Endoscopic third ventriculostomy versus ventriculoperitoneal shunt in pediatric patients: a decision analysis

Endoscopic third ventriculocisternostomy in hydrocephalic children under 2 years of age: appropriate or not? A single-center retrospective cohort study

PURPOSE

Treating hydrocephalus can be difficult in children under the age of 2 years because a high amount of uncertainty exists as to which treatment to perform. In this retrospective cohort study, we analyzed children under the age of 2 years with hydrocephalus undergoing an endoscopic third ventriculocisternostomy (ETV) with respect to ETV outcome.

METHODS

In 59 consecutive patients under the age of 2 years, an ETV was performed between 1999 and 2010 at the Erasmus MC, Sophia Children's Hospital. Demographics, etiology of hydrocephalus, and radiological data were extracted retrospectively from the patients' medical records and operative reports and related to outcome. ETV Success Score (ETVSS) was used to retrospectively calculate the probability of success related to the actual outcome.

RESULTS

In this series, 42.4 % of patients had a successful ETV. The only statistically significant finding concerned age. The failed ETV patients appeared to be younger (0.52 ± 0.60 vs. 0.86 ± 0.56 year, p = 0.005), and when using a cutoff age of 6 months only, five out of 32 infants had a successful ETV (p = 0.002). Of the children with an arachnoid cyst, 57.1 % were treated successfully with an ETV. Of the five patients with a high probability of ETV success, four (80 %) were indeed successfully treated with ETV (p = 0.049).

CONCLUSIONS

Our data confirm the overall ineffectiveness of an ETV in children under the age of 6 months. Nevertheless, using the ETVSS is recommended to aid in the decision-making process even in patients under the age of 6 months.

Time to First Shunt Failure in Pediatric Patients over 1 Year Old: A 10-Year Retrospective Study

Studies comparing alternatives to ventriculoperitoneal (VP) shunting for treatment of hydrocephalus have often relied upon data from an earlier era that may not be representative of contemporary shunt survival outcomes. We sought to determine the shunt survival rate of our cohort and compare our results to previously published shunt survival and endoscopic third ventriculostomy (ETV) success rates. We identified 95 patients between 1 and 18 years of age, who underwent initial VP shunt placement between January 2001 and December 2010. Our study shows a shunt survival rate of 85% at 6 months and 79% at 2 years, for initial shunts in pediatric patients over 1 year of age in this cohort. The overall infection rate was 3%. This compares favorably with published success rates of ETV at similar time points as well as with the rate of infection. This suggests that ventricular shunting remains a viable alternative to ETV in the older child.

Ventriculoperitoneal shunting versus endoscopic third ventriculostomy in the treatment of patients with hydrocephalus related to metastasis

Background:

Between 2005 and 2010, we treated patients with hydrocephalus related to cerebral metastases, who were not good candidates for surgical resection by either endoscopic third ventriculostomy (ETV) or ventriculoperitoneal shunting (VPS). Patients were excluded from ETV if they had a clinical history suggestive of non-obstructive hydrocephalus, including: (1) history of infection or ventricular hemorrhage and (2) leptomeningeal carcinomatosis. The rest of the patients were treated with VPS.

Methods:

We analyzed the clinical outcome of these patient cohorts, to determine whether the efficacy of VPS was compromised due to a history of infection, ventricular hemorrhage, or leptomeningeal carcinomatosis, and compared these results to those patients who underwent ETV.

Results:

Sixteen patients were treated with ETV and 36 patients were treated with VPS. The overall efficacy of symptomatic palliation was comparable in the ETV and VPS patients (ETV = 69%, VPS = 75%). In both groups, patients with more severe hydrocephalic symptoms such as nausea, vomiting, and lethargy were more likely to benefit from the procedure. The overall complication rate for the two groups was comparable (ETV = 12.6%, VPS = 19.4%), although the spectrum of complications differed. The overall survival, initial Karnofsky performance status (KPS), and three-month KPS, were similarly comparable (median survival: ETV 3 months, VPS 5.5 months; initial KPS: ETV = 66 ± 7, VPS = 69 ± 12; 3 months KPS: ETV = 86 ± 7, KPS = 84 ± 12).

Conclusion:

VPS remains a reasonable option for poor RPA grade metastasis patients with hydrocephalus, even in the setting of a previous infection, hemorrhage, or in those with leptomeningeal disease. Optimal treatment of this population will involve the judicious consideration of the relative merits of VPS and ETV.

Endoscopic Third Ventriculostomy Success Score (ETVSS) predicting success in a series of 50 pediatric patients. Are the outcomes of our patients predictable?

PURPOSE

In our series of endoscopic third ventriculostomy (ETV), we sought to establish the relationship between the preoperative prediction using the Endoscopic Third Ventriculostomy Success Score (ETVSS) and the postsurgical success rate.

MATERIALS AND METHODS

This descriptive analytical study comprised 50 pediatric patients who underwent 58 ETV procedures between 2003 and 2011. Data regarding clinical, surgical, and radiological findings were obtained from a continuously updated database. For each patient, we calculated the ETVSS, based on the patient's age, hydrocephalus etiology, and presence of a previous shunt. We considered success to be an established or improved clinical state and at least one of the following radiological criteria: (a) reduction in ventricular size or stable ventricles with disappearance of periventricular edema and increased subarachnoid space over cerebral convexities, (b) flow artifact in sagittal T2FSE MR, or (c) bidirectional flow signal in 2D-CPC MR. Statistical significance was set at p < 0.05. Six months was the minimum postoperative follow-up required.

RESULTS

The ETV was successful in 29 patients (58 %). Patients aged over 1 year achieved the best results (p < 0.019). For those who underwent successful ETV, the mean ETVSS was 71.03 (95 % CI, 66.23-75.84). In those for whom the ETV was not successful, the mean ETVSS was 60 (95 % CI, 53.09-66.90); (p < 0.007).

CONCLUSIONS

The success of ETV in our series could have been predicted by ETVSS. Predictability could help establish stricter surgical selection criteria, thereby obtaining higher success rates, as well as preparing the patients and their families for expected outcomes.

Ventriculoperitoneal shunt surgery outcome in adult transition patients with pediatric-onset hydrocephalus

BACKGROUND

Ventriculoperitoneal shunting remains the most widely used neurosurgical procedure for the management of hydrocephalus, albeit with many complications.

OBJECTIVE

To review and assess the long-term clinical outcome of ventriculoperitoneal shunt surgery in adult transition patients with pediatric-onset hydrocephalus.

METHODS

Patients 17 years or older who underwent ventriculoperitoneal shunt placement for hydrocephalus during their pediatric years (younger than 17 years) were included. Medical charts, operative reports, imaging studies, and clinical follow- up evaluations were reviewed and analyzed retrospectively.

RESULTS

A total of 105 adult patients with pediatric-onset hydrocephalus were included. The median age of the patients was 25.9 years. The median age at the time of the initial ventriculoperitoneal shunt placement was 1.0 year. The median follow-up time for all patients was 17.7 years. The incidence of shunt failure at 6 months was 15.2%, and the overall incidence of shunt failure was 82.9%. Single shunt revision occurred in 26.7% of the patients, and 56.2% had multiple shunt revisions. The cause of hydrocephalus was significantly associated with shunt survival for patients who had shunt failure before the age of 17 years. Being pediatric at first shunt revision, infection, proximal shunt complication, and other causes were independently associated with multiple shunt failures.

CONCLUSION

The findings of this retrospective study show that the long-term ventriculoperitoneal shunt survival remains low in adult transition patients with pediatric-onset hydrocephalus.

Aqueductal developmental venous anomaly as an unusual cause of congenital hydrocephalus: a case report and review of the literature

Introduction

Aqueductal stenosis may be caused by a number of etiologies including congenital stenosis, tumor, inflammation, and, very rarely, vascular malformation. However, aqueductal stenosis caused by a developmental venous anomaly presenting as congenital hydrocephalus is even more rare, and, to the best of our knowledge, has not yet been reported in the literature. In this study, we review the literature and report the first case of congenital hydrocephalus associated with aqueductal stenosis from a developmental venous anomaly.

Case presentation

The patient is a three-day-old, African-American baby girl with a prenatal diagnosis of hydrocephalus. She presented with a full fontanelle, splayed sutures, and macrocephaly. Postnatal magnetic resonance imaging showed triventricular hydrocephalus, suggesting aqueductal stenosis. Examination of the T1-weighted sagittal magnetic resonance imaging enhanced with gadolinium revealed a developmental venous anomaly passing through the orifice of the aqueduct. We treated the patient with a ventriculoperitoneal shunt.

Conclusions

Ten cases of aqueductal stenosis due to venous lesions have been reported and, although these venous angiomas and developmental venous anomalies are usually considered congenital lesions, all 10 cases became symptomatic as older children and adults. Our case is the first in which aqueductal stenosis caused by a developmental venous anomaly presents as congenital hydrocephalus. We hope adding to the literature will improve understanding of this very uncommon cause of hydrocephalus and, therefore, will aid in treatment.

Complications of endoscopic third ventriculostomy: a systematic review

INTRODUCTION

Endoscopic third ventriculostomy (ETV) is an established treatment for hydrocephalus. Most studies focus on success rates, and complications are insufficiently charted. The aim of this study was to perform a systematic review of ETV complications.

METHODS

A Medline search discovered 24 series of ETV (seven in children, five in adults, and 12 in a mixed-age group) with detailed complications reports.

RESULTS

The analysis included 2,672 ETVs performed on 2,617 patients. The cause of hydrocephalus was aqueductal stenosis in 25.9%, tumor 37.0%, meningomyelocele-Chiari II 6.1%, posthemorrhagic 5.8%, postinfectious 1.4%, cysts 3.3%, Chiari I 0.4%, Dandy-Walker malformation 0.3%, cerebellar infarct 0.9%, normal pressure hydrocephalus 1.3%, and not recorded 16.8%. Overall complication rate was 8.8%. Permanent morbidity was 2.1%, neurologic in 1.2% (hemiparesis, gaze palsy, memory disorders, and/or altered consciousness), hypothalamic in 0.9% (diabetes insipidus, weight gain, or precocious puberty). Intraoperative hemorrhage was present in 3.9%, severe in 0.6% (including four cases [0.14%] of basilar rupture). Other surgical complications were 1.13% (three thalamic infarcts, six subdural, six intracerebral, and two epidural hematomas). Cerebrospinal fluid (CSF) infections occurred in 1.8%, CSF leak in 1.7%, anesthetic complications (bradycardia and hypotension) in 0.19% of cases. Postoperative mortality was 0.22% (six patients; sepsis two, hemorrhage three, and thalamic injury one). Another two children suffered delayed "sudden death" (after 25 and 60 months), caused by acute hydrocephalus due to stoma occlusion. There were no differences between pediatric and adult patients or short and long series (cutoff 100 patients). All deaths were reported in long series. Complication rates were insignificantly higher in short series.

CONCLUSIONS

Permanent morbidity after ETV is 2.1%, mortality is 0.22%. The incidence of delayed "sudden death" is 0.07%.

Evaluating the Children's Hospital of Alabama endoscopic third ventriculostomy experience using the Endoscopic Third Ventriculostomy Success Score: an external validation study

OBJECT

Endoscopic third ventriculostomy (ETV) success is dependent on patient characteristics including age, origin of hydrocephalus, and history of shunt therapy. Using these factors, an Endoscopic Third Ventriculostomy Success Score (ETVSS) model was constructed to predict success of therapy. This study reports a single-institution experience with ETV and explores the ETVSS model validity.

METHODS

A retrospective chart review identified 151 consecutive patients who underwent ETV at a pediatric hospital between August 1995 and December 2009. Of these 151, 136 patients had at least 6 months of clinical follow-up. Data concerning patient characteristics, operative characteristics, radiological findings, complications, and success of ETV were collected. The actual success rates were compared with those predicted by the ETVSS model.

RESULTS

The actual success rate of ETV at 6 months was 68.4% (93 of 136 patients), which compared well to the predicted ETVSS of 76.5% ± 12.5% (± SD). The C-statistic was 0.74 (95% CI 0.65-0.83), suggesting that the ability of the ETVSS to discriminate failures from successes was good. Secondary ETV was found to have a hazard ratio for failure of 4.2 (95% CI 2.4-7.2) compared with primary ETV (p < 0.001). The complication rate was 9.3% with no deaths. At the first radiological follow-up, the increased size of ventricles had a hazard ratio for failure of 3.0 (95% CI 1.5-6.0) compared with patients in whom ventricle size either remained stable or decreased (p = 0.002).

CONCLUSIONS

The ETVSS closely predicts the actual success of ETV, fitting the statistical model well. Shortcomings of the model were identified in overestimating success in patients with ETVSS ≤ 70, which may be attributable to the poor success of secondary ETVs in the authors' patient population.

Fetal ventriculomegaly: postnatal management

INTRODUCTION

It is the current status of fetal ventriculomegaly that although the technology for diagnosis is advanced, it does not have significant impact on the management outcome. Fetal ventriculomegaly is mainly treated after birth.

METHODS

We reviewed the literature and suggested policies of postnatal evaluation and surgical management of fetal hydrocephalus. Our experience of 44 cases of fetal ventriculomegaly diagnosed by fetal ultrasonography, in which major poor prognostic factors were absent and for which prenatal pediatric neurosurgical consultation was sought, was also presented.

RESULTS

Our experience showed etiologic heterogeneity of fetal ventriculomegaly although our cases seemed to be surgical candidates more likely than whole group of fetal ventriculomegaly. There were limitations in prenatal evaluation of fetal hydrocephalus. The first step for postnatal management is etiologic classification. It should be clarified after birth whether there is remarkable disturbance of cerebrospinal fluid dynamics or not. The rate of postnatal progression of ventricular dilatation is also important for the decision of treatment plan. For surgical treatment in very young children, special considerations should be paid on technical feasibility, rate of postoperative infection or malfunction, prevention of rapidly developing nervous system from the possible damage, and great plasticity of young brain.

CONCLUSION

Indication, methods, and timing of surgical treatment must be individually tailored according to the etiology, degree and rate of progression of ventriculomegaly, and patient's age when surgical treatment is considered.

Single burr hole endoscopic biopsy with third ventriculostomy-measurements and computer-assisted planning

OBJECTIVE

In cases of non-communicating hydrocephalus, a combined endoscopic third ventriculostomy (ETV) and tumor biopsy might be necessary. We suggest a computer-assisted planning procedure to perform ETV and biopsy via a single burr hole.

METHODS

In 15 patients with non-communicating hydrocephalus with a mass obstructing the Sylvian aqueduct, an ETV in parallel to targeting the lesion was planned to be performed via a single burr hole. Prior to surgery, a 3D MRI data set was planned to be acquired for computer-assisted planning. The lesion target points were located in the third ventricle or in the lateral ventricle. By defining the optimal entry point as single burr hole, the trajectory was calculated to cause the least amount of tissue shift at the foramen of Monro (FM) or within the hemispheric tissue. The burr hole localization was measured relative to nasion and to midline. The diagnostic yield and the success rate of ETV were evaluated.

RESULTS

The optimal entry point for third ventricular lesions was 111 ± 17 mm to the nasion and 16 ± 11 mm to the midline. Tissue shift at the level of FM was 2.4 ± 4 mm. For targeting the floor of the third ventricle in parallel to lesions of the lateral ventricle, the entry point was at 122 ± 11 mm to the nasion and 17 ± 9 mm to the midline. Rate of diagnostic yield was 86.7%. Success rate of ETV at follow-up of 34 ± 19 months was 86.7%.

CONCLUSIONS

Performing ETV in parallel to target paraventricular lesions causing a hydrocephalus is feasible via a single burr hole by using computer-assisted planning and performing a navigated endoscopic procedure.

Complications of endoscopic third ventriculostomy

OBJECT

Endoscopic third ventriculostomy (ETV) is an established treatment for hydrocephalus. Most studies focus on success rate, and complications are insufficiently documented. The aim of this study was to perform a systematic review of ETV complications.

METHODS

A Medline search discovered 34 series of ETV with detailed complications reports (17 series involving exclusively pediatric patient populations, 6 series involving exclusively adults, and 11 series involving mixed adult and pediatric populations).

RESULTS

The analysis included 2985 ETVs performed in 2884 patients. The cause of hydrocephalus was aqueductal stenosis in 29.3% of patients, tumor in 37.6%, meningomyelocele in 7.6%, cysts in 2.6%, cerebellar infarct in 0.9%, Dandy-Walker malformation in 0.6%, and Chiari malformation Type I in 0.4%; 7.4% of the patients had posthemorrhagic hydrocephalus, 1.8% had postinfectious hydrocephalus, and 1.2% had normal pressure hydrocephalus. Hydrocephalus was due to other causes in 1.3% of cases and the cause was not reported in 9.8%. The overall complication rate was 8.5%. The rate of permanent morbidity was 2.38%; the rate of permanent neurological complications was 1.44% (hemiparesis, gaze palsy, memory disorders, altered consciousness), and the rate of permanent hormonal morbidity was 0.94% (diabetes insipidus, weight gain, precocious puberty). The rate of intraoperative hemorrhage rate was 3.7%; the rate of severe intraoperative hemorrhage was 0.6% (including a 0.21% rate of basilar rupture). The rate for intraoperative neural injury (thalamic, forniceal, hypothalamic, and midbrain injuries) was 0.24%. Central nervous system infections occurred in 1.81% of cases, CSF leak in 1.61%, and postoperative intracranial hematomas in 0.81% of cases. The early postoperative mortality rate was 0.21% (6 patients died; 2 of sepsis and 4 of hemorrhage). Another 2 children suffered delayed "sudden death" (one after 25 months and the other after 60 months), caused by acute hydrocephalus due to stoma occlusion. There were no significant differences between series involving pediatric or adult patient populations or series with fewer than 100 or more than 100 patients. All reported deaths were in series involving more than 100 patients.

CONCLUSIONS

Endoscopic third ventriculostomy can be regarded as a low-complication procedure, with an overall complication rate of 8.5%, permanent morbidity rate of 2.4%, mortality rate of 0.21%, and delayed "sudden death" rate of 0.07%.

Minimally invasive neurosurgery for cerebrospinal fluid disorders

This article focuses on minimally invasive approaches used to address disorders of cerebrospinal fluid (CSF) circulation. The author covers the primary CSF disorders that are amenable to minimally invasive treatment, including aqueductal stenosis, fourth ventricular outlet obstruction (including Chiari malformation), isolated lateral ventricle, isolated fourth ventricle, multiloculated hydrocephalus, arachnoid cysts, and tumors that block CSF flow. General approaches to evaluating disorders of CSF circulation, including detailed imaging studies, are discussed. Approaches to minimally invasive management of such disorders are described in general, and for each specific entity. For each procedure, indications, surgical technique, and known outcomes are detailed. Specific complications as well as strategies for their avoidance and management are addressed. Lastly, future directions and the need for structured outcome studies are discussed.

Kulkarni AV, Drake JM, Kestle JR, Mallucci CL, Sgouros S, Constantini S. Endoscopic Third Ventriculostomy Vs Cerebrospinal Fluid Shunt in the Treatment of Hydrocephalus in Children

BACKGROUND

Endoscopic third ventriculostomy (ETV) has preferentially been offered to patients with more favorable prognostic features compared with shunt.

OBJECTIVE

To use advanced statistical methods to adjust for treatment selection bias to determine whether ETV survival is superior to shunt survival once the bias of patient-related prognostic factors is removed.

METHODS

An international cohort of children (≤ 19 years of age) with newly diagnosed hydrocephalus treated with ETV (n = 489) or shunt (n = 720) was analyzed. We used propensity score adjustment techniques to account for 2 important patient prognostic factors: age and cause of hydrocephalus. Cox regression survival analysis was performed to compare time-to-treatment failure in an unadjusted model and 3 propensity score—adjusted models, each of which would adjust for the imbalance in prognostic factors.

RESULTS

In the unadjusted Cox model, the ETV failure rate was lower than the shunt failure rate from the immediate postoperative phase and became even more favorable with longer duration from surgery. Once patient prognostic factors were corrected for in the 3 adjusted models, however, the early failure rate for ETV was higher than that for shunt. It was only after about 3 months after surgery did the ETV failure rate become lower than the shunt failure rate.

CONCLUSIONS

The relative risk of ETV failure is initially higher than that for shunt, but after about 3 months, the relative risk becomes progressively lower for ETV. Therefore, after the early high-risk period of ETV failure, a patient could experience a long-term treatment survival advantage compared with shunt. It might take several years, however, to realize this benefit.

Quality of life after endoscopic third ventriculostomy and cerebrospinal fluid shunting: an adjusted multivariable analysis in a large cohort

OBJECT

Quality of life (QOL) studies comparing treatment with endoscopic third ventriculostomy (ETV) and CSF shunting are very limited. The authors compared QOL outcomes following these 2 treatments in a large cohort of children with hydrocephalus by using multivariable statistical techniques to adjust for possible confounder variables.

METHODS

The families of children between 5 and 18 years of age with previously treated hydrocephalus at 3 Canadian pediatric neurosurgery centers completed measures of QOL: the Hydrocephalus Outcome Questionnaire (HOQ) and the Health Utilities Index Mark 3 (HUI3). Medical records and recent brain imaging studies were reviewed. A linear regression analysis was performed with the QOL measures as the dependent variable. In multivariable analyses, the authors assessed the independent effect of initial hydrocephalus treatment (ETV vs shunting) while adjusting for the treatment center, current patient age, age at initial treatment, etiology of hydrocephalus, total number of days spent in the hospital for initial treatment, total number of days spent in the hospital for subsequent hydrocephalus complications, functioning ETV at follow-up assessment, frequency of seizures, and current ventricle size.

RESULTS

Data from 603 patients were available for analysis. Fifty-eight patients had undergone ETV as their primary treatment and 545 had undergone CSF shunting. Endoscopic third ventriculostomy patients were slightly younger at the follow-up assessment, were older at the first surgery, and spent fewer days in the hospital for hydrocephalus complications. Without adjustment for any confounders, treatment with ETV was associated with significantly higher HOQ physical scores and HUI3 scores. After multivariable adjustment, however, there was no significant difference in any outcome measure. A functioning ETV at the time of the follow-up assessment was not significant in any model.

CONCLUSIONS

Treatment with either ETV or CSF shunting does not appear to be associated with any substantial difference in QOL outcome after adjusting for prognostic factors. Further study is needed to definitively determine the relative QOL benefit of either procedure, if any.

Intracranial hypertension caused by a depressed skull fracture resulting in superior sagittal sinus thrombosis in a pediatric patient: treatment with ventriculoperitoneal shunt insertion

OBJECT

Intracranial hypertension resulting from compression of the superior sagittal sinus (SSS) by an overlying depressed calvarial fracture is a rare condition. Primary surgical treatment for the symptomatic patient in this setting traditionally involves elevation of the fracture, which often carries significant associated morbidity.

METHODS

The authors report a case involving a 6-year-old boy who suffered a closed, depressed, parietooccipital fracture as the result of an unhelmeted all-terrain vehicle accident. This fracture caused compression and subsequent thrombosis of the SSS, which resulted in CSF malabsorption and progressive intracranial hypertension. Initially headache free following the injury, he had developed severe and unremitting headaches by postinjury Day 7. A CT angiography study of the head obtained at this time exhibited thrombosis of the SSS underlying the depressed calvarial fracture. Subsequent lumbar puncture demonstrated markedly elevated intrathecal pressures. Large volumes of CSF were removed, with temporary improvement in symptoms. After medical management with anticoagulation failed, the decision was made to proceed with image-guided ventriculoperitoneal shunt insertion.

RESULTS

The patient's headaches resolved immediately following the procedure, and anticoagulation therapy was reinstituted. Follow-up images obtained 4 months after the injury demonstrated evidence of resolution of the depressed fracture, with recanalization of the SSS. The anticoagulation therapy was then discontinued. To the authors' knowledge, this report is the first description of ventriculoperitoneal shunt insertion as the primary treatment of this infrequent condition.

CONCLUSIONS

This report demonstrates that select patients with this presentation can undergo CSF diversion in lieu of elevation of the depressed skull fracture-a surgical procedure shown to be associated with increased risks when the depressed fracture overlies the posterior SSS. The literature on this topic is reviewed and management of this condition is discussed.

Quality of life in childhood hydrocephalus: a review

PURPOSE

Those with hydrocephalus view quality of life (QOL) as the most important of outcomes. The literature on QOL in hydrocephalus is growing, and we now recognize several of the factors that potentially influence outcome in these children. Neurosurgeons should be aware of the latest findings and how to critically analyze the QOL literature.

METHODS

This paper will attempt to review some general scientific concepts about QOL that neurosurgeons can apply to all patients. As well, we will describe, in some detail, what we currently understand about QOL issues in childhood hydrocephalus specifically, and where future research might take us.

CONCLUSIONS

Quality-of-life assessment is becoming important in advancing our scientific understanding of hydrocephalus.

Prospective surveillance of complications in a pediatric neurosurgery unit

OBJECT

Complications of specific pediatric neurosurgical procedures are well recognized. However, focused surveillance on a specific neurosurgical unit, for all procedures, may lead to better understanding of the most important complications, and allow targeted strategies for quality improvement.

METHODS

The authors prospectively recorded the morbidity and mortality events at a large pediatric neurosurgical unit over a 2-year period. Morbidity was defined as any significant adverse outcome or death (for obstructive shunt failure, within 30 days). Multiple and unrelated complications in the same patient were recorded as separate events.

RESULTS

There were 1082 surgical procedures performed during the evaluation period. One hundred seventy-seven complications (16.4%) occurred in 147 patients. By procedure, the most common complications occurred in vascular surgery (41.7%) and brain tumor surgery (27.9%). The most common complications were CSF leakage (31 cases), a new neurological deficit (27 cases), early shunt or endoscopic third ventriculostomy obstruction (27 cases), and shunt infection (24 cases). Meningitis occurred in 19 cases: in 58% of shunt infections, 13% of CSF leaks, and 10% of wound infections. Sixty-four percent of adverse events required a second procedure, most commonly an external ventricular drain placement or shunt revision.

CONCLUSIONS

Complications in pediatric neurosurgical procedures are common, result in significant morbidity, and more than half the time require a repeat surgical procedure. Targeted strategies to prevent common complications, such as shunt infections or CSF leaks, might significantly reduce this burden.

Quality of life in obstructive hydrocephalus: endoscopic third ventriculostomy compared to cerebrospinal fluid shunt

PURPOSE

In the current literature, there are essentially no comparisons of quality of life (QOL) outcome after endoscopic third ventriculostomy (ETV) and shunt in childhood hydrocephalus. Our objective was to compare QOL in children with obstructive hydrocephalus, treated with either ETV or shunt.

METHODS

A cross-sectional survey was conducted at SickKids, Toronto of children between ages five and 18 years, with obstructive hydrocephalus due to aqueductal obstruction and no other brain abnormalities. Measures of QOL were the Hydrocephalus Outcome Questionnaire and the Health Utilities Index Mark 3. A subset of patients was given the Wechsler Intelligence Scales for Children (WISC-IV).

RESULTS

A total of 47 of 59 (80%) eligible patients participated (24 had ETV as primary treatment, 23 had shunt as primary treatment), with a mean age of 12.1 years (standard deviation 3.9) at assessment. The ETV group was older at initial surgery (p < 0.001) and had larger ventricle size at last follow-up (p = 0.047). In all QOL measures, there were no significant differences between the ETV group and shunt group (all p > or = 0.09). Treatment failure, hydrocephalus complications, and the presence of a functioning ETV at assessment were not associated with QOL differences. Among the 11 children (six ETV, five shunt) who were given the WISC-IV, there were no significant differences between the scores of the ETV group and shunt group (all p > or = 0.11).

CONCLUSIONS

This is the first study to provide a meaningful comparison of QOL after ETV and shunt in children. These preliminary results suggest that there is no obvious difference in QOL after ETV and shunt.