A retrospective analysis of revision endoscopic third ventriculostomy

Repeat endoscopic third ventriculostomy combined with choroid plexus cauterization as salvage surgery for failed endoscopic third ventriculostomy

PURPOSE

Although the endoscopic third ventriculostomy (ETV) is an effective treatment for hydrocephalus, failures do on occasion occur. In such cases, a repeat ETV or shunt insertion is usually performed. However, there is, as of yet, no clear consensus on the best measure to take in the event of a failed ETV. We herein examined the outcomes of a repeat ETV combined with choroid plexus cauterization for ETV failure.

METHODS

All patients who underwent an ETV at the Department of Neurosurgery at Tokyo Metropolitan Children's Medical Center between April 2013 and March 2019 were retrospectively analyzed.

RESULTS

In total, 36 patients received an ETV. Six patients experienced ETV failure; three of these underwent a repeat ETV combined with choroid plexus cauterization. Three of the six patients who experienced early ETV failure received a ventriculoperitoneal shunt. During the median follow-up period of 42 months (range: 32-73 months), all repeat ETVs were successful.

CONCLUSION

A repeat ETV combined with choroid plexus cauterization can be an effective salvage therapy in the event of ETV failure.

Endoscopic third ventriculostomy revision after failure of initial endoscopic third ventriculostomy and choroid plexus cauterization

OBJECTIVE

Primary treatment of hydrocephalus with endoscopic third ventriculostomy (ETV) and choroid plexus cauterization (CPC) is well described in the neurosurgical literature, with wide reported ranges of success and complication rates. The purpose of this study was to describe the safety and efficacy of ETV revision after initial ETV+CPC failure.

METHODS

Prospectively collected data in the Hydrocephalus Clinical Research Network Core Data Project registry were reviewed. Children who underwent ETV+CPC as the initial treatment for hydrocephalus between 2013 and 2019 and in whom the initial ETV+CPC was completed (i.e., not abandoned) were included. Log-rank survival analysis (the primary analysis) was used to compare time to failure (defined as any other surgical treatment for hydrocephalus or death related to hydrocephalus) of initial ETV+CPC versus that of ETV revision by using random-effects modeling to account for the inclusion of patients in both the initial and revision groups. Secondary analysis compared ETV revision to shunt placement after failure of initial ETV+CPC by using the log-rank test, as well as shunt failure after ETV+CPC to that after ETV revision. Cox regression analysis was used to identify predictors of failure among children treated with ETV revision.

RESULTS

The authors identified 521 ETV+CPC procedures that met their inclusion criteria. Ninety-one children underwent ETV revision after ETV+CPC failure. ETV revision had a lower 1-year success rate than initial ETV+CPC (29.5% vs 45%, p < 0.001). ETV revision after initial ETV+CPC failure had a lower success rate than shunting (29.5% vs 77.8%, p < 0.001). Shunt survival after initial ETV+CPC failure was not significantly different from shunt survival after ETV revision failure (p = 0.963). Complication rates were similar for all examined surgical procedures (initial ETV+CPC, ETV revision, ventriculoperitoneal shunt [VPS] placement after ETV+CPC, and VPS placement after ETV revision). Only young age was predictive of ETV revision failure (p = 0.02).

CONCLUSIONS

ETV revision had a significantly lower 1-year success rate than initial ETV+CPC and VPS placement after ETV+CPC. Complication rates were similar for all studied procedures. Younger age, but not time since initial ETV+CPC, was a risk factor for ETV revision failure.

Repeat endoscopic third ventriculostomy success rate according to ventriculostoma closure patterns in children

PURPOSE

This study aimed to examine the success rate of repeat endoscopic third ventriculostomy (redo-ETV) according to pattern of ventriculostoma closure based on observations in 97 paediatric redo-ETV patients.

METHODS

Clinical data and intraoperative video recordings of 97 paediatric hydrocephalus patients who underwent redo-ETV due to ventriculostoma closure at two institutions were retrospectively analysed. We excluded patients with a history of intraventricular haemorrhage, cerebrospinal fluid (CSF) infection or CSF shunt surgery and those with incompletely penetrated membranes during the initial ETV.

RESULTS

Verification of ventriculostoma closure was confirmed with cine phase-contrast magnetic resonance imaging and classified into 3 types: type 1, total closure of the ventriculostoma by gliosis or scar tissue that results in a non-translucent/opaque third ventricle floor; type 2, narrowing/closure of the ventriculostoma by newly formed translucent/semi-transparent membranes; and type 3, presence of a patent ventriculostoma orifice with CSF flow blockage by newly formed reactive membranes or arachnoidal webs in the basal cisterns. The overall success rate of redo-ETV was 37.1%. The success rates of redo-ETV according to closure type were 25% for type 1, 43.6% for type 2 and 38.2% for type 3. The frequency of type 1 ventriculostoma closure was significantly higher in patients with myelomeningocele-related hydrocephalus.

CONCLUSION

For patients with ventriculostoma closure after ETV, reopening of the stoma can be performed. Our findings regarding the frequencies of ventriculostoma closure types and the success rate of redo-ETV in paediatric patients according to ventriculostoma closure type are preliminary and should be verified by future studies.

The effect and evolution of patient selection on outcomes in endoscopic third ventriculostomy for hydrocephalus: A large-scale review of the literature

Endoscopic third ventriculostomy (ETV) has become a popular technique for the treatment of hydrocephalus, but small sample size has limited the generalizability of prior studies. We performed a large-scale review of all available studies to help eliminate bias and determine how outcomes have changed and been influenced by patient selection over time. A systematic literature search was performed for studies of ETV that contained original, extractable patient data, and a meta-analytic model was generated for correlative and predictive analysis. A total of 130 studies were identified, which included 11,952 cases. Brain tumor or cyst was the most common hydrocephalus etiology, but high-risk etiologies, post-infectious or post-hemorrhagic hydrocephalus, accounted for 18.4%. Post-operative mortality was very low (0.2%) and morbidity was only slightly higher in developing than in industrialized countries. The rate of ETV failure was 34.7% and was higher in the first months and plateaued around 20months. As anticipated, ETV is less successful in high-risk etiologies of hydrocephalus and younger patients. Younger patient age and high-risk etiologies predicted failure. ETVs were performed more often in high-risk etiologies over time, but, surprisingly, there was no overall change in ETV success rate over time. This study should help to influence optimal patient selection and offer guidance in predicting outcomes.

Endoscopic third ventriculostomy and repeat endoscopic third ventriculostomy in pediatric patients: the Dutch experience

OBJECTIVE After endoscopic third ventriculostomy (ETV), some patients develop recurrent symptoms of hydrocephalus. The optimal treatment for these patients is not clear: repeat ETV (re-ETV) or CSF shunting. The goals of the study were to assess the effectiveness of re-ETV relative to initial ETV in pediatric patients and validate the ETV success score (ETVSS) for re-ETV. METHODS Retrospective data of 624 ETV and 93 re-ETV procedures were collected from 6 neurosurgical centers in the Netherlands (1998-2015). Multivariable Cox proportional hazards modeling was used to provide an adjusted estimate of the hazard ratio for re-ETV failure relative to ETV failure. The correlation coefficient between ETVSS and the chance of re-ETV success was calculated using Kendall's tau coefficient. Model discrimination was quantified using the c-statistic. The effects of intraoperative findings and management on re-ETV success were also analyzed. RESULTS The hazard ratio for re-ETV failure relative to ETV failure was 1.23 (95% CI 0.90-1.69; p = 0.20). At 6 months, the success rates for both ETV and re-ETV were 68%. ETVSS was significantly related to the chances of re-ETV success (τ = 0.37; 95% bias corrected and accelerated CI 0.21-0.52; p < 0.001). The c-statistic was 0.74 (95% CI 0.64-0.85). The presence of prepontine arachnoid membranes and use of an external ventricular drain (EVD) were negatively associated with treatment success, with ORs of 4.0 (95% CI 1.5-10.5) and 9.7 (95% CI 3.4-27.8), respectively. CONCLUSIONS Re-ETV seems to be as safe and effective as initial ETV. ETVSS adequately predicts the chance of successful re-ETV. The presence of prepontine arachnoid membranes and the use of EVD negatively influence the chance of success.

Outcome of treatment after failed endoscopic third ventriculostomy (ETV) in infants with aqueductal stenosis: results from the International Infant Hydrocephalus Study (IIHS)

INTRODUCTION

After an endoscopic third ventriculostomy (ETV) fails, it is unclear how well subsequent treatment fares, especially in comparison to shunts inserted as primary treatment. In this study, we present a further analysis of the infants enrolled a prospective multicentre study who failed ETV and describe the outcome of their subsequent treatment, comparing this to those who received shunt as their primary treatment.

METHODS

This was a post hoc analysis of data from the International Infant Hydrocephalus Study (IIHS)-a prospective, multicentre study of infants with hydrocephalus from aqueductal stenosis who received either an ETV or shunt. In the current analysis, we compared the results of the 38 infants who failed ETV and the 43 infants who received primary shunt. Patients were followed prospectively for time to treatment failure, defined as the need for repeat CSF diversion procedure (shunt or ETV) or death due to hydrocephalus.

RESULTS

There were a total of 81 patients: 43 primary shunts, 34 shunt post-ETV, and 4 repeat ETV. The median time between the primary ETV and the second intervention was 29 days (IQR 14-69), with no significant difference between repeat ETV and shunt post-ETV. Median length of available follow-up was 800 days (IQR 266-1651), during which time, failure was noted in 3 (75.0%) repeat ETV patients, 10 (29.4%) shunt post-ETV patients, and 9 (20.9%) primary shunt patients. In an adjusted Cox regression model, the risk of failure was higher for repeat ETV compared to primary shunt, but there was no significant difference between primary shunt and shunt post-ETV. No other variable showed statistical significance.

CONCLUSIONS

In our prospective study of infants with aqueductal stenosis, there was no significant difference in failure outcome of shunts inserted after a failed ETV and primary shunts. Therefore, our data do not support the notion that previous ETV confers either a protective or negative effect on subsequently-placed shunts. Larger studies, in a wider ranging population, are required to establish how widely these data apply.

TRIAL REGISTRATION

NCT00652470.

Limitations of Neuroendoscopic Treatment for Pediatric Hydrocephalus and Considerations from Future Perspectives

Neuroendoscopy has become common in the field of pediatric neurosurgery. As an alternative procedure to cerebrospinal fluid shunt, endoscopic third ventriculostomy has been the routine surgical treatment for obstructive hydrocephalus. However, the indication is still debatable in infantile periods. The predictors of late failure and how to manage are still unknown. Recently, the remarkable results of endoscopic choroid plexus coagulation in combination with third ventriculostomy, reported from experiences in Africa, present puzzling complexity. The current data on the role of neuroendoscopic surgery for pediatric hydrocephalus is reported with discussion of its limitations and future perspectives, in this review.

Reopening of an obstructed third ventriculostomy: long-term success and factors affecting outcome in 215 infants

OBJECT

The role of reopening an obstructed endoscopic third ventriculostomy (ETV) as treatment for ETV failure is not well defined. The authors studied 215 children with ETV closure who underwent successful repeat ETV to determine the indications, long-term success, and factors affecting outcome.

METHODS

The authors retrospectively reviewed the CURE Children's Hospital of Uganda database from August 2001 through December 2012, identifying 215 children with failed ETV (with or without prior choroid plexus cauterization [CPC]) who underwent reopening of an obstructed ETV stoma. Treatment survival according to sex, age at first and second operation, time to failure of first operation, etiology of hydrocephalus, prior CPC, and mode of ETV obstruction (simple stoma closure, second membrane, or cisternal obstruction from arachnoid scarring) were assessed using the Kaplan-Meier survival method. Survival differences among groups were assessed using log-rank and Wilcoxon methods and a Cox proportional hazards model.

RESULTS

There were 125 boys and 90 girls with mean and median ages of 229 and 92 days, respectively, at the initial ETV. Mean and median ages at repeat ETV were 347 and 180 days, respectively. Postinfectious hydrocephalus (PIH) was the etiology in 126 patients, and nonpostinfectious hydrocephalus (NPIH) in 89. Overall estimated 7-year success for repeat ETV was 51%. Sex (p = 0.46, log-rank test; p = 0.54, Wilcoxon test), age (< vs > 6 months) at initial or repeat ETV (p = 0.08 initial, p = 0.13 repeat; log-rank test), and type of ETV obstruction (p = 0.61, log-rank test) did not affect outcome for repeat ETV (p values ≥ 0.05, Cox regression). Those with a longer time to failure of initial ETV (> 6 months 91%, 3-6 months 60%, < 3 months 42%, p < 0.01; log-rank test), postinfectious etiology (PIH 58% vs NPIH 42%, p = 0.02; log-rank and Wilcoxon tests) and prior CPC (p = 0.03, log-rank and Wilcoxon tests) had significantly better outcome.

CONCLUSIONS

Repeat ETV was successful in half of the patients overall, and was more successful in association with later failures, prior CPC, and PIH. Obstruction of the original ETV by secondary arachnoid scarring was not a negative prognostic factor, and should not discourage the surgeon from proceeding. Repeat ETV may be a more durable solution to failed ETV/CPC than shunt placement in this context, especially for failures at more than 3 months after the initial ETV. Some ETV closures may result from an inflammatory response that is less robust at the second operation.

Endoscopic third ventriculostomy in the management of hydrocephalus: Outcome analysis of 168 consecutive procedures

BACKGROUND

Endoscopic third ventriculostomy (ETV) is the treatment of choice for obstructive hydrocephalus, but the outcome is still controversial in terms of age and aetiology.

METHODS

Between 1998 and 2011, 168 consecutive procedures were performed in 164 patients, primarily children (56%<18 years of age and 35%<2 years of age). The causes of obstructive hydrocephalus included tumoural pathology, Chiari malformation, congenital obstruction of the aqueduct, post-infectious and post-haemorrhagic membranes, and ventriculo-peritoneal shunt (VPS) malfunctions. Successful ETV was defined by the resolution of symptoms and the avoidance of a shunt.

RESULTS

ETV was successful in 75.6% of patients, but 19% of the patients required VPS in the first month after ETV, and 5.4% required a VPS more than one month after ETV. Four patients were ultimately submitted for second ETVs. In this series, no major permanent morbidity or mortality was observed.

CONCLUSIONS

ETV is a safe procedure and an effective treatment for obstructive hydrocephalus even following the dysfunction of previous VPSs and in children younger than two years.

Factors affecting surgical outcome of endoscopic third ventriculostomy in congenital hydrocephalus

Endoscopic third ventriculostomy (ETV) is an accepted modality of treatment for obstructive hydrocephalus, with good results in adult patients. However in the pediatric age group results vary from poor to similar to the adult population. This study evaluates the outcome of ETV in congenital hydrocephalus of both early and delayed presentation, and investigates factors that determine the outcome. Patients with congenital hydrocephalus who underwent ETV between January 2006 and December 2011 were retrospectively analyzed. Any conditions potentially influencing the need for redo surgery (persistent cerebrospinal fluid [CSF] leak not responding to local measures, tense fontanelle, increased ventricular size, recurrence of symptoms or radiological evidence of failure) were analyzed. A total of 102 patients with a mean age of 7.45years were included. Presenting features were increasing head circumference and delayed milestones. Ninety-eight patients had triventricular hydrocephalus due to aqueductal stenosis. Procedures performed were ETV only (n=74), ETV with aqueductoplasty (n=22), ETV with cystoventriculostomy (n=2) and aqueductoplasty only (n=2). Failure of ETV occurred in 11 patients and all were managed with a ventriculoperitoneal shunt. CSF leak in the perioperative period was the only factor that was significantly associated with failure of ETV. ETV is a safe procedure with a good success rate and can be offered to children with aqueductal stenosis. There is a higher chance of failure if there is a CSF leak in the early or late postoperative period.

An external validation of the ETVSS for both short-term and long-term predictive adequacy in 104 pediatric patients

PURPOSE

This study aims to provide external validation of the "Endoscopic Third Ventriculostomy Success Score (ETVSS)" for both short-term and long-term predictive adequacy.

METHODS

Between 1998 and 2007, we collected clinical follow-up data (after 6 and 36 months) of all 104 hydrocephalic children (<18 years of age) treated by endoscopic third ventriculostomy (ETV) in our hospital. Predictive adequacy of ETVSS for 6- and 36-month periods was tested by means of an unpaired t test, Hosmer-Lemeshow "goodness-of- fit" test, and area under the receiver operating characteristic curve.

RESULTS

Mean follow-up was 73.4 months. For both the short-term (6 months) and the long-term (36 months) periods, the mean predicted probability of ETV for the patients with successful ETV treatment was significantly higher than in the patients with failed ETV treatment. The areas under the curve for the short- and long-term periods were, respectively, 0.82 (95% CI 0.71-0.92) and 0.73 (95% CI 0.62-0.84). For patients with moderate ETVSS (50-70), the median age at first ETV was significantly higher for patients with successful ETV for both short- and long-term periods.

CONCLUSION

In hydrocephalic children, the ETVSS is a useful tool for prediction of outcome after ETV treatment. The ETVSS is more adequate in predicting short-term than long-term success. In our population, it is suggested that success rate for patients with moderate ETVSS could be improved if more weight is attributed to age at first ETV.

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.

Risk factors and tumor response associated with hydrocephalus after gamma knife radiosurgery for vestibular schwannoma

BACKGROUND

This study was designed to investigate the clinical characteristics and risk factors of hydrocephalus after gamma knife radiosurgery (GKRS) for vestibular schwannoma.

METHODS

The authors retrospectively reviewed clinical and neuroimaging findings of 221 patients who underwent GKRS for newly diagnosed vestibular schwannoma. Mean patient age was 54.1 years (range 7-83 years), mean tumor volume was 3,010.4 mm(3) (range 34.7 to 14,300 mm(3)), mean marginal dose was 12.5 Gy (range 11 to 15 Gy), and mean follow-up duration was 31.9 months (range 1 to 107.6 months).

RESULTS

Surgical intervention for cerebrospinal fluid (CSF) diversion after GKRS was necessary in 11 (5 %) of the patients. Median time between GKRS and ventriculoperitoneal (VP) shunt placement was 15.5 months (range 1.8-37.8 months). These 11 patients showed female predominance (11 females) and mean tumor volume was significantly larger than in the other without hydrocephalus (6,509 vs. 2,726 mm(3); p < 0.01). Decreases in tumor enhancement and swelling were observed in all 221 patients, and CSF protein was found to be elevated in five of nine patients with available data at the time of the shunt procedure. Hydrocephalic symptoms improved after VP shunt and tumor sizes further decreased at last follow-up in all patients.

CONCLUSIONS

Hydrocephalus after radiosurgery may co-occur with a temporary change of tumor volume after radiation treatment. Therefore, hydrocephalus should be kept in mind during the time of tumor volume transition. Furthermore, the authors suggest that frequent patient monitoring for hydrocephalus be maintained for up to 3-4 years after GKRS.

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.

Endoscopic third ventriculostomy in patients with shunt malfunction

OBJECTIVE

This paper presents data from a retrospective study of endoscopic third ventriculostomy (ETV) in patients with shunt malfunction and proposes a simple and reasonable post-operative protocol that can detect ETV failure.

METHODS

We enrolled 19 consecutive hydrocephalus patients (11 male and 8 female) who were treated with ETV between April 2001 and July 2010 after failure of previously placed shunts. We evaluated for correlations between the success rate of ETV and the following parameters : age at the time of surgery, etiology of hydrocephalus, number of shunt revisions, interval between the initial diagnosis of hydrocephalus or the last shunt placement and ETV, and the indwelling time of external ventricular drainage.

RESULTS

At the time of ETV after shunt failure, 14 of the 19 patients were in the pediatric age group and 5 were adults, with ages ranging from 14 months to 42 years (median age, 12 years). The patients had initially been diagnosed with hydrocephalus between the ages of 1 month 24 days and 32 years (median age, 6 years 3 months). The etiology of hydrocephalus was neoplasm in 7 patients; infection in 5; malformation, such as aqueductal stenosis or megacisterna magna in 3; trauma in 1; and unknown in 3. The overall success rate during the median follow-up duration of 1.4 years (9 days to 8.7 years) after secondary ETV was 68.4%. None of the possible contributing factors for successful ETV, including age (p=0.97) and the etiology of hydrocephalus (p=0.79), were statistically correlated with outcomes in our series.

CONCLUSION

The use of ETV in patients with shunt malfunction resulted in shunt independence in 68.4% of cases. Age, etiology of hydrocephalus, and other contributing factors were not statistically correlated with ETV success. External ventricular drainage management during the immediate post-ETV period is a good means of detecting ETV failure.