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Chen SM, Chen LY, Lin JH, Salazar N, Yeh TH, Lo WL, Lui TN, Hsieh YC, Chien LN. Comparison of endoscopic third ventriculostomy versus cerebrospinal fluid shunt procedures for the treatment of pediatric hydrocephalus in Taiwan. Childs Nerv Syst 2024:10.1007/s00381-024-06469-7. [PMID: 38806857 DOI: 10.1007/s00381-024-06469-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 05/16/2024] [Indexed: 05/30/2024]
Abstract
PURPOSE Pediatric hydrocephalus is the most common cause of surgically treatable neurological disease in children. Controversies exist whether endoscopic third ventriculostomy (ETV) or cerebrospinal fluid (CSF) shunt placement is the most appropriate treatment for pediatric hydrocephalus. This study aimed to compare the risk of re-operation and death between the two procedures. METHODS We performed a retrospective population-based cohort study and included patients younger than 20-years-old who underwent CSF shunt or ETV for hydrocephalus from the Taiwan National Health Insurance Research Database. RESULTS A total of 3,555 pediatric patients from 2004 to 2017 were selected, including 2,340 (65.8%) patients that received CSF shunt placement and 1215 (34.2%) patients that underwent ETV. The incidence of all-cause death was 3.31 per 100 person-year for CSF shunt group and 2.52 per 100 person-year for ETV group, with an adjusted hazard ratio (HR) of 0.79 (95% confidence interval [CI] = 0.66-0.94, p = 0.009). The cumulative incidence competing risk for reoperation was 31.2% for the CSF shunt group and 26.4% for the ETV group, with an adjusted subdistribution HR of 0.82 (95% CI = 0.70-0.96, p = 0.015). Subgroup analysis showed that ETV was beneficial for hydrocephalus coexisting with brain or spinal tumor, central nervous system infection, and intracranial hemorrhage. CONCLUSION Our data indicates ETV is a better operative procedure for pediatric hydrocephalus when advanced surgical techniques and instruments are available.
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Affiliation(s)
- Shu-Mei Chen
- Department of Neurosurgery, Taipei Medical University Hospital, Taipei Medical University, Taipei, Taiwan
- Department of Surgery, School of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Li-Ying Chen
- Health Data Analytics and Statistics Center, Office of Data Science, Taipei Medical University, Taipei, Taiwan
| | - Jiann-Her Lin
- Department of Neurosurgery, Taipei Medical University Hospital, Taipei Medical University, Taipei, Taiwan
- Department of Surgery, School of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Nicole Salazar
- Julius L. Chambers Biomedical/Biotechnology Institute and Department of Biological & Biomedical Sciences, North Carolina Central University, Durham, NC, USA
| | - Tu-Hsueh Yeh
- Department of Neurology, Taipei Medical University Hospital, Taipei Taipei Medical University, Taipei, Taiwan
- Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Wei-Lun Lo
- Department of Surgery, School of Medicine, Taipei Medical University, Taipei, Taiwan
- Department of Neurosurgery, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan
| | - Tai-Ngar Lui
- Department of Neurosurgery, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan
| | - Yi-Chen Hsieh
- The PhD Program in Medical Neuroscience, College of Medical Science and Technology, Taipei Medical University, 250 Wu-Hsing Street, Taipei, Taiwan.
| | - Li-Nien Chien
- Institute of Health and Welfare Policy, College of Medicine, National Yang Ming Chiao Tung University, No.155, Sec. 2, Linong St., Beitou District, Taipei, Taiwan.
- Graduate Institute of Data Science, College of Management, Taipei Medical University, Taipei, Taiwan.
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2
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Black H, Succop B, Stuebe CM, Torres A, Caddell A, Quinsey C. Low surgical weight associated with ETV failure in pediatric hydrocephalus patients. Neurosurg Rev 2024; 47:176. [PMID: 38644441 DOI: 10.1007/s10143-024-02423-y] [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: 10/30/2023] [Revised: 04/10/2024] [Accepted: 04/16/2024] [Indexed: 04/23/2024]
Abstract
The use of endoscopic third ventriculostomy (ETV) for treatment of pediatric hydrocephalus has higher failure rates in younger patients. Here we investigate the impact of select perioperative variables, specifically gestational age, chronological age, birth weight, and surgical weight, on ETV failure rates. A retrospective review was performed on patients treated with ETV - with or without choroid plexus cauterization (CPC) - from 2010 to 2021 at a large academic center. Analyses included Cox regression for independent predictors and Kaplan-Meier survival curves for time to-event outcomes. In total, 47 patients were treated with ETV; of these, 31 received adjunctive CPC. Overall, 66% of the cohort experienced ETV failure with a median failure of 36 days postoperatively. Patients aged < 6 months at time of surgery experienced 80% failure rate, and those > 6 months at time of surgery experienced a 41% failure rate. Univariate Cox regression analysis showed weight at the time of ETV surgery was significantly inversely associated with ETV failure with a hazard ratio of 0.92 (95% CI 0.82, 0.99). Multivariate analysis redemonstrated the inverse association of weight at time of surgery with ETV failure with hazard ratio of 0.76 (95% CI 0.60, 0.92), and sensitivity analysis showed < 4.9 kg as the optimal cutoff predicting ETV/CPC failure. Neither chronologic age nor gestational age were found to be significantly associated with ETV failure.In this study, younger patients experienced higher ETV failure rates, but multivariate regression found that weight was a more robust predictor of ETV failure than chronologic age or gestational age, with an optimal cutoff of 4.9 kg in our small cohort. Given the limited sample size, further study is needed to elucidate the independent role of weight as a peri-operative variable in determining ETV candidacy in young infants. Previous presentations: Poster Presentation, Congress of Neurological Surgeons.
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Affiliation(s)
- Hannah Black
- School of Medicine, University of North Carolina - Chapel Hill, Chapel Hill, NC, USA
| | - Benjamin Succop
- School of Medicine, University of North Carolina - Chapel Hill, Chapel Hill, NC, USA.
| | | | - Andrea Torres
- Department of Neurosurgery, University of North Carolina - Chapel Hill, Chapel Hill, NC, USA
| | - Andrew Caddell
- School of Medicine, University of North Carolina - Chapel Hill, Chapel Hill, NC, USA
| | - Carolyn Quinsey
- Department of Neurosurgery, University of North Carolina - Chapel Hill, Chapel Hill, NC, USA
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De John BG, Figaji AA, Enslin JMN. Analysis of non-ventriculoperitoneal shunts at Red Cross War Memorial Children's Hospital. Childs Nerv Syst 2024; 40:1099-1110. [PMID: 38091072 DOI: 10.1007/s00381-023-06242-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 11/28/2023] [Indexed: 03/28/2024]
Abstract
BACKGROUND At Red Cross War Memorial Children's Hospital (RCCH), it is the preferred practice to use non-ventriculoperitoneal (non-VP) shunts when the peritoneum is ineffective or contraindicated for cerebrospinal fluid (CSF) diversion and when endoscopy is not an option. The objective of this study is to evaluate the clinical course of patients having undergone these procedures. METHOD A single-centre retrospective review at RCCH wherein 43 children with a total of 59 episodes of non-VP shunt placement over a 12-year period were identified for inclusion. RESULTS Twenty-five ventriculoatrial (VA) and 32 ventriculopleural (VPL) shunts were analysed with a median age at insertion of 2.9 (0.3-14.9) and 5.3 years (0.5-13.4), respectively. The median number of previous shunt procedures prior to VA or VPL shunt insertion was 6.0 (2-28) versus 4.5 (2-17), respectively. Three VA (12.0%) and three VPL (9.4%) shunt patients were lost to follow-up. Of those remaining, 10 VA shunts (45.5%) compared to 19 (65,5%) VPL shunts required revision. One ventriculovesical shunt and one ventriculocholecystic shunt were placed in the same patient after 21 and 25 shunt-related procedures, respectively, and both were revised within 3 weeks of insertion. Median shunt survival was 8 months longer for the VA compared to the VPL shunts, being 13.5 (0-67) and 5 months (0-118), respectively. Complications for VA shunts were low, with the overall shunt sepsis rate in the VA group at 4% (n = 1) compared to 15.6% (n = 5) in the VPL group. CONCLUSION Our findings support that VA and VPL shunts are acceptable second-line options in an already compromised group of patients where safe treatment options are limited, provided attention is paid to the technical details specific to their placement.
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Affiliation(s)
- B G De John
- Department of Surgery, Division of Neurosurgery, University of Cape Town, Cape Town, South Africa.
- Division of Neurosurgery, Red Cross War Memorial Children's Hospital, Cape Town, South Africa.
| | - A A Figaji
- Department of Surgery, Division of Neurosurgery, University of Cape Town, Cape Town, South Africa
- Division of Neurosurgery, Red Cross War Memorial Children's Hospital, Cape Town, South Africa
| | - J M N Enslin
- Department of Surgery, Division of Neurosurgery, University of Cape Town, Cape Town, South Africa
- Division of Neurosurgery, Red Cross War Memorial Children's Hospital, Cape Town, South Africa
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Liu S, Chen P, Yang H, Xie T, Liu T, Li C, Yang L, Li Z, Huang J, Gao Y, Xie Q, Yu Y, Hu F, Zhang X. Role of endoscopic third ventriculostomy in patients undergoing resection of pulvinar area lesions: Preliminary clinical results. J Clin Neurosci 2023; 117:61-67. [PMID: 37774635 DOI: 10.1016/j.jocn.2023.09.018] [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: 08/08/2023] [Revised: 09/13/2023] [Accepted: 09/20/2023] [Indexed: 10/01/2023]
Abstract
BACKGROUND Patients with pulvinar area lesions may develop hydrocephalus at any stage. The role of endoscopic third ventriculostomy (ETV) in this setting remains unclear. METHOD We retrospectively enrolled 15 patients with a mean age of 43 years who underwent endoscopic resection of pulvinar area lesions using the supracerebellar infratentorial approach (SCITA). We compared the different modalities of hydrocephalus management and their outcomes. RESULTS Nine of 15 patients (60.0%) had preoperative obstructive hydrocephalus. Five patients underwent ETV before tumor resection, and none developed postoperative hydrocephalus. Four patients underwent one-stage surgery for tumor removal, and one patient with a polymorphous low-grade neuroepithelial tumor of the young required postoperative ETV. Another patient with diffuse astrocytoma and hydrocephalus underwent concurrent lamina terminalis fenestration and endoscopic resection via the SCITA, which resulted in the resolution of hydrocephalus. The preoperative ETV group had no major postoperative complications, while the non-ETV group had three (0/5 vs. 3/4, P = 0.048). The ETV group also had a shorter intensive care unit stay; however, the difference was not significant (1.2 vs. 2.8; P = 0.188). ETV was effective in alleviating symptoms of postoperative hydrocephalus in patients with midbrain-invading tumors. CONCLUSION Endoscopic surgery via the SCITA can address both tumor and hydrocephalus issues in some cases but has a higher surgical risk and postoperative hydrocephalus rate. Preoperative ETV can prevent these complications and improve postoperative outcomes.
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Affiliation(s)
- Shuang Liu
- Department of Neurosurgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Pin Chen
- Department of Neurosurgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Hantao Yang
- Department of Neurosurgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Tao Xie
- Department of Neurosurgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Tengfei Liu
- Department of Neurosurgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Chen Li
- Department of Neurosurgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Liangliang Yang
- Department of Neurosurgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zeyang Li
- Department of Neurosurgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jinlong Huang
- Department of Neurosurgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yang Gao
- Department of Neurosurgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Qiang Xie
- Department of Neurosurgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yong Yu
- Department of Neurosurgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Fan Hu
- Department of Neurosurgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xiaobiao Zhang
- Department of Neurosurgery, Zhongshan Hospital, Fudan University, Shanghai, China; Digital Medical Research Center, Zhongshan Hospital, Fudan University, Shanghai, China; Shanghai Key Laboratory of Medical Image Computing and Computer-Assisted Intervention, Shanghai, China.
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Fleming CH, Ritter AM, Bruce DA. Development of shunt valves used for treating hydrocephalus: comparison with endoscopy treatment. Childs Nerv Syst 2023; 39:2709-2717. [PMID: 37354289 DOI: 10.1007/s00381-023-06049-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 06/19/2023] [Indexed: 06/26/2023]
Abstract
The pathophysiology of hydrocephalus is not clearly defined. Thus, treatment will remain empirical until a fuller understanding of the various forms of hydrocephalus is achieved. Valve-controlled shunting has been the mainstay of therapy since the late 1950s. Initially, shunting occurred from the ventricular system to the atrium. In the 1970s, VA shunts were replaced by ventriculoperitoneal shunts as the primary location for the distal end. Multiple types of one-way valve systems have been developed in the pursuit of draining the appropriate amount of CSF that avoids either overdrainage or underdrainage while preserving normal brain development and cognition. These valves are reviewed and compared as to their function. Other locations for the distal end of the shunting system are reviewed to include pleural space and gallbladder. The lumbar subarachnoid space as the proximal location for a shunt is also reviewed. The only other surgical alternative for treating hydrocephalus is endoscopic third ventriculostomy. Since 2000, approximately 50% of children with hydrocephalus have been shown to be candidates for ETV. The benefits are the lack of need for an artificial shunt system and thus lower rates of infection and over time fewer reoperations. Future progress is dependent on improved shunt valve systems that are affordable worldwide and ready availability of ETV in developing countries. Anatomic and molecular causes of hydrocephalus need to be defined so that medications or genetic modifications become available for potential cure of hydrocephalus.
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Affiliation(s)
| | - Ann M Ritter
- Virginia Commonwealth University Health System, Richmond, VA, USA
| | - Derek A Bruce
- Neurosurgery & Pediatrics, Children's National Medical Center, Washington D.C, USA.
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Lynch DG, Mehta SH, Shah KA, Toscano D, Pruitt R, Woo HH. Endoscopic Third Ventriculostomy Using Penumbra Artemis™ Neuro Evacuation Device: Technical Case Report and Operative Video. Cureus 2023; 15:e45761. [PMID: 37872915 PMCID: PMC10590497 DOI: 10.7759/cureus.45761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2023] [Indexed: 10/25/2023] Open
Abstract
Endoscopic third ventriculostomy (ETV) is an effective cerebrospinal fluid diversion procedure but can be complicated by the presence of a high-riding basilar artery (BA). A 70-year-old female presented with obstructive hydrocephalus caused by melanoma metastatic to the brainstem in the setting of a high-riding BA. ETV was successfully performed using the Penumbra Artemis™ Neuro evacuation device (Artemis; Penumbra Inc, Alameda, CA, USA) to minimize the risk of injury to the BA. This is to our knowledge the first known Artemis-assisted ETV reported in the English literature, which may reduce the risk of BA injury in selected patients. Further characterization of the benefits and limitations of this procedure is needed.
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Affiliation(s)
| | - Shyle H Mehta
- Neurological Surgery, Northwell Health, Manhasset, USA
| | - Kevin A Shah
- Neurological Surgery, Northwell Health, Manhasset, USA
| | | | - Rachel Pruitt
- Pediatric Neurosurgery, Johns Hopkins University, Baltimore, USA
| | - Henry H Woo
- Neurological Surgery, Northwell Health, Manhasset, USA
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7
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Issa M, Younsi A, Paggetti F, Miotk N, Seitz A, Bendszus M, Wisoff JH, Unterberg A, El Damaty A. Heidelberg ETV score to assess success of ETV in patients with occlusive hydrocephalus: a retrospective single-center study. Neurosurg Rev 2023; 46:214. [PMID: 37644240 PMCID: PMC10465657 DOI: 10.1007/s10143-023-02122-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 08/13/2023] [Accepted: 08/15/2023] [Indexed: 08/31/2023]
Abstract
In aqueduct stenosis, pressure difference below and above level of obstruction leads to bulging of third ventricular floor (TVF) and lamina terminalis (LT). Endoscopic third ventriculocisternostomy (ETV) is the standard treatment in these patients. We tried to assess success of ETV depending on those two radiological changes in aqueduct stenosis. We implemented "Heidelberg ETV score" retrospectively to assess the state of TVF as well as LT in same manner in midsagittal MR image. Every patient had a preoperative, direct, 3-months and one-year postoperative score from -2 to + 2. We correlated the scores to clinical course to decide whether the score is reliable in defining success of ETV. Between 2017-2021, 67 (mean age 25.6 ± 23.9y) patients treated with ETV were included. Success rate of primary and Re-ETVs was 91% over 46.8 ± 19.0 months. A marked shift of score to the left after surgery in success group was noticed through the distribution of score immediate postoperative, 3-months later; 70.2% showed (+ 2) before surgery, 38.9% scored (0) after surgery and 50.9% showed further score drop to (-1) 3 months later, p < 0.001. In cases of failure, there was initial decrease after surgery followed by increase with ETV-failure (mean time to failure: 7.2 ± 5.7 months) in 100%. Significant difference was noticed in Heidelberg score at postoperative 1-year- and failure-MRI follow-up between two groups, p < 0.001. Heidelberg score describes anatomical changes in third ventricle after ETV and can serve in assessment of MR images to define success of the procedure in patients with aqueduct stenosis.
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Affiliation(s)
- Mohammed Issa
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Alexander Younsi
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Filippo Paggetti
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Nikolai Miotk
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Angelika Seitz
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Martin Bendszus
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Jeffrey H Wisoff
- Department of Neurosurgery, Division of Pediatric Neurosurgery, The Hassenfeld Children's Hospital at NYU Langone Health, New York City, NY, USA
| | - Andreas Unterberg
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Ahmed El Damaty
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.
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8
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Albalkhi I, Garatli S, Helal B, Saleh T, AlRamadan AH, Warf BC. Morbidity and etiology-based success rate of combined endoscopic ventriculostomy and choroid plexus cauterization: a systematic review and meta-analysis of 1918 infants. Neurosurg Rev 2023; 46:180. [PMID: 37468790 DOI: 10.1007/s10143-023-02091-4] [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: 06/13/2023] [Revised: 07/12/2023] [Accepted: 07/15/2023] [Indexed: 07/21/2023]
Abstract
Approaches to the treatment of infant hydrocephalus vary among centers. Standard shunting carries a significant infection rate, an unpredictable time-to-failure, and the life-long risk of recurrent failures. Combined choroid plexus cauterization (CPC) and endoscopic third ventriculostomy (ETV) have been increasingly employed over the past decade as an alternative approach in an attempt to avoid shunt dependency. We performed a systematic review and meta-analysis to explore the reported morbidity associated with ETV/CPC and its rate of success reported for specific etiologies of infant hydrocephalus. The protocol of this study was registered with the International prospective register of Systematic Reviews (PROSPERO) with the following registration number: CRD 42022343898. The study utilized four databases of medical literature to perform a systematic search following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Several parameters were extracted from the included studies including authors, publication year, region, study design, sample size, mean age, success rate, complication rate, reported complications, hydrocephalus etiology, median time-to-failure, secondary management after failure, and mean follow-up time. The outcomes of interest, success, and complication rates were pooled using 95% confidence intervals (CI) and a random effects model. Heterogeneity was assessed using the I2 test. Twenty-eight studies met the inclusion criteria from an initial search result of 472 studies. The study included 1938 infants (1918 of which were included in the meta-analysis). The overall success rate of combined ETV/CPC is 0.59 (95% CI (0.53, 0.64), I2 = 82%). Etiology-based success rate is 0.71, 0.70, 0.64, and 0.52 for aqueductal stenosis, myelomeningocele, postinfectious hydrocephalus, and posthemorrhagic hydrocephalus, respectively. The overall complication rate is 0.04 (95% CI (0.02, 0.05), I2 = 14%). Our study presents a comprehensive analysis of the current evidence on the use of ETV/CPC for treating hydrocephalus in infants. The findings demonstrate the potential efficacy of this procedure; however, it is crucial to acknowledge the limitations inherent in the included studies, such as selection bias and limited follow-up, which could have impacted the reported outcomes.
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Affiliation(s)
- Ibrahem Albalkhi
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia.
- Department of Neuroradiology, Great Ormond Street Hospital NHS Foundation Trust, Great Ormond St, London, WC1N 3JH, UK.
| | - Sarah Garatli
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Baraa Helal
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Tariq Saleh
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Abdullah Husain AlRamadan
- Department of Neurosurgery and Spine Surgery, Qatif Central Hospital, First Eastern Health Cluster, Qatif, Saudi Arabia
| | - Benjamin Curtis Warf
- Harvard Medical School, Boston, MA, 02115, USA
- Department of Neurosurgery, Boston Children's Hospital, Boston, MA, 02115, USA
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9
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Dewan MC, Isaacs AM, Cools MJ, Yengo-Kahn A, Naftel RP, Jensen H, Reeder RW, Holubkov R, Haizel-Cobbina J, Riva-Cambrin J, Jafrani RJ, Pindrik JA, Jackson EM, Judy BF, Kurudza E, Pollack IF, Mcdowell MM, Hankinson TC, Staulcup S, Hauptman J, Hall K, Tamber MS, Cheong A, Warsi NM, Rocque BG, Saccomano BW, Snyder RI, Kulkarni AV, Kestle JRW, Wellons JC. Treatment of hydrocephalus following posterior fossa tumor resection: a multicenter collaboration from the Hydrocephalus Clinical Research Network. J Neurooncol 2023; 163:123-132. [PMID: 37129738 PMCID: PMC11225566 DOI: 10.1007/s11060-023-04316-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 04/17/2023] [Indexed: 05/03/2023]
Abstract
OBJECTIVE Persistent hydrocephalus following posterior fossa brain tumor (PFBT) resection is a common cause of morbidity in pediatric brain tumor patients, for which the optimal treatment is debated. The purpose of this study was to compare treatment outcomes between VPS and ETV in patients with persistent hydrocephalus following surgical resection of a PFBT. METHODS A post-hoc analysis was performed of the Hydrocephalus Clinical Research Network (HCRN) prospective observational study evaluating VPS and ETV for pediatric patients. Children who experienced hydrocephalus secondary to PFBT from 2008 to 2021 were included. Primary outcomes were VPS/ETV treatment failure and time-to-failure (TTF). RESULTS Among 241 patients, the VPS (183) and ETV (58) groups were similar in age, extent of tumor resection, and preoperative ETV Success Score. There was no difference in overall treatment failure between VPS and ETV (33.9% vs 31.0%, p = 0.751). However, mean TTF was shorter for ETV than VPS (0.45 years vs 1.30 years, p = 0.001). While major complication profiles were similar, compared to VPS, ETV patients had relatively higher incidence of minor CSF leak (10.3% vs. 1.1%, p = 0.003) and pseudomeningocele (12.1% vs 3.3%, p = 0.02). No ETV failures were identified beyond 3 years, while shunt failures occurred beyond 5 years. Shunt infections occurred in 5.5% of the VPS cohort. CONCLUSIONS ETV and VPS offer similar overall success rates for PFBT-related postoperative hydrocephalus. ETV failure occurs earlier, while susceptibility to VPS failure persists beyond 5 years. Tumor histology and grade may be considered when selecting the optimal means of CSF diversion.
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Affiliation(s)
- Michael C Dewan
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.
- Department of Neurological Surgery, Division of Pediatric Neurological Surgery, Vanderbilt Children's Hospital, 2200 Children's Way, 9226 Doctors Office Tower, Nashville, TN, 37232-9557, USA.
| | - Albert M Isaacs
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Michael J Cools
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Aaron Yengo-Kahn
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Robert P Naftel
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Hailey Jensen
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Richard Holubkov
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Joseline Haizel-Cobbina
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jay Riva-Cambrin
- Department of Clinical Neurosciences, University of Calgary, Alberta, Canada
| | - Ryan J Jafrani
- Department of Neurosurgery, St. Louis Children's Hospital, Washington University, St. Louis, MO, USA
| | - Jonathan A Pindrik
- Division of Pediatric Neurosurgery, Department of Neurological Surgery, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Eric M Jackson
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Brendan F Judy
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elena Kurudza
- Department of Neurosurgery, University of Utah, Salt Lake City, UT, USA
| | - Ian F Pollack
- Department of Neurosurgery, Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Michael M Mcdowell
- Department of Neurosurgery, Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Todd C Hankinson
- Department of Neurosurgery, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - Susan Staulcup
- Department of Neurosurgery, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - Jason Hauptman
- Department of Neurosurgery, University of Washington, Seattle Children's Hospital, Seattle, WA, USA
| | - Koko Hall
- Department of Neurosurgery, University of Washington, Seattle Children's Hospital, Seattle, WA, USA
| | - Mandeep S Tamber
- Department of Surgery, Division of Neurosurgery, British Columbia Children's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Alex Cheong
- Department of Surgery, Division of Neurosurgery, British Columbia Children's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Nebras M Warsi
- Division of Neurosurgery, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Brandon G Rocque
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Alabama at Birmingham, Children's of Alabama, Birmingham, AL, USA
| | - Benjamin W Saccomano
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Alabama at Birmingham, Children's of Alabama, Birmingham, AL, USA
| | - Rita I Snyder
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Abhaya V Kulkarni
- Division of Neurosurgery, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - John R W Kestle
- Department of Neurosurgery, University of Utah, Salt Lake City, UT, USA
| | - John C Wellons
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
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10
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Cattani A, Schwarzer F, Schwarzer M, Spyrantis A, Marquardt G, Schubert-Bast S, Seifert V, Freiman TM. A single center experience of adjusting valve pressure ventriculoperitoneal shunts for the treatment of hydrocephalus in infants under 6 months old. PLoS One 2023; 18:e0282571. [PMID: 36928724 PMCID: PMC10019726 DOI: 10.1371/journal.pone.0282571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 02/19/2023] [Indexed: 03/18/2023] Open
Abstract
INTRODUCTION Ventriculoperitoneal shunt (VPS) with adjustable differential pressure valves are commonly used to treat infants with hydrocephalus avoiding shunt related under- or overdrainage. The aim of this study was to analyse the influence of VPS adjustable differential pressure valve on the head circumference (HC) and ventricular size (VS) stabilization in infants with post intraventricular haemorrhage, acquired and congenital hydrocephali. METHODS Forty-three hydrocephalic infants under 6 months old were prospectively included between 2014 and 2018. All patients were treated using a VPS with adjustable differential pressure valve. HC and transfontanelle ultrasonographic VS measurements were regularly performed and pressure valve modifications were done aiming HC and VS percentiles between the 25th and 75th. The patients were divided into two groups: infants with hydrocephalus due to an intraventricular haemorrhage (IVH-H), and infants with hydrocephalus due to other aetiologies (OAE-H). RESULTS The mean of pressure valve modification was 3.7 per patient in the IVH-H group, versus 2.95 in the OAE-H group. The median of last pressure valve value was higher at 8.5 cm H2O in the IVH-H group comparing to 5 cm H2O in the OAE-H group (p = 0.013). CONCLUSION Optimal VPS pressure valve values could be extremely difficult to settle in order to gain normalisation of the HC and VS in infants. However, after long term follow up (mean of 18 months) and several pressure valve modifications, this normalisation is possible and shows that infants with IVH-H need a higher pressure valve value comparing to infants with OAE-H.
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Affiliation(s)
- Adriano Cattani
- Department of Neurosurgery, Goethe-University Hospital, Frankfurt am Main, Germany
- * E-mail:
| | - Franziska Schwarzer
- Department of Neurosurgery, Goethe-University Hospital, Frankfurt am Main, Germany
| | - Mario Schwarzer
- Department of Neuropaediatrics, Goethe-University Hospital, Frankfurt am Main, Germany
| | - Andrea Spyrantis
- Department of Neurosurgery, Goethe-University Hospital, Frankfurt am Main, Germany
| | - Gerhard Marquardt
- Department of Neurosurgery, Goethe-University Hospital, Frankfurt am Main, Germany
| | - Susanne Schubert-Bast
- Department of Neuropaediatrics, Goethe-University Hospital, Frankfurt am Main, Germany
| | - Volker Seifert
- Department of Neurosurgery, Goethe-University Hospital, Frankfurt am Main, Germany
| | - Thomas M. Freiman
- Department of Neurosurgery, Goethe-University Hospital, Frankfurt am Main, Germany
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11
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Thompson D, Brissette CA, Watt JA. The choroid plexus and its role in the pathogenesis of neurological infections. Fluids Barriers CNS 2022; 19:75. [PMID: 36088417 PMCID: PMC9463972 DOI: 10.1186/s12987-022-00372-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 08/27/2022] [Indexed: 11/10/2022] Open
Abstract
AbstractThe choroid plexus is situated at an anatomically and functionally important interface within the ventricles of the brain, forming the blood-cerebrospinal fluid barrier that separates the periphery from the central nervous system. In contrast to the blood–brain barrier, the choroid plexus and its epithelial barrier have received considerably less attention. As the main producer of cerebrospinal fluid, the secretory functions of the epithelial cells aid in the maintenance of CNS homeostasis and are capable of relaying inflammatory signals to the brain. The choroid plexus acts as an immunological niche where several types of peripheral immune cells can be found within the stroma including dendritic cells, macrophages, and T cells. Including the epithelia cells, these cells perform immunosurveillance, detecting pathogens and changes in the cytokine milieu. As such, their activation leads to the release of homing molecules to induce chemotaxis of circulating immune cells, driving an immune response at the choroid plexus. Research into the barrier properties have shown how inflammation can alter the structural junctions and promote increased bidirectional transmigration of cells and pathogens. The goal of this review is to highlight our foundational knowledge of the choroid plexus and discuss how recent research has shifted our understanding towards viewing the choroid plexus as a highly dynamic and important contributor to the pathogenesis of neurological infections. With the emergence of several high-profile diseases, including ZIKA and SARS-CoV-2, this review provides a pertinent update on the cellular response of the choroid plexus to these diseases. Historically, pharmacological interventions of CNS disorders have proven difficult to develop, however, a greater focus on the role of the choroid plexus in driving these disorders would provide for novel targets and routes for therapeutics.
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12
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Park YS. Treatment Strategies and Challenges to Avoid Cerebrospinal Fluid Shunting for Pediatric Hydrocephalus. Neurol Med Chir (Tokyo) 2022; 62:416-430. [PMID: 36031350 PMCID: PMC9534569 DOI: 10.2176/jns-nmc.2022-0100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Treatment for pediatric hydrocephalus aims not only to shrink the enlarged ventricle morphologically but also to create an intracranial environment that provides the best neurocognitive development and to deal with various treatment-related problems over a long period of time. Although the primary diseases that cause hydrocephalus are diverse, the ventricular peritoneal shunt has been introduced as the standard treatment for several decades. Nevertheless, complications such as shunt infection and shunt malfunction are unavoidable; the prognosis of neurological function is severely affected by such factors, especially in newborns and infants. In recent years, treatment concepts have been attempted to avoid shunting, mainly in the context of pediatric cases. In this review, the current role of neuroendoscopic third ventriculostomy for noncommunicating hydrocephalus is discussed and a new therapeutic concept for post intraventricular hemorrhagic hydrocephalus in preterm infants is documented. To avoid shunt placement and achieve good neurodevelopmental outcomes for pediatric hydrocephalus, treatment modalities must be developed.
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Affiliation(s)
- Young-Soo Park
- Department of Neurosurgery and Children's Medical Center, Nara Medical University
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13
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Saigusa T, Watanabe K, Hada Y, Ishii K, Kameda W, Susa S, Ishizawa K, Ishihara H. Cardio-ankle vascular index is more closely associated than brachial-ankle pulse wave velocity with arterial damage and risk of cardiovascular disease in patients with diabetes. BMC Cardiovasc Disord 2022; 22:365. [PMID: 35945498 PMCID: PMC9364514 DOI: 10.1186/s12872-022-02800-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Accepted: 08/02/2022] [Indexed: 11/15/2022] Open
Abstract
Background This study aimed to compare the usefulness of arterial stiffness parameters, cardio-ankle vascular index (CAVI) and brachial-ankle pulse wave velocity (baPWV), for evaluating arterial damage and risk of cardiovascular disease (CVD) in subjects with diabetes. Methods The study subjects were 277 patients with type 1 or type 2 diabetes. All subjects were evaluated for vascular stiffness using CAVI (n = 154) or baPWV (n = 123). Carotid intima-media thickness (IMT) and the Suita score were also measured because these are established risk factors for future CVD. Associations of both CAVI and baPWV with these established parameters were evaluated in all subjects, and then in 174 subjects with adjustment for covariates by using propensity score matching. Results In all subjects, CAVI and baPWV correlated significantly with both IMT (r = 0.462, P < 0.001, and r = 0.212, P = 0.019, respectively) and the Suita score (r = 0.573, P < 0.001, and r = 0.373, P < 0.001, respectively). The correlation between CAVI and IMT was more significant than that between baPWV and IMT (Z = 2.33, P = 0.020). Similarly, the correlation between CAVI and the Suita score was more significant than that between baPWV and the Suita score (Z = 2.13, P = 0.033). After adjustment by propensity score matching, significant correlations between CAVI and IMT (r = 0.432 P < 0.001) and between CAVI and the Suita score (r = 0.544, P < 0.001) were preserved, though only the association between baPWV and the Suita score was significant (r = 0.289, P = 0.007) while that between baPWV and IMT showed no significance. Again, CAVI showed a significant association with the Suita score than baPWV (Z = 2.02, P = 0.043). Conclusions CAVI is more closely associated than baPWV with arterial damage and risk of CVD in patients with diabetes. Supplementary Information The online version contains supplementary material available at 10.1186/s12872-022-02800-9.
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Affiliation(s)
- Taro Saigusa
- Division of Diabetes and Metabolic Diseases, Department of Internal Medicine, Nihon University School of Medicine, 30-1 Oyaguchikami-cho, Itabashi-ku, 173-8610, Tokyo, Japan
| | - Kentaro Watanabe
- Division of Diabetes and Metabolic Diseases, Department of Internal Medicine, Nihon University School of Medicine, 30-1 Oyaguchikami-cho, Itabashi-ku, 173-8610, Tokyo, Japan. .,Department of Neurology, Hematology, Metabolism, Endocrinology and Diabetology, Yamagata University Faculty of Medicine, 2-2-2 Iida-nishi, 990-9585, Yamagata, Japan.
| | - Yurika Hada
- Department of Neurology, Hematology, Metabolism, Endocrinology and Diabetology, Yamagata University Faculty of Medicine, 2-2-2 Iida-nishi, 990-9585, Yamagata, Japan
| | - Kota Ishii
- Department of Neurology, Hematology, Metabolism, Endocrinology and Diabetology, Yamagata University Faculty of Medicine, 2-2-2 Iida-nishi, 990-9585, Yamagata, Japan
| | - Wataru Kameda
- Department of Neurology, Hematology, Metabolism, Endocrinology and Diabetology, Yamagata University Faculty of Medicine, 2-2-2 Iida-nishi, 990-9585, Yamagata, Japan
| | - Shinji Susa
- Department of Neurology, Hematology, Metabolism, Endocrinology and Diabetology, Yamagata University Faculty of Medicine, 2-2-2 Iida-nishi, 990-9585, Yamagata, Japan
| | - Kenichi Ishizawa
- Department of Neurology, Hematology, Metabolism, Endocrinology and Diabetology, Yamagata University Faculty of Medicine, 2-2-2 Iida-nishi, 990-9585, Yamagata, Japan
| | - Hisamitsu Ishihara
- Division of Diabetes and Metabolic Diseases, Department of Internal Medicine, Nihon University School of Medicine, 30-1 Oyaguchikami-cho, Itabashi-ku, 173-8610, Tokyo, Japan
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14
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Metformin Alleviates Delayed Hydrocephalus after Intraventricular Hemorrhage by Inhibiting Inflammation and Fibrosis. Transl Stroke Res 2022; 14:364-382. [PMID: 35852765 DOI: 10.1007/s12975-022-01026-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 01/22/2022] [Accepted: 04/15/2022] [Indexed: 12/28/2022]
Abstract
Intraventricular hemorrhage (IVH) is a subtype of intracerebral hemorrhage (ICH) with high morbidity and mortality. Posthemorrhagic hydrocephalus (PHH) is a common and major complication that affects prognosis, but the mechanism is still unclear. Inflammation and fibrosis have been well established as the major causes of PHH after IVH. In this study, we aimed to investigate the effects of metformin on IVH in adult male mice and further explored the underlying molecular mechanisms of these effects. In the acute phase, metformin treatment exerted dose-dependent neuroprotective effects by reducing periependymal apoptosis and neuronal degeneration and decreasing brain edema. Moreover, high-dose metformin reduced inflammatory cell infiltration and the release of proinflammatory factors, thus protecting ependymal structure integrity and subependymal neurons. In the chronic phase, metformin administration improved neurocognitive function and reduced delayed hydrocephalus. Additionally, metformin significantly inhibited basal subarachnoid fibrosis and ependymal glial scarring. The ependymal structures partially restored. Mechanically, IVH reduced phospho-AMPK (p-AMPK) and SIRT1 expression and activated the phospho-NF-κB (p-NF-κB) inflammatory signaling pathway. However, metformin treatment increased AMPK/SIRT1 expression and lowered the protein expression of p-NF-κB and its downstream inflammation. Compound C and EX527 administration reversed the anti-inflammatory effect of metformin. In conclusion, metformin attenuated neuroinflammation and subsequent fibrosis after IVH by regulating AMPK /SIRT1/ NF-κB pathways, thereby reducing delayed hydrocephalus. Metformin may be a promising therapeutic agent to prevent delayed hydrocephalus following IVH.
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15
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Prajapati HP, Ansari MA, Jaiswal M. Comparative Outcome Analysis of Endoscopic Third Ventriculostomy and Ventriculoperitoneal Shunt Surgery in Pediatric Hydrocephalus: An Experience of a Tertiary Care Center. Asian J Neurosurg 2022; 17:227-234. [PMID: 36120619 PMCID: PMC9473859 DOI: 10.1055/s-0042-1750780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background
Endoscopic third ventriculostomy (ETV) and ventriculoperitoneal shunt surgery (VPS) are used for the surgical management of pediatric hydrocephalus. There is controversy regarding the safety and efficacy of these procedures according to age, etiologies, and type of hydrocephalus.
Objective
The purpose of this study was to compare the outcomes and complications of ETV and VPS in pediatric hydrocephalus and to evaluate the better procedure.
Material and Methods
We retrospectively analyzed the pediatric hydrocephalus cases that were operated by ETV and VPS at our department from June 2016 to June 2019. Data were analyzed with respect to the etiology of hydrocephalus, age, and gender of the patients. We compared the outcomes (success and failure) depending on age at surgery, etiology, and type of hydrocephalus, complications at 12 months of follow-up. Fisher's exact test and chi-square test were applied to test the significance of difference.
Results
There were 195 pediatric hydrocephalus cases, which were operated by ETV (
n
= 43; 22.05%) and VPS (
n
= 152; 77.95%). The mean age of the cases was 53.63 ± 60.24 (ranged 0.5–204 months) in the ETV group and 53.44 ± 54.10 (ranged 0.3–210 months) in the VPS group. The male-to-female ratio was 1.41:1 in the ETV group and 1.21: 1 in the VPS group. Overall, ETV had successful outcomes in 30(69.77%) cases and VPS in 102(67.11%) cases at 12 months of follow-up. The complication rates were found in 7 (16.28%) cases in the ETV group and 38 (25.0%) cases in the VPS group. At initial 0.5 months of follow-up, ETV required revisions in 6 (13.95%) cases and VPS in 15 (9.87%) cases.
Conclusion
Although the success and failure of both the procedure vary according to the age at surgery, etiology and type of hydrocephalus, and complications, and failure rates on follow-up, there were no statistically significant differences between the two surgical groups in respect to these variables.
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Affiliation(s)
- Hanuman Prasad Prajapati
- Department of Neurosurgery, Uttar Pradesh University of Medical Sciences, Saifai, Etawah, Uttar Pradesh, India
| | - Mohd Ahmad Ansari
- Department of Neurosurgery, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
| | - Manish Jaiswal
- Department of Neurosurgery, King George's Medical University, Lucknow, Uttar Pradesh, India
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16
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Lane J, Akbari SHA. Failure of Endoscopic Third Ventriculostomy. Cureus 2022; 14:e25136. [PMID: 35733459 PMCID: PMC9205383 DOI: 10.7759/cureus.25136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 05/10/2022] [Indexed: 11/30/2022] Open
Abstract
Endoscopic third ventriculostomy (ETV) is an alternative to cerebrospinal fluid (CSF) shunting in the treatment of hydrocephalus. Careful patient selection is critical as patient age, etiology of hydrocephalus, and previous shunting have been shown to influence ETV success rates. Intraoperatively, patient anatomy and medical stability may prevent or limit the completion of the ventriculostomy procedure, and findings such as a patulous third ventricular floor or cisternal scarring may portend a lower chance of successful hydrocephalus treatment. Patients in whom a ventriculostomy is completed may still experience continued symptoms of hydrocephalus or CSF leak, representing an early ETV failure. In other patients, the ETV may prove a durable treatment of hydrocephalus for several months or even years before recurrence of hydrocephalus symptoms. The failure pattern for ETV is different than that of shunting, with a higher early failure rate but improved long-term failure-free survival rates. The risk factors for failure, along with the presentation and management of failure, deserve review.
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17
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Deininger S, Küppers J, Lehnick D, Esslinger P, Winiker H, Lehner M. Endoscopic third ventriculostomy: a feasible treatment option for pediatric hydrocephalus in a high-risk cohort – a single-center report. WORLD JOURNAL OF PEDIATRIC SURGERY 2022; 5:e000374. [DOI: 10.1136/wjps-2021-000374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 02/24/2022] [Indexed: 11/04/2022] Open
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18
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Salah M, Elhuseny AY, Youssef EM. Endoscopic third ventriculostomy for the management of hydrocephalus secondary to posterior fossa tumors: A retrospective study. Surg Neurol Int 2022; 13:65. [PMID: 35242431 PMCID: PMC8888306 DOI: 10.25259/sni_971_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Accepted: 01/05/2022] [Indexed: 12/05/2022] Open
Abstract
Background: Endoscopic third ventriculostomy (ETV) is an effective alternative to ventriculoperitoneal shunting as well as external ventricular drainage for the urgent management of acute hydrocephalus. We performed this study to investigate the efficacy and safety of ETV before tumor resection in managing hydrocephalus in patients with posterior fossa brain tumors (PFBT) in our neurosurgery department. Methods: We conducted this retrospective observational study between February 2018 and February 2020 on all cases diagnosed with PFBT associated with triventricular obstructive hydrocephalus. We retrospectively reviewed the demographic characteristics, operative procedures, and radiological investigations of all cases. During the follow-up period, clinical, as well as radiological success were evaluated. Results: Twenty-two ETV procedures were performed in 22 cases of PFBT (mean age = 22.1 years, SD = 11.4). Of the 22 cases, 8 cases (36.4%) had ependymoma, 7 cases (31.8%) had cerebellar astrocytoma, and 5 cases (22.7 %) had medulloblastoma, while 2 cases (9.1%) had diffuse pontine gliomas. The median follow-up duration was 9 months (range 3–13 months). The most commonly reported clinical presentation was the significant intracranial pressure increase. All operations were performed successfully in all cases. Only two ETV post-tumor resection failures were documented during the follow-up period. Conclusion: Preoperative ETV has shown to be an effective long-term cerebrospinal fluid diversion procedure to manage PFBT-associated hydrocephalus, with a relatively low rate of complications. Further prospective studies are required to assess the regular use of ETV before complete tumor resection.
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Abstract
Reparative inflammation is an important protective response that eliminates foreign organisms, damaged cells, and physical irritants. However, inappropriately triggered or sustained inflammation can respectively initiate, propagate, or prolong disease. Post-hemorrhagic (PHH) and post-infectious hydrocephalus (PIH) are the most common forms of hydrocephalus worldwide. They are treated using neurosurgical cerebrospinal fluid (CSF) diversion techniques with high complication and failure rates. Despite their distinct etiologies, clinical studies in human patients have shown PHH and PIH share similar CSF cytokine and immune cell profiles. Here, in light of recent work in model systems, we discuss the concept of "inflammatory hydrocephalus" to emphasize potential shared mechanisms and potential therapeutic vulnerabilities of these disorders. We propose that this change of emphasis could shift our thinking of PHH and PIH from a framework of life-long neurosurgical disorders to that of preventable conditions amenable to immunomodulation.
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20
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Wubie AB, Teshome GS, Ayele WE, Abebe F, Nigussie TM, Alemu YB, Mekonnen MS. Survival status and predictors of mortality among children who underwent ventriculoperitoneal shunt surgery at public hospitals in Addis Ababa, Ethiopia. Int J Neurosci 2021:1-9. [PMID: 34643151 DOI: 10.1080/00207454.2021.1986492] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Background: Despite the increase in ventriculoperitoneal shunt surgeries performed for children with hydrocephalus, the potential complications and survival of patients after the procedure remains the major challenge for both clinical and public health aspects. This study intends to assess the survival status and scrutinize the predictive factors of mortality among children after a ventriculoperitoneal shunt.Methods: A retrospective cohort study was employed by reviewing charts of 337 systematically selected children who have undergone a ventriculoperitoneal shunt from 2016 to 2018 in Addis Ababa. The extraction tool was used for data collection, Epi-data version 4.4.2 for data entry, and Stata version-14 for cleaning and analysis. Kaplan-Meier curve, log-rank test, and life table were used to describe the data. Cox proportional hazard regression model was used for analysis. Any variable at p < 0.25 in the bi-variable analysis was fitted to multivariate analysis, and significance was declared at p ≤ 0.05. Then, AHR with 95% CI was used to report the association and test the statistical significance. Finally, texts and tables were used to present the results.Results and Conclusion: The incidence rate of mortality was 58.4 per 1000 child-months of observation with a median survival time of 12 months (95%CI: 9.04-14.96). Communicative hydrocephalus (AHR: 1.99, 95% CI: 1.18-3.36), post-traumatic brain injury (AHR: 7.43, 95% CI: 3.21-16.88), emergency surgery (AHR: 1.86, 95% CI: 1.17-3.13) as well as revised shunt procedure (AHR: 8.01, 95% CI: 6.12-13.43) were independent predictors of death. Besides, sunset eye (ARH: 2.01; 95% CI: 1.17-3.47), rapidly increased head size (ARH: 2.05, 95% CI: 1.14-3.37), prolonged antibiotics treatment (AHR: 2.46, 95% CI: 1.82-7.37), and gram-negative infections (AHR: 1.95, 95% CI: 1.60-12.64) were also significantly associated. Hence, health professionals ought to give special attention to patients with identified predictors.
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Affiliation(s)
- Azene Bantie Wubie
- College of Health Science, Debre Markos University, Debre Markos, Ethiopia
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21
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Rennert RC, Brandel MG, Srinivas S, Prajapati D, Al Jammal OM, Brown NJ, Diaz-Aguilar LD, Elster J, Gonda DD, Crawford JR, Levy ML. Palliative endoscopic third ventriculostomy for pediatric primary brain tumors: a single-institution case series. J Neurosurg Pediatr 2021; 28:387-394. [PMID: 34359046 DOI: 10.3171/2021.3.peds20952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Accepted: 03/29/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Children with nonoperative brain tumors, such as diffuse intrinsic pontine gliomas (DIPGs), often have life-threatening hydrocephalus. Palliative shunting is common in such cases but can be complicated by hardware infection and mechanical failure. Endoscopic third ventriculostomy (ETV) is a minimally invasive alternative to treat hydrocephalus without implanted hardware. Herein, the authors report their institutional experience with palliative ETV for primary pediatric brain tumors. METHODS The authors conducted a retrospective review of consecutive patients who had undergone palliative ETV for hydrocephalus secondary to nonresectable primary brain tumors over a 10-year period at Rady Children's Hospital. Collected variables included age, sex, tumor type, tumor location, presence of leptomeningeal spread, use of a robot for ETV, complications, ETV Success Score (ETVSS), functional status, length of survival, and follow-up time. A successful outcome was defined as an ETV performed without clinically significant perioperative complications or secondary requirement for a new shunt. RESULTS Fifteen patients met the study inclusion criteria (11 males, 4 females; average age 7.9 years, range 0.8-21 years). Thirteen patients underwent manual ETV, and 2 patients underwent robotic ETV. Preoperative symptoms included gaze palsy, nausea/vomiting, headache, lethargy, hemiparesis, and seizures. Tumor types included DIPG (3), intraventricular/thalamic glioblastoma (2), and leptomeningeal spread of medulloblastoma (2), anaplastic oligo-/astrocytoma (2), rhabdoid tumor (2), primitive neuroectodermal tumor (1), ganglioglioma (1), pineoblastoma (1), and embryonal carcinoma (1). The mean preoperative ETVSS was 79 ± 8.8. There was 1 perioperative complication, a wound breakdown consistent with refractory hydrocephalus. The mean follow-up was 4.9 ± 5.5 months overall, and mean survival for the patients who died was 3.2 ± 3.6 months. Two patients remained alive at a mean follow-up of 15.7 months. Palliative ETV was successful in 7 patients (47%) and unsuccessful in 8 (53%). While patients with successful ETV were significantly older (11.9 ± 5.6 vs 4.4 ± 4.1 years, p = 0.010), there were no significant differences in preoperative ETVSS (p = 0.796) or postoperative survival (p = 0.476) between the successful and unsuccessful groups. Overall, functional outcomes were similar between the two groups; there was no significant difference in posttreatment Karnofsky Performance Status scores (68.6 ± 19.5 vs 61.3 ± 16.3, p = 0.454), suggesting that including ETV in the treatment algorithm did not worsen outcomes. CONCLUSIONS Palliative ETV is a safe and potentially efficacious treatment option in selected pediatric patients with hydrocephalus from nonoperative brain tumors. Close follow-up, especially in younger children, is required to ensure that patients with refractory symptoms receive appropriate secondary CSF diversion.
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Affiliation(s)
| | | | | | | | | | | | | | - Jennifer Elster
- 3Pediatrics, University of California San Diego, La Jolla; and.,4Rady Children's Hospital, San Diego, California
| | - David D Gonda
- Departments of1Neurological Surgery and.,2Neurosciences, and
| | - John R Crawford
- 2Neurosciences, and.,3Pediatrics, University of California San Diego, La Jolla; and
| | - Michael L Levy
- Departments of1Neurological Surgery and.,2Neurosciences, and
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22
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Yengo-Kahn AM, Wellons JC, Hankinson TC, Hauptman JS, Jackson EM, Jensen H, Krieger MD, Kulkarni AV, Limbrick DD, McDonald PJ, Naftel RP, Pindrik JA, Pollack IF, Reeder R, Riva-Cambrin J, Rozzelle CJ, Tamber MS, Whitehead WE, Kestle JRW. Treatment strategies for hydrocephalus related to Dandy-Walker syndrome: evaluating procedure selection and success within the Hydrocephalus Clinical Research Network. J Neurosurg Pediatr 2021; 28:93-101. [PMID: 33930865 DOI: 10.3171/2020.11.peds20806] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 11/16/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Treating Dandy-Walker syndrome-related hydrocephalus (DWSH) involves either a CSF shunt-based or endoscopic third ventriculostomy (ETV)-based procedure. However, comparative investigations are lacking. This study aimed to compare shunt-based and ETV-based treatment strategies utilizing archival data from the Hydrocephalus Clinical Research Network (HCRN) registry. METHODS A retrospective review of prospectively collected and maintained data on children with DWSH, available from the HCRN registry (14 sites, 2008-2018), was performed. The primary outcome was revision-free survival of the initial surgical intervention. The primary exposure was either shunt-based (i.e., cystoperitoneal shunt [CPS], ventriculoperitoneal shunt [VPS], and/or dual-compartment) or ETV-based (i.e., ETV alone or with choroid plexus cauterization [CPC]) initial surgical treatment. Primary analysis included multivariable Cox proportional hazards models. RESULTS Of 8400 HCRN patients, 151 (1.8%) had DWSH. Among these, the 102 patients who underwent shunt placement (79 VPSs, 16 CPSs, 3 other, and 4 multiple proximal catheter) were younger (6.6 vs 18.8 months, p < 0.001) and more frequently had 1 or more comorbidities (37.3% vs 14.3%, p = 0.005) than the 49 ETV-treated children (28 ETV-CPC). Fifty percent of the shunt-based and 51% of the ETV-based treatments failed. Notably, 100% (4/4) of the dual-compartment shunts failed. Adjusting for age, baseline ventricular size, and comorbidities, ETV-based treatment was not significantly associated with earlier failure compared with shunt-based treatment (HR for failure 1.32, 95% CI 0.77-2.26; p = 0.321). Complication rates were low: 4.9% and 6.1% (p = 0.715) for shunt- and ETV-based procedures, respectively. There was no difference in survival between ETV-CPC- and ETV-based treatment when adjusting for age (HR for failure 0.86, 95% CI 0.29-2.55, p = 0.783). CONCLUSIONS In this North American, multicenter, prospective database review, shunt-based and ETV-based primary treatment strategies of DWSH appear similarly durable. Pediatric neurosurgeons can reasonably consider ETV-based initial treatment given the similar durability and the low complication rate. However, given the observational nature of this study, the treating surgeon might need to consider subgroups that were too small for a separate analysis. Very young children with comorbidities were more commonly treated with shunts, and older children with fewer comorbidities were offered ETV-based treatment. Future studies may determine preoperative characteristics associated with ETV treatment success in this population.
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Affiliation(s)
- Aaron M Yengo-Kahn
- 1Department of Neurosurgery, Vanderbilt University Medical Center; and
- 2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt University, Nashville, Tennessee
| | - John C Wellons
- 1Department of Neurosurgery, Vanderbilt University Medical Center; and
- 2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt University, Nashville, Tennessee
| | - Todd C Hankinson
- 3Department of Neurosurgery, Children's Hospital Colorado, Colorado Springs, Colorado
| | - Jason S Hauptman
- 4Department of Neurosurgery, Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - Eric M Jackson
- 5Department of Neurosurgery, The Johns Hopkins Hospital, Johns Hopkins University, Baltimore, Maryland
| | | | - Mark D Krieger
- 7Department of Neurosurgery, Children's Hospital Los Angeles, University of Southern California, Los Angeles, California
| | - Abhaya V Kulkarni
- 8Division of Neurosurgery, Hospital for Sick Children, Toronto, Ontario, Canada
| | - David D Limbrick
- 9Department of Neurosurgery, Washington University School of Medicine in St. Louis, Missouri
| | - Patrick J McDonald
- 10Division of Neurosurgery, British Columbia Children's Hospital, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Robert P Naftel
- 1Department of Neurosurgery, Vanderbilt University Medical Center; and
- 2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt University, Nashville, Tennessee
| | - Jonathan A Pindrik
- 11Department of Neurosurgery, The Ohio State University College of Medicine, Columbus, Ohio
| | - Ian F Pollack
- 12Department of Neurosurgery, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pennsylvania
| | | | - Jay Riva-Cambrin
- 13Division of Neurosurgery, Alberta Children's Hospital, University of Calgary, Alberta, Canada
| | - Curtis J Rozzelle
- 14Division of Neurosurgery, Children's of Alabama, University of Alabama at Birmingham, Alabama; and
| | - Mandeep S Tamber
- 10Division of Neurosurgery, British Columbia Children's Hospital, The University of British Columbia, Vancouver, British Columbia, Canada
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Chia WL, Zaben M, Leach P. Is cerebrospinal fluid sampling necessary at the time of first ventriculo-peritoneal shunt insertion in paediatric patients? Clin Neurol Neurosurg 2021; 204:106608. [PMID: 33813372 DOI: 10.1016/j.clineuro.2021.106608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 02/27/2021] [Accepted: 03/16/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE We aim to evaluate whether intraoperative cerebrospinal fluid (CSF) sampling during ventriculo-peritoneal (VP) shunt insertion can predict future VP shunt infection or guide its management. METHODS 83 paediatric patients undergoing VP shunt insertion between February 2013 and July 2019 were retrospectively identified. Patient demographics, presence of pre-operative extra ventricular drain (EVD), pre-operative CSF results, and intra-operative CSF results were identified from patient case notes and electronic clinical databases. All included patients were followed up for a minimum of 6 months for identification of shunt infection. RESULTS 90 VP shunt insertions were performed in 83 patients. Age at time of shunt insertion ranged from 5 days to 15.8 years (mean 44.2 months). Tumours were the most common aetiology for hydrocephalus (n = 24). 67 cases (74.4%) had intra-operative CSF samples, of which 2 revealed the presence of bacteria. Only 1 patient with intra-operative CSF sampling positive for growth developed shunt infection during follow up. Two cases developed a shunt infection despite normal intra-operative CSF results. Three cases did not have intra-operative CSF sampling but developed a shunt infection during follow up. Intra-operative CSF culture achieved 33.3% sensitivity and 98.4% specificity for predicting future shunt infection (p = 0.154). The Receiver Operator Characteristic (ROC) curve of intra-operative white cell count (WCC) and shunt infection at 6 months follow up yielded an Area Under the Curve (AUC) of 50.3%. CONCLUSION Our results show that intraoperative CSF sampling as a method to predict future risk of shunt infection and to help inform future antibiotic prescribing is unreliable. Given an AUC of 50.3%, it is no better than chance as a diagnostic tool. Further larger studies are needed to substantiate this.
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Affiliation(s)
- Wen Li Chia
- Cardiff University, School of Medicine, Cardiff, UK.
| | - Malik Zaben
- Department of Paediatric Neurosurgery, University Hospital of Wales, Cardiff, UK
| | - Paul Leach
- Department of Paediatric Neurosurgery, University Hospital of Wales, Cardiff, UK
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24
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Sherrod BA, Iyer RR, Kestle JRW. Endoscopic third ventriculostomy for pediatric tumor-associated hydrocephalus. Neurosurg Focus 2021; 48:E5. [PMID: 31896082 DOI: 10.3171/2019.10.focus19725] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 10/14/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Surgical options for managing hydrocephalus secondary to CNS tumors have traditionally included ventriculoperitoneal shunting (VPS) when tumor resection or medical management alone are ineffective. Endoscopic third ventriculostomy (ETV) has emerged as an attractive treatment strategy for tumor-associated hydrocephalus because it offers a lower risk of infection and hardware-related complications; however, relatively little has been written on the topic of ETV specifically for the treatment of tumor-associated hydrocephalus. Here, the authors reviewed the existing literature on the use of ETV in the treatment of tumor-associated hydrocephalus, focusing on the frequency of ETV use and the failure rates in patients with hydrocephalus secondary to CNS tumor. METHODS The authors queried PubMed for the following terms: "endoscopic third ventriculostomy," "tumor," and "pediatric." Papers with only adult populations, case reports, and papers published before the year 2000 were excluded. The authors analyzed the etiology of hydrocephalus and failure rates after ETV, and they compared failure rates of ETV with those of VPS where reported. RESULTS Thirty-two studies with data on pediatric patients undergoing ETV for tumor-related hydrocephalus were analyzed. Tumors, particularly in the posterior fossa, were reported as the etiology of hydrocephalus in 38.6% of all ETVs performed (984 of 2547 ETVs, range 29%-55%). The ETV failure rate in tumor-related hydrocephalus ranged from 6% to 38.6%, and in the largest studies analyzed (> 100 patients), the ETV failure rate ranged from 10% to 38.6%. The pooled ETV failure rate was 18.3% (199 failures after 1087 procedures). The mean or median follow-up for ETV failure assessment ranged from 6 months to 8 years in these studies. Only 5 studies directly compared ETV with VPS for tumor-associated hydrocephalus, and they reported mixed results in regard to failure rate and time to failure. Overall failure rates appear similar for ETV and VPS over time, and the risk of infection appears to be lower in those patients undergoing ETV. The literature is mixed regarding the need for routine ETV before resection for posterior fossa tumors with associated hydrocephalus. CONCLUSIONS Treatment of tumor-related hydrocephalus with ETV is common and is warranted in select pediatric patient populations. Failure rates are overall similar to those of VPS for tumor-associated hydrocephalus.
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25
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Forte D, Peraio S, Huttunen TJ, James G, Thompson D, Aquilina K. Ventriculoatrial and ventriculopleural shunts as second-line surgical treatment have equivalent revision, infection, and survival rates in paediatric hydrocephalus. Childs Nerv Syst 2021; 37:481-489. [PMID: 32986152 DOI: 10.1007/s00381-020-04887-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 09/09/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE Ventriculoatrial (VA) and ventriculopleural (VPL) shunts are used as alternatives when CSF diversion to the peritoneal compartment with a ventriculoperitoneal (VP) shunt is not possible. The objective of this study is to compare directly the shunt survival and complications for both procedures in this setting in children. METHODS A retrospective analysis of 54 consecutive patients who underwent VA (36) or VPL (18) shunt insertion between January 2002 and December 2017 was conducted. RESULTS The overall mean follow-up was 4.1 (SD 4.3) years, 2.8 (SD 4.1) for VPL and 4.7 (SD 4.4) for VA shunts, respectively (p = 0.11). Twenty-four (66.7%) patients in the VA group and 9 (50.0%) in the VPL group underwent shunt revision (p = 0.236); mean number of revisions was 2.2 (SD 3.0) and 0.94 (SD 1.4) in the VA and VPL groups (p = 0.079). Median time to failure was 8.5 (IQr 78, range 0-176) months for VA and 5.50 (IQr 36, range 0-60) for VPL shunts (log rank (Mantel-Cox) 0.832). Shunt survival at 3, 6, 12 and 30 months was 60.6, 51.5, 36.4 and 27.3%, respectively, for VA and 56.3, 43.8, 37.5 and 37.5% for VPL shunts (log rank (Mantel-Cox) test value 0.727). The infection rate was 13.8% for VA and 5.6% for VPL shunts (p = 0.358). Four patients with VPL shunts (22.2%) developed pleural effusions. Fourteen deaths (25.9%) were recorded during follow-up, 8 (22.2%) in the VA and 6 (33.3%) in the VPL group (p = 0.380); two of the deaths in the VA group were shunt-related. CONCLUSION This study demonstrates that the outcomes of VA and VPL shunts, when used as second-line surgical treatment in paediatric hydrocephalus, were similar, as were the revision, infection and survival rates. The shorter longevity of these shunts compared with the general shunted population may reflect the complex nature of these children.
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Affiliation(s)
- Dalila Forte
- Department of Neurosurgery, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Simone Peraio
- Department of Neurosurgery, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Terhi J Huttunen
- Department of Neurosurgery, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Greg James
- Department of Neurosurgery, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Dominic Thompson
- Department of Neurosurgery, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Kristian Aquilina
- Department of Neurosurgery, Great Ormond Street Hospital NHS Foundation Trust, London, UK.
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26
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Spennato P, Marini A, Cinalli G. In Reply to the Letter to the Editor Regarding "Holocord Syrinx Associated with Shunt Malfunction in Tetraventricular Hydrocephalus". World Neurosurg 2020; 143:610. [PMID: 33167139 DOI: 10.1016/j.wneu.2020.08.112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 08/15/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Pietro Spennato
- Department of Neurosciences and Neurosurgery, Santobono-Pausilipon Children's Hospital, Naples, Italy.
| | - Alessandra Marini
- Department of Neurosciences and Neurosurgery, Santobono-Pausilipon Children's Hospital, Naples, Italy; Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - Giuseppe Cinalli
- Department of Neurosciences and Neurosurgery, Santobono-Pausilipon Children's Hospital, Naples, Italy
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27
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Tamber MS, Naftel RP. Patient and parental assessment of factors influencing the choice of treatment in pediatric hydrocephalus. J Neurosurg Pediatr 2020; 26:490-494. [PMID: 32764167 DOI: 10.3171/2020.5.peds2095] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 05/08/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Choosing between competing options (shunt or endoscopic third ventriculostomy) for the management of hydrocephalus requires patients and caregivers to make a subjective judgment about the relative importance of risks and benefits associated with each treatment. In the context of this particular decision, little is known about what treatment-related factors are important and how they are prioritized in order to arrive at a treatment preference. METHODS The Hydrocephalus Association electronically distributed a survey to surgically treated hydrocephalus patients or their families. Respondents rated the importance of various surgical attributes in their decision-making about treatment choice, and also indicated their preference in hypothetical scenarios involving a trade-off between potential risks and benefits of treatment. Rank-order correlations were used to determine whether certain predictor variables affected the rating of factors or hypothetical treatment choice. RESULTS Eighty percent of 414 respondents rated procedural risks, minimizing repeat surgery, and improving long-term brain function as being very or extremely important factors when deciding on a treatment; 69% rated the need to implant a permanent device similarly. Parent-respondents rated procedural risks higher than patient-respondents. A majority of respondents (n = 209, 54%) chose a procedure with higher surgical risk if it meant that implantation of a permanent device was not required, and respondents were more likely to choose this option if they discussed both treatment options with their surgeon prior to their initial intervention (Spearman rho 0.198, p = 0.001).Although only 144 of 384 total respondents (38%) chose a less established operation if it meant less repeat surgery, patient-respondents were more likely to choose this option compared to parent-respondents (Spearman rho 0.145, p = 0.005). Likewise, patient-respondents were more likely than parent-respondents to choose an operation that involved less repeat surgery and led to worse long-term brain function (Spearman rho 0.160, p = 0.002), an option that was chosen by only 23 (6%) of respondents overall. CONCLUSIONS This study is the first exploration of patient/parental factors that influence treatment preference in pediatric hydrocephalus. Procedural risks, minimizing repeat operations, and the desire to maximize long-term cognitive function appeared to be the most important attributes that influenced treatment decisions that the survey respondents had made in the past. Patients and/or their caregivers appear to see some inherent benefit in being shunt free. It appears that fear of multiple revision operations may drive treatment choice in some circumstances.
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Affiliation(s)
- Mandeep S Tamber
- 1British Columbia Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada; and
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28
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Frame-Based Stereotactic Endoscopic Third Ventriculostomy-Toward Improved Precision and Minimizing Morbidities. World Neurosurg 2020; 140:e240-e246. [PMID: 32437981 DOI: 10.1016/j.wneu.2020.05.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 04/30/2020] [Accepted: 05/02/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND Endoscopic third ventriculostomy (ETV) is a widely accepted treatment for obstructive hydrocephalus. For most practitioners, this procedure will be performed without navigation guidance. Without such guidance, the complications associated with the procedure have ranged from 1% to 8%. We hypothesized that the discrepancy between the surface bony anatomy and internal cranial anatomy contributes to the morbidities associated with ETV. We tested this hypothesis by comparing the position of the entry point defined by the classic Kocher's point relative to the ideal entry point that would result in no manipulation of the endoscope defined by frame-based stereotaxis. METHODS The cranial computed tomography scan of 58 patients who had undergone frame-based stereotactic ETV was reformatted into 3-dimensional renderings. The location of this entry point was compared with the Kocher point, as determined by the external bony anatomy. RESULTS Overall, >70% of the burr holes that provided an ideal trajectory to the third ventricle were ≥0.5 cm from the Kocher point in both the sagittal and the coronal planes. Median deviations of 0.74 and 0.81 cm in the coronal (P < 0.01) and sagittal (P < 0.0001) planes were observed. CONCLUSION The use of stereotactic endoscopic techniques increase the safety of third ventriculostomy by adding precision and reducing otherwise unnecessary surgical maneuvering.
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29
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Bateman GA, Yap SL, Subramanian GM, Bateman AR. The incidence of significant venous sinus stenosis and cerebral hyperemia in childhood hydrocephalus: prognostic value with regards to differentiating active from compensated disease. Fluids Barriers CNS 2020; 17:33. [PMID: 32349763 PMCID: PMC7191733 DOI: 10.1186/s12987-020-00194-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 04/19/2020] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Symptomatic or active hydrocephalus in children is linked to an elevation in intracranial pressure (ICP), which is likely to be multifactorial in origin. The CSF outflow resistance, venous sinus resistance and total cerebral blood flow are likely factors in the ICP elevation. The purpose of this paper is to define the incidence, site and significance of venous sinus stenosis and/or cerebral hyperemia in a cohort of children diagnosed with hydrocephalus at a tertiary referral hospital. METHODS The imaging database was reviewed over a 10 year period and the index MRI of all children between the ages of 4 months and 15 years, who were diagnosed with treatment naive hydrocephalus of any type (excluding secondary to tumor) and had magnetic resonance venography (MRV) and flow quantification were selected. Patients were compared with children undergoing an MRI with MRV and flow quantification who were subsequently shown to have no abnormality. The cross-sectional area and circumference of the sinuses were measured at 4 levels. The hydraulic and effective diameters were calculated. An area stenosis of 65% or greater was deemed significant. A total cerebral blood flow greater than two standard deviations above the mean for controls was taken to be abnormal. RESULTS There were a total of 55 children with hydrocephalus compared to 118 age matched control MRV's and 35 control flow quantification studies. A high grade stenosis occurred in 56% of patients but in none of the controls (p < 0.0001). The commonest site of narrowing was in the distal sigmoid sinus. Cerebral hyperemia occurred in 13% of patients but did not occur in the controls. CONCLUSIONS The elevation in ICP in symptomatic hydrocephalus is multifactorial. Both high grade venous stenosis and cerebral hyperemia are common in childhood hydrocephalus. High grade stenosis was noted to be a risk factor for conservative management failure. Hyperemia was a good prognostic indicator.
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Affiliation(s)
- Grant Alexander Bateman
- Department of Medical Imaging, Newcastle Region Mail Center, John Hunter Hospital, Locked Bag 1, Newcastle, NSW, 2310, Australia. .,Newcastle University Faculty of Health, Callaghan Campus, Newcastle, NSW, Australia.
| | - Swee Leong Yap
- Department of Medical Imaging, Newcastle Region Mail Center, John Hunter Hospital, Locked Bag 1, Newcastle, NSW, 2310, Australia
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30
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Karimy JK, Reeves BC, Damisah E, Duy PQ, Antwi P, David W, Wang K, Schiff SJ, Limbrick DD, Alper SL, Warf BC, Nedergaard M, Simard JM, Kahle KT. Inflammation in acquired hydrocephalus: pathogenic mechanisms and therapeutic targets. Nat Rev Neurol 2020; 16:285-296. [PMID: 32152460 DOI: 10.1038/s41582-020-0321-y] [Citation(s) in RCA: 90] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2020] [Indexed: 12/11/2022]
Abstract
Hydrocephalus is the most common neurosurgical disorder worldwide and is characterized by enlargement of the cerebrospinal fluid (CSF)-filled brain ventricles resulting from failed CSF homeostasis. Since the 1840s, physicians have observed inflammation in the brain and the CSF spaces in both posthaemorrhagic hydrocephalus (PHH) and postinfectious hydrocephalus (PIH). Reparative inflammation is an important protective response that eliminates foreign organisms, damaged cells and physical irritants; however, inappropriately triggered or sustained inflammation can respectively initiate or propagate disease. Recent data have begun to uncover the molecular mechanisms by which inflammation - driven by Toll-like receptor 4-regulated cytokines, immune cells and signalling pathways - contributes to the pathogenesis of hydrocephalus. We propose that therapeutic approaches that target inflammatory mediators in both PHH and PIH could address the multiple drivers of disease, including choroid plexus CSF hypersecretion, ependymal denudation, and damage and scarring of intraventricular and parenchymal (glia-lymphatic) CSF pathways. Here, we review the evidence for a prominent role of inflammation in the pathogenic mechanism of PHH and PIH and highlight promising targets for therapeutic intervention. Focusing research efforts on inflammation could shift our view of hydrocephalus from that of a lifelong neurosurgical disorder to that of a preventable neuroinflammatory condition.
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Affiliation(s)
- Jason K Karimy
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | - Benjamin C Reeves
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | - Eyiyemisi Damisah
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | - Phan Q Duy
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | - Prince Antwi
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | - Wyatt David
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | - Kevin Wang
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | - Steven J Schiff
- Departments of Neurosurgery, Engineering Science & Mechanics, and Physics; Center for Neural Engineering, The Pennsylvania State University, University Park, PA, USA
| | - David D Limbrick
- Departments of Neurosurgery and Pediatrics, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Seth L Alper
- Division of Nephrology and Vascular Biology Research Center, Beth Israel Deaconess Medical Center, Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Benjamin C Warf
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Maiken Nedergaard
- Center for Translational Neuromedicine, University of Rochester Medical Center, Rochester, NY, USA.,Center for Translational Neuromedicine, Faculty of Medical and Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - J Marc Simard
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Kristopher T Kahle
- Departments of Neurosurgery, Pediatrics, and Cellular & Molecular Physiology and Yale-Rockefeller NIH Centers for Mendelian Genomics, Yale School of Medicine, New Haven, CT, USA.
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31
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Luther E, McCarthy D, Sedighim S, Niazi T. Endoscopic third ventriculostomy inpatient failure rates compared with shunting in post-hemorrhagic hydrocephalus of prematurity. Childs Nerv Syst 2020; 36:559-568. [PMID: 31863148 DOI: 10.1007/s00381-019-04465-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 12/04/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE Endoscopic third ventriculostomy (ETV) has gained traction as a method for treating post-hemorrhagic hydrocephalus of prematurity (PHHP) in an effort to obviate lifelong shunt dependence in neonates. However, data remains limited regarding inpatient failures. METHODS A retrospective analysis of the NIS between 1998 and 2014 was performed. Discharges with age < 1 year and ICD-9-CM codes indicating intraventricular hemorrhage of prematurity (772.1x) and ETV/shunt (02.22 and 02.3x) were included. Patients with ICD-9-CM codes for ventricular drain/reservoir (02.21) were excluded to prevent confounding. Time trend series plots were created. Yearly trends were quantified using logarithmic regression analysis. Kaplan-Meier curves were utilized to analyze time to treatment failure. Time to failure for each treatment was compared using log-rank. RESULTS A total of 11,017 discharges were identified. ETV was more likely to be utilized at < 29 weeks gestational age (p = 0.0039) and birth weight < 1000 g (p = 0.0039). Shunts were less likely to fail in older and heavier newborns (OR 0.836 p = 0.00456, OR 0.828 p = 0.0001, respectively). Those initially shunted had lower failure rates compared with ETV (OR 0.44, p < 0.0001) but time to failure was longer with ETV (p = 0.04562). 79.5% of ETVs that failed were shunted after the first failure. Shunts were much less likely to undergo ETV if they failed (OR 0.21, p < 0.0001). Higher grade IVH was predictive of shunt failure but not ETV (OR 2.36, p = 0.0129). CONCLUSIONS Although ETV can be effective in PHHP, it has a much higher initial failure rate than shunting and should thus be chosen based on a multifactorial approach.
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Affiliation(s)
- Evan Luther
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Lois Pope Life Center, 2nd floor, 1095 NW 14th Terrace, Miami, FL, 33136, USA.
| | - David McCarthy
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Lois Pope Life Center, 2nd floor, 1095 NW 14th Terrace, Miami, FL, 33136, USA
| | - Shaina Sedighim
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Lois Pope Life Center, 2nd floor, 1095 NW 14th Terrace, Miami, FL, 33136, USA
| | - Toba Niazi
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Lois Pope Life Center, 2nd floor, 1095 NW 14th Terrace, Miami, FL, 33136, USA.,Department of Neurological Surgery, Nicklaus Children's Hospital, Miami, FL, USA
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32
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Sun T, Guan J. Letter: A Comparison of Ventriculoperitoneal and Ventriculoatrial Shunts in a Population of 544 Consecutive Pediatric Patients. Neurosurgery 2020; 86:E583. [DOI: 10.1093/neuros/nyaa030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Affiliation(s)
- Tong Sun
- Department of Neurosurgery West China Hospital Sichuan University Chengdu, Sichuan, P. R. China
| | - Junwen Guan
- Department of Neurosurgery West China Hospital Sichuan University Chengdu, Sichuan, P. R. China
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33
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Rymarczuk GN, Magge SN. In Reply: A Comparison of Ventriculoperitoneal and Ventriculoatrial Shunts in a Population of 544 Consecutive Pediatric Patients. Neurosurgery 2020; 86:E584. [DOI: 10.1093/neuros/nyaa033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- George N Rymarczuk
- Division of Neurosurgery Walter Reed National Military Medical Center Bethesda, Maryland
- Division of Neurosurgery Children's National Medical Center Washington, District of Columbia
| | - Suresh N Magge
- Division of Neurosurgery Children's National Medical Center Washington, District of Columbia
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Yan H, Karmur BS, Kulkarni AV. Comparing Effects of Treatment: Controlling for Confounding. Neurosurgery 2019; 86:325-331. [DOI: 10.1093/neuros/nyz509] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 09/04/2019] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND
Determining true causal links between an intervention and an outcome forms an imperative task in research studies in neurosurgery. Although the study results sometimes demonstrate clear statistical associations, it is important to ensure that this represents a true causal link. A confounding variable, or confounder, affects the association between a potential predictor and an outcome.
OBJECTIVE
To discuss what confounding is and the means by which it can be eliminated or controlled.
METHODS
We identified neurosurgical research studies demonstrating the principles of eliminating confounding by means of study design and data analysis.
RESULTS
In this report, we outline the role of confounding in neurosurgical studies after giving an overview of its identification. We report on the definition of confounding and effect modification, and the differences in the 2. We explain study design techniques to eliminate confounding, including simple, block, stratified, and minimization randomization, along with restriction of sample and matching. Data analysis techniques of eliminating confounding include regression analysis, propensity scoring, and subgroup analysis.
CONCLUSION
Understanding confounding is important for conducting a good research study. Study design techniques provide the best way to control for confounders, but when not possible to alter study design, data analysis techniques can also provide an effective control.
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Affiliation(s)
- Han Yan
- Division of Neurosurgery, Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Brij S Karmur
- Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Abhaya V Kulkarni
- Division of Neurosurgery, Hospital for Sick Children, University of Toronto, Toronto, Canada
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Muffly MK, Honkanen A, Scheinker D, Wang TNY, Saynina O, Singleton MA, Wang CJ, Sanders L. Hospitalization Patterns for Inpatient Pediatric Surgery and Procedures in California: 2000–2016. Anesth Analg 2019; 131:1070-1079. [DOI: 10.1213/ane.0000000000004552] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Pan IW, Harris DA, Luerssen TG, Lam SK. Comparative Effectiveness of Surgical Treatments for Pediatric Hydrocephalus. Neurosurgery 2019; 83:480-487. [PMID: 28945918 DOI: 10.1093/neuros/nyx440] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Accepted: 07/19/2017] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Pediatric hydrocephalus represents a high health care burden in the United States (US). Surgery is the mainstay of treatment. OBJECTIVE To perform a comparative effectiveness analysis for endoscopic third ventriculostomy (ETV) and cerebrospinal fluid shunt placement in pediatric hydrocephalus patients in the US using a large administrative claims database through the application of propensity scores matching. METHODS The MarketScan® database (Truven Health Analytics, Atlanta, Georgia) 2003 to 2011 was used. Patients 19 yr or younger at first occurrence of ETV or shunt during the study period were included. The study outcome, surgery failure, was defined as further surgical treatment for hydrocephalus subsequent to initial ETV or shunt procedure. Age, etiology of hydrocephalus, and history of shunt were used to create matched samples for the ETV and shunt cohorts. Kaplan-Meier survival curves, stratified log-rank test, and Cox proportional-hazard models were used to analyze samples. RESULTS There were 3231 eligible cases (478 ETV; 2753 shunt). Propensity scores matching produced 455 balanced pairs. For matched samples, 326 of 455 (72%) pairs were concordant, while 129 pairs were discordant in surgery outcomes within 3 mo. Among discordant pairs, ETV patients were more likely to experience surgery failure compared to patients receiving shunt (relative risk = 1.4, P value = .011). Furthermore, patients' age < 1 yr had lower ETV success rates than those with shunt (P value = .009). No similar pattern was found in patients' age ≥ 1 yr. CONCLUSION There was no significant effect on time to failure between patients undergoing ETV and shunt, except in infants' age <1 yr.
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Affiliation(s)
- I-Wen Pan
- Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Dominic A Harris
- Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Thomas G Luerssen
- Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Sandi K Lam
- Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
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McLone D, Frim D, Penn R, Swisher CN, Heydemann P, Boyer KM, Noble AG, Rabiah PK, Withers S, Wroblewski K, Karrison T, Hutson S, Wheeler K, Cohen W, Lykins J, McLeod R. Outcomes of hydrocephalus secondary to congenital toxoplasmosis. J Neurosurg Pediatr 2019; 24:601-608. [PMID: 31491752 DOI: 10.3171/2019.6.peds18684] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 06/10/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Hydrocephalus occurs in children with congenital toxoplasmosis and can lead to severe disability. In these cases, the decision to intervene is often influenced by the expectation of neurological recovery. In this study, clinical responses to neurosurgical intervention in children with hydrocephalus secondary to congenital toxoplasmosis are characterized. METHODS Sixty-five participants with hydrocephalus due to congenital Toxoplasma gondii infection were evaluated as part of the National Collaborative Chicago-based Congenital Toxoplasmosis Study, and their neuroradiographic findings were reviewed. Clinical outcomes were scored on the basis of cognition and motor skills through the use of IQ scores and Gross Motor Function Classification System (GMFCS) level. Outcomes were then analyzed in relation to approach to management, anatomy of hydrocephalus, and time from diagnosis of hydrocephalus to surgical intervention. RESULTS There was considerable variation in the outcomes of patients whose hydrocephalus was treated in early life, ranging from normal cognitive and motor function to profound developmental delay and functional limitation. Of the 65 participants included in the study, IQ and GMFCS level were available for 46 (70.8%). IQ and motor score were highly correlated (r = -0.82, p < 0.001). There were people with differing patterns of hydrocephalus or thickness of cortical mantle on initial presentation who had favorable outcomes. Time to neurosurgical intervention data were available for 31 patients who underwent ventriculoperitoneal (VP) shunt placement. Delayed shunt placement beyond 25 days after diagnosis of hydrocephalus was associated with greater cognitive impairment (p = 0.02). Motor impairment also appeared to be associated with shunt placement beyond 25 days but the difference did not achieve statistical significance (p = 0.13). Among those with shunt placement within 25 days after diagnosis (n = 19), the mean GMFCS level was 1.9 ± 1.6 (range 1-5). Five (29.4%) of 17 of these patients were too disabled to participate in formal cognitive testing, after excluding 2 patients with visual difficulties or language barriers that precluded IQ testing. Of the patients who had VP shunt placement 25 or more days after diagnosis (n = 12), the mean GMFCS level was 2.7 ± 1.4 (range 1-4). Of these, 1 could not participate in IQ testing due to severe visual difficulties and 8 (72.7%) of the remaining 11 due to cognitive disability. CONCLUSIONS VP shunt placement in patients with hydrocephalus caused by congenital toxoplasmosis can contribute to favorable clinical outcomes, even in cases with severe hydrocephalus on neuroimaging. Shunt placement within 25 days of diagnosis was statistically associated with more favorable cognitive outcomes. Motor function appeared to follow the same pattern although it did not achieve statistical significance.
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Affiliation(s)
- David McLone
- 1Northwestern University and Lurie Children's Hospital and Medical Center, Chicago
| | | | - Richard Penn
- 3Department of Bioengineering, College of Engineering, College of Medicine, University of Illinois at Chicago
| | - Charles N Swisher
- 1Northwestern University and Lurie Children's Hospital and Medical Center, Chicago
| | - Peter Heydemann
- 4Department of Pediatrics, Rush University Medical Center, Chicago
| | - Kenneth M Boyer
- 4Department of Pediatrics, Rush University Medical Center, Chicago
| | - A Gwendolyn Noble
- 1Northwestern University and Lurie Children's Hospital and Medical Center, Chicago
| | | | | | | | | | | | | | | | - Joseph Lykins
- 8Pritzker School of Medicine, The University of Chicago
| | - Rima McLeod
- 6Department of Ophthalmology and Visual Science
- 9Department of Pediatrics (Infectious Diseases), Institute of Genomics, Genetics, and Systems Biology, Global Health Center, Toxoplasmosis Center, CHeSS, The College, The University of Chicago, Illinois
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Reid T, Grudziak J, Rodriguez-Ormaza N, Maine RG, Msiska N, Quinsey C, Charles A. Complications and 3-month outcomes of children with hydrocephalus treated with ventriculoperitoneal shunts in Malawi. J Neurosurg Pediatr 2019; 24:120-127. [PMID: 31075763 DOI: 10.3171/2019.2.peds18325] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 02/28/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Hydrocephalus is the most common pediatric neurosurgical condition, with a high prevalence in low- and middle-income countries. Untreated, hydrocephalus leads to neurological disability or death. The epidemiology and outcomes of hydrocephalus treated by ventriculoperitoneal (VP) shunts in Sub-Saharan Africa are not well defined and vary by region. The aim of the present study was to examine the mortality and morbidity rates and predictors of mortality in children treated by VP shunt placement for hydrocephalus at Kamuzu Central Hospital in Lilongwe, Malawi. METHODS This is a prospective study of 100 consecutive children presenting with hydrocephalus who were treated with VP shunt placement from January 2015 to August 2017. Demographics, nutritional status, maternal characteristics, developmental delay, shunt complications, readmissions, and in-hospital and 3-month mortality data were collected. Multivariate logistic regression was used to identify predictors of death within 3 months of surgery. RESULTS Overall, 46% of participants were female, with an average age of 5.4 ± 3.7 months at the time of surgery. The majority of patients were term deliveries (87.8%) and were not malnourished (72.9%). Only 10.8% of children were diagnosed with meningitis before admission. In-hospital and 3-month mortality rates were 5.5% and 32.1%, respectively. The only significant association with mortality was maternal age, with older maternal age demonstrating decreased odds of 3-month mortality (OR 0.9, 95% CI 0.8-1.0, p = 0.045). CONCLUSIONS Surgical management of hydrocephalus with VP shunts portends a high mortality rate in Malawi. The association of younger maternal age with mortality is likely a proxy for social determinants, which appear to contribute as much to mortality as patient factors. VP shunting is inadequate as a sole surgical management of hydrocephalus in resource-limited settings.
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Affiliation(s)
| | | | | | | | - Nelson Msiska
- 3Department of Surgery, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Carolyn Quinsey
- 4Neurosurgery, University of North Carolina at Chapel Hill, North Carolina; and
| | - Anthony Charles
- Departments of1Surgery.,3Department of Surgery, Kamuzu Central Hospital, Lilongwe, Malawi
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Zhou WJL, Wang X, Peng JY, Ma SC, Zhang DN, Guan XD, Diao JF, Niu JX, Li CD, Jia W. Clinical Features and Prognostic Risk Factors of Choroid Plexus Tumors in Children. Chin Med J (Engl) 2019; 131:2938-2946. [PMID: 30539906 PMCID: PMC6302644 DOI: 10.4103/0366-6999.247195] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background: Decision-making concerning the treatment of choroid plexus tumor (CPT) in pediatric patients remains a topic of considerable debate. The aim of this work was to describe clinical features and prognostic risk factors of CPT in the pediatric population and to provide theoretical opinions regarding clinical decisions for CPT. Methods: The data of 96 patients with CPT and younger than 14 years were retrospectively analyzed. Clinical characteristics such as pathological type of CPTs, rate and severity of hydrocephalus, treatment and outcome, and recurrence were investigated. For categorical variables, the Pearson's Chi-square test was performed. The Mann–Whitney U-test was used for comparisons between nonnormally distributed parameters. Log-rank test was used for progression-free survival (PFS). Results: The study included 70 choroid plexus papilloma (CPP) cases, 17 atypical choroid plexus papilloma (aCPP) cases, and 9 choroid plexus carcinoma (CPC) cases. Compared with patients with CPP or aCPP, patients with CPC had a shorter disease course (median: CPP, 4 months; aCPP, 2 months; CPC, 1 month; H: 23.5, P < 0.001), higher rate of acute hydrocephalus (CPP, 27.1%; aCPP, 52.9%; CPC, 77.8%; χ2 = 10.9, P < 0.05), and lower incidence of cure rate (CPP, 85.7%; aCPP, 70.5%; CPC, 33.3%; χ2 = 13.5, P < 0.05). The severity of hydrocephalus with tumor in the lateral or third ventricle was significantly higher than that with tumors in the fourth ventricle (severe hydrocephalus: lateral ventricle, 51.7%; third ventricle, 47.0%; fourth ventricle, 11.1%; χ2 = 26.0, P < 0.001). Patients with gross total surgical resection had no better PFS than those with partial resection because of the use of adjuvant therapy in the latter (χ2 = 4.0, P > 0.05). Patients with CPC experienced shorter time for recurrence than those with CPP or aCPP (χ2 = 40.1, P < 0.0001). Conclusions: Our results indicated that CPP in the fourth ventricle could trigger serious clinical symptoms at an early stage, requiring early intervention. Adjuvant treatment might be necessary for patients with partially resected CPP, aCPP, and CPC to achieve a favorable outcome.
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Affiliation(s)
- Wen-Jian-Long Zhou
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050, China
| | - Xi Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050, China
| | - Jia-Yi Peng
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050, China
| | - Shun-Chang Ma
- Department of Neurosurgery, Beijing Neurosurgical Institute, Capital Medical University, Beijing 100050, China
| | - Dai-Nan Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050, China
| | - Xiu-Dong Guan
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050, China
| | - Jin-Fu Diao
- Department of Neurosurgery, Beijing Tiantan Hospital; Department of Neurosurgery, Beijing Neurosurgical Institute, Capital Medical University, Beijing 100050, China
| | - Jian-Xing Niu
- Department of Neurosurgery, Beijing Armed Police General Hospital, Beijing 100000, China
| | - Chun-De Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050, China
| | - Wang Jia
- Department of Neurosurgery, Beijing Tiantan Hospital; Department of Neurosurgery, Beijing Neurosurgical Institute, Capital Medical University, Beijing 100050, China
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Kestle JRW, Lee A, Anderson RCE, Gociman B, Patel KB, Smyth MD, Birgfeld C, Pollack IF, Goldstein JA, Tamber M, Imahiyerobo T, Siddiqi FA. Variation in the management of isolated craniosynostosis: a survey of the Synostosis Research Group. J Neurosurg Pediatr 2018; 22:627-631. [PMID: 30215587 DOI: 10.3171/2018.7.peds18132] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 07/11/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVEThe authors created a collaborative network, the Synostosis Research Group (SynRG), to facilitate multicenter clinical research on craniosynostosis. To identify common and differing practice patterns within the network, they assessed the SynRG surgeons' management preferences for sagittal synostosis. These results will be incorporated into planning cooperative studies.METHODSThe SynRG consists of 12 surgeons at 5 clinical sites. An email survey was distributed to SynRG surgeons in late 2016, and responses were collected through early 2017. Responses were collated and analyzed descriptively.RESULTSAll of the surgeons-7 plastic/craniofacial surgeons and 5 neurosurgeons-completed the survey. They varied in both experience (1-24 years) and sagittal synostosis case volume in the preceding year (5-45 cases). Three sites routinely perform preoperative CT scans. The preferred surgical technique for children younger than 3 months is strip craniectomy (10/12 surgeons), whereas children older than 6 months are all treated with open cranial vault surgery. Pre-incision cefazolin, preoperative complete blood count panels, and an arterial line were used by most surgeons, but tranexamic acid was used routinely at 3 sites and never at the other 2 sites. Among surgeons performing endoscopic strip craniectomy surgery (SCS), most create a 5-cm-wide craniectomy, whereas 2 surgeons create a 2-cm strip. Four surgeons routinely send endoscopic SCS patients to the intensive care unit after surgery. Two of the 5 sites routinely obtain a CT scan within the 1st year after surgery.CONCLUSIONSThe SynRG surgeons vary substantially in the use of imaging, the choice of surgical procedure and technique, and follow-up. A collaborative network will provide the opportunity to study different practice patterns, reduce variation, and contribute multicenter data on the management of children with craniosynostosis.
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Affiliation(s)
- John R W Kestle
- 1Department of Neurosurgery, Division of Pediatric Neurosurgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah; Departments of
| | | | - Richard C E Anderson
- 3Department of Neurological Surgery, Columbia University, Morgan Stanley Children's Hospital of NewYork-Presbyterian, New York, New York
| | - Barbu Gociman
- 4Division of Plastic Surgery and Reconstructive Surgery, University of Utah, Salt Lake City, Utah
| | - Kamlesh B Patel
- 5Division of Plastic and Reconstructive Surgery, Department of Surgery, and
| | - Matthew D Smyth
- 6Department of Neurosurgery, St. Louis Children's Hospital, Washington University School of Medicine in St. Louis, Missouri; Departments of
| | - Craig Birgfeld
- 7Surgery, Division of Plastic Surgery, Seattle Children's Hospital, University of Washington, Seattle, Washington
| | | | - Jesse A Goldstein
- 9Plastic Surgery, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania; and
| | | | - Thomas Imahiyerobo
- 10Division of Plastic Surgery, Columbia University Medical Center, NewYork-Presbyterian Hospital, New York, New York
| | - Faizi A Siddiqi
- 4Division of Plastic Surgery and Reconstructive Surgery, University of Utah, Salt Lake City, Utah
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Kulkarni AV. First Treatment in Infants With Hydrocephalus: The Case for Shunt. Neurosurgery 2018; 63 Suppl 1:73-77. [PMID: 27399367 DOI: 10.1227/neu.0000000000001287] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Abhaya V Kulkarni
- Division of Neurosurgery, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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Xu K, Khine KT, Ooi YC, Quinsey CS. A systematic review of shunt-related extraneural metastases of primary central nervous system tumors. Clin Neurol Neurosurg 2018; 174:239-243. [PMID: 30292900 DOI: 10.1016/j.clineuro.2018.09.038] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 09/24/2018] [Accepted: 09/26/2018] [Indexed: 11/19/2022]
Abstract
Extraneural metastasis (ENM) of primary central nervous system (CNS) tumors is an uncommon occurrence. Case reports and case series describe ENM after shunting, but this phenomenon has not been well characterized. In this review we aim to better understand the risk factors and clinical implications of ENM associated with shunting. A literature search of cases of ENM related to shunt placement in patients with primary CNS tumors reported through January 2018 was performed using PubMed and Google Scholar. We identified 106 cases of ENM of primary CNS tumors related to shunt placement. The three most common tumor histologies resulting in ENM were germinoma (24%), medulloblastoma (21%), and glioblastoma (11%). Of the patients with ENM, 48% had leptomeningeal spread and 37% had brain or spinal cord metastasis. Mean survival time from shunt placement was 13 months. Ventriculoatrial-shunted cases had higher rates of widespread metastasis and shorter average survival time from shunt placement (2 months) than the average of all types of shunts. Given the known association with ENM, careful consideration should be given to shunt placement in patients with primary CNS tumors, especially germinomas, medulloblastomas, and glioblastomas. Appropriate surveillance should be instituted after shunt placement, and leptomeningeal or neural metastasis should prompt the consideration of potential ENM. When considering distal shunt options, our review suggests that ventriculoatrial shunts should be avoided if possible. For truly obstructive pathologies, the risk of ENM is a further indication to consider other treatment options such as endoscopic third ventriculostomy rather than shunt placement.
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Affiliation(s)
- Kali Xu
- University of North Carolina School of Medicine, Chapel Hill, North Carolina, United States
| | - Kay T Khine
- Department of Ophthalmology, Kittner Eye Center, University of North Carolina School of Medicine, Chapel Hill, North Carolina, United States; Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida, United States
| | - Yinn Cher Ooi
- Department of Neurosurgery, David Geffen School of Medicine at the University of California (UCLA), Los Angeles, California, United States
| | - Carolyn S Quinsey
- Department of Neurosurgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina, United States.
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Uche EO, Okorie C, Iloabachie I, Amuta DS, Uche NJ. Endoscopic third ventriculostomy (ETV) and ventriculoperitoneal shunt (VPS) in non-communicating hydrocephalus (NCH): comparison of outcome profiles in Nigerian children. Childs Nerv Syst 2018; 34:1683-1689. [PMID: 29860541 DOI: 10.1007/s00381-018-3848-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 05/21/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND Endoscopic third ventriculostomy (ETV) and ventriculo-peritoneal shunt (VPS) although recognized surgical options for non-communicating hydrocephalus have debatable applications. OBJECTIVE We analysed a prospective cohort of age-matched children with non-tumor, non-communicating hydrocephalus treated with the two surgical modalities using clinically measurable parameters. METHODS A single institution analysis of age-matched patients with non-communicating hydrocephalus treated with VPS or ETV over a 3-year period. Occipitofrontal circumference (OFC), milestone, shunt independence as well as complication profiles of patients were recorded and analysed. Mean follow-up period was 1.27 ± 0.19 years 95%CI). Data analysis were performed using SPSS version 15, Chicago, IL. Statistical tests were set at 95% significance level. RESULTS Fifty-five patients were enrolled, 25 patients had ETV, while 30 had VPS. Mean age was 2.3 ± 0.7 years (95% CI) with a range of 3 months to 4.5 years. Aqueductal stenosis was the most common indication. OFC profile decline was significant among the VPS group when compared with ETV group at 3 months follow-up (χ2 = 7.59, df = 1, p < 0.05). There was no difference among the two treatment groups χ2 = 2.47, df = 1, p > 0.05) in milestone profile. Thirteen percent of VPS, compared to (4%) ETV patients, had sepsis (χ2 = 4.59, df = 1 p < 0.05). Ninety-two percent of ETV patients remained shunt free, while 80% of shunted patients achieved ETV independence. Two patients died among the VPS group compared to one patient in the ETV group. CONCLUSION VPS compared to ETV is associated with an earlier milestone and OFC response. ETV is associated with lower rates of sepsis and mortality.
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Affiliation(s)
- Enoch Ogbonnaya Uche
- Neurosurgery Unit, Department of Surgery, UNTH, University of Nigeria Teaching Hospital, Enugu, 40001, Nigeria.
| | - Chukwuemeka Okorie
- Neurosurgery Unit, Department of Surgery, UNTH, University of Nigeria Teaching Hospital, Enugu, 40001, Nigeria
| | - Izuchukwu Iloabachie
- Neurosurgery Unit, Department of Surgery, UNTH, University of Nigeria Teaching Hospital, Enugu, 40001, Nigeria
| | - Dubem S Amuta
- Neurosurgery Unit, Department of Surgery, UNTH, University of Nigeria Teaching Hospital, Enugu, 40001, Nigeria
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The effect of tumor removal via craniotomies on preoperative hydrocephalus in adult patients with intracranial tumors. Neurosurg Rev 2018; 43:141-151. [PMID: 30120611 DOI: 10.1007/s10143-018-1021-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 07/23/2018] [Accepted: 08/09/2018] [Indexed: 10/28/2022]
Abstract
The efficacy of tumor removal via craniotomies on preoperative hydrocephalus (HC) in adult patients with intracranial tumors is largely unknown. Therefore, we sought to evaluate the effect of tumor resection in patients with preoperative HC and identify the incidence and risk factors for postoperative VP shunt dependency. All craniotomies for intracranial tumors at Oslo University Hospital in patients ≥ 18 years old during a 10-year period (2004-2013) were reviewed. Patients with radiologically confirmed HC requiring surgery and subsequent development of shunt dependency were identified by cross-linking our prospectively collected tumor database to surgical procedure codes for hydrocephalus treatment (AAF). Patients with preexisting ventriculoperitoneal (VP) shunts (N = 41) were excluded. From 4774 craniotomies performed on 4204 patients, a total of 373 patients (7.8%) with HC preoperatively were identified. Median age was 54.4 years (range 18.1-83.9 years). None were lost to follow-up. Of these, 10.5% (39/373) required permanent CSF shunting due to persisting postoperative HC. The risk of becoming VP shunt dependent in patients with preexisting HC was 7.0% (26/373) within 30 days and 8.9% (33/373) within 90 days. Only secondary (repeat) surgery was a significant risk factor for VP shunt dependency. In this large, contemporary, single-institution consecutive series, 10.5% of intracranial tumor patients with preoperative HC became shunt-dependent post-craniotomy, yielding a surgical cure rate for HC of 89.5%. To the best of our knowledge, this is the first and largest study regarding postoperative shunt dependency after craniotomies for intracranial tumors, and can serve as benchmark for future studies.
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Sun T, Yuan Y, Zhang Q, Zhou Y, Li X, Yu H, Tian M, Guan J. Establishing a Preoperative Evaluation System for Lumboperitoneal Shunt: Approach to Attenuate the Risk of Shunt Failure. World Neurosurg 2018; 117:e308-e315. [PMID: 29906581 DOI: 10.1016/j.wneu.2018.06.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2018] [Revised: 06/03/2018] [Accepted: 06/04/2018] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Lumboperitoneal shunt (LPS) has been demonstrated an effective method for the treatment of communicating hydrocephalus in the presence of frequent shunt failure. The objective of the present study was to determine whether establishing a preoperative evaluation system could benefit patients, thus attenuating the risk of LPS failure. METHODS In this 3-year study, treated by LPS, patients undergoing preoperative evaluation were included into the study group and other individuals without preoperative evaluation were included into the control group. Perioperative conditions, including Keifer's hydrocephalus score, symptomatic control rate, Evans index, complications, long-term shunt revision rate, and quality of life, were synchronously investigated. RESULTS A total of 93 eligible patients were included in the study (study group, 51; control group, 42). The baseline characteristics of the 2 groups were basically similar. The results showed that patients in the study group had better short-term improvement in symptoms and imageology, including higher symptomatic control rate (median, 62.5% vs. 50%; P = 0.001), more reduction in Evans index (0.08 ± 0.05 vs. 0.05 ± 0.04; P = 0.002), and lower incidence of postoperative complications (median, 35.3% vs. 57.1%; P = 0.04). Similarly, the incidence of shunt revision in the study group was dramatically lower than in the control group (median, 15.7% vs. 40.9%; P = 0.006) in line with the revision-free curve (P = 0.002), which suggested that most of patients received revision, if needed, within 3 months. In addition, patients in the study group had better quality of life. CONCLUSIONS In conclusion, patients who underwent evaluation before LPS had better short-term and long-term outcomes, suggesting that it would be a promising strategy to correctly select patients for LPS with prolonged favorable shunt outcomes.
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Affiliation(s)
- Tong Sun
- West China School of Medicine, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Yikai Yuan
- West China School of Medicine, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Qiuming Zhang
- West China School of Medicine, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Yicheng Zhou
- West China School of Medicine, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Xuepei Li
- Health Ministry Key Laboratory of Chronobiology, College of Basic Medicine and Forensic Medicine, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Hang Yu
- Health Ministry Key Laboratory of Chronobiology, College of Basic Medicine and Forensic Medicine, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Meng Tian
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Junwen Guan
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China.
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Dewan MC, Lim J, Gannon SR, Heaner D, Davis MC, Vaughn B, Chern JJ, Rocque BG, Klimo P, Wellons JC, Naftel RP. Comparison of hydrocephalus metrics between infants successfully treated with endoscopic third ventriculostomy with choroid plexus cauterization and those treated with a ventriculoperitoneal shunt: a multicenter matched-cohort analysis. J Neurosurg Pediatr 2018; 21:339-345. [PMID: 29393809 DOI: 10.3171/2017.10.peds17421] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE It has been suggested that the treatment of infant hydrocephalus results in different craniometric changes depending upon whether ventriculoperitoneal shunt (VPS) placement or endoscopic third ventriculostomy with choroid plexus cauterization (ETV/CPC) is performed. Without an objective and quantitative description of expected changes to the infant cranium and ventricles following ETV/CPC, asserting successful treatment of hydrocephalus is difficult. By comparing infants successfully treated via ETV/CPC or VPS surgery, the authors of this study aimed to define the expected postoperative cranial and ventricular alterations at the time of clinical follow-up. METHODS Patients who underwent successful treatment of hydrocephalus at 4 institutions with either VPS placement or ETV/CPC were matched in a 3:1 ratio on the basis of age and etiology. Commonly used cranial parameters (including head circumference [HC], HC z-score, fontanelle status, and frontooccipital horn ratio [FOHR]) were compared pre- and postoperatively between treatment cohorts. First, baseline preoperative values were compared to ensure cohort equivalence. Next, postoperative metrics, including the relative change in metrics, were compared between treatment groups using multivariate linear regression. RESULTS Across 4 institutions, 18 ETV/CPC-treated and 54 VPS-treated infants with hydrocephalus were matched and compared at 6 months postoperatively. The most common etiologies of hydrocephalus were myelomeningocele (61%), followed by congenital communicating hydrocephalus (17%), aqueductal stenosis (11%), and intraventricular hemorrhage (6%). The mean age at the time of CSF diversion was similar between ETV/CPC- and VPS-treated patients (3.4 vs 2.9 months; p = 0.69), as were all preoperative cranial hydrocephalus metrics (p > 0.05). Postoperatively, the ventricle size FOHR decreased significantly more following VPS surgery (-0.15) than following ETV/CPC (-0.02) (p < 0.001), yielding a lower postoperative FOHR in the VPS arm (0.42 vs 0.51; p = 0.01). The HC percentile was greater in the ETV/CPC cohort than in the VPS-treated patients (76th vs 54th percentile; p = 0.046). A significant difference in the postoperative z-score was not observed. With both treatment modalities, a bulging fontanelle reliably normalized at last follow-up. CONCLUSIONS Clinical and radiographic parameters following successful treatment of hydrocephalus in infants differed between ETV/CPC and VPS treatment. At 6 months post-ETV/CPC, ventricle size remained unchanged, whereas VPS-treated ventricles decreased to a near-normal FOHR. The HC growth control between the procedures was similar, although the final HC percentile may be lower after VPS. The fontanelle remained a reliable indicator of success for both treatments. This study establishes expected cranial and ventricular parameters following ETV/CPC, which may be used to guide preoperative counseling and postoperative decision making.
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Affiliation(s)
- Michael C Dewan
- 1Department of Neurosurgery, Vanderbilt University, Division of Pediatric Neurosurgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Jaims Lim
- 1Department of Neurosurgery, Vanderbilt University, Division of Pediatric Neurosurgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Stephen R Gannon
- 1Department of Neurosurgery, Vanderbilt University, Division of Pediatric Neurosurgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - David Heaner
- 2Department of Neurosurgery, Children's Healthcare of Atlanta, Georgia
| | - Matthew C Davis
- 3Department of Neurosurgery, University of Alabama at Birmingham, Alabama; and
| | - Brandy Vaughn
- 4Semmes Murphey Clinic.,6Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Joshua J Chern
- 2Department of Neurosurgery, Children's Healthcare of Atlanta, Georgia
| | - Brandon G Rocque
- 3Department of Neurosurgery, University of Alabama at Birmingham, Alabama; and
| | - Paul Klimo
- 4Semmes Murphey Clinic.,6Le Bonheur Children's Hospital, Memphis, Tennessee
| | - John C Wellons
- 1Department of Neurosurgery, Vanderbilt University, Division of Pediatric Neurosurgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Robert P Naftel
- 1Department of Neurosurgery, Vanderbilt University, Division of Pediatric Neurosurgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
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Kulkarni AV, Riva-Cambrin J, Rozzelle CJ, Naftel RP, Alvey JS, Reeder RW, Holubkov R, Browd SR, Cochrane DD, Limbrick DD, Simon TD, Tamber M, Wellons JC, Whitehead WE, Kestle JRW. Endoscopic third ventriculostomy and choroid plexus cauterization in infant hydrocephalus: a prospective study by the Hydrocephalus Clinical Research Network. J Neurosurg Pediatr 2018; 21:214-223. [PMID: 29243972 DOI: 10.3171/2017.8.peds17217] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE High-quality data comparing endoscopic third ventriculostomy (ETV) with choroid plexus cauterization (CPC) to shunt and ETV alone in North America are greatly lacking. To address this, the Hydrocephalus Clinical Research Network (HCRN) conducted a prospective study of ETV+CPC in infants. Here, these prospective data are presented and compared to prospectively collected data from a historical cohort of infants treated with shunt or ETV alone. METHODS From June 2014 to September 2015, infants (corrected age ≤ 24 months) requiring treatment for hydrocephalus with anatomy suitable for ETV+CPC were entered into a prospective study at 9 HCRN centers. The rate of procedural failure (i.e., the need for repeat hydrocephalus surgery, hydrocephalus-related death, or major postoperative neurological deficit) was determined. These data were compared with a cohort of similar infants who were treated with either a shunt (n = 969) or ETV alone (n = 74) by creating matched pairs on the basis of age and etiology. These data were obtained from the existing prospective HCRN Core Data Project. All patients were observed for at least 6 months. RESULTS A total of 118 infants underwent ETV+CPC (median corrected age 1.3 months; common etiologies including myelomeningocele [30.5%], intraventricular hemorrhage of prematurity [22.9%], and aqueductal stenosis [21.2%]). The 6-month success rate was 36%. The most common complications included seizures (5.1%) and CSF leak (3.4%). Important predictors of treatment success in the survival regression model included older age (p = 0.002), smaller preoperative ventricle size (p = 0.009), and greater degree of CPC (p = 0.02). The matching algorithm resulted in 112 matched pairs for ETV+CPC versus shunt alone and 34 matched pairs for ETV+CPC versus ETV alone. ETV+CPC was found to have significantly higher failure rate than shunt placement (p < 0.001). Although ETV+CPC had a similar failure rate compared with ETV alone (p = 0.73), the matched pairs included mostly infants with aqueductal stenosis and miscellaneous other etiologies but very few patients with intraventricular hemorrhage of prematurity. CONCLUSIONS Within a large and broad cohort of North American infants, our data show that overall ETV+CPC appears to have a higher failure rate than shunt alone. Although the ETV+CPC results were similar to ETV alone, this comparison was limited by the small sample size and skewed etiological distribution. Within the ETV+CPC group, greater extent of CPC was associated with treatment success, thereby suggesting that there are subgroups who might benefit from the addition of CPC. Further work will focus on identifying these subgroups.
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Affiliation(s)
- Abhaya V Kulkarni
- 1Division of Neurosurgery, Hospital for Sick Children, University of Toronto, Ontario, Canada
| | - Jay Riva-Cambrin
- 2Section of Neurosurgery, Alberta Children's Hospital, University of Calgary, Alberta, Canada
| | - Curtis J Rozzelle
- 3Department of Neurosurgery, Division of Pediatric Neurosurgery, The University of Alabama at Birmingham and Children's Hospital of Alabama, Birmingham, Alabama
| | - Robert P Naftel
- 4Department of Neurological Surgery, Vanderbilt University, Nashville, Tennessee
| | | | | | | | | | - D Douglas Cochrane
- 1Division of Neurosurgery, Hospital for Sick Children, University of Toronto, Ontario, Canada
| | - David D Limbrick
- 7Department of Neurological Surgery, St. Louis Children's Hospital, St. Louis, Missouri
| | - Tamara D Simon
- 8Department of Pediatrics, Seattle Children's Hospital, Seattle, Washington
| | - Mandeep Tamber
- 9Department of Neurological Surgery, Pittsburgh Children's Hospital, Pittsburgh, Pennsylvania; and
| | - John C Wellons
- 4Department of Neurological Surgery, Vanderbilt University, Nashville, Tennessee
| | | | - John R W Kestle
- 11Department of Neurosurgery, University of Utah, Salt Lake City, Utah
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48
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Kulkarni AV, Schiff SJ, Mbabazi-Kabachelor E, Mugamba J, Ssenyonga P, Donnelly R, Levenbach J, Monga V, Peterson M, MacDonald M, Cherukuri V, Warf BC. Endoscopic Treatment versus Shunting for Infant Hydrocephalus in Uganda. N Engl J Med 2017; 377:2456-2464. [PMID: 29262276 PMCID: PMC5784827 DOI: 10.1056/nejmoa1707568] [Citation(s) in RCA: 94] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Postinfectious hydrocephalus in infants is a major health problem in sub-Saharan Africa. The conventional treatment is ventriculoperitoneal shunting, but surgeons are usually not immediately available to revise shunts when they fail. Endoscopic third ventriculostomy with choroid plexus cauterization (ETV-CPC) is an alternative treatment that is less subject to late failure but is also less likely than shunting to result in a reduction in ventricular size that might facilitate better brain growth and cognitive outcomes. METHODS We conducted a randomized trial to evaluate cognitive outcomes after ETV-CPC versus ventriculoperitoneal shunting in Ugandan infants with postinfectious hydrocephalus. The primary outcome was the Bayley Scales of Infant Development, Third Edition (BSID-3), cognitive scaled score 12 months after surgery (scores range from 1 to 19, with higher scores indicating better performance). The secondary outcomes were BSID-3 motor and language scores, treatment failure (defined as treatment-related death or the need for repeat surgery), and brain volume measured on computed tomography. RESULTS A total of 100 infants were enrolled; 51 were randomly assigned to undergo ETV-CPC, and 49 were assigned to undergo ventriculoperitoneal shunting. The median BSID-3 cognitive scores at 12 months did not differ significantly between the treatment groups (a score of 4 for ETV-CPC and 2 for ventriculoperitoneal shunting; Hodges-Lehmann estimated difference, 0; 95% confidence interval [CI], -2 to 0; P=0.35). There was no significant difference between the ETV-CPC group and the ventriculoperitoneal-shunt group in BSID-3 motor or language scores, rates of treatment failure (35% and 24%, respectively; hazard ratio, 0.7; 95% CI, 0.3 to 1.5; P=0.24), or brain volume (z score, -2.4 and -2.1, respectively; estimated difference, 0.3; 95% CI, -0.3 to 1.0; P=0.12). CONCLUSIONS This single-center study involving Ugandan infants with postinfectious hydrocephalus showed no significant difference between endoscopic ETV-CPC and ventriculoperitoneal shunting with regard to cognitive outcomes at 12 months. (Funded by the National Institutes of Health; ClinicalTrials.gov number, NCT01936272 .).
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Affiliation(s)
- Abhaya V Kulkarni
- From the University of Toronto (A.V.K.) and the Hospital for Sick Children (A.V.K., R.D., J.L.), Toronto; Pennsylvania State University, University Park (S.J.S., V.M., M.P., M.M., V.C.); CURE Children's Hospital of Uganda, Mbale (E.M.-K., J.M., P.S., B.C.W.); and Harvard Medical School and Boston Children's Hospital, Boston (B.C.W.)
| | - Steven J Schiff
- From the University of Toronto (A.V.K.) and the Hospital for Sick Children (A.V.K., R.D., J.L.), Toronto; Pennsylvania State University, University Park (S.J.S., V.M., M.P., M.M., V.C.); CURE Children's Hospital of Uganda, Mbale (E.M.-K., J.M., P.S., B.C.W.); and Harvard Medical School and Boston Children's Hospital, Boston (B.C.W.)
| | - Edith Mbabazi-Kabachelor
- From the University of Toronto (A.V.K.) and the Hospital for Sick Children (A.V.K., R.D., J.L.), Toronto; Pennsylvania State University, University Park (S.J.S., V.M., M.P., M.M., V.C.); CURE Children's Hospital of Uganda, Mbale (E.M.-K., J.M., P.S., B.C.W.); and Harvard Medical School and Boston Children's Hospital, Boston (B.C.W.)
| | - John Mugamba
- From the University of Toronto (A.V.K.) and the Hospital for Sick Children (A.V.K., R.D., J.L.), Toronto; Pennsylvania State University, University Park (S.J.S., V.M., M.P., M.M., V.C.); CURE Children's Hospital of Uganda, Mbale (E.M.-K., J.M., P.S., B.C.W.); and Harvard Medical School and Boston Children's Hospital, Boston (B.C.W.)
| | - Peter Ssenyonga
- From the University of Toronto (A.V.K.) and the Hospital for Sick Children (A.V.K., R.D., J.L.), Toronto; Pennsylvania State University, University Park (S.J.S., V.M., M.P., M.M., V.C.); CURE Children's Hospital of Uganda, Mbale (E.M.-K., J.M., P.S., B.C.W.); and Harvard Medical School and Boston Children's Hospital, Boston (B.C.W.)
| | - Ruth Donnelly
- From the University of Toronto (A.V.K.) and the Hospital for Sick Children (A.V.K., R.D., J.L.), Toronto; Pennsylvania State University, University Park (S.J.S., V.M., M.P., M.M., V.C.); CURE Children's Hospital of Uganda, Mbale (E.M.-K., J.M., P.S., B.C.W.); and Harvard Medical School and Boston Children's Hospital, Boston (B.C.W.)
| | - Jody Levenbach
- From the University of Toronto (A.V.K.) and the Hospital for Sick Children (A.V.K., R.D., J.L.), Toronto; Pennsylvania State University, University Park (S.J.S., V.M., M.P., M.M., V.C.); CURE Children's Hospital of Uganda, Mbale (E.M.-K., J.M., P.S., B.C.W.); and Harvard Medical School and Boston Children's Hospital, Boston (B.C.W.)
| | - Vishal Monga
- From the University of Toronto (A.V.K.) and the Hospital for Sick Children (A.V.K., R.D., J.L.), Toronto; Pennsylvania State University, University Park (S.J.S., V.M., M.P., M.M., V.C.); CURE Children's Hospital of Uganda, Mbale (E.M.-K., J.M., P.S., B.C.W.); and Harvard Medical School and Boston Children's Hospital, Boston (B.C.W.)
| | - Mallory Peterson
- From the University of Toronto (A.V.K.) and the Hospital for Sick Children (A.V.K., R.D., J.L.), Toronto; Pennsylvania State University, University Park (S.J.S., V.M., M.P., M.M., V.C.); CURE Children's Hospital of Uganda, Mbale (E.M.-K., J.M., P.S., B.C.W.); and Harvard Medical School and Boston Children's Hospital, Boston (B.C.W.)
| | - Michael MacDonald
- From the University of Toronto (A.V.K.) and the Hospital for Sick Children (A.V.K., R.D., J.L.), Toronto; Pennsylvania State University, University Park (S.J.S., V.M., M.P., M.M., V.C.); CURE Children's Hospital of Uganda, Mbale (E.M.-K., J.M., P.S., B.C.W.); and Harvard Medical School and Boston Children's Hospital, Boston (B.C.W.)
| | - Venkateswararao Cherukuri
- From the University of Toronto (A.V.K.) and the Hospital for Sick Children (A.V.K., R.D., J.L.), Toronto; Pennsylvania State University, University Park (S.J.S., V.M., M.P., M.M., V.C.); CURE Children's Hospital of Uganda, Mbale (E.M.-K., J.M., P.S., B.C.W.); and Harvard Medical School and Boston Children's Hospital, Boston (B.C.W.)
| | - Benjamin C Warf
- From the University of Toronto (A.V.K.) and the Hospital for Sick Children (A.V.K., R.D., J.L.), Toronto; Pennsylvania State University, University Park (S.J.S., V.M., M.P., M.M., V.C.); CURE Children's Hospital of Uganda, Mbale (E.M.-K., J.M., P.S., B.C.W.); and Harvard Medical School and Boston Children's Hospital, Boston (B.C.W.)
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Madsen PJ, Mallela AN, Hudgins ED, Storm PB, Heuer GG, Stein SC. The effect and evolution of patient selection on outcomes in endoscopic third ventriculostomy for hydrocephalus: A large-scale review of the literature. J Neurol Sci 2017; 385:185-191. [PMID: 29406903 DOI: 10.1016/j.jns.2017.12.025] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 12/14/2017] [Accepted: 12/19/2017] [Indexed: 11/16/2022]
Abstract
Endoscopic third ventriculostomy (ETV) has become a popular technique for the treatment of hydrocephalus, but small sample size has limited the generalizability of prior studies. We performed a large-scale review of all available studies to help eliminate bias and determine how outcomes have changed and been influenced by patient selection over time. A systematic literature search was performed for studies of ETV that contained original, extractable patient data, and a meta-analytic model was generated for correlative and predictive analysis. A total of 130 studies were identified, which included 11,952 cases. Brain tumor or cyst was the most common hydrocephalus etiology, but high-risk etiologies, post-infectious or post-hemorrhagic hydrocephalus, accounted for 18.4%. Post-operative mortality was very low (0.2%) and morbidity was only slightly higher in developing than in industrialized countries. The rate of ETV failure was 34.7% and was higher in the first months and plateaued around 20months. As anticipated, ETV is less successful in high-risk etiologies of hydrocephalus and younger patients. Younger patient age and high-risk etiologies predicted failure. ETVs were performed more often in high-risk etiologies over time, but, surprisingly, there was no overall change in ETV success rate over time. This study should help to influence optimal patient selection and offer guidance in predicting outcomes.
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Affiliation(s)
- Peter J Madsen
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania Silverstein 3rd Floor, 3400 Spruce Street, Philadelphia, PA 19104, USA.
| | - Arka N Mallela
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania Silverstein 3rd Floor, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Eric D Hudgins
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania Silverstein 3rd Floor, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Phillip B Storm
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania Silverstein 3rd Floor, 3400 Spruce Street, Philadelphia, PA 19104, USA; Division of Neurosurgery, Children's Hospital of Philadelphia, Wood Building 6(th) Floor, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Gregory G Heuer
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania Silverstein 3rd Floor, 3400 Spruce Street, Philadelphia, PA 19104, USA; Division of Neurosurgery, Children's Hospital of Philadelphia, Wood Building 6(th) Floor, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Sherman C Stein
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania Silverstein 3rd Floor, 3400 Spruce Street, Philadelphia, PA 19104, USA
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50
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Fallah A, Weil AG, Juraschka K, Ibrahim GM, Wang AC, Crevier L, Tseng CH, Kulkarni AV, Ragheb J, Bhatia S. The importance of extent of choroid plexus cauterization in addition to endoscopic third ventriculostomy for infantile hydrocephalus: a retrospective North American observational study using propensity score-adjusted analysis. J Neurosurg Pediatr 2017; 20:503-510. [PMID: 28984539 DOI: 10.3171/2017.7.peds16379] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVE Combined endoscopic third ventriculostomy (ETC) and choroid plexus cauterization (CPC)-ETV/CPC- is being investigated to increase the rate of shunt independence in infants with hydrocephalus. The degree of CPC necessary to achieve improved rates of shunt independence is currently unknown. METHODS Using data from a single-center, retrospective, observational cohort study involving patients who underwent ETV/CPC for treatment of infantile hydrocephalus, comparative statistical analyses were performed to detect a difference in need for subsequent CSF diversion procedure in patients undergoing partial CPC (describes unilateral CPC or bilateral CPC that only extended from the foramen of Monro [FM] to the atrium on one side) or subtotal CPC (describes CPC extending from the FM to the posterior temporal horn bilaterally) using a rigid neuroendoscope. Propensity scores for extent of CPC were calculated using age and etiology. Propensity scores were used to perform 1) case-matching comparisons and 2) Cox multivariable regression, adjusting for propensity score in the unmatched cohort. Cox multivariable regression adjusting for age and etiology, but not propensity score was also performed as a third statistical technique. RESULTS Eighty-four patients who underwent ETV/CPC had sufficient data to be included in the analysis. Subtotal CPC was performed in 58 patients (69%) and partial CPC in 26 (31%). The ETV/CPC success rates at 6 and 12 months, respectively, were 49% and 41% for patients undergoing subtotal CPC and 35% and 31% for those undergoing partial CPC. Cox multivariate regression in a 48-patient cohort case-matched by propensity score demonstrated no added effect of increased extent of CPC on ETV/CPC survival (HR 0.868, 95% CI 0.422-1.789, p = 0.702). Cox multivariate regression including all patients, with adjustment for propensity score, demonstrated no effect of extent of CPC on ETV/CPC survival (HR 0.845, 95% CI 0.462-1.548, p = 0.586). Cox multivariate regression including all patients, with adjustment for age and etiology, but not propensity score, demonstrated no effect of extent of CPC on ETV/CPC survival (HR 0.908, 95% CI 0.495-1.664, p = 0.755). CONCLUSIONS Using multiple comparative statistical analyses, no difference in need for subsequent CSF diversion procedure was detected between patients in this cohort who underwent partial versus subtotal CPC. Further investigation regarding whether there is truly no difference between partial versus subtotal extent of CPC in larger patient populations and whether further gain in CPC success can be achieved with complete CPC is warranted.
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Affiliation(s)
- Aria Fallah
- 1Department of Neurosurgery, Mattel Children's Hospital, David Geffen School of Medicine at University of California, Los Angeles.,2Brain Research Institute, University of California, Los Angeles
| | - Alexander G Weil
- 3Division of Pediatric Neurosurgery, Department of Surgery, Sainte Justine Hospital, University of Montreal, Quebec; and
| | - Kyle Juraschka
- 4Division of Neurosurgery, The Hospital for Sick Children, University of Toronto, Ontario, Canada
| | - George M Ibrahim
- 4Division of Neurosurgery, The Hospital for Sick Children, University of Toronto, Ontario, Canada
| | - Anthony C Wang
- 1Department of Neurosurgery, Mattel Children's Hospital, David Geffen School of Medicine at University of California, Los Angeles
| | - Louis Crevier
- 3Division of Pediatric Neurosurgery, Department of Surgery, Sainte Justine Hospital, University of Montreal, Quebec; and
| | - Chi-Hong Tseng
- 5Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, California
| | - Abhaya V Kulkarni
- 4Division of Neurosurgery, The Hospital for Sick Children, University of Toronto, Ontario, Canada
| | - John Ragheb
- 6Department of Pediatric Neurosurgery, Nicklaus Children's Hospital, University of Miami, Florida
| | - Sanjiv Bhatia
- 6Department of Pediatric Neurosurgery, Nicklaus Children's Hospital, University of Miami, Florida
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