Neuropsychological Outcome after Endoscopic Third Ventriculostomy

Idiopathic Aqueductal Stenosis: Late Neurocognitive Outcome in ETV Operated Adult Patients

Objective

The 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 Methods

A 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.

Results

All 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.

Conclusion

Endoscopic 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.

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

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

Cognitive and gait outcomes after primary endoscopic third ventriculostomy in adults with chronic obstructive hydrocephalus

OBJECTIVE

The object of this study was to determine the short- and long-term efficacy of primary endoscopic third ventriculostomy (ETV) on cognition and gait in adults with chronic obstructive hydrocephalus.

METHODS

Patients were prospectively accrued through the Adult Hydrocephalus Clinical Research Network patient registry. Patients with previously untreated congenital or acquired obstructive hydrocephalus were included in this study. Gait velocity was assessed using a 10-m walk test. Global cognition was assessed with the Montreal Cognitive Assessment (MoCA). Only patients with documented pre- and post-ETV gait analysis and/or pre- and post-ETV MoCA were included.

RESULTS

A total of 74 patients had undergone primary ETV, 42 of whom were analyzed. The remaining 32 patients were excluded, as they could not complete both pre- and post-ETV assessments. The mean age of the 42 patients, 19 (45.2%) of whom were female, was 51.9 ± 17.1 years (range 19-79 years). Most patients were White (37 [88.1%]), and the remainder were Asian. Surgical complications were minor. Congenital etiologies occurred in 31 patients (73.8%), with aqueductal stenosis in 23 of those patients (54.8%). The remaining 11 patients (26.2%) had acquired cases. The gait short-term follow-up cohort (mean 4.7 ± 4.1 months, 35 patients) had a baseline median gait velocity of 0.9 m/sec (IQR 0.7-1.3 m/sec) and a post-ETV median velocity of 1.3 m/sec (IQR 1.1-1.4 m/sec). Gait velocity significantly improved post-ETV with a median within-patient change of 0.3 m/sec (IQR 0.0-0.6 m/sec, p < 0.001). Gait velocity improvements were sustained in the long term (mean 14 ± 2.8 months, 12 patients) with a baseline median velocity of 0.7 m/sec (IQR 0.6-1.3 m/sec), post-ETV median of 1.3 m/sec (IQR 1.1-1.7 m/sec), and median within-patient change of 0.4 m/sec (IQR 0.2-0.6 m/sec, p < 0.001). The cognitive short-term follow-up cohort (mean 4.6 ± 4.0 months, 38 patients) had a baseline median MoCA total score (MoCA TS) of 24/30 (IQR 23-27) that improved to 26/30 (IQR 24-28) post-ETV. The median within-patient change was +1 point (IQR 0-2 points, p < 0.001). However, this change is not clinically significant. The cognitive long-term follow-up cohort (mean 14 ± 3.1 months, 15 patients) had a baseline median MoCA TS of 23/30 (IQR 22-27), which improved to 26/30 (IQR 25-28) post-ETV. The median within-patient change was +2 points (IQR 1-3 points, p = 0.007), which is both statistically and clinically significant.

CONCLUSIONS

Primary ETV can safely improve symptoms of gait and cognitive dysfunction in adults with chronic obstructive hydrocephalus. Gait velocity and global cognition were significantly improved, and the worsening of either was rare following ETV.

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

OBJECTIVE

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

METHODS

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

RESULT

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

CONCLUSIONS

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

Neurocognitive Complications after Ventricular Neuroendoscopy: A Systematic Review

In recent years, neuroendoscopic treatment of hydrocephalus and various ventricular pathologies has become increasingly popular. It is considered by many as the first-choice treatment for the majority of these cases. However, neurocognitive complications following ventricular neuroendoscopic procedures may occur leading mostly to amnesia, which might have a grave effect on the patient's quality of life. Studies assessing neurocognitive complications after ventricular neuroendoscopic procedures are sparse. Therefore, we conducted a systematic review assessing the available literature of neurocognitive complications and outcome after ventricular neuroendoscopy. Of 1216 articles screened, 46 were included in this systematic review. Transient and permanent neurocognitive complications in 2804 ventricular neuroendoscopic procedures occurred in 2.0% (n = 55) and 1.04% (n = 28) of the patients, respectively. Most complications described are memory impairment, followed by psychiatric symptoms (psychosyndrome), cognitive impairment not further specified, declined executive function, and confusion. However, only in 20% of the series describing neurocognitive complications or outcome (n = 40) was neurocognition assessed by a trained neuropsychologist in a systematic manner. While in most of these series only a part of the included patients underwent neuropsychological testing, neurocognitive assessment was seldom done pre- and postoperatively, long-term follow up was rare, and patient's cohorts were small. A paucity of studies analyzing neurocognitive complications and outcome, through systematic neuropsychological testing, and the correlation with intraoperative lesions of neuronal structures (e.g., fornix) exists in the literature. Therefore, the neurocognitive and emotional morbidity after ventricular neuroendoscopic procedures might be underestimated and warrants further research.

The long-term outcomes of endoscopic third ventriculostomy in pediatric hydrocephalus, with an emphasis on future intellectual development and shunt dependency

OBJECTIVEThe goal of this study was to clarify the long-term outcome of endoscopic third ventriculostomy (ETV) in pediatric hydrocephalus in light of the ETV Success Score (ETVSS), shunt dependency, and intellectual development.METHODSThe authors retrospectively analyzed pediatric patients with hydrocephalus who underwent ETV between 2002 and 2012 and who were followed for longer than 5 years as a single-center cohort. The data of the patients' pre- and postoperative status were collected. The relationships between ETVSS and the full-scale IQ as well as shunt dependency were analyzed. The usefulness of ETVSS for repeat ETV and the change of radiological parameters of ventricle size before and after ETV were also analyzed. The success of ETV was defined as no requirement for further CSF diversion procedures.RESULTSFifty ETVs were performed in 40 patients. The average ETVSS was 61 and the success rate at 6 months was 64%. The mean follow-up was 9.9 years (5.2-15.3 years), and the long-term success rate of ETV was 50%. The Kaplan-Meier survival curve continued to show a statistically significant difference among patients with a low, moderate, and high ETVSS, even after 6 months (p = 0.002). After 15 months from the initial ETV, no patients required additional CSF diversion surgery. There was no statistical significance between ETVSS and the long-term full-scale IQ or shunt dependency (p = 0.34 and 0.12, respectively). The radiological improvement in ventricle size was not associated with better future educational outcome.CONCLUSIONSThe ETVSS was correlated with the long-term success rate. After 15 months from the initial ETV, no patients required an additional CSF diversion procedure. The ETVSS was not considered to be correlated with long-term intellectual status.

Endoscopic Third Ventriculostomy: Success and Failure

Endoscopic third ventriculostomy (ETV) has now become an accepted mode of hydrocephalus treatment in children. Varying degrees of success for the procedure have been reported depending on the type and etiology of hydrocephalus, age of the patient and certain technical parameters. Review of these factors for predictability of success, complications and validation of success score is presented.

Endoscopic third ventriculostomy for treatment of adult hydrocephalus: long-term follow-up of 163 patients

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.

Ventricular volume and neurocognitive outcome after endoscopic third ventriculostomy: is shunting a better option? A review

BACKGROUND

Shunts are generally associated with a smaller post-treatment ventricular size in comparison to endoscopic third ventriculostomy (ETV).

METHODS

To determine whether such a difference in ventricular size has neurocognitive implications, we reviewed the current literature pertaining to the (1) neurocognitive sequelae of hydrocephalus, (2) neurocognitive outcome after ETV, (3) extent of reversal of neurocognitive changes associated with hydrocephalus after shunting, and (4) data on correlation between post-treatment ventricular volume and neurocognitive outcome after ETV.

RESULTS

Collectively, the results of the available studies should call into question the correlation between the residual postoperative ventricular volume and neurocognitive outcome.

CONCLUSION

The available literature is so far in support of ETV as a valid and effective treatment modality in hydrocephalic patients. No sufficient evidence is available to justify resorting to shunting on the premise that it is associated with a better neurocognitive outcome.