Neuroendoscopic third ventriculostomy for failed shunts

Clinical Outcome of Endoscopic Procedure in Patients with Shunt Malfunction

OBJECTIVE

The goal of this study was to analyze the clinical outcomes of endoscopic third ventriculostomy (ETV) and endoscopic septostomy when shunt malfunction occurs in a patient who has previously undergone placement of a ventriculoperitoneal shunt.

METHODS

From 2001 to 2020 at Seoul National University Children's Hospital, patients who underwent ETV or endoscopic septostomy for shunt malfunction were retrospectively analyzed. Initial diagnosis (etiology of hydrocephalus), age at first shunt insertion, age at endoscopic procedure, magnetic resonance or computed tomography image, subsequent shunting data, and follow-up period were included.

RESULTS

Thirty-six patients were included in this retrospective study. Twenty-nine patients, 18 males and 11 females, with shunt malfunction underwent ETV. At the time of shunting, the age ranged from 1 day to 15.4 years (mean, 2.4 years). The mean age at the time of ETV was 13.1 years (range, 0.7 to 29.6 years). Nineteen patients remained shunt revision free. The 5-year shunt revisionfree survival rate was 69% (95% confidence interval [CI], 0.54-0.88). Seven patients, three males and four females, with shunt malfunction underwent endoscopic septostomy. At the time of shunting, the age ranged from 0.2 to 12 years (mean, 3.9 years). The mean age at the time of endoscopic septostomy was 11.9 years (range, 0.5 to 29.5 years). Four patients remained free of shunt revision or addition. The 5-year shunt revision-free survival rate was 57% (95% CI, 0.3-1.0). There were no complications associated with the endoscopic procedures.

CONCLUSION

The results of our study demonstrate that ETV or endoscopic septostomy can be effective and safe in patients with shunt malfunction.

Endoscopic third ventriculostomy in previously shunt-treated patients

OBJECTIVE

Endoscopic third ventriculostomy (ETV) is an option for treatment of hydrocephalus, including for patients who have a history of previous treatment with CSF shunt insertion. The purpose of this study was to report the success of postshunt ETV by using data from a multicenter prospective registry.

METHODS

Prospectively collected data in the Hydrocephalus Clinical Research Network (HCRN) Core Data Project (i.e., HCRN Registry) were reviewed. Children who underwent ETV between 2008 and 2019 and had a history of previous treatment with a CSF shunt were included. A Kaplan-Meier survival curve was created for the primary outcome: time from postshunt ETV to subsequent CSF shunt placement or revision. Univariable Cox proportional hazards models were created to evaluate for an association between clinical and demographic variables and subsequent shunt surgery. Postshunt ETV complications were also identified and categorized.

RESULTS

A total of 203 children were included: 57% male and 43% female; 74% White, 23% Black, and 4% other race. The most common hydrocephalus etiologies were postintraventricular hemorrhage secondary to prematurity (56, 28%) and aqueductal stenosis (42, 21%). The ETV Success Score ranged from 10 to 80. The median patient age was 4.1 years. The overall success of postshunt ETV at 6 months was 41%. Only the surgeon's report of a clear view of the basilar artery was associated with a lower likelihood of postshunt ETV failure (HR 0.43, 95% CI 0.23-0.82, p = 0.009). None of the following variables were associated with postshunt ETV success: age at the time of postshunt ETV, etiology of hydrocephalus, sex, race, ventricle size, number of previous shunt operations, ETV performed at time of shunt infection, and use of external ventricular drainage. Overall, complications were reported in 22% of patients, with CSF leak (8.6%) being the most common complication.

CONCLUSIONS

Postshunt ETV was successful in treating hydrocephalus, without subsequent need for a CSF shunt, in 41% of patients, with a clear view of the basilar artery being the only variable significantly associated with success. Complications occurred in 22% of patients. ETV is an option for treatment of hydrocephalus in children who have previously undergone shunt placement, but with a lower than expected likelihood of success.

Endoscopic Third Ventriculostomy in Failed Ventriculoperitoneal Shunt in Pediatric Population

Introduction

Ventriculoperitoneal (VP) shunt malfunction is common in pediatric age group patients. There is a high complication rate and revision rate of VP shunt. Endoscopic third ventriculostomy (ETV) can alleviate these complications and can act as an effective alternative for the treatment of hydrocephalus in this age group of patients.

Materials and Methods

The authors retrospectively reviewed the management and outcome of 36 failed VP shunts in pediatric patients for the treatment of hydrocephalus. The surgeries were performed between November 2010 and January 2016 in a tertiary care hospital. The minimal follow-up period was 3 months. We divided the patients into the following age groups: <1 year (eight infants), 1-10 years (18 children), and 10-18 years (10 children). The success of the procedure was determined by age, sex, type of hydrocephalus, and the number of shunt revisions and malfunction before ETV. Children with different age (P = 0.839) and sex group did not show any significant data (P = 0.798). Children with communicating hydrocephalus had a success rate of 52.9% (17 patients), and children with noncommunicating hydrocephalus had a success rate of 84.2% (19 patients). The success rate in children with only one shunt malfunction was 57.1% (21 patients), whereas in 15 children with two or more shunt malfunctions, the success rate of ETV was 86.7%.

Conclusions

The authors conclude that ETV is an effective alternative for the treatment of hydrocephalus in children. Age does not present a contraindication for ETV in failed VP shunt.

Endoscopic third ventriculostomy for VP shunt malfunction during the third trimester of pregnancy: illustrative case

BACKGROUND

Endoscopic third ventriculostomy (ETV) is a successful procedure for treating noncommunicating hydrocephalus as an alternative to initial ventriculoperitoneal (VP) shunt placement and as a salvage procedure when a VP shunt fails. Physiological changes of pregnancy can lead to VP shunt failure and complicate the management of shunt malfunction, particularly in the third trimester.

OBSERVATIONS

The authors present a case in which an ETV was successfully used in the third trimester (31 weeks of gestation) of pregnancy for acute hydrocephalus due to VP shunt malfunction, and the patient went on to deliver a healthy baby at term; the patient remained well in the long-term follow-up. An English-language PubMed literature review revealed four cases of VP shunt failure successfully treated with an ETV in the first or second trimester but no such reports in the third trimester of pregnancy.

LESSONS

ETV appears to be a safe and effective alternative to VP shunt replacement in the late prenatal period of pregnancy.

Endoscopic third ventriculostomy for myelomeningocele-related hydrocephalus after shunt failure: Long-term outcome in a series of 8 patients

OBJECTIVE

Endoscopic third ventriculostomy (ETV) has now become an accepted mode of hydrocephalus treatment. However, the long-term effects of ETV for myelomeningocele-related hydrocephalus (MMC-rH) after shunt malfunction remains unclear. We aimed to assess the long-term outcome and the factors associated with the success of ETV for MMC-rH after shunt malfunction.

METHODS

We performed a retrospective analysis of data collected between 2001 and 2018 from 8 patients with MMC-rH after shunt malfunction, who underwent ETV at the Kurume University Hospital and were followed up for at least 5 years. We extracted data regarding age, sex, clinical symptoms, radiological imaging, intraoperative findings, and outcomes.

RESULTS

The overall success rate was 62.5% and their ETV success score is 67.5. The most frequent clinical symptom was intracranial hypertension symptoms (100 %), followed by Chiari type II symptoms (87.5 %). In preoperative MRI scans, we observed aqueduct stenosis in 6 cases, Chiari type II malformations in 7 cases, four patients had a narrow prepontine cistern, five patients had an absent septum pellucidum, and three presented with stenosis of the foramen of Monro. All cases in the failure group had the above 5 symptoms. Based on intraoperative findings, a thick third ventricle floor was found in 5 patients. Two patients had a thin hypothalamic adhesion in the third ventricle floor. They had no major complications.

CONCLUSION

ETV for MMC-rH after shunt malfunction is an effective treatment option. However, we recommend that a neurosurgeon with extensive experience in neuroendoscopy perform ETV because MMC patients more often had intraventricular malformations than those with other hydrocephalus diseases.

Converting Pediatric Patients and Young Adults From a Shunt to a Third Ventriculostomy: A Multicenter Evaluation

BACKGROUND

Endoscopic third ventriculostomy (ETV) is an effective primary treatment for certain forms of hydrocephalus. However, its use in children with an existing shunt is less well known.

OBJECTIVE

To report a multicenter experience in attempting to convert patients from shunt dependence to a third ventriculostomy and to determine predictors of success.

METHODS

Three participating centers provided retrospectively collected information on patients with an attempted conversion from a shunt to an ETV between December 1, 2008, and April 1, 2018. Demographic, clinical, and radiological data were recorded. Success was defined as shunt independence at the last follow-up.

RESULTS

Eighty patients with an existing ventricular shunt underwent an ETV. The median age at the time of the index ETV was 9.9 yr, and 44 (55%) patients were male. The overall success rate was 64% (51/80), with a median duration of follow-up of 2.0 yr (range, 0.1-9.4 yr). Four patients required a successful repeat ETV at a median of 1.7 yr (range, 0.1-5.7 yr) following the index ETV. Only age was predictive of ETV failure on multivariate analysis (odds ratio 0.86 [95% CI 0.78-0.94], P = .005). No patient less than 6 mo of age underwent an ETV, and of the 5 patients between 6 and 12 mo of age, 4 failed.

CONCLUSION

Although not every shunted patient will be a candidate for an ETV, nor will they be successfully converted, an ETV should at least be considered in every child who presents with a shunt malfunction or who has an externalized shunt.

Functional and Radiological Parameters to Assess Outcome of Endoscopic Third Ventriculostomy in Shunt Failure Patients

Background:

Placement of ventriculoperitoneal shunt is a standard treatment for hydrocephalus. The risk of shunt malfunction in the first year is 25%–40% making endoscopic third ventriculostomy (ETV) a feasible option in those patients with shunt failure.

Aim:

The aim of this study was to evaluate ETV as a viable option in patients with shunt malfunction and to correlate the clinical outcome following successful ETV with functional and radiological outcomes.

Materials and Methods:

All patients who underwent ETV as a diversion procedure for hydrocephalus following shunt failure or malfunction over 1 year were studied. Functional outcome was evaluated by Wee function independence measure score carried out preoperatively, postoperatively, and at 6-month follow-up. Similar comparison was carried out for radiological parameters such as effacement of gyri, periventricular lucency, frontal horn diameter (maximum), Evans’ index, and third ventricular diameter.

Results:

Of 15 patients, 61.5% were shunt free after ETV. All the failures were noted in the first month following the procedure. The factors, which showed statistically significant correlation with the outcome of ETV, included age (P = 0.030), preoperative functional score (P = 0.006), and all the three components of the functional scoring, namely self-care score (P = 0.087), motor control score (P = 0.035), and neurocognitive score (P = 0.003). Parameters such as Evans’ index, maximum frontal horn diameter, and third ventricular diameter showed no significant difference between preoperative and postoperative scans. In follow-up imaging, only the frontal horn diameter showed a significant improvement (P = 0.047).

Conclusion:

ETV leads to significant neurocognitive improvement and postoperative functional status making it a viable option in patients who present with shunt malfunction.

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.

Simultaneous ventriculoperitoneal shunt removal and endoscopic third ventriculostomy for three patients previously treated for intracranial germ cell tumors more than 20 years ago

BACKGROUND

Obstructive hydrocephalus is the most common complication of intracranial germ cell tumors (IGCTs). Although ventriculoperitoneal shunts (VPSs) were previously used for treating this condition, they have recently been replaced by endoscopic third ventriculostomy (ETV), as the latter can avoid various complications caused by a VPS and can preserve physiological cerebrospinal fluid (CSF) dynamics. Therefore, if a VPS malfunctioned in patients who had previously been treated for IGCTs, it seems reasonable to consider removing the problematic VPS, followed by ETV, as long as magnetic resonance imaging reveals third ventricle floor ballooning and the cause of obstruction in the ventricular system, which are indicators for ETV.

CASE PRESENTATION AND DISCUSSION

Here, we present the cases of three patients who underwent simultaneous removal of malfunctioning VPSs and ETV, more than 20 years (range 20-27 years) after initial treatment for IGCT and relevant obstructive hydrocephalus. Despite a relatively long shunt dependency, their obstructive hydrocephalus was well-managed by ETV, probably because CSF absorptive capacity remained intact after IGCT ablation by radio-chemotherapy.

CONCLUSION

Patients with previously treated IGCTs can thus be released from the need for a VPS, regardless of long-term shunt dependency.

Endoscopic Third Ventriculostomy Instead of Shunt Revision in Children Younger Than 3 Years of Age

OBJECTIVE

Endoscopic third ventriculostomy (ETV) is a valuable option in the treatment of shunt failure, but no clinical data exist for young children. The aim of this study was to elucidate the role of ETV in patients younger than 3 years of age with shunt malfunction.

METHODS

A cohort of 37 patients younger than 3 years of age with shunt malfunction underwent ETV instead of shunt revision. Patients' preoperative condition and medical history were studied to determine the impact of a number of variables on outcome. The Fisher exact test was used to assess differences among groups.

RESULTS

Median age at ETV was 21.6 months (8-36 months). Diagnosis was obstructive hydrocephalus in 24 patients and communicating hydrocephalus in 13. Median age at initial shunt placement was 3.2 months (10 days to 30 months). The etiology of shunt malfunction was obstruction (n = 27) or infection (n = 10). Overall ETV failure rate was 40.5% (15/37). Patients whose age at initial shunt placement was <6 months and/or who had a preterm birth history had higher relative rates of ETV failure. Other variables, including type of hydrocephalus, interval between initial shunt placement and ETV, history of intraventricular bleeding and/or infection, and etiology of shunt malfunction, did not significantly affect the final outcome.

CONCLUSIONS

Patients younger than 3 years with obstructive or communicating hydrocephalus may benefit from ETV in the event of shunt malfunction and have about a 60% probability of becoming shunt free.

Endoscopic Third Ventriculostomy in 250 Adults With Hydrocephalus

BACKGROUND:

Endoscopic third ventriculostomy (ETV) has been used predominantly in the pediatric population in the past. Application in the adult population has been less extensive, even in large neurosurgical centers. To our knowledge, this report is one of the largest adult ETV series reported and has the consistency of being performed at 1 center.

OBJECTIVE:

To determine the efficacy, safety, and outcome of ETV in a large adult hydrocephalus patient series at a single neurosurgical center. In addition, to analyze patient selection criteria and clinical subgroups (including those with ventriculoperitoneal shunt [VPS] malfunction or obstruction and neurointensive care unit patients with extended ventricular drainage before ETV) to optimize surgical results in the future.

METHODS:

We conducted a retrospective review of adult ETV procedures performed at our center between 2000 and 2014.

RESULTS:

The overall rate of success (no further cerebrospinal fluid diversion procedure performed plus clinical improvement) of 243 completed ETVs was 72.8%. Following is the number of procedures with the success rate in parentheses: aqueduct stenosis, 56 (91%); communicating hydrocephalus including normal pressure hydrocephalus, nonnormal pressure hydrocephalus, and remote head trauma, 57 (43.8%); communicating hydrocephalus in postoperative posterior fossa tumor without residual tumor, 14 (85.7%); communicating hydrocephalus in subarachnoid hemorrhage without intraventricular hemorrhage, 23 (69.6%); obstruction from tumor/cyst, 42 (85.7%); VPS obstruction (diagnosis unknown), 23 (65.2%); intraventricular hemorrhage, 20 (90%); and miscellaneous (obstructive), 8 (50%). There were 9 complications in 250 intended procedures (3.6%); 5 (2%) were serious.

CONCLUSION:

Use of ETV in adult hydrocephalus has broad application with a low complication rate and reasonably good efficacy in selected patients.

Endoscopic Third Ventriculostomy in Children with Myelomeningocele: A Case Series

Hydrocephalus develops in up to 80-90% of children with myelomeningocele (MM) after closure of the defect. Traditionally, ventriculoperitoneal shunts have been used to manage hydrocephalus in these patients. A role for endoscopic third ventriculostomy (ETV) in MM has provoked much debate, principally due to anatomical variants described, which may complicate the procedure. We present 7 cases of children with MM and hydrocephalus undergoing a total of 10 ETV procedures. All patients demonstrated clinical improvement (in acute/subacute cases) or stabilization (in chronic cases). Three patients requiring a second ETV have shown clinical stability and renewed radiological evidence of functioning ventriculostomies in follow-up since reintervention. ETV can be used, albeit cautiously, in selected cases of hydrocephalus associated with MM. However, the frequency with which anatomical variation is encountered and the difficulty of the assessment of success make the procedure more challenging than usual.

Prior CSF shunting increases the risk of endoscopic third ventriculostomy failure in the treatment of obstructive hydrocephalus in adults

INTRODUCTION

Endoscopic third ventriculostomy (ETV) is accepted as an effective treatment for obstructive hydrocephalus (OHC); however, its benefit in patients previously treated with cerebrospinal fluid (CSF) shunting remains unclear. The value of concurrent ETV and ventriculoperitoneal (VP) shunting in patients with frequent shunt failure remains unstudied.

METHODS

Outcomes were compared between OHC patients receiving ETV as initial CSF diversion treatment (n= 19) versus OHC patients receiving ETV for shunt failure (n= 11) by log-rank analysis and Kaplan-Meier plots of recurrence-free periods. To determine if the performance of ETV with concurrent shunt revision decreased the incidence of catastrophic treatment failure in patients experiencing frequent and emergent shunt failures (n = 8), the time to treatment failure after ETV and shunt revision was compared with the mean duration of their previous CSF shunts.

RESULTS

ETV after shunt failure was 2.5-fold more likely to fail [risk ratio (RR): 2.48, p<0.05] versus ETV as initial CSF diversion treatment for OHC. Following ETV as initial CSF diversion treatment, 17 patients (89%) experienced immediate improvement and 65% remained recurrence-free at year 2. Following ETV after shunt failure, 16 patients (71%) experienced immediate improvement, but only 25% remained recurrence-free at year 2. In patients with a history of multiple shunt revisions and complications, concurrent use of ETV and VP shunt did not significantly decrease treatment failure. However, the incidence of catastrophic shunt failure requiring acute intervention decreased (43% versus 17%).

CONCLUSION

In our experience with ETV for OHC, prior CSF shunting in patients with obstructive hydrocephalus was associated with the decreased time to treatment failure following conversion to ETV. ETV may be less effective for the treatment of OHC in previously shunted patients. ETV combined with concurrent CSF shunting may be an important strategy to prevent catastrophic treatment failure in OHC patients with a history of multiple shunt revisions and complications.

Complications and subsequent removal of retained shunt hardware after endoscopic third ventriculostomy: case series

This case series highlights multiple complications and subsequent removal of retained shunt hardware in pediatric patients after successful endoscopic third ventriculostomy (ETV). Removal or retention of existing shunt hardware following ETV represents an important dilemma. Prior studies have reported infections and organ perforation related to nonfunctioning shunts but none in the context of successful ETV. Data obtained in 3 children with hydrocephalus treated at the authors' institution were retrospectively reviewed after the patients experienced complications due to retained shunt hardware following ETV. Etiologies of hydrocephalus included tectal glioma and intraventricular hemorrhage. All 3 patients had a history of multiple shunt revisions and underwent urgent ETV in the setting of a shunt malfunction. In each case, the entire shunt system was left in situ, but it became the source of subsequent complications. Two of the 3 patients presented with the shunt infected by gram-negative bacilli 10 days and 4.5 months postoperatively, respectively. The remaining patient experienced wound dehiscence over the shunt valve 4.5 months after ETV. In all patients, the complications were managed successfully by removing the shunt hardware. None of the patients required repeat shunt insertion from the time of removal throughout the follow-up period (mean 24 months, range 9-36 months). During the study period, a total of 6 patients with indwelling shunt hardware underwent ETV with the expectation of being shunt independent. Among these 6 patients, 3 experienced no complications from the retained hardware whereas 3 patients (50%) ultimately experienced adverse consequences related to retained hardware. This case series illustrates complications involving retained shunt hardware after successful ETV. These examples support consideration of shunt removal at the time of ETV in the appropriate context.

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.

Amenorrhea complicating endoscopic third ventriculostomy in the pediatric age group

Endoscopic third ventriculostomy (ETV) is an accepted option in the treatment of obstructive hydrocephalus in children and is considered by many pediatric neurosurgeons to be the treatment of choice in this population. The procedure involves perforation of the floor of the third ventricle, specifically, the tuber cinereum, which is part of the hypothalamic-pituitary axis of cerebral endocrine regulation. Endocrine dysfunction, such as amenorrhea, weight gain, and precocious puberty, which are recognized only months to years after the procedure, may be underreported because patients and physicians may not relate the endocrine sequelae to the ETV. Few detailed reports of endocrine-related complications following ETV exist to better understand these issues. In this study, the authors add to the literature with case descriptions of and correlative laboratory findings in 2 adolescent girls who underwent ETV for obstructive hydrocephalus and in whom amenorrhea subsequently developed.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Stereotactic versus endoscopic surgery in periventricular lesions

OBJECT

Endoscopic and stereotactic surgery have gained widespread acceptance as minimally invasive tools for the diagnosis of intracerebral pathologies. We investigated the specific advantages and disadvantages of each technique in the assessment of periventricular lesions.

METHOD

This study included a retrospective series of 70 patients with periventricular lesions. Endoscopic surgery was performed in 17 patients (mean age, 37 years; range, 4 months-78 years) and stereotactic biopsy in 55 patients (mean age, 63 years; range, 23-80 years), including two patients who underwent both procedures.

RESULTS

Hydrocephalus was present in 13/17 patients in the endoscopic group (77%) and in 11/55 patients in the stereotactic group (20%). Diagnosis was achieved in all patients in the endoscopic group and in all but one patient in the stereotactic group, in whom histological diagnosis was obtained by endoscopic biopsy during a second operation. In the endoscopic group, additional procedures performed included ventriculostomy (2/17), cyst fenestration (3/17), endoscopic shunt revision (3/17) and placement of Rickham reservoirs or external cerebrospinal fluid drains (6/17). Adverse events occurred in one patient after endoscopy (chronic subdural hematoma) and in two patients after stereotactic surgery (one mild hemiparesis and one transitory paresis of the contralateral leg).

CONCLUSIONS

Endoscopic and stereotactic surgery have distinct advantages and disadvantages in approaching periventricular lesions. The advantages of endoscopy encompass the possibility to perform additional surgical procedures during the same session (e.g. tumour reduction, third ventriculostomy, fenestration of a cyst). The visual control reduces the hazard of injury to anatomical structures and allows for a better control of bleeding although there is a considerable blind-out in such situations. The advantages of stereotactic surgery include a smaller approach and precise planning of the trajectory. It is usually performed under local anaesthesia. Both methods provide a safe and efficient therapeutic option in periventricular lesions with low surgical-related morbidity.

Shunt dependence: myths and facts

INTRODUCTION

Chronically shunted patients are believed to be unable to have a shunt-free life. Nevertheless, sometimes shunt removal is possible after an endoscopic third ventriculostomy, even after long periods of cerebral spinal fluid diversion.

RESULTS AND DISCUSSION

We perform a literature review that leads to a discussion of this subject in the light of the current medical knowledge.

Endoscopic third ventriculostomy in previously shunted children: a retrospective study

PURPOSE

The aim of this study was to assess the mid-term results, success rates, and time-to-failure of secondary endoscopic third ventriculostomy (secondary ETV), as well as the complex management of preoperative and postoperative cares.

METHODS

To this purpose, a retrospective analysis of a pediatric population of 22 children who underwent endoscopic third ventriculostomy (ETV) after shunt malfunction (secondary ETV) was performed.

RESULTS

The failure rate, given by the percentage of new shunt replacement in the first 3 months after ETV, was 36%, with a mean time to failure of 14.3 days. All the failures were evident within 1 month after the ETV. Despite the small number of patients in our series, we found no significant correlation between ETV failure and both patient age and hydrocephalus etiology (p = 0.47 and p = 0.78, respectively).

CONCLUSIONS

In our experience, ETV secondary to shunt malfunction in pediatric patients has a success rate of 64%. As it is a safe and rapid treatment option even in emergency conditions, it is worth performing this procedure in previously shunted children.

Third ventriculostomy in a single pediatric surgical unit

PURPOSE

Endoscopic third ventriculostomy (ETV) is a successful method of treatment for obstructive hydrocephalus that has become popular over the last 20 years. The purpose of this paper is to study the outcome of infants with obstructive hydrocephalus treated by ETV by a single surgeon and to evaluate the safety, reliability, and efficacy of this treatment.

METHODS

All data were collected retrospectively. Between July 1999 and June 2005, 14 children underwent an ETV. In one child, a second ETV was performed. The age of the eight female and six male patients at the time of ETV ranged from less than 1 month up to 13 years and 11 months. The indication for an ETV was an obstructive hydrocephalus. Median follow-up period was 5 years and 9 months. The need of a further operation after ETV was defined as a failure of ETV.

RESULTS

In six patients, the first ETV was successful. In the remaining eight patients, there was a need for further treatment (ventriculoperitoneal shunt). Although the follow-up shunt failed in one patient, he was successfully treated by a second ETV.

CONCLUSION

Our study suggests that ETV can be successfully done in a small pediatric unit, but with a lower success rate because of small caseload, and therefore, lower experience and routine of the surgeon. Therefore, we propose a centralization of patients to obtain a higher number of cases. We confirm that ETV is a safe, reliable, and efficient method with a better outcome in children than infants.

Complications of Endoscopic Third Ventriculostomy in Previously Shunted Patients

Objective:

Endoscopic third ventriculostomy (ETV) is considered to be a safe and effective treatment in selected patients as an initial treatment for obstructive hydrocephalus and at the time of shunt malfunction in previously shunted patients. We compared the outcome and complications of ETV between patients with newly diagnosed hydrocephalus and those with previous shunting procedures.

Methods:

A retrospective review of patients undergoing ETV from 1996 to 2004 at Alberta's Childrens Hospital and Foothills Medical Centre was completed. Patient data included symptoms at clinical presentation, cause of hydrocephalus, age at initial shunt, number of previous shunt revisions, age at ETV, complications, and subsequent shunting procedures performed.

Results:

A total of 131 patients were identified with a minimum follow-up duration of 1 year; 71 (82.5%) of 86 patients who underwent ETV as a primary procedure and 36 (80%) of 45 patients who had ETV at the time of shunt malfunction were shunt-free at the last follow-up evaluation. Patients younger than 1 year old who underwent ETV were more likely to require an additional procedure for control of their hydrocephalus (P&lt; 0.01). Serious complications after ETV occurred more frequently in patients who presented at the time of shunt malfunction (14 of 45 patients, 31%) compared with patients who underwent primary ETV (seven of 86 patients, 8%) (P = 0.02). Previously shunted patients with a history of two or more revisions (P= 0.03) and who experienced a serious complication at the time of ETV (P = 0.01) were more likely to require shunt replacement.

Conclusion:

ETV is an effective treatment both in selected patients with newly diagnosed hydrocephalus and in patients with a previous shunting procedure who are presenting with malfunction. Complications of ETV occur more frequently in previously shunted patients than in patients treated for newly diagnosed hydrocephalus, and care must be taken in the selection and treatment of these patients.

Ventricular anatomy of hydrocephalus associated with myeloschisis and endoscopic third ventriculostomy

OBJECTS

To characterize the anatomical features of the ventricular regions in patients with myeloschisis and related to successful performance of endoscopic third ventriculostomy (ETV).

METHODS

Radiological and endoscopic findings of 21 myeloschisis patients were retrospectively reviewed. Radiological features that could interfere with endoscopic procedures were (1) a huge massa intermedia (12/19), (2) sloping of the third ventricular floor (3/10), (3) narrow anteroposterior length of the third ventricular floor (2/10), and (4) narrow prepontine cistern (8/21). Endoscopic findings were (a) a narrow foramen of Monro (0/3), (b) hypertrophy of the anterior commissure (1/3), (c) sloping of the third ventricle floor (1/3), (d) a huge massa intermedia (3/3), and (e) opaque third ventricular floor (3/3). These endoscopic findings did not interfere with endoscopic procedures by using the Oi-HandyPro neuroendoscope without the above-mentioned radiological features 3 or 4.

CONCLUSION

Narrow anteroposterior length of the third ventricular floor and narrow prepontine cistern are not infrequently observed. Preoperative evaluation and intraoperative inspection of these findings are very important in successful performance of ETV.

Endoscopic management of hydrocephalus in pediatric patients: a review of indications, techniques, and outcomes

Although ventriculoperitoneal shunting remains the treatment of choice for many children with hydrocephalus, advances in endoscopic technology have greatly expanded the treatment options for these patients. For selected patients with obstructive hydrocephalus, endoscopic third ventriculostomy and other endoscopic techniques offer substantial advantages over shunting. As with any surgical procedure, appropriate patient selection is critical to successful outcomes. This article reviews modern endoscopic techniques available to treat hydrocephalus, with a focus on selection criteria and outcomes.

Endoscopic Third Ventriculostomy in Pediatric Patients: The Canadian Experience

OBJECTIVE

Reports from relatively small series of pediatric patients predominantly from single centers have hampered accurate analysis of outcome from endoscopic third ventriculostomy. We combined patients from nine pediatric neurosurgery centers across Canada to obtain a better estimate of outcome and identify factors affecting success of the procedure.

METHODS

Databases were recoded for uniformity. Failure of the procedure was defined as any subsequent operation or death resulting from hydrocephalus. Time to failure was analyzed by Kaplan-Meier estimate and Cox proportional hazard analysis.

RESULTS

During a 15-year period (1989–2004), 368 patients underwent the procedure. The average age was 6.5 years, and 57% were male. Aqueduct stenosis and tumors were the most common etiology, comprising 34 and 29%, respectively. Twenty-two percent of the patients had been previously shunted. The 1- and 5-year success rates were 65 and 52%, respectively. Factors included in the Cox model were age, sex, etiology of hydrocephalus, previous surgery, center volume, and surgeon volume. By multivariate analysis, only age had a significant effect on outcome, with younger patients failing at higher rates, particularly neonates and infants.

CONCLUSION

Based on data from multiple Canadian centers, age seems to be the primary determinant of outcome in endoscopic third ventriculostomy in pediatric patients. Failure rates are particularly high in neonates and young infants; thus, the role of this procedure in this age group should be carefully considered.

Audits can improve neurosurgical practice--illustrated by endoscopic third ventriculostomy

OBJECTIVE

A single-center, retrospective study was performed to evaluate the effect of audit on the patient selection for endoscopic third ventriculostomy (ETV).

MATERIALS AND METHODS

Between 01.01.99 and 07.31.01, 134 patients underwent ETV (group 1). During this period, there was no consensus within the neurosurgical community as to patient selection criteria for ETV. A review of our clinical practice in August 2001 demonstrated significantly lower ETV success rates for patients <6 months of age, patients with communicating hydrocephalus (HC) and for patients with prior shunt surgery. Thus, stricter patient selection criteria were established. Between 08.01.01 and 12.31.02, 54 patients were operated (group 2). The two groups were compared with respect to age, type of HC, previous shunt surgeries and ETV success rates. The primary outcome event was ETV malfunction, defined as symptoms and/or signs of increased intracranial pressure leading to repeat ETV or shunt implantation. Follow-up was done through outpatient clinics and telephone interviews. Average follow-up time was 12 months (range 0-44 months). No patient was lost to follow-up.

RESULTS

The overall 1-year ETV success rate in group 2 (65%) was significantly higher than in group 1 (53%) (p < 0.04). Group 2 had a significantly higher proportion of patients >6 months of age (p = 0.013) and with obstructive HC (p = 0.001).

CONCLUSION

Patient selection criteria critically affect the overall ETV success rate. An audit of our results led to a significant change in clinical practice, thereby improving the ETV success rates and patient care.

Neurofiberscopic biopsy of tumors of the pineal region and posterior third ventricle: indications, technique, complications, and results

OBJECTIVE

Evaluation of results of the neurofiberscopic biopsy of tumors of the pineal region and posterior third ventricle.

METHODS

From 2001 to 2004, 23 patients (mean age, 30.6 yr) with tumors located in the pineal region or posterior third ventricle underwent neurofiberscopic biopsy with simultaneous third ventriculostomy. The procedure was indicated for verification of the histological diagnosis of the neoplasm, which was planned to be treated by radiotherapy and/or chemotherapy without open surgery (eight patients), establishment of the pathological diagnosis for further choice of the most appropriate treatment strategy (11 patients), differentiation of the recurrent neoplasm and radiation necrosis (two patients), and decompression of the large tumor-associated cyst (two patients). In six previously shunted patients, substitution of the ventriculoperitoneal shunt on the third ventricle stoma was performed.

RESULTS

There was no postoperative mortality or permanent morbidity. In all cases, the obtained tissue sample was sufficient for pathological diagnosis. Transient postoperative complications included fever (15 patients), nausea and vomiting (three patients), and diplopia (one patient). On the long-term follow-up, delayed third ventricular stoma failure caused by tumor regrowth and scar formation was found in one patient, and dissemination of the malignant glioma through the subarachnoid space was found in another patient.

CONCLUSION

Neurofiberscopic biopsy represents a useful method for sampling of tumors of the pineal region and posterior third ventricle, which can be effectively used in both previously shunted and shunt-free patients.

Endoscopic third ventriculostomy in the treatment of hydrocephalus in pediatric patients

Advances in surgical instrumentation and technique have lead to an extensive use of endoscopic third ventriculostomy in the management of pediatric hydrocephalus. The aim of this work was to point out the leading aspects related to this technique. After a review of the history, which is now almost one century last, the analysis of the endoscopic ventricular anatomy is aimed to detail normal findings and possible anatomic variations which might influence the correct conclusion of the procedure. The overview of modern endoscopic instrumentation helps to understand the technical improvements that have contributed to significantly reduce the operative invasiveness. Indications are analysed from a pathogenetic standpoint with the intent to better understand the results reported in the literature. A further part of the paper is dedicated to the neuroradiological and clinical means of outcome evaluation, which are still a matter of debate. Finally a review of transient and permanent surgical complications is performed looking at their occurrence in different hydrocephalus etiologies.

Hydrothorax Due to Ventriculopleural Shunting in a Child with Spina Bifida on Chronic Dialysis: Third Ventriculostomy as an Alternative of Cerebrospinal Diversion

The purpose of this paper is to describe the risks of ventriculopleural shunt in patients with spina bifida and end-stage-renal-diseases (ESRD), and to describe endoscopic third ventriculostomy as an alternative for the combination of cerebrospinal shunt and dialysis modality. We report a 16-year-old boy with spina bifida on chronic dialysis with a massive unilateral hydrothorax and respiratory distress complicating a ventriculopleural (VPL) shunt. Two thoracocenteses were performed, draining 3200 ml of a clear fluid. The VPL shunt was removed and revised successfully to a third ventriculostomy (TVE). Peritoneal dialysis (PD) was the initial dialysis modality. After 12 months on PD, the patient was transferred to hemodialysis (HD) because of refractory peritonitis. Hydrothorax developed while the patient was on PD, reaching its maximum 2 months after the transference to HD. To our knowledge there has been no other report of ventriculopleural (VPL) shunt failure, and endoscopic TVE, as a cerebrospinal fluid (CSF) diversion alternative in patients on chronic dialysis.

Endoscopic third ventriculostomy for obstructive hydrocephalus

The indications for neuroendoscopy are not only constantly increasing, but even the currently accepted indications are constantly being adjusted and tailored. This is also true for one of the most frequently used neuroendoscopic procedures, the endoscopic 3rd ventriculostomy (ETV) for obstructive hydrocephalus. ETV has gained popularity and widespread acceptance during the past few years, but little attention has been paid to the techniques of the procedure. After a short introduction describing the history of ETV, an overview is given of all the different techniques that have been and still are employed to open the floor of the 3rd ventricle. The spectrum of indications for ETV has been widely enlarged over the last years. Initially, the use of this procedure was restricted to patients older than 2 years, to patients with an obvious triventricular hydrocephalus, and to those with a bulging, translucent floor of the 3rd ventricle. Nowadays, indications include all kinds of obstructive hydrocephalus but also communicating forms of hydrocephalus. The results of endoscopic procedures in treating these pathologies are given under special consideration of shunt technologies. In summary, from the review of the publications since the first ETV performed by Mixter in 1923, this technique is the treatment of choice for obstructive hydrocephalus caused by different etiologies and is an alternative to cerebrospinal fluid shunt application.

Cerebrospinal Fluid Diversion Procedures

Cerebrospinal fluid (CSF) diversion procedures remain the principal method of treatment of hydrocephalus and an important option in treating idiopathic intracranial hypertension. Recent advances in CSF shunt hardware offer some promise in reducing the rate of complications. Third ventriculostomy has become an increasingly practiced alternative to conventional shunting in an ever-widening patient population. Long-term follow-up studies have identified complications of lumboperitoneal shunt placement. Advances in surgical navigation suggest that ventriculoperitoneal shunting may be a viable alternative in patients with idiopathic intracranial hypertension.

Hydrocephalus

Hydrocephalus is not an exotic condition in general pediatric practice. A general pediatrician might expect to serve two to five children with CSF shunts. This article reviews posthemorrhagic hydrocephalus in detail.