Clinical and surgical outcome of endoscopic third ventriculostomy (ETV) and ventriculoperitoneal shunt (VPS) in patients with Long-Standing Overt Ventriculomegaly in Adults (LOVA): a systematic review

OBJECTIVES

The optimal surgical procedure for long-standing overt ventriculomegaly in adults (LOVA) remains controversial.

METHODS

A systematic search of three databases was performed for studies published between January 1999 and March 2022. This systematic review included 12 studies with a total of 318 patients with LOVA surgically treated. PRISMA guidelines were followed.

RESULTS

Gait disturbance (74.8%) and headache (59.7%) were the most common clinical presentation. Overall, the rate of postoperative clinical improvement at the last follow-up was 83.6% (95% CI 78.1-86.1). A lower rate of postoperative clinical improvement or halt of progression of presenting symptoms was observed after ETV (211/257 = 82.1% 95% CI 76.2-85.1%) compared with VPS (55/61 = 90.2% 95% CI 80.3-96.1%). Overall, surgical and postoperative complications were reported in 22/297 patients (7.5% 95% CI 4.4-20%) (11 studies). A higher rate of surgical complications was observed in patients treated with VPS (19.7% 95 CI 5.9-46.7%), compared with patients treated with ETV (4.3% 95% CI 2.1-10.9%). The overall rate of second surgery due to failure of first surgical approach (ETV or VPS) was 46/275 (16.7%).

DISCUSSION

This meta-analysis confirmed the efficacy of EVT and VPS in symptomatic patients with LOVA, reporting a roughly 84% of postoperative clinical improvement or halt of progression of symptoms. A higher rate of surgical complications was observed in patients treated with VPS compared with patients treated with ETV. In addition, roughly 18% of patients treated with ETV required a further VPS. These findings should be considered when advising LOVA patients regarding the management of hydrocephalus.

Long standing overt ventriculomegaly in adults (LOVA): a systematic review and meta-analysis of endoscopic third ventriculostomy vs ventriculoperitoneal shunt as first line treatment

BACKGROUND

Long standing overt ventriculomegaly in adults (LOVA) is a heterogenous term describing forms of adult hydrocephalus. LOVA incidence is increasing, yet the optimal treatment strategy for symptomatic cases remains unclear. We compared the success and complication rates between Endoscopic Third Ventriculostomy (ETV) and Ventriculoperitoneal Shunt (VPS) as a first line treatment for LOVA.

METHODS

A systematic review and meta-analysis was conducted in accordance with PRISMA guidelines (PROSPEROID CRD42021277542). Three databases were searched, and articles published from 2000 to October 2022 included (last search date 30^th September 2022). Success rates and complications of both ETV and VPS were compared using random effects models.

RESULTS

Of 895 articles identified, 22 studies were included in the analysis (556 patients- 346 treated with ETV, 210 VPS). Mean age was 44.8 years. The most common presenting symptoms were gait disturbance (N=178), headache (N=156), and cognitive decline (N=134). Combined success rates were 81.8% (N=283/346) in the ETV group and 86.7% (N=182/210) in the VPS group (median follow up 41 months). There was no difference in success rates between ETV and VPS groups (Odds Ratio [OR] 0.94, 95% CI 0.86-1.03, I² = 0%). Combined complication rates were 4.6% (N=16/346) in the ETV group and 27.1% (N=57/210) in the VPS group. ETV had a lower rate of postoperative complications (OR 0.22, 95% CI 0.11-0.33, I² = 0%).

CONCLUSIONS

Symptomatic LOVA can be successfully managed with surgical intervention. ETV and VPS have similar success rates when used as first line treatment. However, VPS has a higher complication rate.

Surgical Treatment of Long-Standing Overt Ventriculomegaly in Adults (LOVA): A Comparative Case Series between Ventriculoperitoneal Shunt (VPS) and Endoscopic Third Ventriculostomy (ETV)

Background: Long-standing overt ventriculomegaly in adults (LOVA) is an uncommon type of adult chronic hydrocephalus. In recent years, conflicting case series described different outcomes after treatment of LOVA with endoscopic third ventriculostomy (ETV) or ventriculoperitoneal shunt (VPS). The aim of this study is to report a single institutional surgical experience of patients with LOVA in order to evaluate the clinical outcome of those patients treated with one or, sometimes, both surgical procedures, analyzing the main clinical features of these patients, before and after surgery. Methods: We conducted a retrospective study on 31 patients with diagnosis of LOVA, who were treated in our University Hospital between December 2010 and October 2020. We reported gender, age, clinical presentation, surgical treatment, and clinical outcome according to the Kiefer index (KI). Evans’ index, head circumference, aqueductal stenosis and expanded/destroyed sella turcica were assessed on preoperative MRI. Results: The most common clinical manifestation was gait disturbances (100%) followed by urinary incontinence in 23 (74.2%) patients and cognitive deficits in 22 (71%) patients. On preoperative MRI, the overall mean Evans’s Index was 0.49, whereas the overall mean head circumference was 57.3 cm. Twenty-three patients (74.2%) had obliterated cortical sulci, 20 (64.5%) patients had aqueductal stenosis, and 22 (71%) patients had an expanded/destroyed sella turcica on preoperative MRI. Fifteen (48.4%) patients underwent ETV and sixteen (51.6%) were treated with VPS as first surgical procedure. Four (26.6%) out of fifteen patients treated with ETV required a subsequent VPS. The overall median age of patients was 64 (IQR: 54.5–74) and the overall median follow-up was 57 months (IQR 21.5–81.5). Overall morbidity was 22.5%. Mean recovery index (RI), according to KI, was 3.8 ± 4.3 and 2.2 ± 5.6 (p = 0.05) at last follow-up in patients treated with ETV and VPS, respectively. Conclusions: The choice of surgical treatment of LOVA remains under discussion. Although EVT is a tempting option for patients with LOVA, conversion to VP shunt is not uncommon.

How should we treat long-standing overt ventriculomegaly in adults (LOVA)? A retrospective cohort study

Long-standing overt ventriculomegaly in adults (LOVA) is a heterogenous group of conditions with differing presentations. Few studies have evaluated success rates of available surgical treatments, or ascertained the natural history. There is a need to assess the efficacy of both endoscopic third ventriculostomy (ETV) and ventriculoperitoneal shunt (VPS) as first-line treatments. We conducted a retrospective, single-centre study of adults with LOVA at a tertiary neurosurgery centre in England, UK, aiming to identify presentation, management strategy, and outcome following treatment. A total of 127 patients were included (mean age 48.1 years, 61/127 male). Most patients were symptomatic (73.2%, n = 93/127, median symptom duration 10 months). The most common symptoms were gait ataxia, headache, and cognitive decline (52.8%, 50.4%, and 33.9%, respectively). Fourteen patients had papilloedema. Ninety-one patients (71.7%) underwent surgery (84 ETV, 7 VPS). Over a median follow-up of 33.0 months (interquartile range [IQR] 19.0-65.7), 82.4% had a clinical improvement after surgery, and 81.3% had radiological improvement. Clinical improvement rates were similar between ETV and VP shunt groups (82.1% vs 85.7%, p = 0.812). Surgical complication rates were significantly lower in the ETV group than the VP shunt group (4.8% vs 42.9%, p < 0.001). Of the patients treated surgically, 20 (22.0%) underwent further surgery, with 14 patients improving. This study demonstrates the efficacy of ETV as a first-line treatment for LOVA.

Long-standing Overt Ventriculomegaly in Adults and Endoscopic Third Ventriculostomy, the Perfect Treatment for the Proper Diagnosis

OBJECTIVE

Long-standing overt ventriculomegaly in adults (LOVA) is form of hydrocephalus that develops during childhood, manifesting its symptoms during adulthood. Only a small number of LOVA case series have been published, and controversies regarding optimal management still exist. The authors collected a series of symptomatic LOVA patients treated successfully using endoscopic third ventriculostomy (ETV), aiming to strengthen what has been reported in the literature on ETV's role in both neurologic and neurocognitive outcomes.

METHODS

Between 2002 and 2020, we collected 40 case studies of patients treated using an ETV. Associated pathologies were documented in 14 cases. All patients underwent magnetic resonance scans preoperatively and postoperatively while only 29 patients were submitted during follow-up to neurocognitive assessment.

RESULT

At a mean follow-up of 6 years, 36 patients (90%) reported either an improvement or a stabilization of their presenting symptoms. Headache improved subjectively in 11 patients (27.5%), balance and gait disturbances improved in all patients, urinary incontinence improved in 24 patients (60%), memory disturbances subjectively improved in 21 patients (52.5%), and visual deficits improved in 5 patients (12.5%). Four patients (10%) had symptom progression, which occurred 6 to 24 months after surgery with radiologic evidence of ETV failure.

CONCLUSIONS

LOVA is a form of hydrocephalus that must be correctly identified. A correct magnetic resonance study and comprehensive neuropsychologic assessment are crucial to identify it in order to define proper management. From our analysis, ETV represents the gold standard treatment granting rewarding results that are maintained in a long-term follow-up.