Update on Endoscopic Third Ventriculostomy in Children

Third Ventricular Floor Bowing Indicates Surgical Success in Patients Undergoing Endoscopic Third Ventriculostomy-Systematic Review and Meta-Analysis

OBJECTIVE

This meta-analysis aimed to evaluate the prognostic performance of third ventricular floor bowing (TVFB) as a marker for surgical success in patients undergoing endoscopic third ventriculostomy (ETV).

METHODS

We performed a comprehensive literature search for studies comparing ETV success in patients with TVFB compared with those without using PubMed, SCOPUS, Embase, and EuropePMC. TVFB was defined as inferior bowing or bulging deformation or convex third ventricular floor. Surgical success was defined as resolution of symptoms post surgery and requires no further intervention for hydrocephalus. The outcome was surgical success in patients with TVFB compared with those without TVFB. The effect estimate was reported as odds ratio (OR).

RESULTS

Five studies comprising 439 patients were included in this meta-analysis. The prevalence of overall surgical success was 42%. The prevalence of surgical success was 85% in patients with TVFB. TVFB was associated with increased success rates (OR 5.94 [95% confidence interval 3.07, 11.5], P < 0.001; I²: 26.04%, P = 0.248). TVFB was associated with sensitivity 0.83, specificity 0.54, positive likelihood ratio 1.8, negative likelihood ratio 0.32, diagnostic OR 6, and area under curve 0.81 (0.77-0.84) for surgical success. Presence of TVFB confers to a 56% rate of surgical success, and no TVFB confers to a rate of 19% surgical success. The association between TVFB and surgical success was not affected by age (coefficient: -0.03, P = 0.474) and aqueductal stenosis (P = -0.05, P = 0.237).

CONCLUSIONS

This meta-analysis showed that the presence of TVFB was associated with increased ETV success.

Opening and closure of intraventricular neuroendoscopic procedures in infants under 1 year of age: institutional technique, case series and review of the literature

PURPOSE

Intraventricular neuroendoscopic techniques, particularly third ventriculostomy, are employed increasingly in the management of infantile hydrocephalus. However, surgical access to the ventricular cavities is associated with a risk of post-operative cerebrospinal fluid (CSF) leak. Here, we describe a structured, multi-layered approach to wound opening and closure which aims to maximise the natural tissue barriers against CSF leakage. We present a series of patients undergoing this technique and subsequently review the literature regarding opening and closure techniques in paediatric intraventricular neuroendoscopic procedures.

METHODS

We performed a retrospective case series analysis of patients under 1 year of age who underwent intraventricular neuroendoscopic procedures in a single institution over a 5-year period. Patients were identified from an institutional operative database, and operation notes and clinical records were subsequently reviewed.

RESULTS

28 patients fulfilled the inclusion criteria for this study. The mean age at operation was 9 weeks. 27 patients underwent endoscopic third ventriculostomy whilst 1 underwent endoscopic septostomy, and all patients underwent our structured, multi-layered opening and closure technique. Follow-up ranged from 4 months to 5 years. There were no cases of post-operative CSF leak, infection or wound breakdown. 12 patients remained shunt-free at the last follow-up, with the remaining 16 requiring shunt insertion for progressive hydrocephalus at a mean of 24 days post-operatively.

CONCLUSION

Various methods aiming to prevent post-operative CSF leak have been reported in the literature. We propose that our institutional technique may be of benefit in minimising this risk in infants undergoing endoscopic third ventriculostomy and similar intraventricular neuroendoscopic procedures.

Endoscopic third ventriculostomy in obstructive hydrocephalus: A case report and analysis of operative technique

BACKGROUND

The endoscopic third ventriculostomy (ETV) is a neuroendoscopical procedure that represents a more suitable alternative to the extracranial shunting. It consists of fenestrating the floor of the third ventricle and thus establishing a free flow of the cerebrospinal fluid from the ventricles to the site of resorption in the subarachnoid space. It offers a more physiological solution and a chance at a shunt-free life for children with hydrocephalus. The main indication for the procedure is obstructive hydrocephalus, however, it can also be useful in patients with other forms of hydrocephalus.

CASE SUMMARY

We present a treatment flow of a 9-year-old patient, diagnosed with an obstructive hydrocephalus due to tectal glioma that was successfully treated with an ETV. We review the important factors influencing the success rate such as age, aetiology, shunt history, preoperative planning and visualisation of the basilar artery.

CONCLUSION

Even though the ETV effectively controls obstructive hydrocephalus in more than 75% of all cases, the overall success rate of the procedure varies and could be approved by the correct preoperative patient selection.