Anestesia para Tercerventriculostomía endosópica

7/31/2019 Anestesia para Tercerventriculostoma endospica

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Ori gi nal I nvest i gat i ons

Turkish Neurosurgery 2012, Vol: 22, No: 2, 148-155148

Rcivd: 09.01.2011 /accptd: 30.07.2011

DOI: 10.5137/1019-5149.JTN.4118-11.1

ABSTRACT

AIm: Endoscopic third ventriculostomy (ETV) is currently considered the best alternative to shunt systems in the treatment o triventricularhydrocephalus. However, there has been very ew published data about the anaesthetic management and the complications o ETV procedurein inants. In this report, we detail our experience with 57 inants, who underwent ETV as an initial treatment or obstructive triventricularhydrocephalus between 2003 and 2010.

mAterIAl a methOds: Anesthesia chart-records were retrospectively investigated and perioperative data were classiied according tothe stages o the procedure.

results: In this series, mean heart rate values showed a statistically signiicant dierence in the period concerning the balloon dilatationo ventriculostomy oriice. An episode o bradycardia occurred in 2 patients during balloon dilatation. Ater the defation o the balloon,bradycardia resolved immediately without administration o any medication. Video recordings o those two patients revealed that one o themhad a narrow and opaque tuber cinereum, and the other had a shallow interpeduncular cistern.

COnClusIOn: During ETV procedure in inants, bradycardia may be a serious complication especially when perorming balloon dilatationo the ventriculostomy oriice. We believe that close communication between the surgeon and the anaesthetist is extremely essential in thisstage o the procedure.

KeywOrds: Anesthesia, Bradycardia, Endoscopic third ventriculostomy, Inant

Z

AmA: Endoskopik nc ventriklostomi (ETV) gnmzde triventrikler hidrosealinin tedavisinde ant cerrahisine en iyi alternatitir.Ancak, bu ilemin inant ya grubuna ait serilerdeki anestezi ynnden zelliklerini ve komplikasyonlarn tartan yaynlarn says son dereceazdr. Bu almada, 2003 ila 2010 seneleri arasnda obstrkti triventrikler hidroseali tans ile primer ilem olarak ETV uygulanan 57 inantolgu serisinde bu yndeki deneyimimiz sunulmutur.

yntem v Gereler: Olgu serisinin anestezi kaytlar retrospekti olarak incelenmi ve perioperati veriler cerrahi prosedrn aamalarnagre snfandrlarak deerlendirilmitir.

BulGulAr: Olgu serisinde, ventriklostomi aznn balonla dilatasyonu sahasn ieren cerrahi periyodun kalp atm hz asndan dierperiyodlardan anlaml ark gsterdii grlmtr. Balon dilatasyonu sahasnda 2 olguda bradikardi epizodu gzlenmi olup, bu srelerherhangi bir medikasyon gerektirmeden balonun indirilmesi ile birlikte sonlanmtr. Bu olgulara ait cerrahi video kaytlar gzden geirildiinde;

bir olguda dar ve opak tuber sinereum varl, dierinde ise s interpedinkler sisterna yaps olduu dikkat ekmitir.

sOnu: nantlardaki ETV ileminde, zellikle ventriklostomi aznn balonla geniletilmesi esnasnda bradikardi ciddi bir komplikasyonolarak ortaya kabilir. Prosedrn zellikle bu aamasnda cerrah ve anestezistin dikkatli ve yakn ibirlii ierisinde olmalarnn ok nemliolduuna inanyoruz.

AnAhtAr sZCKler: Anestezi, Bradikardi, Endoskopik nc ventriklostomi, nant

Corrpondnc ddr:Volkn eUs / E-mi: [email protected]

die ozdaMar1, Vn ETus2, sv cEYlaN2, Mine solak1, kmi TokEr1

1Kocaeli University, Faculty of Medicine, Department of Anaesthesiology, Kocaeli, urkey2Kocaeli University, Faculty of Medicine, Department of Neurosurgery, Kocaeli, urkey

anthtic Conidrtion nd PrioprtivFtur of endocopic Tird Vntriculotomy in

Infnt: anlyi of 57 Cnfant Olgularn Endoskopik nc Ventriklostomi leminde Anestezive Perioperatif zellikler: 57 Olguluk Serinin Analizi


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Turkish Neurosurgery 2012, Vol: 22, No: 2, 148-155 149

Ozdamar D. et al:Endoscopic Tird Ventriculostomy and Anaesthetic Considerations

InTRoduCTIon

Endoscopic third ventriculostomy (ETV) is currentlyconsidered the best alternative to cerebrospinal fuid shuntsystems in the treatment o triventricular hydrocephalus.Although dierent opinions exist in the literature about the

eectiveness o ETV in children under 1 year old (2, 7, 19, 23),there seems to be growing evidence that the success o ETVdepends mainly on the etiology o the hydrocephalus and noton the age o the patient alone (3, 6, 8, 16, 20, 22). Becausethe anaesthesia or ETV procedure diers in many ways romconventional neurosurgical operations, anaesthesiologistsare aced with the perioperative requirements and risks o thispopular procedure. Intraoperative hemodynamic changesduring ETV have been extensively studied with confictingresults. In a previous study, tachycardia was ound to be morerequent than bradycardia and was attributed to an increasein intracranial pressure (ICP) and systemic hypertension (25).Obviously increasing ICP indenitely may lead to cardiac

arrest and bradycardia may be one o the rst indicators obending cardiac arrest during ETV. Leach et al. reported aproound bradycardia leading to a short-lived, spontaneouslyresolving episode o asystole in two occasions during ETV(25).

In the literature, there have been ew publications aboutthe anaesthetic management o ETV procedure, analyzingpaediatric and adult patients together and in those reportsthe analyzed data included both paediatric and adult agegroups (5,10). This retrospective study is a unique report othe perioperative anaesthetic management o ETV procedurein paediatric patients younger than 1 year o age. We report

our anaesthetic management experience on 57 inants,who underwent ETV as an initial treatment or triventricularhydrocephalus.

MATeRIAl a MeThodS

The study was approved by the University InstitutionalResearch Board. The anaesthetic charts o the inants (< 12months o age) who underwent ETV as an initial treatmentor triventricular hydrocephalus between February 2003and September 2010 at our University Hospital wereanalyzed retrospectively. The data o 57 inants who metthe ollowing criteria were included in the study: (a) inantswith primary congenital aqueductal stenosis, in whom the

ETV procedure has been perormed as an initial treatmentor hydrocephalus; (b) inants with secondary aqueductalstenosis (due to all space-occupying lesions such as tumorsand cysts in the third and ourth ventricles or within thecerebellum/ posterior ossa) in whom the ETV procedure hasbeen perormed as an initial treatment or hydrocephalus;(c) inants with inection related hydrocephalus inwhom radiological examination showed a triventricularhydrocephalus indicating an obstructive componentsecondary to the history o CSF inection; (d) inants in whomhydrocephalus was accompanied by myelomeningoceleand Chiari type 2 malormation; and (e) inants with post-

hemorrhagic hydrocephalus, who were diagnosed as non-communicating hydrocephalus because during imagingstudies o fow dynamics, the site o obstruction seemed tobe the aqueduct. The data o the endoscopic procedureswith the ollowing criteria were excluded rom the study: (a)

inection related or post-hemorrhagic hydrocephalus withventricular compartmentalization or associate cystic lesions;(b) inants with triventricular hydrocephalus in whom the ETVprocedure has been perormed as an alternative treatmentor the mechanical dysunction o ventriculoperitoneal shunt;(c) inants in whom the ETV procedure has been perormedbeore; (d) cases in which hydrocephalus was accompaniedby congenital cardiovascular pathologies and (e) inants withthe history o serious pulmonary problems.

Age, sex, ASA scores o the patients, premedication, durationo the anaesthesia and surgery, anesthetic drugs used, typeo the irrigation fuid, and perioperative vital parameters othe patients (blood pressure, heart rate, body temperature,

peripheral oxygen saturation and end-tidal CO2) were listed.Per operative and early postoperative complications werealso listed.

In this study design, the video recordings o the 57 inantswere reviewed and technical eatures, complications and theduration o endoscopic procedures were analyzed.

Anaesthetic Management

The same anesthetic method was used or all the patients inthis series. None o the patients received premedication.

All patients were monitored with electrocardiogram (ECG),peripheral oxygen saturation (SPO

2), noninvasive blood

pressure monitor, end-tidal CO2 (ETCO2) and body temperaturevia rectal route (RT) during the procedure. All patientsreceived a 1/3 5% dextrose + 0.09% NaCl inusion beginningrom the commencement o anaesthesia until the end othe surgical procedure. Intraoperative fuid managementwas directed towards to maintain the normovolemic state.Anaesthesia was induced with sevofurane inhalation, i.vbolus remientanyl 0.5 g kg-1 and i.v bolus mivacurium 0.2mg kg-1, and was maintained with 23 % Sevofurane in 50% air in oxygen. All patients were mechanically ventilated atpressure controlled mode with 8 to 10 mL kg-1 tidal volumewith an appropriate rate to maintain the ETCO2 between3035 mmHg. Maintanance o the drug doses, i.v bolus

0.1 mg kg-1 mivacurium, and 0.02 g kg-1 remientanyl wasused. A heating blanket was used to prevent hypothermiaduring surgery. Paracetamol 25 mg kg-1 was given rectally orpostoperative analgesia.

The data collected rom the anaesthetic charts were analyzedat 7 periods: beore induction (period 1), surgical incision(period 2), endoscopic exploration (period 3), peroration othe third ventricle foor (period 4), balloon dilatation (period5), the end o skin closure (period 6), and ater extubation(period 7). HR, SBP, DBP, ETCO2, SPO2 and RT values werelisted according to these periods.


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ETV Surgery

Patients were selected or ETV procedure according tomagnetic resonance imaging ndings that suggestednoncommunicating hydrocephalus with obstruction at orbelow the level o aqueductus Sylvii.

All ETV procedures have been perormed with similartechnique using reehand method by the same neurosurgeon(V.E). A 0 degree rigid rod lens neuroendoscope with anouter diameter o 4.0 mm (Karl Storz GmbH & Co., Tuttlingen,Germany) has been used through a guiding tube. Alloperative procedures have been recorded by video imagingsystem (Karl Storz Telecam, SL). Ideally, the peroration in thefoor o the third ventricle was made in the tuber cinereumbetween the inundibular recess o the pituitary stalk andthe anterior border o the mammillary bodies. This allowsentry into the interpeduncular cistern and avoids injury tothe basilar apex. In our technique o perorming ETV, weusually used the tip o the monopolar coagulating probe or

making a blunt peroration in the foor and preerred not tomake any coagulation unless we encountered a thick foor.The puncture site was dilated by infating a 3-French doubleballoon catheter (Integra Neurosciences Inc., NJ, USA). Anythickened and diuse arachnoidal trabeculations and websin the interpeduncular cistern were eradicated successullywith blunt dissection until ree communication along thebasilar artery was visualized. Lactated Ringers solution at 37C was used or irrigation. Ater the endoscopic procedure,all patients were ollowed in the postoperative care unit untilthey were transported to the ward.

Statistical Analysis

All o the data were expressed as means standarddeviation (SD). Perioperative SBP, DBP, HR, ETCO2, SPO2 andRT values were analyzed using repeated measures ANOVAand Bonerroni tests. P


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When the video recordings o endoscopic procedure o thosetwo patients were reviewed, it was noticed that the rst casehad a narrow and opaque tuber cinereum (Figure 1A), and thesecond one had a very shallow interpeduncular cistern (Figure1B). No surgical complication, i.e. mechanical neural tissueinjury o necessitating vigorous irrigation was encountered inthose two cases.

In our series, 3 cases (5.2%) required ventriculoperitoneal (VP)shunting in the same session or the reason that ETV havenot provided sucient bypass or the cerebrospinal fuiddue to distorted anatomy. Five patients (8.7%) developed

An episode o bradycardia (heart rate < 100 beats per minute)occurred only in 2 o the 57 patients during the dilatationo ventriculostomy orice. HR decreased to 94 beats perminute in the rst case (in the subgroup o inection relatedhydrocephalus) and 89 beats per minute in the second case (in

the subgroup o myelomeningocele related hydrocephalus).In both o the cases, bradycardia lasted or less than 30seconds and resolved immediately ater the defation o theballoon. There was no need or any medication in both cases.The duration o the endoscopic procedure was 41 minutes orthe rst case and was 44 minutes or the second case.

Tab II: The perioperative changes in heart rate (HR) values o the subgroups with dierent etiology o hydrocephalus are shown inseven periods, representing the seven stages o the surgical procedure namely; beore anesthesia induction (Period 1), during surgicalincision and burr hole preparation (Period 2), during endoscopic exploration (Period 3), during peroration o the third ventricle foor(Period 4), during balloon dilatation (Period 5), at the end o skin closure (Period 6), and ater extubation (Period 7). HR is expressed innumber o beats per minute (BPM) and the values shown in the table are expressed as mean standard deviation.

etigy f hyrcpas

Ma hart Rat Vas (BPM) i t Pris f Srgry

Pri 1 Pri 2 Pri 3 Pri 4 Pri 5 Pri 6 Pri 7

Primary aqueductal stenosis 14116 14214 13917 14013 13414 13611 13711

Secondary aqueductal stenosis dueto space-occupying lesions suchas tumors and cysts in the thirdand ourth ventricles or within thecerebellum/ posterior ossa

13615 14013 13815 13912 13516 13713 13610

Myelomeningocele-relatedhydrocephalus

13814 13611 13511 13817 *11713 13012 13410

Inection-related hydrocephalus 13715 13510 1339 13610 *11412 1278 1329

Post-hemorrhagic hydrocephalus 13412 13712 13513 13711 *11514 1259 1319

* p< 0.05

Figr 1: Neuroendoscopic views o the two patients in whom an evident episode o bradycardia was encountered during theballoon dilatation o the ventriculostomy orice. A) Neuroendoscopic view o the third ventricle foor in the rst case. A narrow andnon-transparent tuber cinereum (tc) is seen anterior to the mamillary bodies (stars). B) Neuroendoscopic view through the narrowinterpeduncular cistern o the second case. Note the close proximity o the basilar artery (BA) and clivus (Cl).

A B


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prolonged recovery because o the short duration o thissurgical procedure (11). In our series, we also did not give anypremedication to the cases. We used sevofurane inhalationanaesthesia or the induction o anaesthesia.

The age-specic bolus dose o remientanil has been shown

to acilitate tracheal intubation with or without the use oneuromuscular blocking agents (21). Remientanil, as a shortterm acting opioid, has also gained popularity in pediatriccases recently (4, 9, 27, 28, 29). For this reason we preerredremientanil or the induction o anaesthesia as many authorsdid in the recent years. Remientanil also provides an easytitration o analgesia with haemodynamic stability andprompt recovery allowing early neurological assessmentwhich are the undamental goals o the neuroanaestheticmanagement.

As in the vast majority o intracranial procedures, in ETVprocedure, nitrous oxide (N

20) has also been suggested to

avoid because o the potential possibility o rising intracranialpressure and o the risks or pneumoencephalus andpneumoventricle (4).

Another important issue in ETV procedure is the necessityo adequate muscle relaxation. As a rule, under nocircumstances should the patient move intraoperativelybecause any movement with the endoscope in place couldcause misdirection and serious neurological or neurovasculardamage. In our cases we preerred mivacurium as musclerelaxant and used additional doses when needed.

Concerning the perioperative complications o ETV procedure,bradycardia or other types o cardiovascular responses arerequently discussed in the literature (5, 10, 12, 17, 25, 26, 30).

In their study, Van Aken et al. have shown that tachycardiawas more requent than bradycardia and this was attributedto an increase in intracranial pressure (ICP) and systemichypertension, which has been caused by high-speed fuidirrigation (30).

El-Dawlatly reported an incidence o 41 % bradycardia duringETV, which was attributed to stimulation o the foor o thirdventricle with the tip o the neuroendoscope (15).

Baykan et al, reported bradycardia intraoperatively alonein 28.1% o their cases and the rates or asystole and orbradycardia ollowing tachycardia was repoted as 0.5% and12.4% respectively (5). Derbent et al, encountered bradycardiain only 1 o the 24 patients or a short period during ballooninfation with possible temporary brain stem ischemia andsubsequent bradycardia (10).

In this study, statistically signicant decrease in the meanHR values o the specic case groups (cases with inectionrelated hydrocephalus, post-hemorrhagic hydrocephalusand myelomeningocele related hydrocephalus) uniqueto the balloon dilatation period is noteworthy. However, nosignicant dierence in the mean SBP and DBP values wasound in this period. This result may be interpreted as a mildbradycardia-inducing eect o the balloon infation without

mild venous bleeding during ETV, which was controlled withirrigation in all cases.

All o the inants were extubated at the end o anaeshesia andtranserred to the recovery room and were also transerredto the surgical ward without any early postoperative

complication.

dISCuSSIon

ETV combines a minimally invasive approach with a visualcontrol o manipulations, and is currently considered thebest alternative to cerebrospinal fuid shunt systems in thetreatment o triventricular hydrocephalus. Many authorshave reported that success with ETV in the treatment ohydrocephalus depends largely on appropriate patientselection (16, 18, 19, 22, 23). One o the controversial issueson perorming ETV in the pediatric population is age. Thequestion whether inants and very young children have ahigher risk o treatment ailure ater ETV than older children

is still being debated. In their study Cinalli et al. have shownthat ETV could be successully perormed even in patientsless than 6 months old (8), even though this young age waspreviously considered a contra-indication (25). In their studyGorayeb et al. reported a success rate o 64% in childrenyounger than 1 year o age, who have undergone ETV orobstructive hydrocephalus and they advocated the use oETV, when appropriate, regardless o age younger than 1 year(20). Also, to our experience, the success o ETV is etiologyrelated rather than age-dependent. Our center has publisheda success rate o 56% in patients under 2 years o age. In thisstudy, the analysis o the results in subgroups with dierentetiologies o the hydrocephalus showed that the success rates

o ETV diered remarkably between dierent etiologies ohydrocephalus (16).

Despite the growing evidence that ETV can be successullyperormed in inants, there exist only ew publications aboutthe anaesthetic management and the complications o ETVprocedure in inantile age group (5, 10, 13). Characteristicso neonates and inants are dierent rom older childrenand adult patients. The main dierences are lower bloodpressure, aster heart rate, aster respiratory rate, lower lungcompliance and higher ratio o body surace area to bodyweight. When ETV procedure is perormed in hydrocephalicinants, anaesthesiologists are conronted with additionalperioperative requirements and risks such as limited cardiac

and thermoregulation reserves. In the present study, theeatures and perioperative complications o ETV procedure ininantile age group were discussed by analyzing the data o57 inants.

The main goals o neuroendoscopic anaesthesia are acareul preoperative evaluation and a proper anestheticplan, which allow precise cerebral haemodynamic controland rapid postanaesthetic emergence or early neurologicalassessment.

In his report, El-Dawlatly has suggested that premedicationcan be banned in ETV procedure to avoid oversedation and


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o the procedure. In our routine practice o ETV procedure weseldom use high-speed fuid irrigation and we try to avoid anincrease in intraventricular pressure by admitting ree outfowo the irrigant through the outfow tube. In their report El-Dawlatly et al. described in detail a method or measuring

third ventricle pressure during ETV and they ound a negativecorrelation between third ventricle pressure and heartrate changes during ETV. In the same study they reportedbradycardia in 6 o 14 patients and they have described theirdirect management o intraoperative bradycardia during ETVby withdrawing the scope away rom the foor o the thirdventricle (14). In another study, they reported bradycardia in20 o 49 patients (13).

Aside rom third ventricular pressure or stimulation o thefoor o the third ventricle by the tip o the endoscope, thecomposition o the irrigation fuid is also important duringETV. It has been shown that irrigation o the ventricles withsaline produces a marked hypertension, causing bradycardia

by the pressor refex (30). This could explain why EI-Dawlatlyet al. experienced a relatively high rate o bradycardia intheir series, as they used saline irrigant (13,14). A balancedelectrolyte solution such as Ringer lactate has reported to bea better choice as compared to saline, because it caused onlya mild temporary hypotension (30). We used Lactated Ringerssolution at 37 C or irrigation and a low rate o bradycardia(4.4%) in our series seems to support this data. We dorecommend the use o Lactated Ringers solution as inusatefuid and especially at 37 C to prevent hypothermia in inants.

ConCluSIon

As neurosurgeons continue to gain experience with ETV, the

indications or this procedure are constantly being reviewedand expanded. Since there is growing evidence that ETVcan be successully perormed in inants with triventricularhydrocephalus, the number o centers perorming ETV ininantile age group is increasing. Thus the anaesthesiologistsare being conronted with specic perioperative requirementsand risks in this age group. However, there exist only ewauthentic publications about the anaesthetic managementand the complications o ETV procedure in inantile agegroup. With the increasing interest in ETV, it is important tounderstand the physiological changes that occur during thisprocedure. Especially the autonomic changes are extremelyimportant to the neuroanaesthetist. In this study, we

report our experience on 57 inants. To our experience, theollowing issues should be taken into consideration by theanaesthesiologists who would be involved in conducting ETVprocedure in this age group:

Hydrocephalic inants need special considerationsregarding the head size and anatomical landmarks o theirairways. Especially in cases, in which the hydrocephalusis accompanied with other congenital malormations(neural tube deects, Dandy-Walker malormation)anatomical structure o the airways should be examinedcareully beore the operation.

creating a signicant haemodynamic imbalance in inantsduring ETV. To our experience, tuber cinereum is usuallynon-transparent in post-inective or post-hemorrahgictriventricular hydrocephalus cases and generally it showsresistance to peroration and balloon dilatation. Also the

inants with myelomeningocele related hydrocephalus,requently show anomalies o the third ventricle foor suchas narrow, opaque or parenchymatous tuber cinereum orsmall anterior chamber o the third ventricle as well as ashallow prepontine cistern conguration. We suggest that,in those case groups, it may be easier or the third ventriclefoor and the contents o the interpeduncular cistern toundergo a temporary ischemia due to reduced regionalcerebral perusion or due to direct mechanical pressureduring the balloon dilatation period. Besides this, an evidentepisode o bradycardia was encountered in two inantsduring the balloon dilatation o the ventriculostomy oricein those case subgroups. In both cases bradycardia had

resolved immediately ater defating the balloon withoutadministration o any medication. When ETV video recordingso those two patients were reviewed, we have noticed thatone o them (a case with inection related hydrocephalus) hada quite narrow and opaque tuber cinereum, and the other (acase with myelomeningocele related hydrocephalus) had ashallow interpeduncular cistern.

The central nervous system plays a crucial role inregularization o vasomotor tone and cardiac unction.Medulla oblongata, where the dorsal vagal nucleus andparasympathetic preganglionic neurons are embedded, isinvolved in cardiovascular unction. The unction o the dorsalvagal nucleus may indirectly be infuenced by descending

autonomic pathways that travel through the midbrain andpons or by supranuclear modulation rom hypothalamiccenters (5). We suggest that, especially in cases with a narrowor tough tuber cinereum or a shallow interpeduncular cisternconguration, the third ventricle foor and the contents othe interpeduncular cistern seem to be easily aected duringthe balloon dilatation period and may promote an indirectparasympathetic activity, which results in bradycardia. To ourexperience, the cooperation o the neuroanaesthetist andthe neurosurgeon during this stage o the ETV procedure iso extreme importance. Just beore perorming the balloondilatation, the neurosurgeon should inorm the anaesthetistabout the anatomical eatures o the third ventricle foor

and about the interpeduncular cistern i possible. Also theneuroanaesthetist should warn the surgeon immediately incase o bradycardia or other types o cardiovascular responses.

In ETV procedure, a vigorous irrigation may result in a sharprise in the third ventricular pressure or may cause a localdistortion o the autonomic nuclei o the hypothalamus.Pressure changes at the midbrain and the hypothalamusare believed to produce alterations in autonomic outfow,which consequently may contribute to the developmento haemodynamic changes (2). In our series we did notexperience any haemodynamic complications in those stages


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Anesthesiol 12: 262270, 20003. Balthasar AJ, Kort H, Cornips EM, Beuls EA, Weber JW, Vles

JS: Analysis o the success and ailure o endoscopic thirdventriculostomy in inants less than 1 year o age. Childs NervSyst 23: 151-155, 2007

4. Batra YK, Al Qattan AR, Ali SS, Qureshi MI, Kuriakose D,Migahed A: Assessment o tracheal intubating conditionsin children using remientanil and propool without musclerelaxant. Paediatr Anaesth 14: 452-456, 2004

5. Baykan N, Isbir O, Gercek A, Dagcinar A, Ozek MM: Tenyears o experience with paediatric neuroendoscopic thirdventriculostomy: Features and perioperative complicationso 210 cases. J Neurosurg Anesthesiol 17: 3337, 2005

6. Beems T, Grotenhuis JA: Is the success rate o endoscopic thirdventriculostomy age-dependent? An analysis o the results oendoscopic third ventriculostomy in young children. ChildsNerv Syst 18: 605608, 2002

7. Buxton N, Macarthur D, Mallucci C, Punt J, Vloeberghs M:Neuroendoscopic third ventriculostomy in patients less than1 year old. Pediatr Neurosurg 29: 73-76, 1998

8. Cinalli G, Sainte-Rose C, Chumas P, Zerah M, Brunelle F, LotG, Pierre-Kahn A, Renier D: Failure o third ventriculostomy inthe treatment o aqueductal stenosis in children. J Neurosurg90: 448454, 1999

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14. El-Dawlatly AA, Murshid W, El-Khwsky F: Endoscopicthird ventriculostomy: A study o intracranial pressure vs.haemodynamic changes. Minim Invasive Neurosurg 42:198200, 1999

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Most o these patients have raised ICP, thereore allmeasures that avoid an excessive rise o ICP should beconsidered. Nitrous oxide is preerably avoided becauseo the potential possibility o rising ICP, pneumocephalusand pneumoventricle.

As a general principle, under no circumstances should thepatient move intraoperatively because any movementwith the endoscope in place could cause misdirectionand serious neurological damage. A non-depolarizingand intermediate action type muscle relaxant shouldbe used to acilitate endotracheal intubation and toensure immobilization o the inant intraoperatively.Especially in cases, where the intraventricular anatomicallandmarks are distorted or the foor o the third ventricleis abnormal, the endoscopic procedure may take longertime because o the diculty in gaining orientation oro some minor complications such as venous bleedingor minor parenchymal injury. In post-inective or post-

hemorrhagic triventricular hydrocephalus cases tubercinereum is usually non-transparent and may showresistance to peroration and dilatation. Also, theinterpedincular cistern may oten present multiple andtough arachnoidal webs in these cases, which means thatthe neurosurgeon requires additional time or eradicatingthose membranes successully with blunt dissection untilree communication along the basilar artery is visualized.In such circumstances the duration o the procedure maygo longer, so we strongly suggest a close communicationbetween the neurosurgeon and the anaesthetist or theuse o additional muscle relaxant doses.

We believe that close communication between the

neurosurgeon and the anaesthetist is extremelyessential in certain stages o the ETV, such as perorationand balloon dilatation o the tuber cinereum, whileperorming this procedure in inants. One should alsokeep in mind that, especially the inants with inectionrelated hydrocephalus, post-hemorrhagic hydrocephalusor myelomeningocele related hydrocephalus seem tohave predisposition to show a decrease in heart rateduring the balloon dilatation o the ventriculostomyorice or may even develop bradycardia. We recommendthat anaesthesiologists rigorously monitor cardiovascularchanges and strict vigilance should be maintained orimmediate detection o bradycardia.

Although, using proper anesthetic management andsurgical techniques minimalize the complications andmakes ETV procedure considerably sae in inantile patientpopulation, we advise to perorm these procedures incenters where neonatal and pediatric intensive care unitsare available.


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25. Leach P, Thorne J, Palmer J: Response to: Ten years experiencewith paediatric neuroendoscopic third ventriculostomyeatures and perioperative complications o 210 cases. JNeurosurg Anesthesiol 17:172, 2005

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Anestesia para Tercerventriculostomía endosópica

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