Center for Fetal and Placental Research, Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center (CCHMC), Cincinnati, Ohio, USA.
University of Cincinnati, College of Medicine, Cincinnati, Ohio, USA.
Neurosurgery. 2023 Jun 1;92(6):1303-1311. doi: 10.1227/neu.0000000000002361. Epub 2023 Feb 10.
Congenital obstructive hydrocephalus generates progressive irreversible fetal brain damage by ventricular enlargement and incremental brain tissue compression that leads to maldevelopment and poor clinical outcomes. Intrauterine treatments such as ventriculo-amniotic shunting have been unsuccessfully tried in the eighties.
To assess if prenatal endoscopic third ventriculostomy (ETV) is feasible in a large animal model and optimize this technique for ventricular decompression and potential arrest of fetal brain damage in fetal lambs.
We generated hydrocephalus in 50 fetal lambs by injecting a polymeric agent into the cisterna magna at midgestation (E85). Subsequently, 3 weeks later (E105), fetal ETV was performed using a small rigid fetoscope. The endoscopy entry point was located anterior to the coronal suture, 7 mm from the midline.
We obtained clear visualization of the enlarged lateral ventricles by endoscopy in the hydrocephalic fetal lambs. The floor of the third ventricle was bluntly perforated and passed with the scope for a successful ETV. Total success was achieved in 32/50 cases (64%). Causes of failure were blurred vision or third ventricle obliteration by BioGlue in 10/50 (20%) cases, anatomic misdirection of the endoscope in 5 (10%) cases, 2 cases of very narrow foramen of Monro, and 1 case of choroid plexus bleeding. If we exclude the cases artificially blocked by the polymer, we had a successful performance of prenatal-ETV in 80% (32/40) of hydrocephalic fetuses.
Despite the inherent difficulties arising from ovine brain anatomy, this study shows that innovative fetal ETV is technically feasible in hydrocephalic fetal lambs.
先天性梗阻性脑积水通过脑室扩大和逐渐增加的脑组织压迫导致胎儿脑损伤不可逆转，进而导致脑发育不良和临床预后不良。八十年代，人们曾尝试将脑室-羊膜分流术用于宫内治疗，但并未成功。
评估在大型动物模型中是否可行产前内镜第三脑室造瘘术（ETV），并优化该技术以实现脑室减压，并可能阻止胎儿羊水中胎羊的脑损伤。
我们在妊娠中期（E85 时）通过向小脑延髓池注射聚合剂在 50 只胎羊中产生脑积水。随后，在 3 周后（E105），使用小型刚性羊膜镜进行胎儿 ETV。内镜入口位于冠状缝前，中线 7 毫米处。
我们在患有脑积水的胎羊中通过内镜获得了清晰的扩大侧脑室图像。第三脑室底部被钝性穿孔，并通过内镜成功进行 ETV。50 例中有 32 例（64%）完全成功。失败的原因包括 10 例（20%）视野模糊或第三脑室被生物胶阻塞、5 例（10%）内镜解剖方向错误、2 例Monro 孔非常狭窄和 1 例脉络丛出血。如果将被聚合物人为阻塞的病例排除在外，我们在 40 例脑积水胎羊中有 80%（32 例）成功进行了产前 ETV。
尽管羊脑解剖结构固有困难，但本研究表明，创新性的胎儿 ETV 在患有脑积水的胎羊中具有技术可行性。
