy support infrastructure in 15 ± 0.5 patients. The permanent morbidity and mortality rates in our series were 3% and 7,8%, respectively.

Conclusion: Neuroendoscopy is currently a well-established tool with extensive data support and applications when compared with classic techniques. Authors recommend extensive training for local neurosurgeons and logistic acquisition for national health system hospitals allowing more exposure for local neurosurgeons to the technique, wide coverage of patients and more data gathering for future publications.

Keywords

neuroendoscopy, endoscopic surgery, haemorrhagic stroke, intraventricular hemorrhage, hydrocephalus, brain tumour

Abbreviations

CHS: Cerebellar Haemorrhagic Stroke; IVH: Intraventricular Hemorrhage; ETV: Endoscopic Third Ventriculostomy; HH: Hypothalamic Hamartoma; MIS: Minimal Invasive Surgery

Introduction

Neuroendoscopy field began with great promise when first announced. However, the technology available to the pioneers of the technique was far too primitive for these purposes and it stumbled upon limitations like: poor illumination, inadequate magnification and instruments [1-3].

Two other factors were involved in the technique´s decline:

The advent of ventriculoperitoneal shunts

Ventricular shunt placement marked the beginning of the “era of ventricular CSF shunting” and the end of the initial era of neuroendoscopy. Nulsen and Spitz in 1952 detailed the procedure and was a landmark for the treatment of hydrocephalus, reinforced in the years to come by other authors and substantial data would confirm low mortality rates and high success rates, superior to other available treatments at the time [4,5].

Microsurgery

The birth of microneurosurgery in the 1960s pushed neuroendoscopy further into the background due to microscope characteristics that addressed all of the deficiencies of the neuroendoscope (adequate illumination and magnification). The microneurosurgery era was clearly felt as reports of neuroendoscopic procedures in the literature became sparse [6,7].

In Africa there is low or no availability of neuroendoscopy in some regions and it´s no novelty that the continent is severely deprived of neurosurgical care. According to WFNS, the continent accounts for 15% of the global volume of neurosurgical disease, African hospitals and health care networks have access to <1% of the neurosurgeon community. Even in the more privileged north and south (Egypt South and Africa who concentrates the majority of neurosurgeons in the continent), there is uneven delivery of care in urban areas [8,9]. In Angola only one private centre has routinely practice in neuroendoscopy techniques. The rationale behind the technique´s preference are minimal damage to normal structures, carries a lower rate of complications, and achieves excellent outcomes for patient and hospital indicators [3,4].

We discuss historical aspects of neuroendoscopy and present, future perspectives and brief case series of our private center´s experience with the technique.

Methods

From April 2017 to October 2019, retrospective analysis of prospectively acquired cases submitted to neuroendoscopic procedures performed by the author. Clinical data, as well as cranial computed tomography and magnetic resonance imaging reports, operation notes as well as follow-up records, were obtained and analysed.

During the surgical procedure, author performed neuroendoscopic techniques (transnasal, transcortical), some assisted by tubular retractor (VBAS by Vycor Medical).

Inclusion criteria

All patients who had cranial endoscopic intervention in our unit within the study period were enrolled into the study.

Patients where possible or their first-degree relatives were interviewed at presentation. All endoscopy procedures were performed with a 0-degree rigid Karl Storz endoscope. Challenges experienced during the course of patient care, complications and clinical outcomes were recorded. The mean follow-up period was 6 months ± 4 (95% CL), range 6 months to 1 year. For patients with hydrocephalus, shunt independence was the primary outcome measure, and this was assessed using appropriate clinical status parameters such as occipitofrontal circumference (OFC). For patients with intracranial cysts, the outcome was assessed using symptom profile and supportive neuroradiological features only. A positive response was defined as shunt independence or improvement in clinical status and neuro-radiological parameter(s) as outlined above. Data acquisition and analysis were performed using Epi info (CDC, USA). Tests of statistical significance were set at 95% level.

Authors assessed and discuss patient´s group of procedures (Table 1), length of stay and prognosis at 30 days and 90 days after the intervention.

Table 1. Types of neuroendoscopic procedures from April 2017 to October 2019

Name of procedure

No. of patients

Endoscopic third ventriculostomy

2

Intraventricular hemorrhage with hydrocephalus

11

Intraparenchymal hemorrhage

33

Colloid cyst

2

Pituitary adenoma

3

Total

51

Results

Of the 51 cranial neuroendoscopic interventions (corresponds to 15% of the overall cases operated at our service) during the study period. Patients were between the ages of 1 year and 75 years with a mean of 5.7 ± 1.5 years (95% confidence interval (CI)). Haemorrhagic stroke for endoscopic intervention in 44 (86.2%) patients. Endoscopic assisted haematoma drainage was the most performed neuroendoscopic procedure. Major challenges experienced were patient dependent in 30 ± 3.0 patients (95% CL), learning curve related in 15 ± 1 patients, and poor endoscopy support infrastructure in 15 ± 0.5 patients. Complications were significantly more common in the first 30 days of neuroendoscopy (χ2= 8.26, df = 1, P > 0.05). Overall, n=30 (59%) patients in our study experienced a positive outcome. The permanent morbidity and mortality rates in our series were 3% and 7,8%, respectively.

Discussion

The first neurosurgical endoscopic procedure was performed by L’Espinasse in 1910, he reported the use of a cystoscope to perform fulguration of the choroid plexus in two infants with hydrocephalus [1,11].

Nowadays neuroendoscopy is currently used for all types of neurosurgically treatable diseases such as intracranial cysts, intraventricular tumors, hypothalamic hamartoma (HH), skull base tumors, haemorrhagic stroke, craniosynostosis, degenerative spine disease, and rare subtypes of hydrocephalus [11,13,14].

We reported an initial experience with neuroendoscopy in our country, presenting our current experience and highlights of the challenges experienced in performing transcranial endoscopic surgery in our centre that currently is the only hospital in our country offering a diverse neuroendoscopy service although centres from other regions have previously reported their experiences.

Among the classic indications for neuroendoscopy (aqueductal stenosis, arachnoid cyst, colloid cysts); our centre had more exposure to other pathologies like haemorrhagic stroke with success outcomes similar to other series [14,15].

What´s next for neuroendoscopy? The once abandoned technique has in this century and due to technologic evolution a bright light to shine and become a main workhorse for neurosurgeons, having among many other goals: telemanipulated neurosurgery with supervisory-controlled robotic systems, shared control systems, and even fully robotic telesurgery. Nanotechnology developments are needed to address future indications for minimally or even ultramicro-access neurosurgery [4]. In the future, one can expect routine use of the endoscope for management of a multitude of neurosurgically treatable pathological conditions, either as the primary surgical approach or as an adjunct [4,11,14].

Conclusion

Endoscopic surgery performed has proven to be a very effective technique with many approach/corridors applied to a wide range of diseases exclusively or as assisted technique with less complications when compared with classic techniques. Although neuroendoscopy techniques are associated with improved results in many neurosurgical diseases, there are have limitations, such as: training and skills improvement , high learning curve, Proper case selection of comparatively simple procedures in the beginning, a multidisciplinary team approach [11,12].

Authors conclude that neuroendoscopy has a wide range of applications, many of them suitable for countries with low income like ours, lowering the dependence of hardware like shunts; alteplase for diseases like hydrocephalus and stroke.

Limitations

Small pool of patients and personal experience of a single surgeon, which may create some personal bias.

References

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  5. Nulsen FE, Spitz EB (1951) Treatment of hydrocephalus by direct shunt from ventricle to jugular vein. Surg Forum 2: 399–403. [Crossref]
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  8. Jacobson JH II, Wallman LJ, Schumacher GA, Flanagan M, Suarez EL, et al. (1962) Microsurgery as an aid to middle cerebral artery endarterectomy. J Neurosurg 19: 108-15. [Crossref]
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  11. Yadav YR, Jitin Bajaj, Vijay Parihar, Shailendra Ratre, Anurag Pateriya (2018) Practical Aspects of Neuroendoscopic Techniques and Complication Avoidance: A Systematic Review. Turk Neurosurg 28: 329-340. [Crossref]
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  14. Scaggiante J, Zhang X, Mocco J, Kellner CP (2018) Minimally Invasive Surgery Meta-Analysis for ICH. Stroke 49: 2612-2620. [Crossref]
  15. Hanley DF, Thompson RE, Muschelli J, Rosenblum M, McBee N, et al. (2016) Safety and efficacy of minimally invasive surgery plus alteplase in intracerebral haemorrhage evacuation (MISTIE): a randomised, controlled, open-label, phase 2 trial. Lancet Neurol 15: 1228–1237.

Editorial Information

Editor-in-Chief

Shangming Zhang
Penn State Hershey Medical Center, USA

Article Type

Research Article

Publication history

Received: August 17, 2020
Accepted: August 31, 2020
Published: September 04, 2020

Copyright

©2020 Neto S. 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.

Citation

Neto S, Piedade E, Eugénio A, Miguel A, Rosa N (2020) Neuroendoscopy: Challenges in a developing country and future perspectives. A single centre experience in Angola. Neuro Neurosurg 4: DOI: 10.15761/NNS.1000135.

Corresponding author

Sérgio Neto

Neuroscience Department, Neurosurgery Service, Girassol Clinic, Luanda-Angola

E-mail : bhuvaneswari.bibleraaj@uhsm.nhs.uk

Table 1. Types of neuroendoscopic procedures from April 2017 to October 2019

Name of procedure

No. of patients

Endoscopic third ventriculostomy

2

Intraventricular hemorrhage with hydrocephalus

11

Intraparenchymal hemorrhage

33

Colloid cyst

2

Pituitary adenoma

3

Total

51