Endoscopic management of septated, multiloculated hydrocephalus

Multiloculated hydrocephalus: Evolution of treatments and outcome

Multiloculated hydrocephalus has an overall dismal functional outcome; imaging, early diagnosis, and technological advancements have made new roads in its management. Thirty infants with multiloculated hydrocephalus were studied. Progressive enlargement of the head was the most common presentation in 77%; of these, 47% were treated for neonatal meningitis and septicemia and 20% had suffered birth trauma. The majority required a single ventriculoperitoneal shunt; nine of them required multiple shunts; and six were managed with endoscopic fenestration and endoscopic third ventriculostomy. On follow-up, shunt malfunction was the most common complication. Only 26% of the survivors could achieve normal, neuropsychological developments. The mortality in this series is 6.7%.

A Case of Multiloculated Hydrocephalus

Multiloculated hydrocephalus (MLH) is a disease in which no single treatment has shown to be superior to others. The authors report a pediatric case of postmeningitic MLH diagnosed at the age of 3 months. It was treated with antibiotics and right ventriculoperitoneal (VP) shunt. At 10 months of age, the patient again presented with gross MLH and non-functioning shunt tube. Patient underwent endoscopic fenestration of the multiple cysts along with endoscopic-guided left VP shunt. At 1 year of age, the patient again presented with MLH with large right-sided cyst. Patient again underwent right VP shunt. The child improved in postoperative period and hence discharged. Pediatric MLH is a neurosurgical challenge. The prognosis is guarded and it is not possible to assure the parents regarding the cure of the disease. Decision of treatment options is difficult since there is no end to the treatment of many such cases. Neuroendoscopy has a definite role in MLH.

Treatment of multi-loculated hydrocephalus using endoscopic cyst fenestration and endoscopic guided VP shunt insertion

OBJECTIVE

To evaluate the role of endoscopic cyst fenestration and endoscopic guided VP shunt insertion in multi-loculated hydrocephalus in children.

METHOD

A retrospective analysis was performed on 20 patients with multi-loculated hydrocephalus who underwent endoscopic cyst fenestration (ECF) alone or in combination with VP shunt revision or insertion between August 2014 and December 2016 with the extended follow-up period to December 2017.

RESULTS

Thirty-one ECFs were performed: ECF alone, 10 operations in 8 cases, and 21 ECFs with shunt insertion in 12 cases. Eighteen of 20 patients required a VP shunt, 7 cases required multiple shunts. All patients with a previous shunt remained shunt dependent; and 6 cases with no prior shunt underwent endoscopic guided ventricular catheter insertion after ECF; only 2 cases did not require a shunt after ECF. The rate of repeated ECFs was 0.25 operations/year and the shunt revision rate was 0.11 operations/year. VP shunt or cystoperitoneal shunt without repeat ECF was used in 7 cases (35%). Mean duration between operations was 71 days in repeated ECF and 16 days in added-on shunt. The most common cause of re-operations was new formation of intraventricular fibrosis or compartmentalization causing ventricular catheter blockage.

CONCLUSION

Endoscopic cyst fenestration and endoscopic assisted VP shunt insertion minimize shunt complications in multi-loculated hydrocephalus. Shunt independence is unusual.