International Infant Hydrocephalus Study: initial results of a prospective, multicenter comparison of endoscopic third ventriculostomy (ETV) and shunt for infant hydrocephalus

Success Rate of Endoscopic Third Ventriculostomy in Children Younger Than 1 Year With Idiopathic Congenital Aqueductal Stenosis and Long-term Follow-up

INTRODUCTION

The indication for endoscopic third ventriculostomy is often contested in children younger than 1 year. This study aims to establish the benefits of this modality in children with idiopathic congenital aqueductal stenosis.

METHODS

Retrospective analysis was performed on patients <1 year old with idiopathic congenital aqueductal stenosis undergoing endoscopic third ventriculostomy between 2004 and 2020. Preoperative cerebral imaging was performed in all cases. Endoscopic third ventriculostomy efficacy and overall patient outcome were evaluated over the entirety of the monitoring period averaging 146 months (range, 34-218 months). Outcome was assessed by modified Rankin Scale score. Treatment success was assessed in relation to the Endoscopic Third Ventriculostomy Success Score (ETVSS), patient age, and perioperative findings of membranes in the interpeduncular cistern.

RESULTS

The study comprised 14 children aged from 6 to 280 days, mean age 16 weeks, with 11 patients aged <6 months. The characteristic presentation was progressive macrocephaly, with the setting sun sign in 2 cases. The overall Endoscopic Third Ventriculostomy Success Score was 52.1%, whereas endoscopic third ventriculostomy was successful in 12 patients (85.7%) in the first year postoperation and in 11 cases (78.6%) in the long term. Endoscopic third ventriculostomy failure was not related to patient age (P > .99) or perioperative findings of interpeduncular cistern membranes (P = .51). Patient outcome averaged modified Rankin Scale score 1. Most children were without or with minimal disability.

CONCLUSIONS

We consider endoscopic third ventriculostomy a safe and effective modality for the initial treatment of patients aged <1 year presenting with congenital aqueductal stenosis-based hydrocephalus.

Clinical and radiologic criteria to predict endoscopic third ventriculostomy success in non-communicating pediatric hydrocephalus

OBJECTIVE

Endoscopic third ventriculocisternostomy (ETV) became the relevant treatment option for non-communicating pediatric hydrocephalus. ETV success was predicted in relation to age, diagnosis, and previous shunt implantation. Radiological factors are usually taken for indication decision-making. The aim of this study is to investigate radiological signs of non-communicating hydrocephalus for ETV success in a single-center retrospective analysis.

PATIENTS AND METHODS

ETV interventions were collected from a 10-year period (2010-2019) from our institution. Clinical patient characteristics such as prematurity, age, diagnosis, and previous shunt treatment and follow-up in terms of possible shunt implantation or revision surgeries were investigated. Radiological data was retrieved from the in-house PACS system to analyze preoperative signs for non-communicating hydrocephalus such as ventricular size, pressure gradients at the third ventricle, and any signs of obstruction from internal towards external cerebral spinal fluid communication. Fisher's test was used to demonstrate the significance of each individual predictor. A multivariable model was built using the backward elimination method with multiple logistic regression.

RESULTS

From 136 ETV interventions, 95 met the inclusion criteria (age < 18 years; > 6-month follow-up; MR image data availability, treatment goal for shunt independence). In chi-square statistical evaluation of single parameters age > 6 months (OR 32.5; 95% CI 4.8-364), ventricular width (FOHR < 0.56; OR 6.1; 95% CI 2.2-16.3) and non-post-hemorrhagic hydrocephalus as underlying diagnosis (OR 13.1; 95% CI 1.9-163) showed significant increased odds ratio for shunt independence during follow-up. Logistic regression analysis for multiple parameters showed age > 6 months (OR 29.3; 95% CI 4.1-606) together with outward bulged lamina terminalis (OR 4.6; 95% CI 1.2-19.6), smaller FOHR (continuous parameter; OR 2.83 × 10-5; 95% CI 4.7 × 10-9-0.045), and non-4th-ventricular-outlet obstruction (4thVOO; OR 0.31; 95% CI 0.09-1.02) as significant factors for ETV success.

CONCLUSION

ETV has become a relevant treatment for non-communicating hydrocephalus, with typical MR image characteristics. Analyzing radiological markers as predictors for success smaller ventricular width and outward displaced lamina terminalis was relevant in combination with age > 6 months. Since the analysis is based on single-center experience, a larger cohort of patients with a multi-center approach should further investigate the combined clinical and radiological criteria.

Congenital Obstructive Hydrocephalus With Status Post-endoscopic Third Ventriculostomy Bilateral Subdural Hygroma and Pneumocephalus: A Case Report

Pediatric neurosurgery faces a major difficulty in the treatment of hydrocephalus, a condition marked by an abnormal build-up of cerebrospinal fluid (CSF) in the brain. Its prevalence varies between 0.5 and 0.8 per 1,000 live births worldwide, with different etiologies, including congenital abnormalities and acquired diseases. With benefits including a lower risk of infection and avoiding issues due to the shunt, endoscopic third ventriculostomy (ETV) has become a beneficial surgical technique in certain instances. Bypassing clogged ventricular channels, ETV creates a new channel for CSF drainage. Despite its effectiveness, a thorough examination of underlying disease and anatomical variables is necessary for positive outcomes in patient selection. To give patients, the best possible care, this article attempts to summarize the prevalence of hydrocephalus and the part that ETV plays in managing it. It also emphasizes the significance of customized surgical techniques. It is critical to comprehend the incidence of hydrocephalus and available treatment choices to enhance the infant's quality of life and long-term outcomes.

Low surgical weight associated with ETV failure in pediatric hydrocephalus patients

The use of endoscopic third ventriculostomy (ETV) for treatment of pediatric hydrocephalus has higher failure rates in younger patients. Here we investigate the impact of select perioperative variables, specifically gestational age, chronological age, birth weight, and surgical weight, on ETV failure rates. A retrospective review was performed on patients treated with ETV - with or without choroid plexus cauterization (CPC) - from 2010 to 2021 at a large academic center. Analyses included Cox regression for independent predictors and Kaplan-Meier survival curves for time to-event outcomes. In total, 47 patients were treated with ETV; of these, 31 received adjunctive CPC. Overall, 66% of the cohort experienced ETV failure with a median failure of 36 days postoperatively. Patients aged < 6 months at time of surgery experienced 80% failure rate, and those > 6 months at time of surgery experienced a 41% failure rate. Univariate Cox regression analysis showed weight at the time of ETV surgery was significantly inversely associated with ETV failure with a hazard ratio of 0.92 (95% CI 0.82, 0.99). Multivariate analysis redemonstrated the inverse association of weight at time of surgery with ETV failure with hazard ratio of 0.76 (95% CI 0.60, 0.92), and sensitivity analysis showed < 4.9 kg as the optimal cutoff predicting ETV/CPC failure. Neither chronologic age nor gestational age were found to be significantly associated with ETV failure.In this study, younger patients experienced higher ETV failure rates, but multivariate regression found that weight was a more robust predictor of ETV failure than chronologic age or gestational age, with an optimal cutoff of 4.9 kg in our small cohort. Given the limited sample size, further study is needed to elucidate the independent role of weight as a peri-operative variable in determining ETV candidacy in young infants. Previous presentations: Poster Presentation, Congress of Neurological Surgeons.

Outcomes of endoscopic third ventriculostomy (ETV) and ventriculoperitoneal shunt (VPS) in the treatment of paediatric hydrocephalus: Systematic review and meta-analysis

PURPOSE

To evaluate the outcomes of endoscopic third ventriculostomy (ETV) and ventriculoperitoneal shunt (VPS) in the treatment of paediatric hydrocephalus.

METHODS

We searched PubMed, MEDLINE, and Cochrane Central Register of Controlled Trials databases for articles published from 2000 to May 2023 (last search date May 6, 2023). Keywords searched included "endoscopic third ventriculostomy", "ventriculoperitoneal shunting", "paediatric population", and "outcomes". Using random-effects models, we compared success rates and complications of ETV and VPS. The primary outcome was ETV vs.VPS success rates, and the secondary outcome was post-treatment complications. Included studies reported on treatment success and complication rates.

RESULTS

Out of 126 articles, 8 RCTs and 1 prospective study were included. Six studies reported primary outcome data (806 patients identified: 464 in ETV group, 342 in VPS group). Combined success rates were 81.8% (n = 283/346) for ETV and 86.7% (n = 182/210) for VPS (median follow-up 41 months). There was no difference in success rates between ETV and VPS groups (risk ratio 0.84, 95% confidence interval 0.80-0.90, I2 = 0%, p = 0.93). Combined complication rates were 4.6% (n = 16/346) in the ETV group and 27.1% (n = 57/210) in the VPS group. ETV had a lower rate of postoperative complications (risk ratio 0.76, 95% confidence interval 0.42-1.38, I2 = 53%, p = 0.04).

CONCLUSIONS

Both ETV and VPS are viable surgical options for the management of paediatric hydrocephalus with similar success rates when used as first-line treatment. However, our study concluded that VPS results in a higher complication rate.

REGISTRATION

This systematic review and meta-analysis was formally registered in the PROSPERO International database under the registration number CRD42023452907 on the 29th of August 2023.

Hydrocephalus in prematurity: does valve choice make a difference?

PURPOSE

Extremely premature neonates diagnosed with post-haemorrhagic hydrocephalus (PHH) are recognised to have particularly poor outcomes. This study assessed the impact of a number of variables on outcomes in this cohort, in particular the choice of shunt valve mechanism.

METHODS

Electronic case notes were retrospectively reviewed of all premature neonates admitted to our centre for management of hydrocephalus between 2012 and 2021. Data included (i) gestational age, (ii) birth weight, (iii) hydrocephalus aetiology, (iv) surgical intervention, (v) shunt system, (vi) 'surgical burden' and (vii) wound failure and infection rate. Data was handled in Microsoft Excel and statistical analysis performed in SPSS v27.0 RESULTS: N = 53 premature hydrocephalic patients were identified (n = 28 (52.8%) female). Median gestational age at birth was 27 weeks (range: 23-36 + 6 weeks), with n = 35 extremely preterm patients and median birth weight of 1.9 kg (range: 0.8-3.6 kg). Total n = 99 programmable valves were implanted (n = 28 (28.3%) de novo, n = 71 (71.2%) revisions); n = 28 (28.3%) underwent n ≥ 1 pressure alterations, after which n = 21 (75%) patients had symptoms improve. In n = 8 patients exchanged from fixed to programmable valves, a mean reduction of 1.9 revisions per patient after exchange was observed (95%CI: 0.36-3.39, p = 0.02). Mean overall shunt survival was 39.5 weeks (95%CI: 30.6-48.5); 33.2 weeks (95%CI: 25.2-41.1) in programmable valves and 35.1 weeks (95%CI: 19.5-50.6) in fixed pressure (p = 0.22) with 12-month survival rates of 25.7% and 24.7%, respectively (p = 0.22). Shorter de novo shunt survival was associated with higher operation count overall (Pearson's R: - 0.54, 95%CI: - 0.72 to - 0.29, p < 0.01). Wound failure, gestational age and birth weight were significantly associated with shorter de novo shunt survival in a Cox regression proportional hazards model; gestational age had the greatest impact on shunt survival (Exp(B): 0.71, 95%CI: 0.63-0.81, p < 0.01).

CONCLUSION

Hydrocephalus is especially challenging in extreme prematurity, with a shorter de novo shunt survival associated with higher number of future revisions. Programmable valves provide flexibility with regard to pressure setting, with the potential for fewer shunt revisions in this complex cohort.

Endoscopic third ventriculostomy (ETV) or ventriculoperitoneal shunt (VPS) for paediatric hydrocephalus due to primary aqueductal stenosis

PURPOSE

The purpose of this study was to compare outcomes of endoscopic third ventriculostomy (ETV) and ventriculoperitoneal shunt (VPS) in children with symptomatic triventricular hydrocephalus due to primary aqueductal stenosis.

METHOD

This is a retrospective analytical study. Patients who underwent either ETV or VPS as the first procedure for hydrocephalus due to primary aqueductal stenosis were included in the study.

RESULT

A total of 89 children were included in the study for analysis. The mean age was 8.4 years. Forty-four (49.4%) had their first surgery as ETV and 45 (50.6%) had their first surgery as VPS. Overall, 34 (38.2%) patients required a second surgery (either ETV or VPS) for persistent or recurrent hydrocephalus. The mean follow-up duration was 832.9 days. The overall complication rate was 13.5%. The mean timing of the second surgery after index surgery was 601.35 days. Factors associated with a second surgery were the presence of complications, high protein in cerebrospinal fluid, the relative change of frontal-occipital horn ratio (FOHR) and Evans' index. The survival of the first surgery was superior in ETV (751.55 days) compared to VPS (454.49 days), p = 0.013. The relative change of fronto-occipital horn index ratio (FOIR) was high in the VPS (mean 7.28%) group compared to the ETV (mean 4.40%), p = 0.001 group.

CONCLUSION

Overall procedural survival was better after ETV than VPS for hydrocephalus due to aqueductal stenosis. VPS causes more reduction in linear indices of ventricles as compared to ETV, however, is not associated with the success or complication of the procedure.

Prenatal dispositions and genetic analysis of monozygotic female twins with suprasellar cysts and hydrocephalus: A case report

INTRODUCTION

We present a unique case of monozygotic female twins with virtually identical clinical and radiological presentations of supratentorial hydrocephalus and cystic formations from the suprasellar cistern.

DISCUSSION

Evaluating genetic predispositions and prenatal exposures is crucial for hydrocephalus in twins. Familial cases imply a genetic contribution to the development of these anomalies, including chromosomal abnormalities and specific variants linked to arachnoid cyst formation in various syndromes. Extensive genetic analyses found no pathogenic variants in the twins. Prenatal exposure to anti-epileptic medication was known during pregnancy and may be associated with fetal abnormalities, but not central nervous system (CNS) malformations, and was therefore not considered the cause of the condition in the twins. The twins presenting simultaneously with hydrocephalus caused by suprasellar cysts (SAC) underwent a two-step surgical management: initial ventriculoperitoneal shunt (VPS) placement followed by fenestration. Postoperative imaging showed cyst reduction, but a secondary VPS was necessary in both cases.

CONCLUSION

Genetic analysis is less likely to identify a monogenic etiology in non-syndromic cases of SACs, which are assumed to be multifactorial. There is no established evidence linking a teratogenic effect of anti-epileptic drugs to CNS malformations. Moreover, the surgical treatment of this complex condition constitutes a point of discussion.

Intracranial Neuroendoscopy in Children and Adults: Where Do the Differences Lie?

BACKGROUND

Intraventricular neuroendoscopy has evolved into an essential adjunct in neurosurgery and is used across all age groups for various indications. However, studies comparing neuroendoscopic procedures between children and adults are scarce. The aim of this study is to compare various aspects between adults and children undergoing neuroendoscopy.

METHODS

We retrospectively analyzed the data from consecutive patients dichotomized into 2 cohorts, pediatric (age <18 years) and adult (age ≥18 years) groups, in whom intracranial neuroendoscopy was performed between 2013 and 2020 (pediatric group) and 2010 and 2020 (adult group).

RESULTS

Of 132 patients who underwent intracranial neuroendoscopic surgery, 47 (35.6%) were children and 85 (64.4%) were adults. The most common indications for the children and adults were intraventricular or paraventricular tumors (23.4%) and aqueduct stenosis (40%), respectively. Their clinical condition at the last follow-up was unchanged or improved for 90.5% of the children and 92.1% of the adults. An increased endoscopic third ventriculostomy success score was predictive of endoscopic third ventriculostomy success in the pediatric cohort (odds ratio, 1.073; P = 0.043). The postoperative rates of transient (pediatric, 23.4%; adult, 18.8%) and permanent (pediatric, 0%; adult, 1.2%) complications were comparable. The rate of secondary surgery was higher for the pediatric cohort (38.3%) than for the adult cohort (17.6%).

CONCLUSIONS

The indications for neuroendoscopy vary between adults and children, although the long-term clinical outcome is comparable. The rate of secondary surgery is significantly higher for pediatric patients, especially for those aged <1 year. Because neuroendoscopy is considerably more frequent in pediatric patients, including pediatric neurosurgeons in adult neuroendoscopic cases could potentially help lower the complication rates and increase the success rates.

Diagnosis and Surgical Management of Neonatal Hydrocephalus

Neonatal hydrocephalus represents an important pathological condition with significant impact on medical care and neurocognitive development. This condition requires early recognition, appropriate medical and surgical management, and long-term surveillance by clinicians and pediatric neurosurgeons. Common etiologies of neonatal and infant hydrocephalus include intraventricular hemorrhage related to prematurity with subsequent post-hemorrhagic hydrocephalus, myelomeningocele, and obstructive hydrocephalus due to aqueductal stenosis. Clinical markers of elevated intracranial pressure include rapid increases in head circumference across percentiles, elevation and firmness of the anterior fontanelle, splitting or splaying of cranial sutures, upgaze palsy, lethargy, frequent emesis, or episodic bradycardia (unrelated to other comorbidities). Complementing these clinical markers, imaging modalities used for the diagnosis of neonatal hydrocephalus include head ultrasonography, brain magnetic resonance imaging, and head computed tomography in urgent or emergent situations. Following diagnosis, temporizing measures may be employed prior to definitive treatment and include ventricular access device or ventriculo-subgaleal shunt insertion. Definitive surgical management involves permanent cerebrospinal fluid (CSF) diversion via CSF shunt insertion, or endoscopic third ventriculostomy with or without choroid plexus cauterization. Surgical decision-making and approaches vary based on patient age, hydrocephalus etiology, neuroanatomy, imaging findings, and medical comorbidities. Indications, surgical techniques, and clinical outcomes of these procedures continue to evolve and elicit significant attention in the research environment. In this review we describe the epidemiology, pathophysiology, clinical markers, imaging findings, early management, definitive surgical management, and clinical outcomes of pediatric patients with neonatal hydrocephalus.

Cerebrospinal Fluid Homeostasis and Hydrodynamics: A Review of Facts and Theories

BACKGROUND AND PURPOSE

According to the classical hypothesis, the cerebrospinal fluid (CSF) is actively secreted inside the brain's ventricular system, predominantly by the choroid plexuses, before flowing unidirectionally in a cranio-caudal orientation toward the arachnoid granulations (AGs), where it is reabsorbed into the dural venous sinuses. This concept has been accepted as a doctrine for more than 100 years and was subjected only to minor modifications. Its inability to provide an adequate explanation to questions arising from the everyday clinical practice, in addition to the ever growing pool of experimental data contradicting it, has led to the identification of its limitations. Literature includes an increasing number of studies suggesting a more complex mechanism than that previously described. This review article summarizes the proposed mechanisms of CSF regulation, referring to the key clinical and experimental developments supporting or defying them.

METHODS

A non-systematical literature search of the major databases was performed for studies on the mechanisms of CSF homeostasis. Gray literature was additionally assessed employing a hand-search technique. No restrictions were imposed regarding the time, language, or type of publication.

CONCLUSION

CSF secretion and absorption are expected to take place throughout the entire brain's capillaries network under the regulation of hydrostatic and osmotic gradients. The unidirectional flow is defied, highlighting the possibility of its complete absence. The importance of AGs is brought into question, potentiating the significance of the lymphatic system as the primary site of reabsorption. However, the definition of hydrocephalus and its treatment strategies remain strongly associated with the classical hypothesis.

Endoscopic third ventriculostomy for hydrocephalus in a patient with achondroplasia: a case report and literature review

Hydrocephalus, a complication of achondroplasia, requires treatment when it is symptomatic. Hydrocephalus associated with achondroplasia is often treated with ventriculoperitoneal shunting, and endoscopic third ventriculostomy (ETV) is rarely performed in these patients. Here, we report the case of an 18-month-old boy with achondroplasia and progressive hydrocephalus who underwent ETV. He had a family history of achondroplasia and was diagnosed with achondroplasia at birth. Magnetic resonance imaging (MRI) at the age of 1 month showed no hydrocephalus. At the age of 15 months, he was admitted to our hospital due to increased head circumference. He had developmental delays, and MRI showed hydrocephalus with ballooning of the third ventricle. The ETV success score was 80 points; therefore, we performed ETV. Postoperatively, the progression of head circumference increase was controlled. The ventricular size remained unchanged on MRI at 13 months after surgery. Recently, an association between non-communicating hydrocephalus and achondroplasia has been reported. Depending on age and imaging findings, ETV may be effective in some patients with achondroplasia with hydrocephalus.

Endoscopic Third Ventriculostomy - A Review

BACKGROUND

Endoscopic third ventriculostomy (ETV) has become a proven modality for treating obstructive and selected cases of communicating hydrocephalus.

OBJECTIVE

This review aims to summarize the indications, preoperative workup, surgical technique, results, postoperative care, complications, advantages, and limitations of an ETV.

MATERIALS AND METHODS

A thorough review of PubMed and Google Scholar was performed. This review is based on the relevant articles and authors' experience.

RESULTS

ETV is indicated in obstructive hydrocephalus and selected cases of communicating hydrocephalus. Studying preoperative imaging is critical, and a detailed assessment of interthalamic adhesions, the thickness of floor, arteries or membranes below the third ventricle floor, and prepontine cistern width is essential. Blunt perforation in a thin floor, while bipolar cautery at low settings and water jet dissection are preferred in a thick floor. The appearance of stoma pulsations and intraoperative ventriculostomography reassure stoma and basal cistern patency. The intraoperative decision for shunt, external ventricular drainage, or Ommaya reservoir can be taken. Magnetic resonance ventriculography and cine phase-contrast magnetic resonance imaging can determine stoma patency. Good postoperative care with repeated cerebrospinal fluid drainage enhances outcomes in selected cases. Though the complications mostly occur in an early postoperative phase, delayed lethal ones may happen. Watching live surgeries, assisting expert surgeons, and practicing on cadavers and models can shorten the learning curve.

CONCLUSION

ETV is an excellent technique for managing obstructive and selected cases of communicating hydrocephalus. Good case selection, methodical technique, and proper training under experts are vital.

Surgical management of intracranial arachnoid cysts in pediatric patients: radiological and clinical outcome

OBJECTIVE

Congenital intracranial cysts account for a significant portion of intracranial lesions in the pediatric population. The efficiency of surgical treatment in a pediatric cohort with intracranial arachnoid cysts (ACs) at different locations regarding clinical symptoms and mass effect was evaluated.

METHODS

A retrospective study of all children who underwent surgical treatment of an intracranial AC during an 11-year period (2007-2018) was performed. Demographics, clinical symptoms, and radiological cyst size pre- and postoperatively, as well as the reoperation rate and possible treatment complications, were analyzed.

RESULTS

A total of 116 intracranial cysts at 8 different anatomical locations were surgically treated in 113 children (median age 5 years and 10 months) predominantly by endoscopic technique (84%). The complication rate was 3%, and the reoperation rate was 16%. Preoperative cyst enlargement was significantly more common in infants (p < 0.0001), as was the need for reoperation (p = 0.023). After a median radiological follow-up of 26 months, > 50% reduction of cyst volume was seen in 53 cysts (46%), and 47 cysts (40%) showed a 10%-50% reduction. Acute clinical symptoms improved: nausea and vomiting, accelerated head growth, and headaches improved at 100%, 92% and 89%, respectively. However, chronic symptoms responded less favorably after a median clinical follow-up of 26 months.

CONCLUSIONS

The strategy of predominantly endoscopic treatment with navigation planning is efficient to alleviate clinical symptoms and to significantly reduce the mass effect of pediatric intracranial cysts at different anatomical locations. The subgroup of infants requires close pre- and postoperative monitoring.

The role of the Liliequist membrane in the third ventriculostomy

Endoscopic third ventriculostomy (ETV) is a hydrocephalus treatment procedure that involves opening the Liliequist membrane (LM). However, LM anatomy has not been well-studied neuroendoscopically, because approach angles differ between descriptive and microsurgical anatomical explorations. Discrepancies in ETV efficacy, especially among children age 2 and younger, may be due to incomplete LM opening. The objective of this study was to characterize the LM anatomically from a neuroendoscopic perspective to better understand the impact of anatomical features during LM ostomy and the ETV success rate. Additionally, the ETV success score was tested to predict patient outcome after the intraoperatively difficult opening of LM. Fifty-four patients who underwent ETV were prospectively analyzed with a mean follow-up of 53.1 months (1-90 months). The ETV technical parameters of difficulty were validated by seven expert neurosurgeons. The pediatric population (44) of this study represents the majority of patients (81.4%). The overall ETV success rate was 68.5%. Anomalies on the IIIVT floor resulted in an increased rate of ETV failure. The IIIVT was anomalous, and LM was thick in 33.3% of cases. Fenestration of LM was difficult in 39% of cases, and the LM and TC were opened separately in 55.6% of cases. The endoscopic third ventriculostomy success score (ETVSS) accurately predicted the level of difficulty opening the LM (p = 0.012), and the group with easy opening presented greater durability in ETV success. Neurosurgeons should be aware of the difficulty level of the overture of LM during ETV and its impact on long-term ETV effectiveness.

External validation of the ETV success score in 313 pediatric patients: a Brazilian single-center study

The endoscopic third ventriculostomy (ETV) success score (ETVSS) was developed to predict the success rate of ETV at 6 months. In this study, the authors assessed the performance of this score for > 6 months, i.e., at 12 months, and provided external validation in Brazilian children. All children undergoing first ETV (without choroid plexus cauterization) at a Brazilian single institution for > 20 years were included in the study. The ETVSS was retrospectively calculated for each patient and compared with the actual success of the procedure observed at 6 and 12 months after the procedure. A total of 313 eligible children underwent initial ETV, 34.18% of whom had undergone shunt placement before ETV. The most common etiologies were aqueductal stenosis (45%) and non-tectal brain tumors (20.8%). ETV was successful at 6 months in 229 patients (73.16%) compared with the 61.3% predicted by the ETVSS. The overall actual success rate observed at 1 year after ETV was 65.1% (204 patients). The area under the receiver operating characteristic curve was 0.660 at 6 months and 0.668 at 1 year, which suggested a tendency for the ETVSS to underestimate the actual success rate of ETV at both timepoints. The ETVSS showed good success prediction in accordance with the actual ETV success rate and proved to be useful during the decision-making process of ETV.

Neuroendoscopic surgery in neonates - indication and results over a 10-year practice

PURPOSE

Neuroendoscopic procedures for treatment of term and preterm newborn infants, such as endoscopic lavage for posthemorrhagic hydrocephalus, are gaining popularity despite sparse data. This single-institution report compiles all neuroendoscopic surgical procedures performed in neonates during a 10-year period.

METHODS

Charts and electronic records were reviewed of all consecutive newborns who underwent a neuroendoscopic procedure before reaching a postmenstrual age of 44 weeks between 09/2010 and 09/2020. Available documentation was reviewed regarding the performed neuroendoscopic procedure, course of disease, complications, and all re-operations throughout the first year of life.

RESULTS

During the 10-year study period, 116 infants (median gestational age at birth: 29 ¹/7 weeks) underwent a total of 153 neuroendoscopic procedures (median postmenstrual age at surgery: 35 ⁰/7 weeks). The most common indication at the time of the neuroendoscopic procedures (n = 153) was intraventricular hemorrhage (IVH, n = 119), intraventricular infection (n = 15), congenital malformation (n = 8), isolated 4th ventricle (n = 7), multiloculated hydrocephalus (n = 3), and tumor (n = 1). Thirty-eight of 116 children (32.8%) underwent 43 operative revisions after 153 neuroendoscopic procedure (28.1%). Observed complications requiring surgical revision were secondary infection (n = 11), CSF fistula (n = 9), shunt dysfunction (n = 8), failure of ETV (n = 6), among others. 72 children (62%) of 116 children required permanent CSF diversion via a shunt. The respective shunt rates per diagnosis were 47 of 80 (58.8%) for previously untreated IVH, 11 of 13 (84.6%) for intraventricular infection. Shunt survival rate for the first year of life was 74% for the whole cohort.

CONCLUSION

The experience with this large cohort of neonates demonstrates the feasibility of neuroendoscopic technique for the treatment of posthemorrhagic or postinfectious hydrocephalus. Rate and type of complications after neuroendoscopic procedures were within the expected range. Assessing the potential long-term benefits of neuroendoscopic techniques has to await results of ongoing studies.

Integrated understanding of hydrocephalus - a practical approach for a complex disease

Most of childhood hydrocephalus are originating during infancy. It is considered to be a complex disease since it is developed on the basis of heterogeneous pathophysiological mechanisms and different pathological conditions as well as during different age groups. Hence, it is of relevant importance to have a practical concept in mind, how to categorize hydrocephalus to surgically better approach this disease. The current review should offer further basis of discussion on a disease still most frequently seen in Pediatric Neurosurgery. Current literature on pathophysiology and classification of pediatric hydrocephalus has been reviewed to integrate the different published concepts of hydrocephalus for pediatric neurosurgeons. The current understanding of infant and childhood hydrocephalus pathophysiology is summarized. A simplified concept based on seven factors of CSF dynamics is elaborated and discussed in the context of recent discussions. The seven factors such as pulsatility, CSF production, major CSF pathways, minor CSF pathways, CSF absorption, venous outflow, and respiration may have different relevance and may also overlap for the individual hydrocephalic condition. The surgical options available for pediatric neurosurgeons to approach hydrocephalus must be adapted to the individual condition. The heterogeneity of hydrocephalus causes mostly developing during infancy warrant a simplified overview and understanding for an everyday approach. The proposed guide may be a basis for further discussion and may serve for a more or less simple categorization to better approach hydrocephalus as a pathophysiological complex disease.

Opening and closure of intraventricular neuroendoscopic procedures in infants under 1 year of age: institutional technique, case series and review of the literature

PURPOSE

Intraventricular neuroendoscopic techniques, particularly third ventriculostomy, are employed increasingly in the management of infantile hydrocephalus. However, surgical access to the ventricular cavities is associated with a risk of post-operative cerebrospinal fluid (CSF) leak. Here, we describe a structured, multi-layered approach to wound opening and closure which aims to maximise the natural tissue barriers against CSF leakage. We present a series of patients undergoing this technique and subsequently review the literature regarding opening and closure techniques in paediatric intraventricular neuroendoscopic procedures.

METHODS

We performed a retrospective case series analysis of patients under 1 year of age who underwent intraventricular neuroendoscopic procedures in a single institution over a 5-year period. Patients were identified from an institutional operative database, and operation notes and clinical records were subsequently reviewed.

RESULTS

28 patients fulfilled the inclusion criteria for this study. The mean age at operation was 9 weeks. 27 patients underwent endoscopic third ventriculostomy whilst 1 underwent endoscopic septostomy, and all patients underwent our structured, multi-layered opening and closure technique. Follow-up ranged from 4 months to 5 years. There were no cases of post-operative CSF leak, infection or wound breakdown. 12 patients remained shunt-free at the last follow-up, with the remaining 16 requiring shunt insertion for progressive hydrocephalus at a mean of 24 days post-operatively.

CONCLUSION

Various methods aiming to prevent post-operative CSF leak have been reported in the literature. We propose that our institutional technique may be of benefit in minimising this risk in infants undergoing endoscopic third ventriculostomy and similar intraventricular neuroendoscopic procedures.

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on the Treatment of Pediatric Hydrocephalus: Update of the 2014 Guidelines

BACKGROUND

The Congress of Neurological Surgeons reviews its guidelines according to the Institute of Medicine's recommended best practice of reviewing guidelines every 5 yrs. The authors performed a planned 5-yr review of the medical literature used to develop the “Pediatric hydrocephalus: systematic literature review and evidence-based guidelines” and determined the need for an update to the original guideline based on new available evidence.

OBJECTIVE

To perform an update to include the current medical literature for the “Pediatric hydrocephalus: systematic literature review and evidence-based guidelines”, originally published in 2014.

METHODS

The Guidelines Task Force used the search terms and strategies consistent with the original guidelines to search PubMed and Cochrane Central for relevant literature published between March 2012 and November 2019. The same inclusion/exclusion criteria were also used to screen abstracts and to perform the full-text review. Full text articles were then reviewed and when appropriate, included as evidence and recommendations were added or changed accordingly.

RESULTS

A total of 41 studies yielded by the updated search met inclusion criteria and were included in this update.

CONCLUSION

New literature resulting from the update yielded a new recommendation in Part 2, which states that neuro-endoscopic lavage is a feasible and safe option for the removal of intraventricular clots and may lower the rate of shunt placement (Level III). Additionally a recommendation in part 7 of the guideline now states that antibiotic-impregnated shunt tubing reduces the risk of shunt infection compared with conventional silicone hardware and should be used for children who require placement of a shunt (Level I). &lt;https://www.cns.org/guidelines/browse-guidelines-detail/pediatric-hydrocephalus-guideline&gt;

Surgical resource utilization after initial treatment of infant hydrocephalus: comparing ETV, early experience of ETV with choroid plexus cauterization, and shunt insertion in the Hydrocephalus Clinical Research Network

OBJECTIVE

Few studies have addressed surgical resource utilization-surgical revisions and associated hospital admission days-following shunt insertion or endoscopic third ventriculostomy (ETV) with or without choroid plexus cauterization (CPC) for CSF diversion in hydrocephalus. Study members of the Hydrocephalus Clinical Research Network (HCRN) investigated differences in surgical resource utilization between CSF diversion strategies in hydrocephalus in infants.

METHODS

Patients up to corrected age 24 months undergoing initial definitive treatment of hydrocephalus were reviewed from the prospectively maintained HCRN Core Data Project (Hydrocephalus Registry). Postoperative courses (at 1, 3, and 5 years) were studied for hydrocephalus-related surgeries (primary outcome) and hospital admission days related to surgical revision (secondary outcome). Data were summarized using descriptive statistics and compared using negative binomial regression, controlling for age, hydrocephalus etiology, and HCRN center. The study population was organized into 3 groups (ETV alone, ETV with CPC, and CSF shunt insertion) during the 1st postoperative year and 2 groups (ETV alone and CSF shunt insertion) during subsequent years due to limited long-term follow-up data.

RESULTS

Among 1090 patients, the majority underwent CSF shunt insertion (CSF shunt, 83.5%; ETV with CPC, 10.0%; and ETV alone, 6.5%). Patients undergoing ETV with CPC had a higher mean number of revision surgeries (1.2 ± 1.6) than those undergoing ETV alone (0.6 ± 0.8) or CSF shunt insertion (0.7 ± 1.3) over the 1st year after surgery (p = 0.005). At long-term follow-up, patients undergoing ETV alone experienced a nonsignificant lower mean number of revision surgeries (0.7 ± 0.9 at 3 years and 0.8 ± 1.3 at 5 years) than those undergoing CSF shunt insertion (1.1 ± 1.9 at 3 years and 1.4 ± 2.6 at 5 years) and exhibited a lower mean number of hospital admission days related to revision surgery (3.8 ± 10.3 vs 9.9 ± 27.0, p = 0.042).

CONCLUSIONS

Among initial treatment strategies for hydrocephalus, ETV with CPC yielded a higher surgical revision rate within 1 year after surgery. Patients undergoing ETV alone exhibited a nonsignificant lower mean number of surgical revisions than CSF shunt insertion at 3 and 5 years postoperatively. Additionally, the ETV-alone cohort demonstrated significantly fewer hospital admission days related to surgical management of hydrocephalus within 3 years after surgery. These findings suggest a time-dependent benefit of ETV over CSF shunt insertion regarding surgical resource utilization.

Progressive hydrocephalus despite early complete reversal of hindbrain herniation after prenatal open myelomeningocele repair

OBJECTIVE

Open prenatal myelomeningocele (MMC) repair is typically associated with reversal of in utero hindbrain herniation (HBH) and has been posited to be associated with a reduction in both postoperative prenatal and immediate postnatal hydrocephalus (HCP) risks. However, the long-term postnatal risk of HCP following HBH reversal in these cases has not been well defined. The authors describe the results of a long-term HCP surveillance in a cohort of patients who underwent prenatal MMC repair at their institution.

METHODS

A retrospective review of all prenatal MMC repair operations performed at the Mayo Clinic between 2012 and 2017 was conducted. Pertinent data regarding the clinical courses of these patients before and after MMC repair were summarized. Outcomes of interest were occurrences of HBH and HCP and the need for intervention.

RESULTS

A total of 9 prenatal MMC repair cases were identified. There were 7 cases in which MRI clearly demonstrated prenatal HBH, and of these 86% (6/7) had evidence of HBH reversal after repair and prior to delivery. After a mean postnatal follow-up of 20 months, there were 3 cases of postnatal HCP requiring intervention. One case that failed to show complete HBH reversal after MMC repair required early ventriculoperitoneal shunting. The other 2 cases were of progressive, gradual-onset HCP despite complete prenatal HBH reversal, requiring endoscopic third ventriculostomy with choroid plexus cauterization at ages 5 and 7 months.

CONCLUSIONS

Although prenatal MMC repair can achieve HBH reversal in a majority of well-selected cases, the prevention of postnatal HCP requiring intervention appears not to be predicated on this outcome alone. In fact, it appears that in a subset of cases in which HBH reversal is achieved, patients can experience a progressive, gradual-onset HCP within the 1st year of life. These findings support continued rigorous postnatal surveillance of all prenatal MMC repair patients, irrespective of postoperative HBH outcome.

The Current State of Clinical Trials Studying Hydrocephalus: An Analysis of ClinicalTrials.gov

Introduction

Hydrocephalus is a significant public health concern estimated to affect 380,000 new individuals annually. In addition, it exhibits an increasingly high financial burden for the healthcare industry. Clinical trials are the gold standard for evaluating preventative and therapeutic strategies to bring potential treatments to the forefront of clinical practice.

Methods

A study of the ClinicalTrials.gov was conducted in April 2019 to examine all current and previously reported clinical trials studying hydrocephalus. Studies were reviewed to extrapolate information to characterize the current state of research being conducted for hydrocephalus.

Results

In total, 80 clinical trials met inclusion criteria and were analyzed: 48.8% were observation and 51.2% were interventional. Of those, 55% have been completed while 30.0% are still recruiting, and 15.0% are not yet recruiting. The United States has the most clinical trials (42.0%) and a plurality of trials has a sample size of 0-50 participants. The majority of studies included only adults (53.8%). Of those studies, 54.0% were cohort and the majority were prospective (74.0%). Of the different types of hydrocephalus, normal pressure hydrocephalus and pediatric hydrocephalus have generated the most interest for research comprising a majority of the clinical trial registry. While 44 of the trials are complete, only 20 have published results in peer-reviewed literature highlighting the need for improvement in publishing study results even if the results of the trials are null.

Conclusion

Most clinical trials to date have pertained to the treatment of normal pressure hydrocephalus and pediatric hydrocephalus. While great advancements have been made for the treatment of hydrocephalus, there remains much room for improvements in therapeutic interventional modalities as well as ensuring the reporting of all undertaken clinical trials.

Hydrocephalus in infants: the unique biomechanics and why they matter

OBJECT

Hydrocephalus diagnosed prenatally or in infancy differs substantially from hydrocephalus that develops later in life. The purpose of this review is to explore hydrocephalus that begins before skull closure and full development of the brain. Understanding the unique biomechanics of hydrocephalus beginning very early in life is essential to explain two poorly understood and controversial issues. The first is why is endoscopic third ventriculostomy (ETV) less likely to be successful in premature babies and in infants? The second relates to shunt failure in a subset of older patients treated in infancy leading to life-threatening intracranial pressure without increase in ventricular volume.

METHODS

The review will utilize engineering concepts related to ventricular volume regulation to explain the unique nature of hydrocephalus developing in the fetus and infant. Based on these concepts, their application to the treatment of complex issues of hydrocephalus management, and a review of the literature, it is possible to assess treatment strategies specific to the infant or former infant with hydrocephalus-related issues throughout life.

RESULTS

Based on engineering, all hydrocephalus, except in choroid plexus tumors or hyperplasia, relates to restriction of the flow of cerebrospinal fluid (CSF). Hydrocephalus develops when there is a pressure difference from the ventricles and a space exterior to the brain. When the intracranial volume is fixed due to a mature skull, that difference is between the ventricle and the cortical subarachnoid space. Due to the distensibility of the skull, hydrocephalus in infants may develop due to failure of the terminal absorption of CSF. The discussion of specific surgical treatments based on biomechanical concepts discussed here has not been specifically validated by prospective trials. The rare nature of the issues discussed and the need to follow the patients for decades make this quite difficult. A prospective registry would be helpful in the validation of surgical recommendations.

CONCLUSION

The time of first intervention for treatment of hydrocephalus is an important part of the history. Treatment strategies should be based on the assessment of the roll of trans-mantle pressure differences in deciding treatment strategies. Following skull closure distension of the ventricles at the time of shunt failure requires a pressure differential between the ventricles and the cortical subarachnoid space.

Cranial and ventricular size following shunting or endoscopic third ventriculostomy (ETV) in infants with aqueductal stenosis: further insights from the International Infant Hydrocephalus Study (IIHS)

PURPOSE

The craniometrics of head circumference (HC) and ventricular size are part of the clinical assessment of infants with hydrocephalus and are often utilized in conjunction with other clinical and radiological parameters to determine the success of treatment. We aimed to assess the effect of endoscopic third ventriculostomy (ETV) and shunting on craniometric measurements during the follow-up of a cohort of infants with symptomatic triventricular hydrocephalus secondary to aqueductal stenosis.

METHODS

We performed a post hoc analysis of data from the International Infant Hydrocephalus Study (IIHS)-a prospective, multicenter study of infants (< 24 months old) with hydrocephalus from aqueductal stenosis who were treated with either an ETV or shunt. During various stages of a 5-year follow-up period, the following craniometrics were measured: HC, HC centile, HC z-score, and frontal-occipital horn ratio (FOR). Data were compared in an analysis of covariance, adjusting for baseline variables including age at surgery and sex.

RESULTS

Of 158 enrolled patients, 115 underwent an ETV, while 43 received a shunt. Both procedures led to improvements in the mean HC centile position and z-score, a trend which continued until the 5-year assessment point. A similar trend was noted for FOR which was measured at 12 months and 3 years following initial treatment. Although the values were consistently higher for ETV compared with shunt, the differences in HC value, centile, and z-score were not significant. ETV was associated with a significantly higher FOR compared with shunting at 12 months (0.52 vs 0.44; p = 0.002) and 3 years (0.46 vs 0.38; p = 0.03) of follow-up.

CONCLUSION

ETV and shunting led to improvements in HC centile, z-score, and FOR measurements during long-term follow-up of infants with hydrocephalus secondary to aqueductal stenosis. Head size did not significantly differ between the treatment groups during follow-up, however ventricle size was greater in those undergoing ETV when measured at 1 and 3 years following treatment.

Endoscopic third ventriculostomy versus ventriculoperitoneal shunt in pediatric and adult population: a systematic review and meta-analysis

Treatment options for hydrocephalus include endoscopic third ventriculostomy (ETV) and ventriculoperitoneal shunt (VPS). Some ambiguity remains regarding indications, safety, and efficacy for these procedures in different clinical scenarios. The objective of the present study was to pool the available evidence to compare outcomes among patients with hydrocephalus undergoing ETV versus VPS. A systematic search of the literature was conducted via PubMed, EMBASE, and Cochrane Library through 11/29/2018 to identify studies evaluating failure and complication rates, following ETV or VPS. Pooled effect estimates were calculated using random effects. Heterogeneity was assessed by the Cochrane Q test and the I² value. Heterogeneity sources were explored through subgroup analyses and meta-regression. Twenty-three studies (five randomized control trials (RCTs) and 18 observational studies) were meta-analyzed. Comparing ETV to VPS, failure rate was not statistically significantly different with a pooled relative risk (RR) of 1.48, 95%CI (0.85, 2.59) for RCTs and 1.17 (0.89, 1.53) for cohort studies; P-interaction: 0.44. Complication rates were not statistically significantly different between ETV and VPS in RCTs (RR: 1.34, 95%CI: 0.50, 3.59) but were statistically significant for prospective cohort studies (RR: 0.47, 95%CI: 0.30, 0.78); P-interaction: 0.07. Length of hospital stay was no different, when comparing ETV and VPS. These results remained unchanged when stratifying by intervention type and when regressing on age when possible. No significant differences in failure rate were observed between ETV and VPS. ETV was found to have lower complication rates than VPS in prospective cohort studies but not in RCTs. Further research is needed to identify the specific patient populations who may be better suited for one intervention versus another.

Endoscopic third ventriculostomy inpatient failure rates compared with shunting in post-hemorrhagic hydrocephalus of prematurity

PURPOSE

Endoscopic third ventriculostomy (ETV) has gained traction as a method for treating post-hemorrhagic hydrocephalus of prematurity (PHHP) in an effort to obviate lifelong shunt dependence in neonates. However, data remains limited regarding inpatient failures.

METHODS

A retrospective analysis of the NIS between 1998 and 2014 was performed. Discharges with age < 1 year and ICD-9-CM codes indicating intraventricular hemorrhage of prematurity (772.1x) and ETV/shunt (02.22 and 02.3x) were included. Patients with ICD-9-CM codes for ventricular drain/reservoir (02.21) were excluded to prevent confounding. Time trend series plots were created. Yearly trends were quantified using logarithmic regression analysis. Kaplan-Meier curves were utilized to analyze time to treatment failure. Time to failure for each treatment was compared using log-rank.

RESULTS

A total of 11,017 discharges were identified. ETV was more likely to be utilized at < 29 weeks gestational age (p = 0.0039) and birth weight < 1000 g (p = 0.0039). Shunts were less likely to fail in older and heavier newborns (OR 0.836 p = 0.00456, OR 0.828 p = 0.0001, respectively). Those initially shunted had lower failure rates compared with ETV (OR 0.44, p < 0.0001) but time to failure was longer with ETV (p = 0.04562). 79.5% of ETVs that failed were shunted after the first failure. Shunts were much less likely to undergo ETV if they failed (OR 0.21, p < 0.0001). Higher grade IVH was predictive of shunt failure but not ETV (OR 2.36, p = 0.0129).

CONCLUSIONS

Although ETV can be effective in PHHP, it has a much higher initial failure rate than shunting and should thus be chosen based on a multifactorial approach.

Third ventricle floor bowing: a useful measurement to predict endoscopic third ventriculostomy success in infantile hydrocephalus

BACKGROUND

Preoperative judgment who will benefit from endoscopic third ventriculostomy (ETV) in infantile hydrocephalus remains controversial and no sufficient clue exists. Although ETV success score (ETVSS) is a useful scale in predicting ETV success in hydrocephalus, its efficacy in infants younger than 1 year old has been limited. This study aimed to verify the efficacy of a newly defined sign, "third ventricle floor bowing (TVFB)," in predicting ETV success in infantile hydrocephalus for the first time and discuss the mechanism of this sign and its clinical meanings.

METHODS

Between January 2013 and April 2018, hydrocephalic infants (age ≤ 12 months) with third ventricle floor bowing were treated endoscopically in the Department of Neurosurgery, West China Hospital. The medical records of these patients were reviewed. Additionally, we undertook a detailed review of the reported data on the treatment of infantile hydrocephalus with endoscopic third ventriculostomy (ETV).

RESULTS

A total of 42 infants underwent ETV alone in our institution, with a median age of 7.3 ± 3.8 months. Common etiologies included postinfectious (26.2%), arachnoid cyst (14.3%), aqueductal stenosis (11.9%), and congenital condition (11.9%). The complications included seizure (2.4%), CSF leak (2.4%), and subdural effusion (2.4%). During the average follow-up of 21.7 ± 13.1 months, the ETV success rate predicted by third ventricle floor bowing (TVFB) was 71.4%, which was higher than 6-month success rate predicted by the ETVSS (52.3%). However, it was difficult to reach statistical significance (P = 0.072) due to the limited sample size and further studies with larger sample size were needed.

CONCLUSIONS

Our study suggests TVFB can serve as a useful method for selecting ETV candidates in infantile hydrocephalus preoperatively. And we speculate that good ventricle compliance and pressure difference between the ventricle and subarachnoid space are essential elements in ensuring ETV success.

Endoscopic third ventriculostomy in children with third ventricular pressure gradient and open ventricular outlets on MRI

OBJECTIVE

Patients with non-communicating hydrocephalus due to aqueductal stenosis are often successfully treated with endoscopic third ventriculocisternostomy (ETV). In hydrocephalus, due to other locations of obstruction of the major CSF pathways, endoscopic treatment may also be a good option. We investigated our cohort of patients treated by ETV with patent ventricular outflow but pressure gradient signs at the third ventricle in a single-center retrospective study.

METHODS

We retrospectively reviewed records and imaging studies of 137 patients who underwent an ETV in our department in the time period of June 2010 to March 2018. We included patients who showed the following findings in MRI: 1st: open Sylvian aqueduct, 2nd: open outlets of the 4th ventricle, 3rd: open spinal canal, 4th: intra-/extraventricular pressure gradient seen at the 3rd ventricle and excluded patients with history of CSF infection or hemorrhage. Perioperative clinical state and possible complications or reoperations were recorded. Shunt dependency and changes in ventricular dilatation were measured as frontal and occipital horn ratio (FOHR) before surgery and during follow-up.

RESULTS

A total of 21 patients met the defined criteria. During the mean follow-up time of 40.7 ± 30 months (range; 5-102 months), two children had to undergo a re-ETV, and six children (all < 1 year of age) received a VP shunt. ETV shunt-free survival was 100% for children > 1 year of age. The ventricular width measured as FOHR was significantly reduced after ETV 0.5 ± 0.08 (range 0.42-0.69; p < 0.05). FOHR was significantly reduced at last follow-up shunt independent patients (0.47 ± 0.05; range 0.41-0.55; p < 0.001) CONCLUSION: We conclude that ETV seems to be a successful treatment option for patients with MRI signs of intra-/extraventricular pressure gradient at the 3rd ventricle and patent aqueduct and fourth ventricular outlets in children older than 1 year of age. This condition is observed only rarely and warrants further research on a multicenter basis in order to get more solid data of its pathophysiology.

Comparative Effectiveness of Surgical Treatments for Pediatric Hydrocephalus

BACKGROUND

Pediatric hydrocephalus represents a high health care burden in the United States (US). Surgery is the mainstay of treatment.

OBJECTIVE

To perform a comparative effectiveness analysis for endoscopic third ventriculostomy (ETV) and cerebrospinal fluid shunt placement in pediatric hydrocephalus patients in the US using a large administrative claims database through the application of propensity scores matching.

METHODS

The MarketScan® database (Truven Health Analytics, Atlanta, Georgia) 2003 to 2011 was used. Patients 19 yr or younger at first occurrence of ETV or shunt during the study period were included. The study outcome, surgery failure, was defined as further surgical treatment for hydrocephalus subsequent to initial ETV or shunt procedure. Age, etiology of hydrocephalus, and history of shunt were used to create matched samples for the ETV and shunt cohorts. Kaplan-Meier survival curves, stratified log-rank test, and Cox proportional-hazard models were used to analyze samples.

RESULTS

There were 3231 eligible cases (478 ETV; 2753 shunt). Propensity scores matching produced 455 balanced pairs. For matched samples, 326 of 455 (72%) pairs were concordant, while 129 pairs were discordant in surgery outcomes within 3 mo. Among discordant pairs, ETV patients were more likely to experience surgery failure compared to patients receiving shunt (relative risk = 1.4, P value = .011). Furthermore, patients' age < 1 yr had lower ETV success rates than those with shunt (P value = .009). No similar pattern was found in patients' age ≥ 1 yr.

CONCLUSION

There was no significant effect on time to failure between patients undergoing ETV and shunt, except in infants' age <1 yr.

Comparing the Efficiency of Two Treatment Methods of Hydrocephalus: Shunt Implantation and Endoscopic Third Ventriculostomy

Introduction:

Hydrocephalus is one of the most common diseases in children, and its treatment requires brain operation. However, the pathophysiology of the disease is very complicated and still unknown.

Methods:

Endoscopic Third Ventriculostomy (ETV) and Ventriculoperitoneal Shunt (VPS) implantation are among the common treatments of hydrocephalus. In this study, Cerebrospinal Fluid (CSF) hydrodynamic parameters and efficiency of the treatment methods were compared with numerical simulation and clinical follow-up of the treated patients.

Results:

Studies have shown that in patients under 19 years of age suffering from hydrocephalus related to a Posterior Fossa Brain Tumor (PFBT), the cumulative failure rate was 21% and 29% in ETV and VPS operation, respectively. At first, the ETV survival curve shows a sharp decrease and after two months it gets fixed while VPS curve makes a gradual decrease and reaches to a level lower than ETV curve after 5.7 months. Post-operative complications in ETV and VPS methods are 17% and 31%, respectively. In infants younger than 12 months with hydrocephalus due to congenital Aqueduct Stenosis (AS), and also in the elderly patients suffering from Normal Pressure Hydrocephalus (NPH), ETV is a better treatment option. Computer simulations show that the maximum CSF pressure is the most reliable hydrodynamic index for the evaluation of the treatment efficacy in these patients. After treatment by ETV and shunt methods, CSF pressure decreases about 9 and 5.3 times, respectively and 2.5 years after shunt implantation, this number returns to normal range.

Conclusion:

In infants with hydrocephalus, initial treatment by ETV was more reasonable than implanting the shunt. In adult with hydrocephalus, the initial failure in ETV occurred sooner compared to shunt therapy; however, ETV was more efficient.

The Scanty Knowledge of Endoscopic Third Ventriculostomy in Infants

Introduction:

Hydrocephalus (HCP) remains one of the commonest pathologies treated in developing countries. Endoscopic third ventriculostomy (ETV) has become the alternative to shunt-divergen procedures in the treatment of many pathologies of the cerebral fluid in the brain. Age has been considered a limitation to perform the procedure, we started to perform ETV In younger patients earlier than many other units. Objectives: In this study, we demonstrate the overall efficacy of ETV in infants younger than 1-year of age and to subsequently report the outcome of this procedure.

Methods:

From 2000 till 2016 we have performed a total of 386 cases of ETV of all ages. 71-cases were infants (below 1-year of age). Our study was undertaken to evaluate these cases. Patients were divided into two subgroups according to the cause of hydrocephalus; obstructive HCP, communicating HCP.

Results:

Mean time for follow up was 52 months. Mean age at surgery was 137days (7- 351days). The population included 31-females and 40-males, while10 infants were premature. Success rates were; 91.6%, 63.6% correspond to each sub-group with an overall success rate of 73.24%.

Conclusion:

ETV in infants is feasible, technically more demanding. Success rate justifies the procedure to be performed in such age group of patients. ETV can be used, attentively, in cases of hydrocephalus associated with MMC, morbidity and mortality does not differ from the general population.

Endoscopic third ventriculostomy versus shunt for pediatric hydrocephalus: a systematic literature review and meta-analysis

BACKGROUND

Optimized management of pediatric hydrocephalus remains the subject of debate. Ventriculoperitoneal shunt is largely considered the standard of care. However, the advancements and introduction of new cerebrospinal fluid (CSF) diversion approaches including the use of endoscopic third ventriculostomy (ETV) offer appealing alternatives that have been reported in numerous observational series.

OBJECTIVE

To evaluate the comparative safety and efficacy of shunting and ETV in pediatric hydrocephalus cases.

METHODS

This systematic literature review was performed according to the PRISMA guidelines. Eligible studies were identified through a search of PubMed (Medline) and Cochrane until October 2018. A random effects model meta-analysis was conducted and the I-square was used to assess heterogeneity. The ROBINS-1 tool and Cochrane tool were used to assess risk of bias in the observational and randomized studies, respectively.

RESULTS

Fourteen studies including 8419 patients were identified. Patients in the ETV group had a statistically significant lower risk of infection compared to shunt (OR: 0.19; 95% CI: 0.07-0.53; I²: 0%). All-cause mortality (OR: 0.77; 95% CI: 0.35-1.68; I²: 0%), post-operative CSF leak (OR: 1.53; 95% CI: 0.37-6.31; I²: 0%), and reoperation rates were similar between the two study groups (OR: 0.72; 95% CI: 0.39-1.32; I²: 93.5%). Subgroup analyses for re-operation demonstrated that ETV in Africa (OR: 0.13; 95% CI: 0.03-0.48; I²: 0%) and Europe (OR: 0.39; 95% CI: 0.30-0.52; I²:1.4%) was associated with significantly lower odds of re-operation compared to shunt, but not in USA/Canada (OR: 1.49; 95% CI: 0.85-2.63; I²:86.2%). Meta-regression analyses of age and duration of follow-up did not affect re-operation rates.

CONCLUSIONS

ETV was associated with a statistically significant lower risk of procedure-related infection compared to shunt. All-cause mortality, CSF leak, and re-operation rates were similar between the study groups. Subgroup analysis based on the geographic region showed that ETV is associated with statistically significant lower odds for re-operation in Europe and Africa, but not in USA/Canada. Future RCTs are needed to validate the results of this study and elucidate the cause of this heterogeneity.

TROPHY registry study design: a prospective, international multicenter study for the surgical treatment of posthemorrhagic hydrocephalus in neonates

INTRODUCTION

Among children with hydrocephalus, neonates with intraventricular hemorrhage (IVH) and posthemorrhagic hydrocephalus (PH) are considered a group with one of the highest complication rates of treatment. Despite continued progress in neonatal care, a standardized and reliable guideline for surgical management is missing for this challenging condition. Thus, further research is warranted to compare common methods of surgical treatment. The introduction of neuroendoscopic lavage has precipitated the establishment of an international registry aimed at elaborating key elements of a standardized surgical treatment.

METHODS

The registry is designed as a multicenter, international, prospective data collection for neonates aged 41 weeks gestation, with an indication for surgical treatment for IVH with ventricular dilatation and progressive hydrocephalus. The following initial temporizing surgical interventions, each used as standard treatment at participating centers, will be compared: external ventricular drainage (EVD), ventricular access device (VAD), ventricular subgaleal shunt (VSGS), and neuroendoscopic lavage (NEL). Type of surgery, perioperative data including complications and mortality, subsequent shunt surgeries, ventricular size, and neurological outcome will be recorded at 6, 12, 36, and 60 months.

RESULTS

An online, password-protected website will be used to collect the prospective data in a synchronized manner. As a prospective registry, data collection will be ongoing, with no prespecified endpoint. A prespecified analysis will take place after a total of 100 patients in the NEL group have been entered. Analyses will be performed for safety (6 months), shunt dependency (12, 24 months), and neurological outcome (60 months).

CONCLUSION

The design and online platform of the TROPHY registry will enable the collection of prospective data on different surgical procedures for investigation of safety, efficacy, and neurodevelopmental outcome of neonates with IVH and hydrocephalus. The long-term goal is to provide valid data on NEL that is prospective, international, and multicenter. With the comparison of different surgical treatment modalities, we hope to develop better therapy guidelines for this complex neurosurgical condition.

[Factors of endoscopic third ventriculostomy efficacy in infants with obstructive hydrocephalus under one year of age]

Endoscopic surgery for obstructive hydrocephalus in children is an alternative to shunts. Currently, the efficacy of endoscopic third ventriculostomy (ETV) in infants up to one year of age is increasingly discussed among neurosurgeons. To increase the efficacy of ETV, many surgeons raise the question: what factors may affect the efficacy of this procedure in the younger age group?

OBJECTIVE

To study the factors affecting the efficacy of ETV.

MATERIAL AND METHODS

A total of 88 ETVs were performed in infants under one year of age in our clinic in 2012-2016. Subsequently, 43 (48.9%) children underwent CSF shunting, and one child underwent repeated ETV. The mean time until the appearance of clinical signs of stoma closure was 3.9 months (116 days).

RESULTS

The procedure was most effective in the case of congenital obstructive hydrocephalus (64.5% of successful operations) and also in children over the age of 6 months (63.6% of successful operations). The efficacy in post-hemorrhagic hydrocephalus was 40%. The efficacy in grade 4 intraventricular hemorrhage was lowest and amounted to 25%. The total efficacy of ETV in children under one year of age in our study was 51.1%.

CONCLUSION

In the case of congenital obstructive hydrocephalus, the efficacy of ETV is maximal and amounts to 64.5%. To achieve the highest efficacy of ETV in infants under one year of age, careful selection of patients at the preoperative stage is necessary, with allowance for many factors affecting treatment outcome.

Prospective multicenter studies in pediatric hydrocephalus

Prospective multicenter clinical research studies in pediatric hydrocephalus are relatively rare. They cover a broad spectrum of hydrocephalus topics, including management of intraventricular hemorrhage in premature infants, shunt techniques and equipment, shunt outcomes, endoscopic treatment of hydrocephalus, and prevention and treatment of infection. The research methodologies include randomized trials, cohort studies, and registry-based studies. This review describes prospective multicenter studies in pediatric hydrocephalus since 1990. Many studies have included all forms of hydrocephalus and used device or procedure failure as the primary outcome. Although such studies have yielded useful findings, they might miss important treatment effects in specific subgroups. As multicenter study networks grow, larger patient numbers will allow studies with more focused entry criteria based on known and evolving prognostic factors. In addition, increased use of patient-centered outcomes such as neurodevelopmental assessment and quality of life should be measured and emphasized in study results. Well-planned multicenter clinical studies can significantly affect the care of children with hydrocephalus and will continue to have an important role in improving care for these children and their families.

International Infant Hydrocephalus Study (IIHS): 5-year health outcome results of a prospective, multicenter comparison of endoscopic third ventriculostomy (ETV) and shunt for infant hydrocephalus

INTRODUCTION

One of the most important unanswered questions in pediatric hydrocephalus is determining whether treatment with endoscopic third ventriculostomy (ETV) versus shunt results in improved health status and quality of life (QOL). To answer this, the International Infant Hydrocephalus Study (IIHS) was started in 2005 as a prospective, multicenter study to compare ETV and shunt in infants (< 24 months old) with symptomatic triventricular hydrocephalus from aqueductal stenosis. Herein, we present the 5-year primary outcome results.

METHODS

IIHS utilized a prospective comprehensive cohort design, in which patients received ETV or shunt, based on either randomization or parental preference. For this analysis, we pooled the randomized arm and the parental preference arm, analyzing them together. At 5 years of age, children were assessed with the Health Utilities Index Mark 2 (HUI-2) (primary outcome) and the Hydrocephalus Outcome Questionnaire (HOQ), a measure of QOL. Results were compared in an analysis of covariance, adjusting for baseline variables including age at surgery and baseline development status.

RESULTS

From a total of 158 patients who met eligibility criteria, complete 5-year outcomes were available on 78 (19 treated initially with shunt, 61 treated initially with ETV), assessed at a mean age of 62.1 months (SD 6.3). The mean 5-year HUI-2 utility score was 0.90 (SD 0.19) for ETV and 0.94 (SD 0.10) for shunt (p = 0.21). The mean 5-year HOQ overall score was 0.81 (SD 0.15) for ETV and 0.85 (SD 0.12) for shunt (p = 0.42). Similarly, there were no significant differences noted between 5-year HOQ subscores (cognitive, social-emotional, physical) or developmental measures at 1, 2, and 3 years.

CONCLUSIONS

This is the first prospective direct comparison of long-term outcomes of ETV and shunt for infant hydrocephalus. These results suggest that overall health status and quality of life in this cohort of infants treated for aqueductal stenosis are high, with no significant difference between those treated initially with ETV or shunt.

TRIAL REGISTRATION

NCT00652470.

Experience in shunt management on revision free survival in infants with myelomeningocele

OBJECTIVE

Depending on the etiology of hydrocephalus in childhood, the shunt therapy still remains challenging due to frequent shunt complications leading to possible revisions such as shunt infection or shunt malfunction. In myelomeningocele (MMC) patients who often require shunt therapy, higher revisions rates were reported. In a single-center retrospective study, experiences on shunt regimen on hydrocephalus associated with MMC are presented.

METHODS

Data of 160 infant hydrocephalus cases younger than 1 year of age at the time of implantation were retrospectively reviewed from the hospital database. These patients received an adjustable differential pressure valve with gravitational unit and antibiotic impregnated catheters as a primary or secondary implant during the time period of April 2007 to July 2015. The subgroup of infants cases with MMC (n = 44; age 50.6 ± 80.6 days) were compared to the remaining cohort of other hydrocephalus etiology (control group). The shunt and valve revision free survival rates were recorded until July 2017.

RESULTS

During the mean follow-up of 48.7 ± 19.2 (7-114) months, the shunt revision free survival was 87% at 1 year and 49% at 60 months in the MMC cohort. The control group showed a shunt survival rate of 68% at 1 year and 39% at 60 months. Similarly, the valve revision free survival rate showed a significant higher rate of 92% at 1 year and 69% at 60 months in the MMC group compared to the control group (75% at 1 year and 51% at 60 months; p < 0.05). During the entire follow-up period, 37% of the MMC infants underwent a revision operation in contrast to the control group of 40%.

CONCLUSION

The presented shunt strategy showed improved revision free survival rates in infants with a MMC-related hydrocephalus in comparison to other etiologies of hydrocephalus in infants, which might relate to infection prophylaxis and high drainage resistance integrated in the shunt system.

Endoscopic third ventriculostomy and choroid plexus cauterization in infant hydrocephalus: a prospective study by the Hydrocephalus Clinical Research Network

OBJECTIVE High-quality data comparing endoscopic third ventriculostomy (ETV) with choroid plexus cauterization (CPC) to shunt and ETV alone in North America are greatly lacking. To address this, the Hydrocephalus Clinical Research Network (HCRN) conducted a prospective study of ETV+CPC in infants. Here, these prospective data are presented and compared to prospectively collected data from a historical cohort of infants treated with shunt or ETV alone. METHODS From June 2014 to September 2015, infants (corrected age ≤ 24 months) requiring treatment for hydrocephalus with anatomy suitable for ETV+CPC were entered into a prospective study at 9 HCRN centers. The rate of procedural failure (i.e., the need for repeat hydrocephalus surgery, hydrocephalus-related death, or major postoperative neurological deficit) was determined. These data were compared with a cohort of similar infants who were treated with either a shunt (n = 969) or ETV alone (n = 74) by creating matched pairs on the basis of age and etiology. These data were obtained from the existing prospective HCRN Core Data Project. All patients were observed for at least 6 months. RESULTS A total of 118 infants underwent ETV+CPC (median corrected age 1.3 months; common etiologies including myelomeningocele [30.5%], intraventricular hemorrhage of prematurity [22.9%], and aqueductal stenosis [21.2%]). The 6-month success rate was 36%. The most common complications included seizures (5.1%) and CSF leak (3.4%). Important predictors of treatment success in the survival regression model included older age (p = 0.002), smaller preoperative ventricle size (p = 0.009), and greater degree of CPC (p = 0.02). The matching algorithm resulted in 112 matched pairs for ETV+CPC versus shunt alone and 34 matched pairs for ETV+CPC versus ETV alone. ETV+CPC was found to have significantly higher failure rate than shunt placement (p < 0.001). Although ETV+CPC had a similar failure rate compared with ETV alone (p = 0.73), the matched pairs included mostly infants with aqueductal stenosis and miscellaneous other etiologies but very few patients with intraventricular hemorrhage of prematurity. CONCLUSIONS Within a large and broad cohort of North American infants, our data show that overall ETV+CPC appears to have a higher failure rate than shunt alone. Although the ETV+CPC results were similar to ETV alone, this comparison was limited by the small sample size and skewed etiological distribution. Within the ETV+CPC group, greater extent of CPC was associated with treatment success, thereby suggesting that there are subgroups who might benefit from the addition of CPC. Further work will focus on identifying these subgroups.

Hydrocephalus in children under the age of five from diagnosis to short-/medium-/long-term progression: a retrospective review of 142 children

The aim of this study is to evaluate the clinical history and prognosis of children with early-onset hydrocephalus. The retrospective study's inclusion criteria were hydrocephalus diagnosis before the age of 5 years, independent of aetiology, and birth details, January 1, 2000 to December 31, 2014. Overall, 142 children were entered into the study, divided into 11 aetiological groups: premature-birth post-intraventricular haemorrhage (16%), brain tumours (16%), spina bifida (15%), aqueductal stenosis (8%), post-meningitis (8%), post-haemorrhage (8%), Dandy-Walker malformation (6%), unknown origin (6%), arachnoid cyst (5%), miscellaneous obstruction (4%), and various causes (8%). In total, 23 patients died, primarily from the tumour group. Ventriculostomy, performed 42 times, was successful in 20 patients. Overall, 226 internal shunts were placed in 99 children. Infectious complications affected 19% of children after shunt placement and 51% after mechanical complications. Mean follow-up was 4 years 10 months, with 61% of children progressing fairly well, especially those with aqueductal stenosis, cysts, and unknown or diverse obstructive causes. Post-meningitis hydrocephalus displayed the poorest outcome. Isolated obstructive hydrocephalus exhibited better prognosis, with most obstructive aetiologies effectively treated via ventriculostomy. Children treated by shunt placement were more at risk of complications. Aetiologies with associated abnormalities and neurological sequelae had poorer outcomes.

Endoscopic third ventriculostomy in children with a fiber optic neuroendoscopy

OBJECTIVE

Endoscopic third ventriculostomy (ETV) provides a shunt-free treatment for obstructive hydrocephalus children. With rapidly evolving technology, the semi-rigid fiber optic neuroendoscopy shows a potential application in ETV by blunt fenestration. A retrospective analysis of our experience is reviewed.

METHODS

The authors review infants and children who underwent ETV using this technique from June 2004 to June 2016 with radiological and clinical follow-up done by a single surgeon. Patients who underwent ETV with channel scope were excluded. Demographic variables and operative reports were collected. Improvement of preoperative symptoms and avoidance of additional cerebrospinal fluid (CSF) diversion procedures were considered a success. The ETV success score (ETVSS) was used to correlate with clinical outcomes.

RESULTS

A total of 79 patients were included with a mean age of 8.3 ± 5.5 years, and 40.5% were female. The mean clinical and radiographic follow-up was 38.6 ± 40.9 months. The overall complication rate was 6.3%, while 73.4% were considered successful. The ETV failure cases received conversion to ventriculoperitoneal shunt or redo of ETV with a median time of 2 months. The mean ETV success score was 74.3 ± 11.8 with positive correlation between success rate (P < 0.05). Kaplan-Meier failure-free survival rates of 30-day, 90-day, 6-month, 1-year, and 2-year were 89.9, 83.5, 78.5, 75.9, and 74.6%. Eight patients required redo ETV, and five of these patients required eventual shunt placements. Approximately 61.9% of failure occurred within 3 months. Patients with post-intraventricular hemorrhage (IVH) /infection, and age younger than 12 months had the poorest outcome (P < 0.05).

CONCLUSIONS

Blunt dissection of the third ventricle floor under endoscopic vision with the stylet tip of a fiber optic neuroendoscopy is safe and requires less equipment in the pediatric population. This technique is successful with an optimistic long-term outcome except for infants and the post-IVH and infectious subgroups.

Controlled Trial to Compare Therapeutic Efficacy of Endoscopic Third Ventriculostomy Plus Choroid Plexus Cauterization with Ventriculoperitoneal Shunt in Infants with Obstructive Hydrocephalus

Context:

Ventriculoperitoneal (VP) shunt and endoscopic third ventriculostomy (ETV) are the established surgical treatments for obstructive hydrocephalus (HCP). Powerful evidence regarding the best therapeutic approach for infants with obstructive HCP is lacked.

Aims:

Comparison of the therapeutic efficacy of VP shunt and ETV/choroid plexus cauterization (CPC) in infants with obstructive HCP.

Settings and Design:

This was a randomized, active control, unblind, single-center, clinical trial.

Methods:

Infants with obstructive HCP were randomly allocated to each intervention group (ETV/CPC or VP shunt). They were monitored for at least 6 months for any sign of raised intracranial pressure (rICP). The recurrence of rICP signs requiring surgical intervention was considered as intervention failure.

Statistical Analysis:

The association between intervention group and outcome was tested with Chi-square test, and P = 0.05 or less was considered statistically significant.

Results:

Of the total fifty patients entering the study, 49 were included in the final analysis, 27 of them were in VP shunt and 22 in ETV/CPC group. Seventeen patients (34%) were female and 33 (66%) were male with mean age of 3.74 ± 3.1 months (range = 10 days – 11 months). Thirty-nine (79.6%) were under 6 months of age and the remaining were 6 months or older. The overall success rate in 36-month follow-up was 88.5% and 68.2% for VP shunt and ETV/CPC, respectively, with the difference being not statistically significant.

Conclusion:

The current study determined no inferiority of ETV/CPC compared to VP shunt, and therefore, it may become an efficient treatment for obstructive HCP in infants.

Update on Endoscopic Third Ventriculostomy in Children

Endoscopic third ventriculostomy (ETV) provides a physiological restoration of cerebrospinal fluid and a shunt-free option for hydrocephalus children. Continuous developments in techniques and instruments have improved ETV as the first-line treatment. This paper focuses on the recent advances in surgical techniques, instruments, predictive models, imaging tools, and new cohort studies. The efficacy, safety, indications, and remaining challenges of ETV are discussed. More patients undergo ETV with a better outcome, identifying a new era of hydrocephalus treatment. Deeper understanding of ETV will improve a better shunt-free survival for pediatric hydrocephalus patients.