- Surgery is seldom needed in children with NCC: It should be considered in cases of intraventricular cysts, hydrocephalus, and also extra- or intramedullary spinal cord cysticercosis (57).
- Standard positioning for craniotomy: No special consideration is necessary in regard to classical neurosurgical techniques.
- Head fixation with pins: Rigid fixation is not always required.
- Ventricular endoscopy: Free intraventricular cysts are best removed endoscopically. But even if the cyst ruptures during the procedure, there is no associated ventriculitis. Occasionally ependymitis occurs with multiple intraventricular loculations and endoscopy may allow communication between various cavities (i.e. fenestrations of the septum pellucidum) to allow the placement of a single ventricular shunt). Endoscopic third ventriculostomy can be performed when there is a noninflammatory cerebrospinal fluid blockage at the level of the aqueduct or fourth ventricle. (20,35,58)
Endoscopic removal of third ventricular cysticercosis cyst. This video shows a cysticercosis cyst within the third ventricle and the removal of its capsule after it was drained. The video goes on to show the creation of a third ventriculostomy.
- Endoscopic third ventriculostomy: Ideal for obstructive hydrocephalus restricted to the sylvian aqueduct but has no value if inflammation of the basal cisterns is detected (35).
- When decompression needed: An open craniotomy may be required in the case of space-occupying lesions not suitable to endoscopic removal.
Removal of IVth ventricular cysticercosis cyst. Seen is exposed posterior fossa and upper spinal canal and the extraction of a cysticercosis cyst laying wihtin the IVth ventricle.
- Other surgical indications: A craniotomy may also be needed to treat large parenchymal colloidal cysts, subarachnoid racemose cysts causing mass effect and atypical single cyst granulomas requiring biopsy. Surgery might even be indicated for intractable epilepsy (1,2,5).
- Laminotomy or laminectomy: Although some patients may be best treated with antiparasitic drugs, surgical treatment is indicated in cases of spinal cord or radicular compression by free or intramedullary cysts (1).
Intradural extramedullary spinal cysticercosis. Cysts are seen around the spinal cord (arrow)
- Ventriculoperitoneal shunt: The treatment of choice for patients with inflammatory obstruction of the ventricular system is shunting. Shunt revision rate is extremely high, with revisions being required in more than half of the patients, mainly during the first postoperative year (5).
- Standard closure: In the usual fashion without any special consideration.