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Porto Junior S, Ramos JVB, da Cunha BLB, da Silva da Paz MG, de Oliveira Lima TV, Moreira LR, de Avellar LM. Ventriculo - Gallbladder shunt. J Clin Neurosci 2024; 121:83-88. [PMID: 38368659 DOI: 10.1016/j.jocn.2024.02.002] [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: 12/19/2023] [Revised: 01/21/2024] [Accepted: 02/05/2024] [Indexed: 02/20/2024]
Abstract
INTRODUCTION Permanent liquor diversion is associated with a high risk of failure and often requires re-intervention. The ventriculo-gallbladder shunt (VGS) has been recognized as a last-resort alternative for treating hydrocephalus when the peritoneum or other distal sites are no longer suitable for receiving shunts. This article aims to report a case from a neurosurgery referral service in Brazil and review the literature on this issue. METHODS A systematic literature review was conducted in accordance with the PRISMA statement. The PubMed, Embase, and Web of Science databases were searched for data screening and extraction. The reported case was conducted with ethical approval from the neurosurgical hospital's ethics committee. RESULTS G.B.S, male, 43 years old, no comorbidities, who has been dealing with a 12-year history of hydrocephalus, with post-surgical chronic fungal meningitis. Two years ago, he underwent a ventriculoatrial shunt (VAS) placement due to multiple ventriculoperitoneal shunt (VPS) failures. Endocarditis was suspected, and the VAS was removed. As an alternative, VGS was implanted 6 months ago, and since then, there has been no need for a new system review. The gallbladder has an absorptive capacity of 1500 cc of liquid daily, which is more than the normal daily production of cerebrospinal fluid (CSF). Therefore, it is a good alternative when the ventriculoperitoneal shunt is not feasible due to postsurgical peritoneal adhesions or when there are contraindications for ventriculoatrial shunts. CONCLUSION VGS is an alternative for patients who cannot undergo the most common surgical interventions, such as VPS.
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Affiliation(s)
- Silvio Porto Junior
- Bahiana School of Medicine and Public Health, Brazil; General Hospital Roberto Santos, Brazil.
| | - João Victor Brito Ramos
- Bahiana School of Medicine and Public Health, Brazil; General Hospital Roberto Santos, Brazil
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Goel A, Galloway L, Abualsaud S, Chowdhury Y, Gan P, Flint G, Tsermoulas G. Factors affecting endoscopic third ventriculostomy success in adults. Acta Neurochir (Wien) 2023; 165:4021-4029. [PMID: 38017131 DOI: 10.1007/s00701-023-05882-2] [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: 09/27/2023] [Accepted: 10/26/2023] [Indexed: 11/30/2023]
Abstract
BACKGROUND Endoscopic third ventriculostomy (ETV) is a standard treatment in hydrocephalus of certain aetiologies. The most widely used predictive model is the ETV success score. This is frequently used to predict outcomes following ETV in adult patients; however, this was a model developed in paediatric patients with often distinct aetiologies of hydrocephalus. The aim of this study was to assess the predictive value of the model and to identify factors that influence ETV outcomes in adults. METHODS A retrospective study design was used to analyse consecutive patients who underwent ETV at a tertiary neurosurgical centre between 2012 and 2020. Observed ETV outcomes at 6 months were compared to pre-operative predicted ETV success scores. A multivariable Bayesian logistic regression analysis was used to determine the factors that best predicted ETV success and those factors that were redundant. RESULTS A total of 136 patients were analysed during the 9-year study. Thirty-one patients underwent further cerebrospinal fluid diversion within 6 months. The overall ETV success rate was 77%. Observed ETV outcomes corresponded well with predicted outcomes using the ETV success score for the higher scores, but less well for lower scores. Location of obstruction at the aqueduct irrespective of aetiology was the best predictor of success with odds of 1.65 of success. Elective procedures were also associated with higher success compared to urgent ones, whereas age under 70, nature and location of obstructive lesion (other than aqueductal) did not influence ETV success. CONCLUSION ETV was successful in three-quarters of adult patient with hydrocephalus within 6 months. Obstruction at the level of the aqueduct of any aetiology was a good predictor of ETV success. Clinicians should bear in mind that adult hydrocephalus responds differently to ETV compared to paediatric hydrocephalus, and more research is required to develop and validate an adult-specific predictive tool.
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Affiliation(s)
- Aimee Goel
- Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Edgbaston, Birmingham, UK.
| | - Luke Galloway
- Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Edgbaston, Birmingham, UK
| | - Suhaib Abualsaud
- Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Edgbaston, Birmingham, UK
| | - Yasir Chowdhury
- Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Edgbaston, Birmingham, UK
| | - Peter Gan
- Department of Neurosurgery, Waikato Hospital, Hamilton, New Zealand
| | - Graham Flint
- Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Edgbaston, Birmingham, UK
| | - Georgios Tsermoulas
- Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Edgbaston, Birmingham, UK
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Koutsouras GW, Steinmetz E, Tichenor M, Schmidt B, Mohan YS, Krishnamurthy S. Endoscopic Third Ventriculostomy and Cortical Biopsy in Patients With Normal Pressure Hydrocephalus. Cureus 2022; 14:e31523. [DOI: 10.7759/cureus.31523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2022] [Indexed: 11/16/2022] Open
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4
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Sharafat S, Khan Z, Azam F, Ali M. Frequency of success and complications of primary endoscopic third ventriculostomy in infants with obstructive hydrocephalous. Pak J Med Sci 2022; 38:267-270. [PMID: 35035437 PMCID: PMC8713220 DOI: 10.12669/pjms.38.1.4097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 08/27/2021] [Accepted: 09/12/2021] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES To determine the success rate and complications of primary endoscopic third ventri-culostomy (ETV) in infants with obstructive hydrocephalous. METHODS This case series was conducted at the Department of Neurosurgery, Medical and Teaching Institute, Lady Reading Hospital Peshawar from July 2016 to June 2018. All consecutive patients with age less than one year who underwent ETV for primary obstructive hydrocephalous, of both gender, were included in the study. The patients were followed up to six months after surgery. The data was entered in a specially designed Performa. Patients' data was analyzed using SPSS version 21.0. RESULTS We had total 21 patients with age less than one year during the study period. Male patients were 11 (52.4%). Success rate of ETV at six months of follow up was 12 (57.1%). Post-op complications observed were in 9.52% (2/21) cases. One patient had cerebrospinal fluid CSF) leak and the other had significant bleed. CONCLUSION ETV is successful in 57.1% of infants with obstructive type of hydrocephalous. The post op complications in case of ETV are lower than Ventriculo-peritoneal shunts. Therefore, ETV can be offered to infants having obstructive hydrocephalous.
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Affiliation(s)
- Seema Sharafat
- Seema Sharafat, FCPS. Department of Neurosurgery Medical and Teaching Institute, Lady Reading Hospital, Peshawar, Pakistan
| | - Zahid Khan
- Zahid Khan, FCPS. Department of Neurosurgery Medical and Teaching Institute, Lady Reading Hospital, Peshawar, Pakistan
| | - Farooq Azam
- Farooq Azam FCPS. Department of Neurosurgery Medical and Teaching Institute, Lady Reading Hospital, Peshawar, Pakistan
| | - Mumtaz Ali
- Mumtaz Ali, FCPS. Department of Neurosurgery Medical and Teaching Institute, Lady Reading Hospital, Peshawar, Pakistan
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Bruscella S, Solari D, Somma T, Barbato M, Gangemi M, Cavallo LM. Predicting endoscopic third ventriculostomy success in adult hydrocephalus: preliminary assessment of a modified ETV success score for adults (ETVSS-A) in a series of 47 patients. J Neurosurg Sci 2019; 66:33-39. [PMID: 31565904 DOI: 10.23736/s0390-5616.19.04712-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Endoscopic third ventriculostomy is an established treatment for noncommunicating hydrocephalus. In carefully selected patients, it can be adopted for the management of communicating variant; however controversy exists in regards to the definition of the appropriate candidates. Predictive score of Endoscopic Third Ventriculostomy Success (ETVSS) has been reported for pediatric and mixed populations only. Our purpose was to define a ETV success score for adult population (ETVSS-A), measuring the strength of correlation between preoperative score retrospectively evaluated and the success rates achieved in a class of adult patients. METHODS A retrospective analysis of 47 cases which received ETV procedure at our Institution between 2015 and 2018 was run. Demographic data,clinical history,preoperative and postoperative signs were reviewed and ETVSS-A was calculated. Thereafter ETVSS-A results were compared with the actual success rates. RESULTS 29 patients(61,7%) presented unchanged or improvedclinical status with a mean ETVSS-A of 54.5%;18 patients(38,3%) worsened with mean ETVSS-A of 37,7%. We found that age,type of hydrocephalus and symptoms of admission are each apart important factors in predicting ETV success:older patients and those with non-obstructive hydrocephalus had the lowest predicted ETV success. In patients in whom ETV was actually successful, the pre-operative ETVSS-A was significantly higher as compared to those patients in whom we observed a poor surgical outcome. CONCLUSIONS From the results of this series, though small and retrospectively analyzed, it seems that ETVSS-A can be considered as a useful instrument to help neurosurgeon in predicting the ETV success and though define a more accurate surgical strategy in cases of hydrocephalus. Wider series and prospective studies are attended to validate these preliminary results.
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Affiliation(s)
- Sara Bruscella
- Division of Neurosurgery, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Domenico Solari
- Division of Neurosurgery, Università degli Studi di Napoli "Federico II", Naples, Italy -
| | - Teresa Somma
- Division of Neurosurgery, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Marcello Barbato
- Division of Neurosurgery, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Michelangelo Gangemi
- Division of Neurosurgery, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Luigi M Cavallo
- Division of Neurosurgery, Università degli Studi di Napoli "Federico II", Naples, Italy
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Baroncini M, Kuchcinski G, Le Thuc V, Bourgeois P, Leroy HA, Baille G, Lebouvier T, Defebvre L. Is endoscopic third ventriculostomy safe and efficient in the treatment of obstructive chronic hydrocephalus in adults? A prospective clinical and MRI study. Acta Neurochir (Wien) 2019; 161:1353-1360. [PMID: 31069530 DOI: 10.1007/s00701-019-03932-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 04/24/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND In case of suspected normal pressure hydrocephalus, MRI is performed systematically and can sometimes highlight an obstruction of the flow pathways of the CSF (aqueductal stenosis or other downstream obstruction). It seems legitimate for these patients to ask the question of a treatment with endoscopic third ventriculostomy (ETV), even if the late decompensation of an obstruction may suggest an association with a CSF resorption disorder. The aim of this study was to evaluate clinical and radiological evolution after ETV in a group of elderly patients with an obstructive chronic hydrocephalus (OCH). METHODS ETV was performed in 15 patients with OCH between 2012 and 2017. Morphometric (callosal angle, ventricular surface, third ventricular width, and Evans' index) and velocimetric parameters (stroke volume of the aqueductal (SVa) CSF) parameters were measured prior and after surgery with brain MRI. The clinical score (mini-mental status examination (MMSE) and the modified Larsson's score, evaluating walking, autonomy, and incontinence) were performed pre- and postoperatively. RESULTS SVa was less than 15 μL/R-R in 12 out of the 15 patients; in the other three cases, the obstruction was located at a distance from the middle part of the aqueduct. Fourteen out of 15 patients were significantly improved: mean Larsson's score decreased from 3.8 to 0.6 (P ≤ 0.01) and mean MMSE increased from 25.7 to 28 (P = 0.084). Evans' index and ventricular area decreased postoperatively and the callosal angle increased (P ≤ 0.01). The mean follow-up lasted 17.9 months. No postoperative complications were observed. CONCLUSION ETV seems to be a safe and efficient alternative to shunt for chronic hydrocephalus with obstruction; the clinical improvement is usual and ventricular size decreases slightly.
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Affiliation(s)
- Marc Baroncini
- Department of Neurosurgery, Lille University Hospital (CHU Lille), University of Lille, Rue Emile Laine, Lille, France.
| | - Gregory Kuchcinski
- Department of Neuroradiology, Lille University Hospital (CHU Lille), University of Lille, Lille, France
| | - Vianney Le Thuc
- Department of Neuroradiology, Lille University Hospital (CHU Lille), University of Lille, Lille, France
| | - Philippe Bourgeois
- Department of Neurosurgery, Lille University Hospital (CHU Lille), University of Lille, Rue Emile Laine, Lille, France
| | - Henri Arthur Leroy
- Department of Neurosurgery, Lille University Hospital (CHU Lille), University of Lille, Rue Emile Laine, Lille, France
| | - Guillaume Baille
- Department of Neurology, Lille University Hospital (CHU Lille), University of Lille, Lille, France
| | - Thibaud Lebouvier
- Department of Neurology, Lille University Hospital (CHU Lille), University of Lille, Lille, France
| | - Luc Defebvre
- Department of Neurology, Lille University Hospital (CHU Lille), University of Lille, Lille, France
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Endoscopic Third Ventriculostomy in Cases of Ventriculoperitoneal Shunt Malfunction: Does Shunt Duration Play a Role? World Neurosurg 2019; 127:e799-e808. [DOI: 10.1016/j.wneu.2019.03.268] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Revised: 03/26/2019] [Accepted: 03/27/2019] [Indexed: 11/23/2022]
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8
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Breimer GE, Dammers R, Woerdeman PA, Buis DR, Delye H, Brusse-Keizer M, Hoving EW. Endoscopic third ventriculostomy and repeat endoscopic third ventriculostomy in pediatric patients: the Dutch experience. J Neurosurg Pediatr 2017; 20:314-323. [PMID: 28708018 DOI: 10.3171/2017.4.peds16669] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVE After endoscopic third ventriculostomy (ETV), some patients develop recurrent symptoms of hydrocephalus. The optimal treatment for these patients is not clear: repeat ETV (re-ETV) or CSF shunting. The goals of the study were to assess the effectiveness of re-ETV relative to initial ETV in pediatric patients and validate the ETV success score (ETVSS) for re-ETV. METHODS Retrospective data of 624 ETV and 93 re-ETV procedures were collected from 6 neurosurgical centers in the Netherlands (1998-2015). Multivariable Cox proportional hazards modeling was used to provide an adjusted estimate of the hazard ratio for re-ETV failure relative to ETV failure. The correlation coefficient between ETVSS and the chance of re-ETV success was calculated using Kendall's tau coefficient. Model discrimination was quantified using the c-statistic. The effects of intraoperative findings and management on re-ETV success were also analyzed. RESULTS The hazard ratio for re-ETV failure relative to ETV failure was 1.23 (95% CI 0.90-1.69; p = 0.20). At 6 months, the success rates for both ETV and re-ETV were 68%. ETVSS was significantly related to the chances of re-ETV success (τ = 0.37; 95% bias corrected and accelerated CI 0.21-0.52; p < 0.001). The c-statistic was 0.74 (95% CI 0.64-0.85). The presence of prepontine arachnoid membranes and use of an external ventricular drain (EVD) were negatively associated with treatment success, with ORs of 4.0 (95% CI 1.5-10.5) and 9.7 (95% CI 3.4-27.8), respectively. CONCLUSIONS Re-ETV seems to be as safe and effective as initial ETV. ETVSS adequately predicts the chance of successful re-ETV. The presence of prepontine arachnoid membranes and the use of EVD negatively influence the chance of success.
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Affiliation(s)
- Gerben E Breimer
- Department of Neurosurgery, University Medical Center Groningen.,Departments of 2 Pathology and
| | - Ruben Dammers
- Department of Neurosurgery, Erasmus MC, Sophia Children's Hospital, Rotterdam
| | - Peter A Woerdeman
- Department of Neurosurgery, Rudolf Magnus Institute of Neuroscience, University Medical Center, Utrecht
| | - Dennis R Buis
- Neurosurgery, Academic Medical Center Amsterdam.,Department of Neurosurgery, VU University Medical Center, Neurosurgical Center Amsterdam
| | - Hans Delye
- Department of Neurosurgery, Radboud University Nijmegen Medical Centre, Nijmegen; and
| | | | - Eelco W Hoving
- Department of Neurosurgery, University Medical Center Groningen
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9
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Wu Y, Li C, Zong X, Wang X, Gui S, Gu C, Zhang Y. Application of endoscopic third ventriculostomy for treating hydrocephalus-correlated Chiari type I malformation in a single Chinese neurosurgery centre. Neurosurg Rev 2017; 41:249-254. [PMID: 28326451 PMCID: PMC5748424 DOI: 10.1007/s10143-017-0844-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Revised: 03/01/2017] [Accepted: 03/09/2017] [Indexed: 11/29/2022]
Abstract
The correlation between hydrocephalus and Chiari type I malformation (CIM) has been debated since Chiari's first descriptions of CIM but some studies have shown that CIM and hydrocephalus (HCP) could cause symptoms/disease of each other or vice versa. Recent research has found that treatment focused on hydrocephalus with ventricle enlargement also provides alleviation of CIM and even of syringomyelia. However, the lack of consensus among previous studies left unanswered the question of how endoscopic third ventriculostomy (ETV) addresses CIM and why it fails. Ten symptomatic hydrocephalic patients associated with CIM underwent ETV from October 2002 to May 2012. The clinical features and neuroimaging of all patients were reviewed. Statistical analysis was applied to evaluate the changes in the tonsillar ectopia and the ventricle dilation after operation. The mean follow-up period of this series was 92 months (range 24-163 months). Eight patients (80%) remained shunt free or experienced symptom relief following ETV. The remaining two patients were identified as failures due to the deterioration of symptoms or subsequent hindbrain decompression. Endoscopic third ventriculostomy provides an effective treatment for hydrocephalus associated with CIM, which can relieve HCP and improve the symptoms of CIM in most patients. The clinical outcomes are related to the major cause of the tonsillar herniation.
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Affiliation(s)
- Yiping Wu
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Institute for Brain Disorders Brain Tumor Center|, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Department of Neurosurgery, Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi, China
| | - Chuzhong Li
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Institute for Brain Disorders Brain Tumor Center|, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xuyi Zong
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xinsheng Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Songbai Gui
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Caiping Gu
- Department of Neurosurgery, Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi, China
| | - Yazhuo Zhang
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Institute for Brain Disorders Brain Tumor Center|, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
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Isaacs AM, Bezchlibnyk YB, Yong H, Koshy D, Urbaneja G, Hader WJ, Hamilton MG. Endoscopic third ventriculostomy for treatment of adult hydrocephalus: long-term follow-up of 163 patients. Neurosurg Focus 2017; 41:E3. [PMID: 27581315 DOI: 10.3171/2016.6.focus16193] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The efficacy of endoscopic third ventriculostomy (ETV) for the treatment of pediatric hydrocephalus has been extensively reported in the literature. However, ETV-related long-term outcome data are lacking for the adult hydrocephalus population. The objective of the present study was to assess the role of ETV as a primary or secondary treatment for hydrocephalus in adults. METHODS The authors performed a retrospective chart review of all adult patients (age ≥ 18 years) with symptomatic hydrocephalus treated with ETV in Calgary, Canada, over a span of 20 years (1994-2014). Patients were dichotomized into a primary or secondary ETV cohort based on whether ETV was the initial treatment modality for the hydrocephalus or if other CSF diversion procedures had been previously attempted respectively. Primary outcomes were subjective patient-reported clinical improvement within 12 weeks of surgery and the need for any CSF diversion procedures after the initial ETV during the span of the study. Categorical and actuarial data analysis was done to compare the outcomes of the primary versus secondary ETV cohorts. RESULTS A total of 163 adult patients with symptomatic hydrocephalus treated with ETV were identified and followed over an average of 98.6 months (range 0.1-230.4 months). All patients presented with signs of intracranial hypertension or other neurological symptoms. The primary ETV group consisted of 112 patients, and the secondary ETV consisted of 51 patients who presented with failed ventriculoperitoneal (VP) shunts. After the initial ETV procedure, clinical improvement was reported more frequently by patients in the primary cohort (87%) relative to those in the secondary ETV cohort (65%, p = 0.001). Additionally, patients in the primary ETV group required fewer reoperations (p < 0.001), with cumulative ETV survival time favoring this primary ETV cohort over the course of the follow-up period (p < 0.001). Fifteen patients required repeat ETV, with all but one experiencing successful relief of symptoms. Patients in the secondary ETV cohort also had a higher incidence of complications, with one occurring in 8 patients (16%) compared with 2 in the primary ETV group (2%; p = 0.010), although most complications were minor. CONCLUSIONS ETV is an effective long-term treatment for selected adult patients with hydrocephalus. The overall ETV success rate when it was the primary treatment modality for adult hydrocephalus was approximately 87%, and 99% of patients experience symptomatic improvement after 2 ETVs. Patients in whom VP shunt surgery fails prior to an ETV have a 22% relative risk of ETV failure and an almost eightfold complication rate, although mostly minor, when compared with patients who undergo a primary ETV. Most ETV failures occur within the first 7 months of surgery in patients treated with primary ETV, but the time to failure is more prolonged in patients who present with failed previous shunts.
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Affiliation(s)
- Albert M Isaacs
- Division of Neurosurgery, Department of Clinical Neuroscience
| | | | - Heather Yong
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Geberth Urbaneja
- Adult Hydrocephalus Program, Department of Clinical Neuroscience
| | - Walter J Hader
- Division of Neurosurgery, Department of Clinical Neuroscience;,Pediatric Neurosurgery Program, Department of Clinical Neuroscience, University of Calgary, Alberta; and
| | - Mark G Hamilton
- Adult Hydrocephalus Program, Department of Clinical Neuroscience;,Division of Neurosurgery, Department of Clinical Neuroscience;,Pediatric Neurosurgery Program, Department of Clinical Neuroscience, University of Calgary, Alberta; and
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11
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Waqar M, Ellenbogen JR, Stovell MG, Al-Mahfoudh R, Mallucci C, Jenkinson MD. Long-Term Outcomes of Endoscopic Third Ventriculostomy in Adults. World Neurosurg 2016; 94:386-393. [DOI: 10.1016/j.wneu.2016.07.028] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2016] [Revised: 07/07/2016] [Accepted: 07/08/2016] [Indexed: 11/30/2022]
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12
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Lam S, Harris DA, Lin Y, Rocque BG, Ham S, Pan IW. Outcomes of endoscopic third ventriculostomy in adults. J Clin Neurosci 2016; 31:166-71. [PMID: 27394377 DOI: 10.1016/j.jocn.2016.03.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Accepted: 03/08/2016] [Indexed: 11/27/2022]
Abstract
Endoscopic third ventriculostomy (ETV) is an alternative to ventriculoperitoneal shunting for treatment of hydrocephalus. Studies have reported favorable outcomes for up to three-quarters of adult patients. We performed the first ETV outcomes study using an administrative claims database, examining current practice for adult patients in the United States. We interrogated the Truven Health MarketScan® database for Current Procedural Terminology codes corresponding to ETV and ventriculoperitoneal shunt from 2003- to 2011, including patients over 18years and data from initial and subsequent hospitalizations. ETV failure was defined as any subsequent ETV or shunt procedure. Five hundred twenty-five patients underwent ETV with 6months minimum follow-up. Mean age was 45.9years (range: 18-86years). Mean follow-up was 2.2years (SD: 1.6years, range: 0.5-8.4years). Etiology of hydrocephalus was 21.3% tumor, 9.0% congenital/aqueductal stenosis, 15.8% hemorrhage, and 53.9% others. ETV was successful in 74.7% of patients. Of 133 who failed, 25 had repeat ETV; 108 had shunt placement. Longer length of stay for index surgery was associated with higher risk of failure (hazard ratio (HR): 1.03, p<0.001), as was history of previous shunt (HR: 2.45, p<0.001). Among patients with repeat surgeries, median time to failure was 25days. This study represents a longitudinal analysis of nationwide ETV practice over 9years. Success rate in this large cohort is similar to that published by other single-center retrospective studies. Age and geographic variation may be associated with surgeon choice of ETV or shunt placement after failure of the initial ETV.
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Affiliation(s)
- Sandi Lam
- Department of Neurosurgery, Baylor College of Medicine, Texas Children's Hospital, Department of Neurosurgery, 6701 Fannin St., Ste. 1230-01, Houston, TX 77030, USA.
| | - Dominic A Harris
- Department of Neurosurgery, Baylor College of Medicine, Texas Children's Hospital, Department of Neurosurgery, 6701 Fannin St., Ste. 1230-01, Houston, TX 77030, USA
| | - Yimo Lin
- Department of Neurosurgery, Baylor College of Medicine, Texas Children's Hospital, Department of Neurosurgery, 6701 Fannin St., Ste. 1230-01, Houston, TX 77030, USA
| | - Brandon G Rocque
- Department of Neurosurgery, Section of Pediatric Neurosurgery, University of Alabama at Birmingham, AL 35294, USA
| | - Sandra Ham
- University of Chicago, Center for Health and Social Sciences, Chicago, IL 60637, USA
| | - I-Wen Pan
- Department of Neurosurgery, Baylor College of Medicine, Texas Children's Hospital, Department of Neurosurgery, 6701 Fannin St., Ste. 1230-01, Houston, TX 77030, USA
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Vardakis JC, Chou D, Tully BJ, Hung CC, Lee TH, Tsui PH, Ventikos Y. Investigating cerebral oedema using poroelasticity. Med Eng Phys 2015; 38:48-57. [PMID: 26749338 DOI: 10.1016/j.medengphy.2015.09.006] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Revised: 08/05/2015] [Accepted: 09/10/2015] [Indexed: 12/21/2022]
Abstract
Cerebral oedema can be classified as the tangible swelling produced by expansion of the interstitial fluid volume. Hydrocephalus can be succinctly described as the abnormal accumulation of cerebrospinal fluid (CSF) within the brain which ultimately leads to oedema within specific sites of parenchymal tissue. Using hydrocephalus as a test bed, one is able to account for the necessary mechanisms involved in the interaction between oedema formation and cerebral fluid production, transport and drainage. The current state of knowledge about integrative cerebral dynamics and transport phenomena indicates that poroelastic theory may provide a suitable framework to better understand various diseases. In this work, Multiple-Network Poroelastic Theory (MPET) is used to develop a novel spatio-temporal model of fluid regulation and tissue displacement within the various scales of the cerebral environment. The model is applied through two formats, a one-dimensional finite difference - Computational Fluid Dynamics (CFD) coupling framework, as well as a two-dimensional Finite Element Method (FEM) formulation. These are used to investigate the role of endoscopic fourth ventriculostomy in alleviating oedema formation due to fourth ventricle outlet obstruction (1D coupled model) in addition to observing the capability of the FEM template in capturing important characteristics allied to oedema formation, like for instance in the periventricular region (2D model).
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Affiliation(s)
- John C Vardakis
- Department of Mechanical Engineering, University College London, Torrington Place, London WC1E 7JE, UK
| | - Dean Chou
- Institute of Biomedical Engineering & Department of Engineering Science, University of Oxford, Oxford OX1 3PJ, UK
| | - Brett J Tully
- First Light Fusion Ltd., Begbroke Science Park, Begbroke, Oxfordshire OX5 1PF, UK
| | - Chang C Hung
- Stroke Center and Department of Neurology, Chang Gung Memorial Hospital, Linkou Medical Center and College of Medicine, Taoyuan, Taiwan; Department of Electrical Engineering, College of Engineering, Chang Gung University, Taoyuan, Taiwan
| | - Tsong H Lee
- Stroke Center and Department of Neurology, Chang Gung Memorial Hospital, Linkou Medical Center and College of Medicine, Taoyuan, Taiwan
| | - Po-Hsiang Tsui
- Department of Medical Imaging and Radiological Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan; Medical Imaging Research Center, Institute for Radiological Research, Chang Gung University and Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Yiannis Ventikos
- Department of Mechanical Engineering, University College London, Torrington Place, London WC1E 7JE, UK.
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Gaab MR. Commentary: Endoscopic Third Ventriculostomy in 250 Adults With Hydrocephalus: Patient Selection, Outcomes, and Complications. Neurosurgery 2015; 78:120-3. [PMID: 26418875 DOI: 10.1227/neu.0000000000001037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Michael R Gaab
- Department of Neurosurgery, Hannover Nordstadt Hospital, Hannover, Germany
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Labidi M, Lavoie P, Lapointe G, Obaid S, Weil AG, Bojanowski MW, Turmel A. Predicting success of endoscopic third ventriculostomy: validation of the ETV Success Score in a mixed population of adult and pediatric patients. J Neurosurg 2015. [PMID: 26207604 DOI: 10.3171/2014.12.jns141240] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- Moujahed Labidi
- Neurological Sciences Department, Division of Neurosurgery, CHU de Québec-Hôpital de l'Enfant-Jésus, Québec City; and
| | - Pascale Lavoie
- Neurological Sciences Department, Division of Neurosurgery, CHU de Québec-Hôpital de l'Enfant-Jésus, Québec City; and
| | - Geneviève Lapointe
- Neurological Sciences Department, Division of Neurosurgery, CHU de Québec-Hôpital de l'Enfant-Jésus, Québec City; and
| | - Sami Obaid
- Surgery Department, Division of Neurosurgery, CHUM-Hôpital Notre-Dame, Montréal, Québec, Canada
| | - Alexander G Weil
- Surgery Department, Division of Neurosurgery, CHUM-Hôpital Notre-Dame, Montréal, Québec, Canada
| | - Michel W Bojanowski
- Surgery Department, Division of Neurosurgery, CHUM-Hôpital Notre-Dame, Montréal, Québec, Canada
| | - André Turmel
- Neurological Sciences Department, Division of Neurosurgery, CHU de Québec-Hôpital de l'Enfant-Jésus, Québec City; and
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Endoscopic third ventriculostomy - effectiveness of the procedure for obstructive hydrocephalus with different etiology in adults. Wideochir Inne Tech Maloinwazyjne 2014; 9:586-95. [PMID: 25561997 PMCID: PMC4280426 DOI: 10.5114/wiitm.2014.46076] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Revised: 07/29/2014] [Accepted: 09/21/2014] [Indexed: 12/03/2022] Open
Abstract
Introduction After a time of domination of shunt placement, endoscopic third ventriculostomy (ETV) has been increasingly applied in treatment of obstructive hydrocephalus. Aim To assess the effectiveness of ETV in treatment of adults with three-ventricle hydrocephalus of different etiology. Material and methods Ninety-six patients with obstructive hydrocephalus were studied: 24 with primary aqueductal stenosis, 61 with brain tumor, and 2 with basilar tip aneurysm. In 9 patients the etiology of hydrocephalus remained undetermined. The assessment of treatment results was based on clinical and radiological criteria. Results Clinical improvement was observed in 74 (77.1%) patients, and radiological improvement in 52 (54.2%). One patient died. Follow-up of 24 patients with primary aqueductal stenosis has shown that in 20 (83.3%) of them clinical improvement has been stable, and in 14 (58.3%) radiological improvement has been observed. Two patients required shunt placement due to hydrocephalus recurrence 12–24 months after the ETV procedure. Among 9 patients with undefined hydrocephalus, 3 required shunt placement within 6 months after ETV (2 shunted previously). Endoscopic third ventriculostomy treatment in a patient with hydrocephalus caused by basilar tip aneurysm succeeded. The assessment of ETV effectiveness in oncological patients has been indirect in view of the underlying disease. Conclusions The best results of ETV treatment have been demonstrated for patients with primary aqueductal stenosis. Ventricle size cannot determine the effectiveness of treatment as an individual requirement. Endoscopic third ventriculostomy is effective in previously shunted patients although the prediction of outcome should be cautious. Endoscopic third ventriculostomy enables preparation for further therapy and is palliative treatment in oncological patients with secondary hydrocephalus.
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Zandian A, Haffner M, Johnson J, Rozzelle CJ, Tubbs RS, Loukas M. Endoscopic third ventriculostomy with/without choroid plexus cauterization for hydrocephalus due to hemorrhage, infection, Dandy-Walker malformation, and neural tube defect: a meta-analysis. Childs Nerv Syst 2014; 30:571-8. [PMID: 24374638 DOI: 10.1007/s00381-013-2344-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2013] [Accepted: 12/10/2013] [Indexed: 10/25/2022]
Abstract
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.
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Affiliation(s)
- Anthony Zandian
- Department of Anatomical Sciences, School of Medicine, St. George's University, West Indies, Grenada
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Vardakis JC, Tully BJ, Ventikos Y. Exploring the efficacy of endoscopic ventriculostomy for hydrocephalus treatment via a multicompartmental poroelastic model of CSF transport: a computational perspective. PLoS One 2013; 8:e84577. [PMID: 24391968 PMCID: PMC3877339 DOI: 10.1371/journal.pone.0084577] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Accepted: 11/23/2013] [Indexed: 11/22/2022] Open
Abstract
This study proposes the implementation of a Multiple-Network Poroelastic Theory (MPET) model coupled with finite-volume computational fluid dynamics for the purpose of studying, in detail, the effects of obstructing CSF transport within an anatomically accurate cerebral environment. The MPET representation allows the investigation of fluid transport between CSF, brain parenchyma and cerebral blood, in an integral and comprehensive manner. A key novelty in the model is the amalgamation of anatomically accurate choroid plexuses with their feeding arteries and a simple relationship relaxing the constraint of a unique permeability for the CSF compartment. This was done in order to account for the Aquaporin-4-mediated swelling characteristics. The aim of this varying permeability compartment was to bring to light a feedback mechanism that could counteract the effects of ventricular dilation and subsequent elevations of CSF pressure through the efflux of excess CSF into the blood system. This model is used to demonstrate the impact of aqueductal stenosis and fourth ventricle outlet obstruction (FVOO). The implications of treating such a clinical condition with the aid of endoscopic third (ETV) and endoscopic fourth (EFV) ventriculostomy are considered. We observed peak CSF velocities in the aqueduct of the order of 15.6 cm/s in the healthy case, 45.4 cm/s and 72.8 cm/s for the mild and severe cases respectively. The application of ETV reduced the aqueductal velocity to levels around 16-17 cm/s. Ventricular displacement, CSF pressure, wall shear stress (WSS) and pressure difference between lateral and fourth ventricles (ΔP) increased with applied stenosis, and subsequently dropped to nominal levels with the application of ETV. The greatest reversal of the effects of atresia come by opting for ETV rather than the more complicated procedure of EFV.
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Affiliation(s)
- John C. Vardakis
- Institute of Biomedical Engineering and Department of Engineering Science, University of Oxford, Oxford, United Kingdom
| | - Brett J. Tully
- Oxyntix Ltd., Department of Engineering Science, University of Oxford, Oxford, United Kingdom
| | - Yiannis Ventikos
- Department of Mechanical Engineering, University College London, Torrington Place, London, United Kingdom
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Vogel TW, Bahuleyan B, Robinson S, Cohen AR. The role of endoscopic third ventriculostomy in the treatment of hydrocephalus. J Neurosurg Pediatr 2013; 12:54-61. [PMID: 23682819 DOI: 10.3171/2013.4.peds12481] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Hydrocephalus remains a major public health problem. Conventional treatment has relied on extracranial shunting of CSF to another systemic site, but this approach is associated with a high rate of complications. Endoscopic third ventriculostomy (ETV) is a novel treatment for select forms of hydrocephalus that can eliminate the need for implantation of a lifelong ventricular shunt system. However, the indications for ETV are contested and its long-term effectiveness is not well established. METHODS The authors selected 100 consecutive patients who underwent ETV for hydrocephalus beginning in 1994. Patients were enrolled and treated at a single institution by a single surgeon. The primary outcome was success of ETV, with success defined as no need for subsequent surgery for hydrocephalus. RESULTS Ninety-five patients satisfied the inclusion criteria. The mean follow-up period was 5.1 years (median 4.7 years) with follow-up data available for as long as 17 years. Patients commonly presented with headache (85%), ataxia (34%), emesis (29%), and changes in vision (27%). The success rate for ETV was 75%. Twenty-one patients (22%) in the series had malfunctioning shunts preoperatively and 13 (62%) were successfully treated with ETV. Preoperative inferior bowing of the third ventricle floor on MRI was significantly associated with ETV success (p < 0.05). CONCLUSIONS Endoscopic third ventriculostomy is an effective and durable treatment for select patients with hydrocephalus. When successful, the procedure eliminates the lifelong complications associated with implanted ventricular shunts.
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Affiliation(s)
- Timothy W Vogel
- Department of Neurosurgery, Boston Children's Hospital, Boston, Massachusetts 02115, USA
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