Management of hydrocephalus by endoscopic third ventriculostomy in patients with myelomeningocele

Lobar holoprosencephaly with associated meningocele: A rare case report of a 25-year-old patient with multiple seizures

Lobar holoprosencephaly (HPE) represents the mildest form of HPE, featuring an interhemispheric fissure extending along most of the entire midline, with the thalami remaining unfused. Lobar HPE is usually diagnosed in the prenatal stage or infancy; however, cases of adult-onset are exceedingly rare. Here, we present a 25-year-old patient who was presented with multiple episodes of seizures and was subsequently diagnosed with lobar HPE accompanied by a meningocele. By shedding light on this rare brain malformation, we hope to raise awareness among healthcare professionals and stimulate further research into the pathogenesis, clinical course, and management of adult-onset HPE.

Endoscopic Surgery for Deeply Located Intracranial Cysts: Risk Factors for Re-Operation and Symptom Improvement

PURPOSE

We investigated the results of endoscopic fenestration for deeply located intracranial cysts (DLICs), risk factors for re-operation, and symptom improvement.

MATERIALS AND METHODS

We included 51 patients with DLICs who underwent endoscopic fenestration between November 2006 and October 2022. The median age was 5±20 years (6 days-67 years), and 36 (70.6%) patients were aged <20 years. The male-to-female ratio was 1.3:1. The ventriculoscope was used to fenestrate the cysts, which had diameters under 4.5 mm. The volume of DLICs was measured separately on serial magnetic resonance imaging, and the patients were followed up for 32±40 months.

RESULTS

The mean preoperative volume of DLICs was 63.5±87.4 cm³, which decreased to 23.7±56.2 cm³ postoperatively, with a 45.4%±32.1% decrease rate in 32 months. All DLICs were approached appropriately, avoiding the eloquent areas. Overall, 39 (76.5%) patients showed symptom improvement after a single operation, which was preserved without recurrence, whereas 12 (23.5%) underwent a second operation [shunting (17.6%) or repeating the endoscopic fenestration (5.9%)] owing to symptom aggravation and recurrent cysts. Patients aged <12 months showed 7.4 times more re-operation rate (p=0.046) and 7.4 times less symptom improvement (p=0.038) compared to those with older age. Females showed 6.5 times more re-operation rate (p=0.037) and 7.1 times less symptom improvement (p=0.027) than males. No patients experienced complications such as cerebrospinal fluid leakage, postoperative hemorrhage, or infection.

CONCLUSION

Endoscopic surgery is feasible for the treatment of DLICs. Female sex and age <12 months are risk factors for re-operation and less symptom improvement.

Prognostic factors for endoscopic third ventriculostomy success in hydrocephalus with myelomeningocele

PURPOSE

Myelomeningocele (MMC) is a prevalent neural tube closure defect often associated with hydrocephalus, necessitating surgical intervention in a significant proportion of cases. While ventriculoperitoneal shunting (VPS) has been a standard treatment approach, endoscopic third ventriculostomy (ETV) has emerged as a promising alternative. However, factors influencing the success of ETV in MMC patients remain uncertain. This retrospective observational study aimed to identify clinical and radiological factors correlating with a higher success rate of ETV in MMC patients.

METHODS

Medical records of MMC patients who underwent ETV at a tertiary care center between 2015 and 2021 were reviewed. Demographic, clinical, and radiological data were analyzed. ETV success was defined as the absence of further hydrocephalus treatment during follow-up.

RESULTS

Of 131 MMC patients, 21 met inclusion criteria and underwent ETV. The overall success rate of ETV was 57.1%, with a six-month success rate of 61.9%. Age ≤ 6 months was significantly associated with lower ETV success (25%) compared to older patients (76.9%) (OR: 0.1; 95% CI 0.005-2.006; p = 0.019). Radiological factors, including posterior fossa dimensions and linear indices, did not exhibit statistically significant associations with ETV success.

CONCLUSION

Age emerged as a significant factor affecting ETV success in MMC patients, with younger patients exhibiting lower success rates. Radiological variables did not significantly influence ETV outcomes in this study. Identifying predictors of ETV success in MMC patients is crucial for optimizing treatment strategies and improving patient outcomes.

A challenging case of endoscopic third ventriculostomy

Background

Although controversial, endoscopic third ventriculostomy (ETV) in the management of Myelomeningocele and Chiari type II malformation-related hydrocephalous is gaining wider popularity and use. With variable success rates, it can be proposed as a first or second option after shunt malfunction. ETV in post-infectious hydrocephalus may also be considered as an alternative to shunting. With reported success rates of 50-60%, failure is attributed to anatomical reasons and/or to pathological subarachnoid space scarring that may result from infectious processes. Similarly, ETV in repeated shunt malfunctions is an acceptable option that may offer shunt independency. In all situations, case-by-case selection and discussion are to be considered.

Case Description

A 5-year-old boy with a history of surgically treated lumbosacral myelomeningocele and ventriculoperitoneal shunting at six months of age is presented. During the course following the initial surgery, he experienced multiple shunt malfunctions, with two episodes of meningitis, leading to 7 shunt revision surgeries. Lately, the patient presented a large peritoneal cyst formation that needed regular evacuations. With a magnetic resonance imaging (MRI)-scan showing a large bi-ventricular hydrocephalus and a trapped third ventricle with multiple septations, surgical options included either ventriculoatrial shunting or third ventriculostomy. The latter option, offering shunt independency, was chosen after family consent and risk explanation. The expected success rate of the procedure was discussed and evaluated to 40-60% on the ETV success score. The video describes a step-by-step procedure with detailed radiological and correlated anatomical annotations of a completely distorted anatomy of a multifactorial hydrocephalous. No scarring at the prepontine cistern was observed. Shunt independency was achieved. However, the patient died from late postoperative status epilepticus and pulmonary complications. Whether these postoperative events are directly related to the procedure is unclear, although technically and clinically successful in the short term.

Conclusion

We believe that ETV should be carefully indicated in selected patients with Chiari II, post-infectious hydrocephalus, by experienced hands, as the surgical anatomy can be extremely complex and misleading.

The Top 100 Most Cited Journal Articles on Hydrocephalus

Hydrocephalus represents a significant burden of disease, with more than 383,000 new cases annually worldwide. When the magnitude of this condition is considered, a centralized archive of pertinent literature is of great clinical value. From a neurosurgical standpoint, hydrocephalus is one of the most frequently treated conditions in the field. The focus of this study was to identify the top 100 journal articles specific to hydrocephalus using bibliometric analysis. Using the Journal of Citation Report database, 10 journals were identified. The Web of Science Core Collection was then searched using each journal name and the search term "hydrocephalus." The results were ordered by "Times Cited" and searched by the number of citations. The database contained journal articles from 1976 to 2021, and the following variables were collected for analysis: journal, article type, year of publication, and the number of citations. Journal articles were excluded if they had no relation to hydrocephalus, mostly involved basic science research, or included animal studies. Ten journals were identified using the above criteria, and a catalog of the 100 most cited publications in the hydrocephalus literature was created. Articles were arranged from highest to lowest citation number, with further classification by journal, article type, and publication year. Of the 100 articles referenced, 38 were review articles, 24 were original articles, 15 were comparative studies, 11 were clinical trials, six were multi-center studies, three were cross-sectional, and three were case reports with reviews. Articles were also sorted by study type and further stratified by etiology. If the etiology was not specified, studies were instead subcategorized by treatment type. Etiologies such as aqueductal stenosis, tumors, and other obstructive causes of hydrocephalus were classified as obstructive (n=6). Communicating (n=15) included idiopathic, normal pressure hydrocephalus, and other non-obstructive etiologies. The category "other" (n=3) was assigned to studies that included etiologies, populations, and/or treatments that did not fit into the classifications previously outlined. Through our analysis of highly cited journal articles focusing on different etiologies and the surgical or medical management of hydrocephalus, we hope to elucidate important trends. By establishing the 100 most cited hydrocephalus articles, we contribute one source, stratified for efficient referencing, to facilitate clinical care and future research on hydrocephalus.

Myelomeningocele: Long-Term Neurosurgical Management

Open spina bifida, also known as myelomeningocele (MMC), is the most challenging and severe birth defect of the central nervous system compatible with life and it is due to a failure in the dorsal fusion of the nascent neural tube during embryonic development. MMC is often accompanied by a constellation of collateral conditions, including hydrocephalus, Arnold - Chiari II malformation, brainstem disfunction, hydrosyringomyelia, tethered cord syndrome and scoliosis. Beyond early surgical repair of the dorsal defect, MMC requires lifelong cares. Several additional surgical procedures are generally necessary to improve the long-term outcomes of patients affected by MMC and multidisciplinary evaluations are crucial for early identification and management of the various medical condition that can accompany this pathology. In this chapter, the most common pathological entities associated with MMC are illustrated, focusing on clinical manifestations, treatment strategies and follow up recommendations.

Myelomeningocele: the evolution of care over the last 50 years

PURPOSE

Myelomeningocele (MMC) is one of the representative anomalies in the field of pediatric neurosurgery. During the 50 years of ISPN history, MMC had a tremendous changes in its incidence, clinical management and outcome with advanced understanding of its pathogenesis. We reviewed the changes in MMC during the period.

METHODS

We reviewed the literature review and collected our experiences.

RESULTS

During the 50 years, major changes happened in many aspects of MMC including incidence, pathoembryogenesis, folate deficiency, prevention, prenatal diagnosis, mode of delivery, treatment policy with ethical considerations, clinical treatment including fetal surgery, latex allergy, retethering, management outcome, multidisciplinary team approach, and socioeconomic and family issues.

CONCLUSIONS

There was a great advance in the management and research of MMC during the 50 years. It is a monumental achievement of pediatric neurosurgeons and colleagues of the related fields.

Endoscopic third ventriculostomy for management of hydrocephalus associated with Chiari malformation type II in children

BACKGROUND

Hydrocephalus is commonly associated with Chiari malformation (CM) particularly CM type II. The traditional treatment of hydrocephalus in these patients has been cerebrospinal fluid diversion by shunts. Endoscopic third ventriculostomy (ETV) has emerged as an alternative procedure in these patients.

PURPOSE

Assessment of the clinical and radiological outcomes of ETV in the management of hydrocephalus in children with CM II.

METHODS

This is a prospective study conducted on 18 patients with CM II associated with hydrocephalus admitted to Cairo University hospitals between January 2020 and June 2021. These patients had been managed surgically by ETV. Clinical outcome was assessed based on improvement of manifestations of increased intracranial pressure while radiological outcome was based on the findings of postoperative computed tomography. In cases with early failure, serial lumbar puncture (LP) was performed for 2 days.

RESULTS

ETV was performed as a secondary procedure in 4 cases. The overall success rate of the procedure was 72%, and its success rate as a secondary procedure was 100%. Serial LP was effective in decreasing early failure in 44.4% of cases. Radiological regression of hydrocephalic changes was detected in 50% of the cases.

CONCLUSION

ETV is an efficient and safe procedure in the treatment of hydrocephalus in children with Chiari malformation II, particularly when performed as a secondary procedure. Serial LP following the procedure increases the success rate in patients with early failure.

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 complications: avoidance and management in a stepwise manner

Background

Various complications of endoscopic third ventriculostomy (ETV) have been described. One has to recognize these complications and learn how to avoid them.

Methods

We performed a literature review regarding the reported complications of ETV procedures discussed in a correlated manner with the surgical steps. Furthermore, we reviewed the technical notes described by experienced neuroendoscopists, including surgical indications, choice of the endoscopic entry point and trajectory, anatomic orientation, proper bleeding control and tight closure, to prevent and deal with such complications.

Results and conclusion

A lesson learned that comprehensive knowledge of ventricular anatomy with proper orientation by studying the preoperative images is mandatory and one should be aware of all complication types and rates.

Early Outcome of Endoscopic Third Ventriculostomy With Choroid Plexus Cauterization Versus Ventriculoperitoneal Shunt as Primary Treatment of Hydrocephalus in Children With Myelomeningocele: A Prospective Cohort Study

BACKGROUND

Myelomeningocele is associated with hydrocephalus in 35% to 90% of cases. Hydrocephalus is usually treated with insertion of ventriculoperitoneal shunt; however, there is growing evidence that endoscopic third ventriculostomy (ETV) with choroid plexus cauterization (CPC) is an alternative.

OBJECTIVE

To compare the success rate and morbidity of ETV with CPC and ventriculoperitoneal shunt (VPS) as the primary treatment of hydrocephalus in patients with myelomeningocele.

METHODS

A prospective study from January 2016 to February 2019, involving 46 patients with myelomeningocele who developed hydrocephalus after repair in a tertiary hospital in southwestern Nigeria. Biodata and preoperative features of hydrocephalus were documented. ETV + CPC or VPS was done using standard operative techniques. Patients were followed up monthly for 6 mo.

RESULTS

There were 23 patients in the ETV + CPC arm and 22 patients in the VPS arm. Morbidities were cerebrospinal fluid leak, 8.3% in the ETV + CPC arm and 4.5% in the VPS arm, wound dehiscence, 13.6% in the VPS arm, none in the ETV + CPC arm. At 6-mo follow-up, success rate for ETV + CPC was 60.9% and 59.1% for VPS, P = .9.

CONCLUSION

ETV + CPC had similar success rate with VPS at 6 mo with lower morbidity. ETV + CPC should be considered a viable alternative when treating patients with myelomeningocele and hydrocephalus.

Myelomeningocele in Slovenia: results of a 10-year follow-up

BACKGROUND

Myelomeningocele (MMC) is a congenital malformation that results from a failure in the process of neurulation. A multidisciplinary follow-up is required to manage and treat all associated sequelae. The aim of the study was to present the epidemiological data and the results of the multidisciplinary follow-up of children born in Slovenia with myelomeningocele (MMC) between 2007 and 2017.

METHODS

We presented a retrospective analysis of all children born in Slovenia with between 2007 and 2017. The multidisciplinary follow-up included neurosurgical, urological, neurological, endocrinological and orthopedic expertise.

RESULTS

Twenty children were treated in Slovenia for MMC from 2007 to 2017 (mean follow-up of 7.7 years). 9 MMC were thoracic, 2 higher lumbar, 5 lower lumbar and 4 sacral. Thirteen children needed a CSF shunt, 1 was treated with endoscopic ventriculostomy (ETV). Four children needed a craniocervical decompression and 2 needed a detethering procedure. 14 children had a neurogenic bladder and 17 referred bowel continence. Orthopedic correction of the lower limbs was required in 9 cases. 4 children had seizures, 10 had endocrinological deficits. Among 16 children attending school, 11 were inserted in special educational classes.

CONCLUSIONS

The prevalence of MMC in Slovenia between 2007 and 2017 was 1/10000 births. Our follow-up results are comparable with those of previous, larger studies and confirm the efficacy of treating hydrocephalus with ETV in selected cases and with CSF shunt only in cases of clearly increased intracranial pressure. By adopting this strategy, we reduced the CSF shunt rate to 65%.

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.

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.

Endoscopic third ventriculostomy in patients with myelomeningocele after shunt failure

PURPOSE

Myelomeningocele (MMC) is the most frequent form of spina bifida. Moreover, 90% of patients with MMC have hydrocephalus and require shunt placement. However, shunt failure management in such patients typically involves several shunt revisions, increasing the risk for morbidity and mortality. In this study, we report our experience with endoscopic third ventriculostomy (ETV) in MMC patients with shunts in a Brazilian institution.

METHODS

Patients with MMC who presented with shunt failure and underwent ETV alone between January 1996 and December 2016 were included in this study. Patients who had undergone endoscopic choroid plexus cauterization (CPC) or had non-shunted MMC hydrocephalus were excluded. Various data related to the ETV procedure were collected for each patient, including features, operative characteristics, complications, and ETV success. The follow-up period for the patients was 6-12 months. ETV success scores (ETVSSs) were calculated retrospectively for each patient to compare the predicted success of the procedure with the actual success at 6 months after ETV.

RESULTS

Forty-three MMC patients with shunt failure were included in this study. Of them, 16 (37.2%) had a previous central nervous system (CNS) infection and 4 (9.3%) had complications. Two neuroendoscopies were interrupted, one because of anatomic impossibility due to thickening of the interthalamic adhesion, obliterating the floor of the third ventricle, and another because of intraoperative hemorrhage. One patient developed hyponatremia during the postoperative period, whereas another developed reversible paresis of the oculomotor nerve. The ETVSS predicted a success rate of 49.6% compared with the actual ETV success rate of 53.48% (23 patients) at 6 months. At 12 months, the actual success rate was 41.9% (18 patients). All patients survived the procedure.

CONCLUSION

Our findings indicate that ETV is an effective procedure for managing MMC-related hydrocephalus after shunt failure. The expertise of the neurosurgeon in neuroendoscopy procedures is often the deciding factor when choosing a management option. Accordingly, less experienced neurosurgeons should be warned of the risks of this procedure.

Myelomeningocele-associated hydrocephalus: nationwide analysis and systematic review

OBJECTIVE

Myelomeningocele (MMC), the most severe form of spina bifida, is characterized by protrusion of the meninges and spinal cord through a defect in the vertebral arches. The management and prevention of MMC-associated hydrocephalus has evolved since its initial introduction with regard to treatment of MMC defect, MMC-associated hydrocephalus treatment modality, and timing of hydrocephalus treatment.

METHODS

The Nationwide Inpatient Sample (NIS) database from the years 1998-2014 was reviewed and neonates with spina bifida and hydrocephalus status were identified. Timing of hydrocephalus treatment, delayed treatment (DT) versus simultaneous MMC repair with hydrocephalus treatment (ST), and treatment modality (ETV vs ventriculoperitoneal shunt [VPS]) were analyzed. Yearly trends were assessed with univariable logarithmic regression. Multivariable logistic regression identified correlates of inpatient shunt failure. A PRISMA systematic literature review was conducted that analyzed data from studies that investigated 1) MMC closure technique and hydrocephalus rate, 2) hydrocephalus treatment modality, and 3) timing of hydrocephalus treatment.

RESULTS

A weighted total of 10,627 inpatient MMC repairs were documented in the NIS, 8233 (77.5%) of which had documented hydrocephalus: 5876 (71.4%) were treated with VPS, 331 (4.0%) were treated with ETV, and 2026 (24.6%) remained untreated on initial inpatient stay. Treatment modality rates were stable over time; however, hydrocephalic patients in later years were less likely to receive hydrocephalus treatment during initial inpatient stay (odds ratio [OR] 0.974, p = 0.0331). The inpatient hydrocephalus treatment failure rate was higher for patients who received ETV treatment (17.5% ETV failure rate vs 7.9% VPS failure rate; p = 0.0028). Delayed hydrocephalus treatment was more prevalent in the later time period (77.9% vs 69.5%, p = 0.0287). Predictors of inpatient shunt failure included length of stay, shunt infection, jaundice, and delayed treatment. A longer time between operations increased the likelihood of inpatient shunt failure (OR 1.10, p < 0.0001). However, a meta-analysis of hydrocephalus timing studies revealed no difference between ST and DT with respect to shunt failure or infection rates.

CONCLUSIONS

From 1998 to 2014, hydrocephalus treatment has become more delayed and the number of hydrocephalic MMC patients not treated on initial inpatient stay has increased. Meta-analysis demonstrated that shunt malfunction and infection rates do not differ between delayed and simultaneous hydrocephalus treatment.

ETV in infancy and childhood below 2 years of age for treatment of hydrocephalus

PURPOSE

Age and etiology play a crucial role in success of endoscopic third ventriculostomy (ETV) as a treatment of obstructive hydrocephalus. Outcome is worse in infants, and controversies still exist whether ETV is superior to shunt placement. We retrospectively analyzed 70 patients below 2 years from 4 different centers treated with ETV and assessed success.

METHODS

Children < 2 years who received an ETV within 1994-2018 were included. Patients were classified according to age and etiology; < 3, 4-12, and 13-24 months, etiologically; aqueductal stenosis, post-hemorrhagic-hydrocephalus (PHH), tumor-related, fourth ventricle outflow obstruction, with Chiari-type II and following CSF infection. We investigated statistically the predictors for ETV success through computing Kaplan-Meier estimates using patient's follow-up time and time to ETV failure.

RESULTS

We collected 70 patients. ETV success rate was 41.4%. The highest rate was in tumor-related hydrocephalus and fourth ventricle outlet obstruction (62.5%, 60%) and the lowest rate was in Chiari-type II and following infection (16.7%, 0%). The below 3 months age group showed relatively lower success rate (33.3%) in comparison to older groups which showed similar results (46.4%, 46.6%). Statistically, a previous VP shunt was a predictor for failure (p value < 0.05).

CONCLUSION

Factors suggesting a high possibility of failure were age < 3 months and etiology such as Chiari-type II or following infection. Altered CSF dynamics in patients with PHH and under-developed arachnoid villi may play a role in ETV failure. We do not recommend ETV as first line in children < 3 months of age or in case of Chiari II or following infection.

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.

Fetal surgery for open spina bifida

KEY CONTENT

Spina bifida is a congenital neurological condition with lifelong physical and mental effects.Open fetal repair of the spinal lesion has been shown to improve hindbrain herniation, ventriculoperitoneal shunting, independent mobility and bladder outcomes for the child and, despite an increased risk of prematurity, does not seem to increase the risk of neurodevelopmental impairment.Open fetal surgery is associated with maternal morbidity.Surgery at our institution is offered and performed according to internationally agreed criteria and protocols.Further evidence regarding long-term outcomes, fetoscopic repair and alternative techniques is awaited.

LEARNING OBJECTIVES

To understand the clinical effects, potential prevention and prenatal diagnosis of spina bifida.To understand the rationale and evidence supporting the benefits and risks of fetal repair of open spina bifida.To understand the criteria defining those who are likely to benefit from fetal surgery.

ETHICAL ISSUES

The concept of the fetus as a patient, and issues surrounding fetal death or the need for resuscitation during fetal surgery.The associated maternal morbidity in a procedure performed solely for the benefit of the fetus/child.The financial implications of new surgical treatments.

Neurogenic Bladder Dysfunction as Signal of Late Failure of Endoscopic Third Ventriculostomy in Child with Spina Bifida

BACKGROUND

Endoscopic third ventriculostomy (ETV) is an option for hydrocephalus treatment in patients with myelomeningocele, mostly after a previous shunt dysfunction. Late failure of ETV is a rare event, traditionally associated with dramatic symptoms of intracranial hypertension. In patients with myelodysplasia and neurogenic bladder dysfunction, urodynamic deterioration can be a signal of neurologic worsening as a consequence of tethered cord or shunt problems.

CASE DESCRIPTION

We describe here a rare case of a 12-year-old female patient with myelomeningocele and evidence of a failure 10 years after a previously successful ETV whose initial symptoms were worsening of urinary complaints. After 2 months, she was admitted to the emergency department with seizures and acute hydrocephalus and was shunted.

CONCLUSIONS

Pediatric neurosurgeons must follow myelomeningocele patients with successful ETV for a long time and take care of subtle alterations of organic functions that have a close relationship with central nervous system integrity. A multidisciplinary approach can facilitate this strategy and avoid a tragic outcome.

Review on myelomeningocele management and its current status in Saudi Arabia

Major approaches have emerged in the field of myelomeningocele (MMC) management. The prevalence of MMC in Kingdom of Saudi Arabia is 0.44-1.46/1000 births. Nine point seven percent of pregnant Saudi women take folic acid before conception; MMC is estimated to result in 1,417,500 Saudi Riyals (SAR) in lifetime costs per patient. Abortion should be performed cautiously in Muslim countries; another option may be the intrauterine foetal surgical repair of MMC, which has better neuromotor outcomes and reduces the need for ventriculoperitoneal shunt, albeit with a higher risk of obstetric complications. Seven years after intrauterine foetal surgery emerged, there is a need to establish this service in Kingdom of Saudi Arabia. A multidisciplinary approach is required for MMC patients; surgical closure should be carried out within 72 hours after birth to reduce the risk of infection. Advancing MMC care allows patients to survive to adulthood, and action must be taken to improve the quality of MMC care in Kingdom of Saudi Arabia.

The 50 most cited publications in endoscopic third ventriculostomy: a bibliometric analysis

OBJECTIVEAlthough endoscopic third ventriculostomy (ETV) for the treatment of hydrocephalus was introduced in 1923, the method was relegated to the sidelines in favor of extracranial techniques. Since the 1990s to the beginning of the current century, however, ETV has undergone a remarkable resurgence to become the first-line treatment for obstructive hydrocephalus, and for some groups, the procedure has been applied for communicating hydrocephalus as well. In the present study, the authors identified the top 50 cited ETV works. These articles represent works of significance that document current practices and provide guidance for future inquiry.METHODSThe top 50 cited articles pertaining to ETV were identified using bibliometric data obtained with the Harzing's Publish or Perish software search engine. These high-impact works were evaluated for publication properties including year, country of authorship, category, and journal.RESULTSThe top 50 works were cited an average of 141.02 times with a mean of 9.45 citations per year. Articles published in 2005 were the most numerous in the top 50 group. These top articles were most frequently published in the Journal of Neurosurgery: Pediatrics. Most of the articles were clinical studies reporting on patients in the pediatric age group. The country of most authorship was the US, although many other countries were among the top 50 works.CONCLUSIONSThe present report discusses the bibliometric analysis of the top 50 ETV articles. This list may be useful to those interested in the progress and current status of this procedure.

Long-term follow-up for patients with infantile hydrocephalus treated by choroid plexus coagulation

OBJECTIVEShunt surgery is the most common treatment for hydrocephalus, but it is associated with several long-term complications. Endoscopic choroid plexus coagulation (CPC) and endoscopic third ventriculostomy (ETV) are alternative surgeries that may avoid the need for shunt surgery. Although the short-term efficacy and safety of CPC have been reported in previous studies, long-term outcome, including not only avoiding shunt placement but also intellectual development, remains to be elucidated. The purpose of the present study was to investigate the long-term outcome of CPC.METHODSThe study population comprised patients who had infantile hydrocephalus treated by endoscopic CPC before the age of 24 months and who were followed until at least 5 years of age. Retrospective review was performed using the medical charts. The authors assessed educational status and the full-scale intelligence quotient (FSIQ) using the Wechsler Intelligence Scale for Children (WISC) IV as the means to evaluate the intellectual development.RESULTSFourteen patients with infantile hydrocephalus underwent CPC with or without ETV as a primary surgery. There were no intraoperative complications. In 7 patients (50%), hydrocephalus was successfully controlled without shunt placement. Six patients (43%) eventually required shunt placement. In one patient hydrocephalus was controlled by additional ETV. In the shunt-independent group, 4 patients went to age-appropriate school or achieved age-appropriate development according to intelligence quotient (IQ), 1 patient went to specialized school, and 2 patients had disabilities. In the shunt-dependent group, 4 patients went to an age-appropriate school or achieved age-appropriate development by IQ, 1 patient went to specialized school, and 1 patient had disabilities. The mean FSIQ score in 3 patients without shunts was 90 (range 89-91) and the mean FSIQ score in 4 patients with shunts was 80 (range 48-107). There was no significant difference in the rate of normal development between the shunt-independent group and the shunt-dependent group (p = 0.72).CONCLUSIONSThe CPC with or without ETV can be a safe and effective treatment in children with infantile hydrocephalus. Long-term control of hydrocephalus and normal intellectual development can be achieved in successful cases. Further prospective studies should be required to elucidate appropriate indications.

Endoscopic third ventriculostomy and ventriculoperitoneal shunt for patients with noncommunicating hydrocephalus: A PRISMA-compliant meta-analysis

BACKGROUND

The surgical methods of endoscopic third ventriculostomy (ETV) and ventriculoperitoneal shunt (VS) for patients with noncommunicating hydrocephalus have rapidly increased in the past 2 decades. However, there is controversy regarding the efficacy and safety of these 2 surgical methods for noncommunicating hydrocephalus. The purpose of this study was to identify whether ETV is safer and more efficacious than VS for patients with noncommunicating hydrocephalus.

METHODS

We performed electronic searches in PubMed, Embase, China National Knowledge Internet, and the Cochrane Library to identify studies published up to February 03, 2018. The study summary results included improvement of symptoms, major complications, hematoma, infection, reoperation, mortality, duration of surgery, and hospital stay. Odds ratios (ORs) or standard mean differences (SMDs) with 95% confidence intervals (CIs) were calculated using random-effects models.

RESULTS

We identified 10 observational studies (4 prospective and 6 retrospective studies) with data collected from 2017 patients with noncommunicating hydrocephalus. First, there was no significant difference between ETV and VS for symptom improvement (OR: 0.83; 95%CI: 0.46-1.50; P = .534). Second, ETV was associated with lower incidence of major complications when compared with VS (OR: 0.31; 95%CI: 0.17-0.56; P < .001). Third, ETV has little or no significant effect on hematoma (OR: 0.65; 95%CI: 0.22-1.92; P = .433) and mortality (OR: 0.90; 95%CI: 0.11-7.72; P = .926). Fourth, ETV were associated with lower incidence of infection (OR: 0.20; 95%CI: 0.06-0.69; P = .010) and reoperation (OR: 0.22; 95%CI: 0.08-0.56; P = .002). Finally, patients who received ETV had shorter duration of surgery (SMD: -1.71; 95%CI: -3.16 to -0.27; P = .020) and hospital stay (SMD: -0.91; 95%CI: -1.45 to -0.38; P = .001).

CONCLUSIONS

This meta-analysis provides robust evidence that ETV has greater benefits in terms of major complications, infection, reoperation, duration of surgery, and hospital stay than VS for patients with noncommunicating hydrocephalus.

Successful endoscopic third ventriculostomy in children depends on age and etiology of hydrocephalus: outcome analysis in 51 pediatric patients

PURPOSE

Endoscopic third ventriculostomy (ETV) has become the method of choice in the treatment of hydrocephalus. Age and etiology could determine success rates (SR) of ETV. The purpose of this study is to assess these factors in pediatric population.

METHODS

Retrospective study on 51 children with obstructive hydrocephalus that underwent ETV was performed. The patients were divided into three groups per their age at the time of the treatment: < 6, 6-24, and > 24 months of age. All ETV procedures were performed by the same neurosurgeon.

RESULTS

Overall SR of ETV was 80% (40/51) for all etiologies and ages. In patients < 6 months of age SR was 56.2% (9/16), while 6-24 months of age was 88.9% (16/18) and > 24 months was 94.1% (16/17) (p = 0.012). The highest SR was obtained on aqueductal stenosis. SR of posthemorrhagic, postinfectious, and spina bifida related hydrocephalus was 60% (3/5), 50% (1/2), and 14.3% (1/7), respectively. While SR rate at the first ETV attempt was 85.3%, it was 76.9% in patients with V-P shunt performed previously (p = 0.000).

CONCLUSIONS

Factors indicating a potential failure of ETV were young age and etiology such as spina bifida, other than isolated aqueductal stenosis. ETV is the method of choice even in patients with former shunting. Fast healing, distensible skulls, and lower pressure gradient in younger children, all can play a role in ETV failure. Based on our experience, ETV could be the first method of choice for hydrocephalus even in children younger than 6 months of age.

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.

First 60 fetal in-utero myelomeningocele repairs at Saint Louis Fetal Care Institute in the post-MOMS trial era: hydrocephalus treatment outcomes (endoscopic third ventriculostomy versus ventriculo-peritoneal shunt)

INTRODUCTION

The published results of the Management of Myelomeningocele Study (MOMS) trial in 2011 showed improved outcomes (reduced need for shunting, decreased incidence of Chiari II malformation, and improved scores of mental development and motor function) in the fetal prenatal repair group compared to the postnatal group. Historically, endoscopic third ventriculostomy (ETV) remains as a controversial hydrocephalus treatment option with high failure rates in pediatric patients with a history of myelomeningocele (MMC). We report hydrocephalus treatment outcomes in the fetal in-utero myelomeningocele repair patients who underwent repair at our Saint Louis Fetal Care Institute following the MOMS trial. We looked carefully at ETV outcomes in this patient population and we identified risk factors for failure.

METHODS

At our Saint Louis Fetal Care Institute, we followed the maternal and fetal inclusion and exclusion criteria used by the MOMS trial. The records of our first 60 fetal MMC repairs performed at our institute between 2011 and 2017 were examined. We retrospectively reviewed the charts, prenatal fetal magnetic resonance imaging (MRI) and ultrasound (US) imaging findings, postnatal brain MRI, and Bayley neurodevelopment testing results for infants and children who underwent surgical treatment of symptomatic hydrocephalus (VP shunt versus ETV). Multiple variables possibly related to ETV failure were considered for identifying risk factors for ETV failure.

RESULTS

Between May 2011 and March 2017, 60 pregnant female patients underwent the prenatal MMC repair for their fetuses between 20 and 26 weeks' gestational age (GA) utilizing the standard hysterotomy for exposure of the fetus, and microsurgical repair of the MMC defect. All MMC defects underwent successful in-utero repair, with subsequent progression of the pregnancy. At the time of this study, 58 babies have been born, 56 are alive since there were 2 mortalities in the neonatal period due to prematurity. One patient was excluded given lack of consent for research purposes. From the remaining 55 patient included in this study, a total of 30 infants and toddlers underwent treatment of hydrocephalus (ETV and VPS groups). Twenty-five patients underwent ETV (24 primary ETV and 1 after shunt failure). Nineteen patients underwent shunt placements (6 primary/13 after ETV failure). Mean GA at time of MMC repair for the ETV group was 24 + 6/7 weeks (range 22 + 4/7 to 25 + 6/7). Mean follow up for patients who had a successful ETV was 17.25 months (range 4-57 months). Bayley neurodevelopmental testing results were examined pre- and post-ETV. Overall ETV success rate was 11/24 (45.8%) at the time of this study. The total number of patients who underwent shunt placement was 19/55 (34.5%), while shunting rate was 40% in the MOMS trial. Using a simple logistic regression analysis to identify predictors of ETV failure, ETV age ≤6 months and gestational age ≥23 weeks at repair of myelomeningocele were significant predictors for ETV failure while in-utero ventricular stability ≤4 mm and in-utero ventricular size post-repair ≤15.5 mm were significant predictors for ETV success. None of the listed variables independently predicted classification into ETV success versus ETV failure groups when entered into multiple logistic regression analysis.

CONCLUSIONS

ETV, as an alternative to initial shunting, may continue to show promising results for treating fetal MMC repair patient population who present with symptomatic hydrocephalus during infancy and early childhood. Although our overall CSF diversion rate (ETV and VPS groups) in our fetal MMC group is higher than the MOMS trial, our shunting rate is lower given our higher incidence of patients with successful ETV. To our knowledge, this is the largest reported ETV series in patients who underwent fetal MMC repair. ETV deserves a closer look in the setting of improved hindbrain herniation in fetal in-utero MMC repair patients. In our series, young age (less than 6 months) and late GA at time of fetal MMC repair (after 23 weeks GA) were predictors for ETV failure, while in-utero stability of ventricular size (less than 4 mm) and in-utero ventricular size post-repair ≤15.5 mm were predictors for ETV success. Larger series and potential prospective randomized studies are required for further evaluation of risk factors for ETV failure in the fetal MMC patient population.

Endoscopic Third Ventriculostomy: Success and Failure

Endoscopic third ventriculostomy (ETV) has now become an accepted mode of hydrocephalus treatment in children. Varying degrees of success for the procedure have been reported depending on the type and etiology of hydrocephalus, age of the patient and certain technical parameters. Review of these factors for predictability of success, complications and validation of success score is presented.

Prevention of Complications in Endoscopic Third Ventriculostomy

A variety of complications in endoscopic third ventriculostomy have been reported, including neurovascular injury, hemodynamic alterations, endocrinologic abnormalities, electrolyte imbalances, cerebrospinal fluid leakage, fever and infection. Even though most complications are transient, the overall rate of permanent morbidity is 2.38% and the overall mortality rate is 0.28%. To avoid these serious complications, we should keep in mind potential complications and how to prevent them. Proper decisions with regard to surgical indication, choice of endoscopic entry and trajectory, careful endoscopic procedures with anatomic orientation, bleeding control and tight closure are emphasized for the prevention of complications.

Endoscopic Third Ventriculostomy in Normal Pressure Hydrocephalus and Symptomatic Long-standing Overt Ventriculomegaly

Objectives:

The aim of this study is to define the role and effectiveness for an endoscopic third ventriculostomy (ETV) in patients with seconder normal pressure hydrocephalus(SNPH), idiopathic normal pressure hydrocephalus (INPH) and symptomatic longstanding overt ventriculomegaly (SLOVA).

Materials and Methods:

3 patients with SLOVA, 3 patients with INPH and 3 patients with SNPH underwent ETV were studied retrospectively. The patients had a follow-up of 1-6 years. Preoperative CT or/and MRI of the brain was done in all cases. Tap test was done in all cases. Clinical examination finding were classified according to the by Japanese Committee for Scientific Research (JCSS) on intractable Hydrocephalus. Patients were studied to evaluate of the patency of ventriculosthomy and aqueduclus slyvius by a Cine PC MR and CSF_DRİVE T2 Sequence MRI after 1-6 years.

Results:

Headache, gait disturbance and pollakiuria improved in three patients with SNPH underwent ETV, but dementia didn’t improve in one patient. Pollakiuria and headache improved in three patients with INPH underwent ETV but preoperative gait disturbance grade three remained unchanged in one patient. Headache improved in three patients with SLOVA underwent ETV. Preoperative gait disturbance grade 3 remained unchanged in one patient, but improved pollakiuria. We confirmed the patency of a third ventriculostomy and decreasing degrees of CSF flow into the aquaductus sylvius.

Conclusions:

In properly selected patients with SNPH, SLOVA and INPH who had headache, slight gait disturbance and pollakiuria, mainly those with a short duration of symptoms, ETV may provide good results.

Outcome of Endoscopic Third Ventriculostomy in Pediatric Patients at Zewditu Memorial Hospital, Ethiopia

OBJECTIVE

To determine short-term outcome of endoscopic third ventriculostomy (ETV) in pediatric patients.

METHODS

This was a hospital-based retrospective study of outcome of ETV performed with or without choroid plexus cauterization (CPC) in pediatric patients at Zewditu Memorial Hospital, Addis Ababa, Ethiopia, between January 2012 and December 2014. Medical records were used to complete a structured questionnaire. Outcomes were graded as success or failure. The difference in proportions was examined using χ(2) test.

RESULTS

Of 122 children, 26 underwent a combined ETV and CPC procedure, and 96 underwent ETV alone. The mean and median ages were 1.89 months and 2.0 months, respectively. Most patients were <6 months old (45.1%); 35.2% were >1 year old. The cause of hydrocephalus was myelomeningocele in 42 (34.4%) patients and aqueductal stenosis in 41 (33.6%) patients. The mean and median follow-up periods were 7.2 months and 3.0 months, respectively. The success rate for combined ETV and CPC (66%) was superior to the success rate for ETV alone (47%) among infants <1 year old (P < 0.0001). The overall surgical mortality rate was 2.4%, and the infection rate was 7%.

CONCLUSIONS

In resource-limited countries, ETV can be performed with acceptable results and less mortality and morbidity. Myelomeningocele and aqueductal stenosis were the most common causes of hydrocephalus. In patients <1 year old, the outcome success in patients undergoing combined ETV and CPC (53%) was significantly better compared with patients undergoing ETV alone (25%).

Endoscopic third ventriculostomy as adjunctive therapy in the treatment of low-pressure hydrocephalus in adults

Background:

Treatment of low-pressure hydrocephalus (LPH) may require prolonged external ventricular drainage (EVD) at sub-zero pressures to reverse ventriculomegaly. Endoscopic third ventriculostomy (ETV) has been used in the treatment of noncommunicating hydrocephalus; however, indications for ETV are expanding.

Methods:

Patients with the diagnosis of LPH as defined by the Pang and Altschuler criteria who underwent sub-zero drainage treatment over an 8-year period were included. Patients were divided into two cohorts based on whether or not ETV was employed during their treatment. Time from EVD placement to internalization of shunt was recorded for both groups; time from ETV to placement of shunt was recorded for the patients undergoing ETV.

Results:

Sixteen adult patients with LPH were managed with sub-zero drainage method. Ten (62.5%) patients did not undergo ETV and the average time from first ventriculostomy to shunting was 73 days (range 14–257 days). Six (37.5%) patients underwent ETV during the course of their treatment; average time from initial ventriculostomy to shunt was 114 days (range 0–236 days) (P = 0.16). Time from development of LPH to ETV ranged from 28 days to 6.5 months. In the ETV group, of the 4 patients who underwent shunting, the average time to shunting following ETV was 15.25 days.

Conclusions:

ETV can be used successfully in the management of refractory LPH to decrease the duration of EVD.

Amenorrhea after Endoscopic Third Ventriculostomy for a Failed Shunt in Spina Bifida: Case Report and Review of the Literature

BACKGROUND

Secondary endoscopic third ventriculostomy (ETV) for the management of shunt failure may be efficacious, though it may be followed by more frequent complications (including endocrinological impairment, e.g., amenorrhea) compared to primary ETV. These complications are usually underreported in the literature.

AIM

We report a case of secondary amenorrhea after ETV for the management of shunt failure in a young woman with hydrocephalus associated with myelomeningocele.

METHODS

A 25-year-old woman affected by hydrocephalus and myelomeningocele was admitted for secondary ETV for the management of shunt failure. The endoscopic procedure was preferred over shunt revision based on good results of secondary ETV, especially in patients with hydrocephalus associated with Chiari II malformation and spina bifida.

RESULTS

Despite the surgery being uneventful, the patient had early (postoperative seizure) and late (secondary amenorrhea) complications. In the early postoperative period, she received external ventricular drainage followed by VP shunt reimplantation 2 weeks later. There was no neurological morbidity, but 1 month after the ETV she reported secondary amenorrhea and weight gain. Laboratory investigations ruled out hyperprolactinemia, which had been treated with cabergoline administration with no efficacy since the patient was still without regular periods 1 year later.

CONCLUSION

ETV may be followed by endocrinological complications like amenorrhea that are rarely reported.

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

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

Predicting success of endoscopic third ventriculostomy: validation of the ETV Success Score in a mixed population of adult and pediatric patients

OBJECT

Endoscopic third ventriculostomy (ETV) has become the first line of treatment in obstructive hydrocephalus. The Toronto group (Kulkarni et al.) developed the ETV Success Score (ETVSS) to predict the clinical response following ETV based on age, previous shunt, and cause of hydrocephalus in a pediatric population. However, the use of the ETVSS has not been validated for a population comprising adults. The objective of this study was to validate the ETVSS in a "closed-skull" population, including patients 2 years of age and older.

METHODS

In this retrospective observational study, medical charts of all consecutive cases of ETV performed in two university hospitals were reviewed. The primary outcome, the success of ETV, was defined as the absence of reoperation or death attributable to hydrocephalus at 6 months. The ETVSS was calculated for all patients. Discriminative properties along with calibration of the ETVSS were established for the study population. The secondary outcome is the reoperation-free survival.

RESULTS

This study included 168 primary ETVs. The mean age was 40 years (range 3-85 years). ETV was successful at 6 months in 126 patients (75%) compared with a mean ETVSS of 82.4%. The area under the receiver operating characteristic curve was 0.61, revealing insufficient discrimination from the ETVSS in this population. In contrast, calibration of the ETVSS was excellent (calibration slope = 1.01), although the expected low numbers were obtained for scores < 70. Decision curve analyses demonstrate that ETVSS is marginally beneficial in clinical decision-making, a reduction of 4 and 2 avoidable ETVs per 100 cases if the threshold used on the ETVSS is set at 70 and 60, respectively. However, the use of the ETVSS showed inferior net benefit when compared with the strategy of not recommending ETV at all as a surgical option for thresholds set at 80 and 90. In this cohort, neither age nor previous shunt were significantly associated with unsuccessful ETV. However, better outcomes were achieved in patients with aqueductal stenosis, tectal compressions, and other tumor-associated hydrocephalus than in cases secondary to myelomeningocele, infection, or hemorrhage (p = 0.03).

CONCLUSIONS

The ETVSS did not show adequate discrimination but demonstrated excellent calibration in this population of patients 2 years and older. According to decision-curve analyses, the ETVSS is marginally useful in clinical scenarios in which 60% or 70% success rates are the thresholds for preferring ETV to CSF shunt. Previous history of CSF shunt and age were not associated with worse outcomes, whereas posthemorrhagic and postinfectious causes of the hydrocephalus were significantly associated with reduced success rates following ETV.

Early outcome of combined endoscopic third ventriculostomy and choroid plexus cauterization in childhood hydrocephalus

OBJECT

Although shunts have been the mainstay in treating hydrocephalus over the past 5 decades, the use of endoscopic techniques in addressing this disorder in children offers both the neurosurgeon and the patient a unique opportunity to avoid shunting and its attendant complications. The combination of endoscopic third ventriculostomy (ETV) with choroid plexus cauterization (CPC) remains uncommon in most centers despite its potential promise. The authors sought to investigate the efficacy of combining ETV and CPC (ETV+CPC) in treating childhood hydrocephalus in Nigeria. Infection and spina bifida contribute a high percentage of the cases of hydrocephalus in Nigeria.

METHODS

Over a 2-year period, all children 0-18 years of age who had endoscopic treatment for hydrocephalus were prospectively evaluated to determine the need for subsequent treatment. Children who had the combination of ETV+CPC were identified as a subcategory and form the basis of this retrospective study.

RESULTS

Twenty-two of 38 endoscopically treated children had undergone the combination of ETV+CPC for hydrocephalus of varied etiology. There was a male preponderance (2.5:1), and 90% of the patients were infants. The overall success rate was 75%, with the best outcome in children with spina bifida. One child required a repeat ETV.

CONCLUSIONS

The combination of ETV+CPC is useful in treating children with hydrocephalus of varied etiology. The complication profile is acceptable, and the overall success rate is comparable to that associated with shunt insertion.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

ETV as a last resort

INTRODUCTION

The field of neuroendoscopy is rapidly expanding with increasing indications for endoscopic third ventriculostomy (ETV).

DISCUSSION

As a treatment for hydrocephalus, ETV has the advantage of providing a more physiological cerebrospinal fluid diversion without shunt hardware which reduces the risk of recurrent infection and malfunction. The success rate of ETV has been increasing with decreasing morbidity and mortality.

CONCLUSION

Originally, ETV was indicated for cases of obstructive hydrocephalus, however the indications are expanding. To highlight this, we present a small series of cases were ETV is not traditionally indicated and was a treatment of last choice.

Endoscopic third ventriculostomy with/without choroid plexus cauterization for hydrocephalus due to hemorrhage, infection, Dandy-Walker malformation, and neural tube defect: a meta-analysis

OBJECT

Endoscopic third ventriculostomy (ETV) is a viable alternative to CSF shunting in hydrocephalic patients and is used with varying degrees of success dependent on age and etiology. The purpose of this meta-analysis is to analyze data on ETV and ETV/CPC (choroid plexus cauterization) outcomes in hopes of providing a clear understanding of their limitations in patients with hydrocephalus due to hemorrhage, infection, Dandy-Walker malformation, or neural tube disorders.

METHODS

An extensive PubMed search dating back 11 years was performed on primary ETV or ETV/CPC procedures for hydrocephalus due to infection, hemorrhage, neural tube defects, and Dandy-Walker malformation. ETV success was defined as no intraoperative or post-operative complications and no need for revision surgery at follow-up.

RESULTS

Ten studies were identified for analysis. The data represent 534 patients undergoing primary ETV and 167 patients undergoing primary ETV/CPC. The ETV group reached a 55 % success rate, while the ETV/CPC group reached a 67 % success rate. Success rates of ETV alone for hydrocephalus due to infection, neural tube defects, and intraventricular hemorrhage reached 54, 55, and 57 %, respectively. 84 % success was found in patients older than 2 years of age and 52 % success in patients less than 2 years of age.

CONCLUSIONS

ETV is a valid treatment for hydrocephalus of any etiology. There exists a small difference in success rates between infection, hemorrhage, and neural tube disorders, though not enough to discount ETV for these etiologies. Initial data utilizing ETV/CPC are promising, and additional studies will need to be done to verify such results.

Clinical outcomes of temporary shunting for infants with cerebral pseudomeningocele

OBJECTIVE

Although in the case of subdural collections temporary shunting has been suggested as a viable alternative for definitive drainage of the accumulated fluid until restoration of the normal CSF dynamics, there is no agreement on the best management strategy for pseudomeningocele.

METHODS

The authors performed a retrospective chart review in order to evaluate the clinical outcomes of infants temporarily shunted for pseudomeningocele without encephalocele at our institution (The University of Illinois at Peoria/Illinois Neurological Institute) in the period from 2004 to 2012. The epidemiological characteristics, clinical management, and final outcomes of such subpopulation were compared with a control group which received temporary shunting for subdural hematomas (SDH) during the same period.

RESULTS

Four patients (100% male) ranging in age from 8.9 to 27.1 months (mean = 13.88) with pseudomeningocele and 17 patients (64.7% male) ranging in age from 1.9 to 11.8 months (mean = 4.15) with SDH were identified. Although the initial management included sequential percutaneous subdural tapping in 82% of the patients, all children ultimately failed such strategy, requiring either subdural-peritoneal (81% of the cases) or subgaleal-peritoneal (19% of the cases) shunting. The mean implant duration was 201 days for the pseudomeningocele group and 384 days for the SDH one. Mean post-shunt hospitalization was 2 days for patients with pseudomeningocele and 4 days for patients with SDH. There was no statistical difference in terms of complications, length of hospitalization post-shunting, or clinical outcomes between the patients with pseudomeningocele and those with SDH.

CONCLUSIONS

Temporary shunting of infants with pseudo-meningocele constitutes a viable therapeutic alternative with favorable clinical outcomes and a low risk of shunt dependency similar to those of children with SDH.

Success rate of endoscopic third ventriculostomy in infants below six months of age with congenital obstructive hydrocephalus (a preliminary study of eight cases)

Aim:

In this study, we were assessing the outcome of Endoscopic Third Ventriculostomy (ETV) in infants below six months of age in cases of congenital obstructive hydrocephalus.

Materials and Methods:

The study was done prospectively on eight cases of obstructive hydrocephalus in infants younger than six months of age to assess the success rate of ETV as a primary treatment for hydrocephalus in this age group; in cases of evident failure, a ventriculo-peritoneal (VP) shunt was applied.

Results:

Despite eliminating the factors suggested as causes of ETV failure in infants below six months; the type, as with the communicating hydrocephalus, the thickness of the third ventricular floor, history of previous intracranial hemorrhage or central nervous system infection, still the success rate did not exceed 12.5%.

Conclusions:

The complication rate following ETV was low in comparison to the high frequency (20–80%) and seriousness of the possible postoperative complications following VP shunt with a significant decrease in the quality of patients’ lives. Hence the decision-making as well as the parental counselling were in a trial to estimate the ETV success or the need to perform a shunt in the treatment of obstructive hydrocephalus.

Current state and future development of intracranial neuroendoscopic surgery

Since the introduction of the modern, smaller endoscopes in the 1960s, neuroendoscopy has become an expanding field of neurosurgery. Neuroendoscopy reflects the tendency of modern neurosurgery to aim towards minimalism; that is, access and visualization through the narrowest practical corridor and maximum effective action at the target point with minimal disruption of normal tissue. Transventricular neuroendoscopy allows the treatment of several pathologies inside the ventricular system, such as obstructive hydrocephalus and intra-/paraventricular tumors or cysts, often avoiding the implantation of extracranial shunts or more invasive craniotomic approaches. Endoscopic endonasal transphenoidal surgery allows the treatment of pathologies of the sellar and parasellar region, with the advantage of a wider vision of the surgical field, less traumatism of the nasal structures, greater facility in the treatment of possible recurrences and reduced complications. However, an endoscope may be used to assist microsurgery in virtually any kind of neurosurgical procedures (endoscope-assisted microsurgery), particularly in aneurysm and tumor surgery. Basic principles of optical imaging and the physics of optic fibers are discussed, focusing on the neuroendoscope. The three main chapters of neuroendoscopy (transventricular, endonasal transphenoidal and endoscope-assisted microsurgery) are reviewed, concerning operative instruments, surgical procedures, main indications and results.