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Montemurro N. 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. Neurol Res 2024; 46:81-88. [PMID: 37722694 DOI: 10.1080/01616412.2023.2257461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 07/19/2023] [Indexed: 09/20/2023]
Abstract
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.
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Affiliation(s)
- Nicola Montemurro
- Department of Neurosurgery, Azienda Ospedaliero Universitaria Pisana (AOUP), Pisa, Italy
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Gillespie CS, Fang WYS, Lee KS, Clynch AL, Alam AM, McMahon CJ. Long-Standing Overt Ventriculomegaly in Adults: A Systematic Review and Meta-Analysis of Endoscopic Third Ventriculostomy Versus Ventriculoperitoneal Shunt as First-Line Treatment. World Neurosurg 2023; 174:213-220.e2. [PMID: 36958719 DOI: 10.1016/j.wneu.2023.03.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 03/14/2023] [Accepted: 03/15/2023] [Indexed: 03/25/2023]
Abstract
BACKGROUND Long-standing overt ventriculomegaly in adults (LOVA) is a heterogeneous term describing forms of adult hydrocephalus. LOVA incidence is increasing, yet the optimal treatment strategy for symptomatic cases remains unclear. We compared success rates and complication rates between endoscopic third ventriculostomy (ETV) and ventriculoperitoneal shunt (VPS) as first-line treatment for LOVA. METHODS A systematic review and meta-analysis was conducted in accordance with PRISMA guidelines. Three databases were searched, and articles published from 2000 to October 2022 were included (last search date October 24, 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 in ETV group, 210 in VPS group). 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 0.94, 95% confidence interval 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 (odds ratio 0.22, 95% confidence interval 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. VPS has a higher complication rate.
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Affiliation(s)
- Conor S Gillespie
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom.
| | - Wen Yung Stephanie Fang
- Department of Clinical Neurosciences, St George's, University of London, London, United Kingdom
| | - Keng Siang Lee
- Department of Neurosurgery, King's College Hospital, London, United Kingdom; Department of Basic and Clinical Neurosciences, Maurice Wohl Clinical Neuroscience Institute, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
| | - Abigail L Clynch
- Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, United Kingdom; Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, United Kingdom
| | - Ali M Alam
- Institution of Infection, Veterinary and Ecological Science, University of Liverpool, Liverpool, United Kingdom
| | - Catherine J McMahon
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, United Kingdom
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Blazer-Yost BL. Consideration of Kinase Inhibitors for the Treatment of Hydrocephalus. Int J Mol Sci 2023; 24:ijms24076673. [PMID: 37047646 PMCID: PMC10094860 DOI: 10.3390/ijms24076673] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 03/27/2023] [Accepted: 03/29/2023] [Indexed: 04/07/2023] Open
Abstract
Hydrocephalus is a devastating condition characterized by excess cerebrospinal fluid (CSF) in the brain. Currently, the only effective treatment is surgical intervention, usually involving shunt placement, a procedure prone to malfunction, blockage, and infection that requires additional, often repetitive, surgeries. There are no long-term pharmaceutical treatments for hydrocephalus. To initiate an intelligent drug design, it is necessary to understand the biochemical changes underlying the pathology of this chronic condition. One potential commonality in the various forms of hydrocephalus is an imbalance in fluid–electrolyte homeostasis. The choroid plexus, a complex tissue found in the brain ventricles, is one of the most secretory tissues in the body, producing approximately 500 mL of CSF per day in an adult human. In this manuscript, two key transport proteins of the choroid plexus epithelial cells, transient receptor potential vanilloid 4 and sodium, potassium, 2 chloride co-transporter 1, will be considered. Both appear to play key roles in CSF production, and their inhibition or genetic manipulation has been shown to affect CSF volume. As with most transporters, these proteins are regulated by kinases. Therefore, specific kinase inhibitors are also potential targets for the development of pharmaceuticals to treat hydrocephalus.
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Affiliation(s)
- Bonnie L. Blazer-Yost
- Biology Department, Indiana University—Purdue University, 723 West Michigan Street, Indianapolis, IN 46202, USA
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Palandri G, Carretta A, La Corte E, Giannini G, Martinoni M, Mantovani P, Albini-Riccioli L, Tonon C, Mazzatenta D, Elder BD, Conti A. Open-aqueduct LOVA, LIAS, iNPH: a comparative clinical-radiological study exploring the "grey zone" between different forms of chronic adulthood hydrocephalus. Acta Neurochir (Wien) 2022; 164:1777-1788. [PMID: 35477816 PMCID: PMC9233635 DOI: 10.1007/s00701-022-05215-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 04/07/2022] [Indexed: 11/27/2022]
Abstract
Purpose The definition of chronic adult hydrocephalus encompasses different pathological entities with overlapping characteristics, including long-standing overt ventriculomegaly in adults (LOVA), late-onset idiopathic aqueductal stenosis (LIAS) and idiopathic normal pressure hydrocephalus (iNPH). The aim of our study was to identify preoperative clinical and radiological features peculiar of these diseases providing some pathophysiology inferences on these forms of hydrocephalus. Methods Clinical and radiological preoperative records, type of surgical treatment and clinical outcome of patients with chronic adult hydrocephalus who were surgically treated between 2013 and 2019 were retrospectively reviewed. Univariate and multivariate analyses were performed to evaluate the contribution of each variable to the differential diagnosis. Results In total, 105 patients were included: 18 with LOVA, 23 with LIAS and 64 with iNPH. On multivariate analysis, an enlarged cisterna magna and a more severe ventriculomegaly were associated with the diagnosis of LOVA, while an older age and DESH with iNPH. LIAS patients tend to have an higher prevalence of raised ICP symptoms. Based on that, a clinical and radiological scoring system was developed to distinguish between iNPH and no iNPH cases. A precise cut-off value with a sensitivity of 95.1% and a specificity of 90.6% was identified. Conclusions LOVA, LIAS and iNPH are different forms of chronic adulthood hydrocephalus and present different and peculiar clinical and radiological features, with an impact on the treatment and outcome prediction. The implementation of a clinical-radiological score for differential diagnosis may help the differentiation. Further studies are warranted. Supplementary Information The online version contains supplementary material available at 10.1007/s00701-022-05215-9.
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Affiliation(s)
- Giorgio Palandri
- Department of Neurosurgery, IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Via Altura 3, 40139, Bologna, Italy
| | - Alessandro Carretta
- Department of Neurosurgery, IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Via Altura 3, 40139, Bologna, Italy.
- Department of Biomedical and NeuroMotor Sciences (DIBINEM), University of Bologna, Bologna, Italy.
| | - Emanuele La Corte
- Department of Neurosurgery, IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Via Altura 3, 40139, Bologna, Italy
- Department of Biomedical and NeuroMotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
| | - Giulia Giannini
- Department of Biomedical and NeuroMotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
- Neurology Unit (NEUROMET), IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Bologna, Italy
| | - Matteo Martinoni
- Department of Neurosurgery, IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Via Altura 3, 40139, Bologna, Italy
| | - Paolo Mantovani
- Department of Neurosurgery, IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Via Altura 3, 40139, Bologna, Italy
| | - Luca Albini-Riccioli
- Neuroradiology Unit, IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Bologna, Italy
| | - Caterina Tonon
- Department of Biomedical and NeuroMotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
- Functional and Molecular Neuroimaging Unit, IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Bologna, Italy
| | - Diego Mazzatenta
- Department of Biomedical and NeuroMotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
- Programma Neurochirurgia Ipofisi - Pituitary Unit, IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Bologna, Italy
| | - Benjamin D Elder
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Alfredo Conti
- Department of Neurosurgery, IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Via Altura 3, 40139, Bologna, Italy
- Department of Biomedical and NeuroMotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
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Martinoni M, Miccoli G, Riccioli LA, Santoro F, Bertolini G, Zenesini C, Mazzatenta D, Conti A, Cavallo LM, Palandri G. Idiopathic Aqueductal Stenosis: Late Neurocognitive Outcome in ETV Operated Adult Patients. Front Neurol 2022; 13:806885. [PMID: 35463152 PMCID: PMC9021920 DOI: 10.3389/fneur.2022.806885] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 02/21/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveThe aim of the present study is to evaluate a neurocognitive outcome in patients affected by late-onset idiopathic aqueductal stenosis (LIAS) who underwent endoscopic third ventriculostomy (ETV).Materials and MethodsA prospective study was conducted between January 2015 and December 2017 in a series of 10 consecutive adult patients referred to the Neurosurgery Department of IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy. All the adult patients admitted with absence of CSF flow through the aqueduct in phase-contrast (PC)—MRI sequences or a turbulence void signal in T2—weighted images in midsagittal thin-slice MR sequences underwent a specific neuroradiological, neurological, and neurocognitive assessment pre- and postoperatively.ResultsAll patients affected by gait and sphincter disturbances improved after ETV. Attentive and executive functions as well as visuo-spatial memory and verbal executive functions improved in several patients. Similarly, the affective and behavioral scales improved in almost 50% of the patients. No major complications have been recorded, and no patients required a second surgery for shunt placement.ConclusionEndoscopic third ventriculostomy represents a safe and effective surgical procedure for the treatment of LIAS. In addition to neurological improvement, we demonstrated also postoperative neurocognitive improvement mainly in attentive and executive functions, visuo-spatial memory, verbal executive functions, and behavioral and affective domains.
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Affiliation(s)
- Matteo Martinoni
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Giovanni Miccoli
- Department of Neuroscience and Reproductive and Odontostomatological Sciences, University of Naples Federico II, Naples, Italy
- *Correspondence: Giovanni Miccoli
| | - Luca Albini Riccioli
- Neuroradiology Unit, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Francesca Santoro
- Neurology Unit, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Giacomo Bertolini
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Corrado Zenesini
- Epidemiology and Biostatistics Service, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Diego Mazzatenta
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Alfredo Conti
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Luigi Maria Cavallo
- Department of Neuroscience and Reproductive and Odontostomatological Sciences, University of Naples Federico II, Naples, Italy
| | - Giorgio Palandri
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
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Surgical Treatment of Long-Standing Overt Ventriculomegaly in Adults (LOVA): A Comparative Case Series between Ventriculoperitoneal Shunt (VPS) and Endoscopic Third Ventriculostomy (ETV). INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19041926. [PMID: 35206112 PMCID: PMC8872207 DOI: 10.3390/ijerph19041926] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 02/04/2022] [Accepted: 02/06/2022] [Indexed: 02/01/2023]
Abstract
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.
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Gillespie CS, Richardson GE, Mustafa MA, Evans D, George AM, Islim AI, Mallucci C, Jenkinson MD, McMahon CJ. How should we treat long-standing overt ventriculomegaly in adults (LOVA)? A retrospective cohort study. Neurosurg Rev 2022; 45:3193-3200. [PMID: 35688957 PMCID: PMC9492616 DOI: 10.1007/s10143-022-01812-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Revised: 04/16/2022] [Accepted: 05/10/2022] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Conor S. Gillespie
- Institute of Systems, Molecular and Integrative Biology, School of Medicine, University of Liverpool, Cedar House, Ashton Street, Liverpool, L69 3GE UK ,Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - George E. Richardson
- Institute of Systems, Molecular and Integrative Biology, School of Medicine, University of Liverpool, Cedar House, Ashton Street, Liverpool, L69 3GE UK ,Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Mohammad A. Mustafa
- Institute of Systems, Molecular and Integrative Biology, School of Medicine, University of Liverpool, Cedar House, Ashton Street, Liverpool, L69 3GE UK ,Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Daisy Evans
- School of Medicine, Keele University, Staffordshire, UK
| | - Alan M. George
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK ,School of Medicine, University of Birmingham, Birmingham, UK
| | - Abdurrahman I. Islim
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Conor Mallucci
- Department of Neurosurgery, Alder Hey Children’s NHS Foundation Trust, Liverpool, UK
| | - Michael D. Jenkinson
- Institute of Systems, Molecular and Integrative Biology, School of Medicine, University of Liverpool, Cedar House, Ashton Street, Liverpool, L69 3GE UK ,Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Catherine J. McMahon
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
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