Endoscopic third ventriculostomy prior to resection of posterior fossa tumors in children

Placement of EVD in pediatric posterior fossa tumors: safe and efficient or old-fashioned? The Vienna experience

PURPOSE

The perioperative treatment of hydrocephalus in pediatric posterior fossa tumors with an external ventricular drain (EVD) is the treatment of choice in our center. We analyzed our experience in using EVD concerning safety and effectivity.

METHODS

This is a single-center retrospective cohort study of 100 consecutive pediatric patients who underwent resection for a newly diagnosed tumor in the posterior fossa between 2011 and 2022.

RESULTS

Of the 100 patients with posterior fossa tumors, 80 patients (80%) had radiological signs of hydrocephalus at presentation, 49 patients (49%) of whom underwent placement of an EVD. In 40 patients, the EVD was inserted at a mean of 2.25 days prior to the tumor resection; 9 had the EVD inserted during tumor resection (frontal trajectory in 7 patients, occipital trajectory in 2 patients). Histology revealed pilocytic astrocytoma in 48 patients, medulloblastoma in 32, ependymoma in 11, and other histologic entities in 9 patients. Gross total/near-total resection was achieved in 46 (95.83%) of the 48 pilocytic astrocytomas, 30 (93.75%) of the 32 medulloblastomas, and 11 (100%) of the 11 ependymomas. The mean number of total days with the EVD in place was 8.61 ± 3.82 (range 2-16 days). The mean number of days with an EVD after tumor resection was 6.35 ± 3.8 (range 0-16 days). EVD-associated complications were seen in 6 patients (12.24%) including one infection. None of these resulted in a worse clinical course or any long-term sequelae. Permanent CSF diversion at 6 months after surgery was necessary in 13 patients (13%), including two VP shunt, two SD-shunt, six endoscopic third ventriculostomy (ETV), and three combined VP shunt and ETV procedures. Patients with a medulloblastoma or ependymoma had a higher rate of permanent CSF diversion needed than the group of pilocytic astrocytoma patients (27.9% versus 2.13%, p < 0.001). In patients with metastatic disease, 7 of 17 patients (41.18%) needed a permanent CSF diversion, compared to 6 of 83 patients (7.23%) in the group without metastasis (p = 0.001).

CONCLUSION

The treatment of hydrocephalus in pediatric posterior fossa tumors with an EVD as a temporary measure is safe and effective, provided that a multi-professional understanding for its handling is given and there is no need for a long transport of the children.

Perioperative external ventricular drainage vs. no-EVD strategy in pediatric posterior fossa tumors-pilot study results

INTRODUCTION

Pediatric brain tumors of the posterior fossa often present with occlusive hydrocephalus. Endoscopic third ventriculostomy (ETV) or ventriculoperitoneal shunting (VPS) has been established for definite hydrocephalus treatment. The aim of the study was to analyze the impact and safety of perioperative temporary external ventricular CSF drainage (EVD) placement on postoperative hydrocephalus outcome compared to a no-EVD strategy.

PATIENTS AND METHODS

In a prospective database, 36 posterior fossa tumor patients of 2-18 years were included with a follow-up of 1 year. Fifty-eight percent presented with preoperative hydrocephalus. Patients were assigned to non-hydrocephalus group: group I (n = 15) and to preoperative hydrocephalus, group IIa with EVD placement (n = 9), and group IIb without EVD (n = 12).

RESULTS

Median age of patients was 8.1 years (range 3.17 to 16.58 years). One-third of 21 hydrocephalus patients required ETV or VPS (n = 7). Occurrence of de novo hydrocephalus in group I after surgery was not observed in our cohort. Age and histology were no confounding factor for EVD placement between group IIa and IIb (p = 0.34). The use of EVD did not result in better control of hydrocephalus compared to no-EVD patients considering pre- and postoperative MRI ventricular indices (p = 0.4). Perioperative placement of an EVD resulted in a threefold risk for subsequent VPS or ETV (group IIa 55.5% vs group IIb 16.6%): relative risk for EVD patients compared to no-EVD patients with hydrocephalus was 3.3 (CI = 1.06-13.43, p = 0.09).

CONCLUSION

Perioperative EVD placement appears to harbor a threefold relative risk of requiring subsequent permanent CSF diversion in children above 2 years. EVD was not more effective to control ventricular enlargement compared to tumor removal alone. The no-EVD strategy was safe and did not result in postoperative complications. Thus, to evaluate potential adverse effects on hydrocephalus outcome by EVD placement, a prospective study is warranted to falsify the results.

Risk factors for postresection shunting in children with suprasellar tumor: a retrospective analysis of 124 patients

OBJECTIVE

Hydrocephalus is one of the most significant comorbidities of pediatric suprasellar tumors. Up to 37.5-68.0% of patients were diagnosed with hydrocephalus at admission. However, after surgical resection of the tumor, 9.3-51.4% of the hydrocephalus will persist and require a ventriculoperitoneal shunt (VPS) surgery. The purpose of this study was to identify the risk factors associated with postresection shunting in children with suprasellar tumors.

METHODS

We conducted a retrospective analysis of children who underwent surgery for suprasellar tumors at our department from February 2011 to December 2020. We used univariate and multivariate analysis to screen the factors that might be correlated with postoperative shunt placement, taking into account patients' characteristics, tumor histology/size/calcification, the severity of preoperative hydrocephalus, the involvement of ventricles, external ventricular drainage (EVD) placement, postoperative intraventricular hematoma, the extent of resection, and other surgical details.

RESULTS

A total of 124 children who underwent surgery for suprasellar tumors were included in our study. Hydrocephalus was present in 55 patients (44.3%) at admission; 23 patients (18.5%) received VPS implantation after tumor removal. Univariate analysis showed that the involvement of ventricles (p = 0.002), moderate/severe preoperative hydrocephalus (p = 0.001), postoperative intraventricular hematoma (p = 0.005), and EVD implantation (p = 0.001) were significantly associated with postoperative VPS. Multivariate analysis confirmed that only ventricle involvement (p = 0.002; OR = 5.6; 95%CI 1.8-17.2) and intraventricular hematoma (p = 0.01; OR = 10.7; 95%CI 1.8-64.2) were independent risk factors for postresection shunting.

CONCLUSION

Ventricle involvement and intraventricular hematoma can be identified as independent predictors for postoperative shunting in pediatric suprasellar tumors.

Endoscopic third ventriculostomy for the management of hydrocephalus secondary to posterior fossa tumors: A retrospective study

Background:

Endoscopic third ventriculostomy (ETV) is an effective alternative to ventriculoperitoneal shunting as well as external ventricular drainage for the urgent management of acute hydrocephalus. We performed this study to investigate the efficacy and safety of ETV before tumor resection in managing hydrocephalus in patients with posterior fossa brain tumors (PFBT) in our neurosurgery department.

Methods:

We conducted this retrospective observational study between February 2018 and February 2020 on all cases diagnosed with PFBT associated with triventricular obstructive hydrocephalus. We retrospectively reviewed the demographic characteristics, operative procedures, and radiological investigations of all cases. During the follow-up period, clinical, as well as radiological success were evaluated.

Results:

Twenty-two ETV procedures were performed in 22 cases of PFBT (mean age = 22.1 years, SD = 11.4). Of the 22 cases, 8 cases (36.4%) had ependymoma, 7 cases (31.8%) had cerebellar astrocytoma, and 5 cases (22.7 %) had medulloblastoma, while 2 cases (9.1%) had diffuse pontine gliomas. The median follow-up duration was 9 months (range 3–13 months). The most commonly reported clinical presentation was the significant intracranial pressure increase. All operations were performed successfully in all cases. Only two ETV post-tumor resection failures were documented during the follow-up period.

Conclusion:

Preoperative ETV has shown to be an effective long-term cerebrospinal fluid diversion procedure to manage PFBT-associated hydrocephalus, with a relatively low rate of complications. Further prospective studies are required to assess the regular use of ETV before complete tumor resection.

Permanent Cerebrospinal Fluid Diversion in Adults With Posterior Fossa Tumors: Incidence and Predictors

BACKGROUND

Posterior fossa tumors (PFTs) can cause hydrocephalus. Hydrocephalus can persist despite resection of PFTs in a subset of patients requiring permanent cerebrospinal fluid (CSF) diversion. Characteristics of this patient subset are not well defined.

OBJECTIVE

To define preoperative and postoperative variables that predict the need for postoperative CSF diversion in adult patients with PFTs.

METHODS

We surveyed the CNS (Central Nervous System) Tumor Outcomes Registry at Emory (CTORE) for patients who underwent PFT resection at 3 tertiary-care centers between 2006 and 2019. Demographic, radiographic, perioperative, and dispositional data were analyzed using univariate and multivariate models.

RESULTS

We included 617 patients undergoing PFT resection for intra-axial (57%) or extra-axial (43%) lesions. Gross total resection was achieved in 62% of resections. Approximately 13% of patients required permanent CSF diversion/shunting. Only 31.5% of patients who required pre- or intraop external ventricular drain (EVD) placement needed permanent CSF diversion. On logistic regression, size, transependymal flow, use of perioperative EVD, postoperative intraventricular hemorrhage (IVH), and surgical complications were predictors of permanent CSF diversion. Preoperative tumor size was only independent predictor of postoperative shunting in patients with subtotal resection. In patients with intra-axial tumors, transependymal flow (P = .014), postoperative IVH (P = .001), surgical complications (P = .013), and extent of resection (P = .03) predicted need for shunting. In extra-axial tumors, surgical complications were the major predictor (P = .022).

CONCLUSION

Our study demonstrates that presence of preoperative hydrocephalus in patients with PFT does not necessarily entail the need for permanent CSF diversion. We report the major predictive factors for needing permanent CSF diversion.

Intratumoral Hemorrhage After Endoscopic Third Ventriculostomy for Obstructive Hydrocephalus Caused by Brain Tumors

BACKGROUND

Endoscopic third ventriculostomy (ETV) for obstructive hydrocephalus and endoscopic biopsy (EB) for intraventricular and paraventricular tumors are standard therapies because they are minimally invasive procedures. Although EB-associated hemorrhagic risk has been well documented, there have been only a few reports on hemorrhagic risk associated with ETV. We conducted a single-institution retrospective study on the incidence of hemorrhage secondary to EB and/or ETV.

METHODS

We retrospectively reviewed patient characteristics, procedure, pathological findings, and complications including hemorrhage of 100 patients with intraventricular and paraventricular tumors who underwent EB and/or ETV at our institution from 2000 to 2020.

RESULTS

EB/ETV combined surgery (combined group), EB-alone surgery (EB-alone group), and ETV-alone surgery (ETV-alone group) were performed in 44 (44%), 24 (24%), and 32 (32%) patients, respectively, and all procedures were successful. The rates of definitive and suggestive diagnoses in EB were 76.5% and 23.5%, respectively. Adverse events were observed in 6 patients. In the combined group, acute obstruction of the ETV stoma was observed in 1 patient and transient double vision was observed in 1 patient. Transient aqueductal stenosis/obstruction was observed in 2 patients in the EB-alone group. In the ETV-alone group, hemorrhage was observed in 2 patients; these patients developed intratumoral hemorrhage despite ETV-alone surgery. Subsequently, these 2 patients underwent tumor removal, and the histopathological diagnosis was atypical teratoid/rhabdoid tumor in both.

CONCLUSIONS

For obstructive hydrocephalus with atypical teratoid/rhabdoid tumor, physicians must be aware of the risk of postoperative intratumoral hemorrhage after performing ETV.

Tumor-related hydrocephalus in infants: a narrative review

Primary brain tumors diagnosed during infancy present several challenges for the pediatric neurosurgeon including the management of tumor-related hydrocephalus. Infant tumor-related hydrocephalus (iTRH) is present in over 70% of new diagnoses overall and in over 90% of infants with infratentorial neoplasms. iTRH may be related to direct obstruction of cerebrospinal fluid (CSF) pathways, shedding of protein and/or cells leading to dysfunctional subarachnoid, tumor-related CSF production, or, most frequently, a combination of these mechanisms. Treatment plans must consider the acuity of presentation, the mechanism of iTRH, and the additional neoadjuvant or adjuvant therapies required to treat the neoplasm. This narrative review provides a broad reference on the epidemiology, pathophysiology, and treatment of iTRH.

Endoscopic third ventriculostomy before surgery of third ventricle and posterior fossa tumours decreases the risk of secondary hydrocephalus and early postoperative complications

Endoscopic third ventriculostomy (ETV) is an effective treatment for obstructive hydrocephalus (HCP) at the level of third or fourth ventricle. To date, there is no consensus regarding its role as intervention preceding the operation of tumour removal. The aim of this prospective open-label controlled study is to assess if ETV prevents secondary HCP after tumour removal and if ETV influences the early results of tumour surgery. The study was performed on 68 patients operated for tumours of the third ventricle and posterior fossa. In 30 patients, ETV was performed several days before tumour removal, while in 38 patients, the tumour was removed during a one-stage procedure without ETV. Patients who did not receive ETV before the tumour removal procedure had a higher probability of developing postoperative HCP (n = 12, p = 0.03). They also demonstrated a substantially higher rate of early postoperative complications (n = 20, p = 0.002) and a lower Karnofsky score (p = 0.004) than patients in whom ETV was performed before tumour removal. The performance of external ventricular drainage in the non-ETV group did not prevent secondary HCP (p = 0.68). Postoperative cerebellar swelling (p = 0.01), haematoma (p = 0.04), cerebrospinal fluid leak (p = 0.04) and neuroinfection (p = 0.04) were the main risk factors of persistent HCP. Performance of ETV before tumour removal is not only beneficial for control of acute HCP but also prevents the occurrence of secondary postoperative HCP and may also minimize early postoperative complications.

Endoscopic third ventriculostomy for pediatric tumor-associated hydrocephalus

OBJECTIVE

Surgical options for managing hydrocephalus secondary to CNS tumors have traditionally included ventriculoperitoneal shunting (VPS) when tumor resection or medical management alone are ineffective. Endoscopic third ventriculostomy (ETV) has emerged as an attractive treatment strategy for tumor-associated hydrocephalus because it offers a lower risk of infection and hardware-related complications; however, relatively little has been written on the topic of ETV specifically for the treatment of tumor-associated hydrocephalus. Here, the authors reviewed the existing literature on the use of ETV in the treatment of tumor-associated hydrocephalus, focusing on the frequency of ETV use and the failure rates in patients with hydrocephalus secondary to CNS tumor.

METHODS

The authors queried PubMed for the following terms: "endoscopic third ventriculostomy," "tumor," and "pediatric." Papers with only adult populations, case reports, and papers published before the year 2000 were excluded. The authors analyzed the etiology of hydrocephalus and failure rates after ETV, and they compared failure rates of ETV with those of VPS where reported.

RESULTS

Thirty-two studies with data on pediatric patients undergoing ETV for tumor-related hydrocephalus were analyzed. Tumors, particularly in the posterior fossa, were reported as the etiology of hydrocephalus in 38.6% of all ETVs performed (984 of 2547 ETVs, range 29%-55%). The ETV failure rate in tumor-related hydrocephalus ranged from 6% to 38.6%, and in the largest studies analyzed (> 100 patients), the ETV failure rate ranged from 10% to 38.6%. The pooled ETV failure rate was 18.3% (199 failures after 1087 procedures). The mean or median follow-up for ETV failure assessment ranged from 6 months to 8 years in these studies. Only 5 studies directly compared ETV with VPS for tumor-associated hydrocephalus, and they reported mixed results in regard to failure rate and time to failure. Overall failure rates appear similar for ETV and VPS over time, and the risk of infection appears to be lower in those patients undergoing ETV. The literature is mixed regarding the need for routine ETV before resection for posterior fossa tumors with associated hydrocephalus.

CONCLUSIONS

Treatment of tumor-related hydrocephalus with ETV is common and is warranted in select pediatric patient populations. Failure rates are overall similar to those of VPS for tumor-associated hydrocephalus.

Pediatric posterior fossa tumors outcomes: Experience in a tertiary care center in the Middle East

BACKGROUND

Among all childhood cancers, brain tumors are second only to leukemia in incidence and are the most common solid pediatric tumors. More than 60 % of pediatric brain tumors are infra-tentorial. The first-line treatment for most infra-tentorial tumors in pediatric patients is surgical resection, with the goal of gross-total resection, relief of symptoms and hydrocephalus, and increased survival. The proximity to the fourth ventricle, and therefore, the cerebrospinal fluid (CSF) pathways, predisposes children with posterior fossa tumors to the development of obstructive hydrocephalus and multiple other co-morbidities pre and post-surgery.

OBJECTIVES

This study aims to present our series of pediatric posterior fossa tumor surgeries in the Neurosurgical Department at the American University of Beirut Medical Center(AUBMC) and perform internal quality control for our single-institution consecutive series as one of the largest referral and tertiary care centers in the region. The second purpose of this retrospective study is to weigh the risks of surgery against the presumed advantages and to have specific knowledge about the complication rates, especially those related to the CSF pathway, comparing our results to those in the literature.

METHODS

All pediatric patients (< 18 years of age), referred to our center from different regions in the middle east, and surgically treated for a posterior fossa tumor from June 2006 to June 2018 at the American University of Beirut Medical Center were included. A thorough review of all medical charts was performed to validate all the database records.

RESULTS

The patient sample consisted of 64 patients having a mean age of 6.19 ± 4.42 years and 59.37 % of whom were males. The most common tumor pathology was pilocytic astrocytoma (40.62 %) followed by medulloblastoma (35.93 %) and ependymoma. The most common type of tumor that was seen in patients that developed mutism postoperatively (n = 6, 9.37 %) was medulloblastoma (n = 4, 66.66 %). In this patient sample, 12.28 % (n = 7) of the patients developed hydrocephalus postoperatively.Midline tumors were more associated with the development of mutism(OR = 4.632, p = 0.306) and hydrocephalus (OR = 5.056, p = 0.135) postoperatively, albeit not statistically significantly.The presence of a preoperative shunt was shown to be protective against the development of CSF leak (OR = 0.636, p = 0.767), as none of the patients that came in with CSF diversion developed a CSF leak after their surgery.

CONCLUSION

This study from a single center experience accompanied by a thorough literature review sheds light on the complications frequently encountered after posterior fossa tumor surgery in children. These included transient cerebellar mutism, CSF leak, and hydrocephalus as seen in some of our patients. Our findings highlight the need for prospective studies with well-defined protocols directed at assessing novel ways and approaches to minimize the risk of these complications.

The role of external ventricular drainage for the management of posterior cranial fossa tumours: a systematic review

Posterior cranial fossa tumours frequently develop hydrocephalus as first presentation in up to 80% of paediatric patients and 21.4% of adults, although it resolves after tumour removal in 70-90% and 96%, respectively. New onset hydrocephalus is reported in about 2.1% of adult and 10-40% of paediatric patients after posterior fossa surgery. There is no consensus concerning prophylactic external ventricular drainage (EVD) placement that is frequently used before posterior fossa lesion removal, as well in those cases without clear evidence of hydrocephalus. The aim of the study was to define the most correct management for patients who undergo posterior fossa tumour surgery, thus identifying cohorts of patients who are at risk of persistent hydrocephalus prior to surgery. A systematic review of literature has been performed, following PRISMA guidelines. Most of the studies reported CSF shunt only in the presence of hydrocephalus, whereas only a few authors suggested its prophylactic use in the absence of signs of ventricular dilatation. Predictive factors for postoperative hydrocephalus has been identified, including young age (< 3 years), severe symptomatic hydrocephalus at presentation, EVD placement before surgery, FOHR index > 0.46 and Evans index > 0.4, pseudomeningocele, CSF leak and infection. The use of pre-resection CSF shunt in case of signs and symptoms of hydrocephalus is mandatory, although it resolves in the majority of cases. As reported by several studies included in the present review, we suggest CSF shunt also in case of asymptomatic hydrocephalus, whereas it is not indicated without evidence of ventricular dilatation.