Long-Term Success of Endoscopic Third Ventriculostomy in the Pediatric Population with Aqueductal Stenosis

OBJECTIVE

To evaluate the long-term success rate of endoscopic third ventriculostomy (ETV) in the treatment of hydrocephalus due to aqueductal stenosis in the pediatric population.

METHODS

Between January 2007 and June 2023, a total of 82 children underwent ETV surgery for hydrocephalus and met the inclusion criteria for our study. The children's medical records were reviewed, and cases requiring additional surgery in the months and years following surgery for ventriculostomy failure were reviewed.

RESULTS

The mean age was 5.35 years. Successful ETV was observed in 74 children with a successful ETV rate of 90%. The median follow-up was 6.75 years (2 months to 15.5 years). Eight children (10%) underwent additional surgery. In 7 cases, additional surgery was performed within 3 months, while in the remaining case; a delayed failure was noted (more than 3 years later). At 6 months and 3 years, the cumulative proportion of children with revision-free survival was 91%, declining slightly to 89% at 5 years.

CONCLUSIONS

ETV is highly effective in treating hydrocephalus in pediatric patients with aqueductal stenosis, with a 91% success rate at 6 months and 3 years. Although the success rate drops slightly to 89% at 5 years, it still demonstrates durability. Late failures are usually characterized by symptoms of increased intracranial pressure. While patients with a confirmed successful ETV at 6 months may be considered for reduced follow-up frequency, it is critical to educate them about the symptoms of intracranial hypertension and the importance of seeking medical attention promptly if such symptoms occur.

Robot-assisted endoscopic third ventriculostomy under intraoperative CT imaging guidance

BACKGROUND

The robot-assisted neurosurgical procedures have recently benefited of the evolution of intraoperative imaging, including mobile CT unit available in the operating room. This facilitated use paved the way to perform more neurosurgical procedures under robotic assistance. Endoscopic third ventriculocisternostomy requires both a safe transcortical trajectory and a smooth manipulation.

METHOD

We describe our technique of robot-assisted endoscopic third ventriculocisternostomy combining robotic assistance and intraoperative CT imaging.

CONCLUSION

Robot-assisted endoscopic third ventriculocisternostomy using modern intraoperative neuroimaging can be easily implemented and prevented erroneous trajectory and abrupt endoscopic movements, reducing surgically induced brain damages.

Endoscopic Third Ventriculostomy Using Penumbra Artemis™ Neuro Evacuation Device: Technical Case Report and Operative Video

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.

Novel concepts in the pathogenesis of hydrocephalus

PURPOSE

Hydrocephalus is a multifactorial neurological disorder and one of the most common neurosurgical conditions characterized by excessive cerebrospinal fluid (CSF) accumulation within the brain's ventricles. It can result in dilatation of the ventricular system caused by the inadequate passage of CSF from its point of production within the ventricles to its point of absorption into the systemic circulation. Recent findings on the genetics and molecular studies of hydrocephalus have the potential to improve treatment and quality of life.

METHODS

Review of literature on the novel studies of the pathogenesis of hydrocephalus.

CONCLUSION

Molecular studies on the pathogenesis of hydrocephalus have provided a means to improve the treatment and follow-up of patients with hydrocephalus.

Endovascular Management of a Basilar Artery Pseudoaneurysm After Iatrogenic Injury During Endoscopic Third Ventriculostomy: Case Report

Endoscopic third ventriculostomy (ETV) is a well-established neurosurgical procedure. However, it carries risks of intraoperative complications, among which major vascular injury is the most dangerous. Reportedly, prominent bleeding during ETV has been noted in <1% of cases. Herein, we describe a case of a 34-year-old woman with occlusive hydrocephalus caused by a quadrigeminal cistern arachnoid cyst, who developed a pseudoaneurysm after injury of the basilar artery apex during ETV. Complete obliteration of the pseudoaneurysm with endovascular balloon-assisted coiling was done on the first postoperative day, and the patient demonstrated gradual recovery, but approximately 4 weeks later, she suffered massive rebleeding, seemingly due to rupture of the weak pseudoaneurysm wall, which resulted in her death. Careful evaluation of sagittal T2-weighted magnetic resonance images before ETV may be invaluable for assessment of the basilar artery position in relation to the third ventricle floor. In addition, use of a blunt surgical instrument (instead of a sharp one or cautery) for fenestration may be safer for prevention of arterial injury. Finally, special care should be applied in cases with an opaque third ventricle floor and inability to visualize the basilar artery during ETV.

Endoscopic third ventriculostomy compared to ventriculoperitoneal shunt as treatment for idiopathic normal pressure hydrocephalus: a systematic review and meta-analysis

BACKGROUND

The accepted treatment for idiopathic normal pressure hydrocephalus (iNPH) is the insertion of a ventriculoperitoneal shunt (VPS). Recently, some studies examined endoscopic third ventriculostomy (ETV) for the treatment of iNPH with controversial results. The aim of this systematic review and meta-analysis was to compare ETV to VPS regarding complications and outcome for the treatment of iNPH.

METHODS

We searched Medline, Embase and Scopus. Due to the scarcity of data, we did not include only randomized controlled trials, but also retro- and prospective studies. The primary outcome was failure of cerebrospinal fluid diversion method. Secondary endpoints were clinical postoperative improvement rate, morbidity and mortality.

RESULTS

Out of 311 screened studies, three were included in the quantitative analysis including one RCT and two retrospective cohort studies. No statistically significant difference concerning failure rate of CSF diversion method (ETV 27.5% vs. VPS 33.2%, RR 1.19, 95% CI [0.69-2.04], p = 0.52) or postoperative improvement was found (68% for ETV vs. 72.8% for VPS, RR 0.81, 95% CI [0.57-1.16], p = 0.26). ETV showed a significantly lower complication rate compared to VPS (7.5% vs. 51.1%, RR 0.25, 95% CI [0.08-0.76], p = 0.02).

CONCLUSION

ETV and VPS did not differ significantly regarding their failure rate for iNPH, while ETV showed a significantly lower complication rate than VPS. However, the data available is scarce with only one RCT investigating this important matter. Further well-designed trials are necessary to investigate the clinical outcome of ETV in iNPH.

TRIAL REGISTRATION NUMBER

PROSPERO (ID: CRD42020199173).

Review of the prevention and treatment of hydrocephalus after aneurysmal subarachnoid hemorrhage

Hydrocephalus following a ruptured aneurysm portends a poor prognosis. Patients have to face the risk of infection and shunt obstruction after shunt surgery, which may require a second procedure and greatly reduce the quality of life for survivors. It is crucial to minimize the incidence of hydrocephalus and reduce cerebrospinal fluid shunt dependency. This article reviews current interventions before and after hydrocephalus formation after aneurysmal subarachnoid hemorrhage, focusing on the relationships between treatment options and the incidence of postoperative hydrocephalus, management of cerebrospinal fluid drainage and shunt dependent hydrocephalus, and advocates the combination of prevention and treatment to develop individualized treatment plans for patients.

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

Objective

The aim of the present study is to evaluate a neurocognitive outcome in patients affected by late-onset idiopathic aqueductal stenosis (LIAS) who underwent endoscopic third ventriculostomy (ETV).

Materials and Methods

A prospective study was conducted between January 2015 and December 2017 in a series of 10 consecutive adult patients referred to the Neurosurgery Department of IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy. All the adult patients admitted with absence of CSF flow through the aqueduct in phase-contrast (PC)—MRI sequences or a turbulence void signal in T2—weighted images in midsagittal thin-slice MR sequences underwent a specific neuroradiological, neurological, and neurocognitive assessment pre- and postoperatively.

Results

All patients affected by gait and sphincter disturbances improved after ETV. Attentive and executive functions as well as visuo-spatial memory and verbal executive functions improved in several patients. Similarly, the affective and behavioral scales improved in almost 50% of the patients. No major complications have been recorded, and no patients required a second surgery for shunt placement.

Conclusion

Endoscopic third ventriculostomy represents a safe and effective surgical procedure for the treatment of LIAS. In addition to neurological improvement, we demonstrated also postoperative neurocognitive improvement mainly in attentive and executive functions, visuo-spatial memory, verbal executive functions, and behavioral and affective domains.

Endoscopic third ventriculostomy for the management of hydrocephalus secondary to posterior fossa tumors: A retrospective study

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.

Endoscopic third ventriculostomy in children with chronic communicating congenital hydrocephalus: a single-center cohort retrospective analysis

OBJECTIVE

The aim of this study was to analyze the role of endoscopic third ventriculostomy (ETV) in the treatment of pediatric chronic communicating congenital hydrocephalus (CCCH).

MATERIAL AND METHODS

This retrospective study comprised a series of 11 children with CCCH treated with ETV. Data were recorded on gender, history, presenting symptoms, age at surgery, complications during surgery, clinical evolution, ETV survival, and follow-up period. Radiological variables including ventricular and cephalic diameters were also recorded to determine a series of ventricular indexes in magnetic resonance imaging (MRI) before and after the ETV procedure. The procedure was considered to be successful when there was clinical stability or improvement accompanied by a reduction in the radiological indexes in the postoperative control images, such that there was no need to place an extrathecal cerebrospinal fluid shunt.

RESULTS

Over a mean follow-up period of 35.8 months (range: 6-108 months) from the ETV procedure, three patients required shunt placement; one of these was due to early failure in an 8-month old girl, the only patient younger than 12 months in our series. The radiological indexes were reduced in all patients except for one of the cases of ETV failure. The mean ETV survival among the successful cases was 32.1 months (range: 6-108 months), whilst that of the failed cases was 16 months (range: 6-108 months).

CONCLUSION

Although studies with larger sample sizes are needed, ETV appears to be a promising option for the treatment of this type of patient with CCCH.

Endoscopic Third Ventriculostomy and Endoscopic Intracranial Cyst Fenestration in an Outpatient Ambulatory Surgery Center Yields Reduced Cost But Equal Efficacy and Safety Compared with Surgery in the Hospital

BACKGROUND

A transition is underway in neurosurgery to perform relatively safe surgeries outpatient, often at ambulatory surgery centers (ASC). We sought to evaluate whether simple intracranial endoscopic procedures such as third ventriculostomy and cyst fenestration can be safely and effectively performed at an ASC, while comparing costs with the hospital.

METHODS

A retrospective chart review was performed for patients who underwent elective intracranial neuroendoscopic (NE) intervention at either a quaternary hospital or an affiliated ASC between August 2014 and September 2017. Groups were compared on length of stay, perioperative and 30-day morbidity, as well as clinical outcome at last follow-up. The total cost for these procedures were compared in relative units between all ASC cases and a small subset of hospital cases.

RESULTS

In total, 16 NE operations performed at the ASC (mean patient age 29.8 years) and 37 at the hospital (mean age 15.4 years) with average length of stay of 3.5 hours and 23.1 hours respectively (P < 0.05). There were no acute complications in either cohort or morbid events requiring hospitalization within 30 days. Surgical success was noted for 75% of the ASC patients and 73% of the hospital cohort. The mean cost of 5 randomly selected hospital operations with same-day discharge and 5 with overnight stay was 3.4 and 4.1 times that of the ASC cohort, respectively (P < 0.05).

CONCLUSIONS

Elective endoscopic third ventriculostomy and other simple NE procedures can be safely and effectively performed at an ASC for appropriate patients with significantly reduced cost compared with the hospital.

Characteristics and management of hydrocephalus in adult patients with cerebellar glioblastoma: lessons from a French nationwide series of 118 cases

The characteristics of hydrocephalus associated with cerebellar glioblastoma (cGB) remain poorly known. The objectives were to describe the occurence of hydrocephalus in a French nationwide series of adult patients with cGB, to identify the characteristics associated with hydrocephalus and to analyze the outcomes associated with the different surgical strategies, in order to propose practical guidelines. Consecutive cases of adult cGB patients prospectively recorded into the French Brain Tumor Database between 2003 and 2017 were screened. Diagnosis was confirmed by a centralized neuropathological review. Among 118 patients with cGB (mean age 55.9 years), 49 patients (41.5%) presented with pre-operative hydrocephalus. Thirteen patients (11.0%) developed acute (n=7) or delayed (n=6) hydrocephalus postoperatively. Compared to patients without hydrocephalus at admission, patients with hydrocephalus were younger (52.0 years vs 58.6 years, p=0.03) and underwent more frequently tumor resection (93.9% vs 73.9%, p=0.006). A total of 40 cerebrospinal-fluid diversion procedures were performed, including 18 endoscopic third ventriculostomies, 12 ventriculoperitoneal shunts and 10 external ventricular drains. The different cerebrospinal-fluid diversion options had comparable functional results and complication rates. Among the 89 patients surgically managed for cGB without prior cerebrospinal-fluid diversion, 7 (7.9%) were long-term shunt-dependant. Hydrocephalus is frequent in patients with cGB and has to be carefully managed in order not to interfere with adjuvant oncological treatments. In case of symptomatic hydrocephalus, a cerebrospinal-fluid diversion is mandatory, especially if surgical resection is not feasible. In case of asymptomatic hydrocephalus, a cerebrospinal-fluid diversion has to be discussed only if surgical resection is not feasible.

Efficacy and safety of flexible versus rigid endoscopic third ventriculostomy in pediatric and adult populations: a systematic review and meta-analysis

Endoscopic third ventriculostomy (ETV) is a well-established surgical procedure for hydrocephalus treatment, but there is sparse evidence on the optimal choice between flexible and rigid approaches. A meta-analysis was conducted to compare efficacy and safety profiles of both techniques in pediatrics and adults. A comprehensive search was conducted on PubMED, EMBASE, and Cochrane until 11/10/2019. Efficacy was evaluated comparing incidence of ETV failure, while safety was defined by the incidence of perioperative complications, intraoperative bleedings, and deaths. Random-effects models were used to pool the incidence. Out of 1365 studies, 46 case series were meta-analyzed, yielding 821 patients who underwent flexible ETV and 2918 who underwent rigid ETV, with an age range of [5 days–87 years]. Although flexible ETV had a higher incidence of failure in adults (flexible: 54%, 95%CI: 22–82% vs rigid: 20%, 95%CI: 22–82%) possibly due to confounding due to etiology in adults treated with flexible, a smaller difference was seen in pediatrics (flexible: 36%, pediatric: 32%). Safety profiles were acceptable for both techniques, with a certain degree of variability for complications (flexible 2%, rigid 18%) and death (flexible 1%, rigid 3%) in pediatrics as well as complications (rigid 9%, flexible 13%), death (flexible 4%, rigid 6%) and intra-operative bleeding events (rigid 6%, flexible 8%) in adults. No clear superiority in efficacy could be depicted between flexible and rigid ETV for hydrocephalus treatment. Safety profiles varied by age but were acceptable for both techniques. Well-designed comparative studies are needed to assess the optimal endoscopic treatment option for hydrocephalus.

Assessment of neurological symptoms in adult hydrocephalus occlusus. A pilot study

BACKGROUND

Comprehensively describe and compare (pre⁄postoperatively) the clinical symptomatology in adult non-communicated hydrocephalus. Associated hydrocephalus signs were analyzed with the idiopathic Normal Pressure Hydrocephalus Scale (iNPH Scale). A standardized clinical scale for non-communicated hydrocephalus is currently not in use.

METHODS

Ten patients with hydrocephalus occlusus (HO) were analyzed. Hydrocephalus signs were examined with the iNPH Scale in gait, neuropsychology, continence, and balance before and three months after treatment with shunt operation or third endoscopic ventriculostomy.

RESULTS

Patients significantly improved in iNPH total score (25.8%) and gait score (35.4%) three months after neurosurgical intervention. Domain scores in neuropsychology, continence, and balance reached statistical trends (p ≤ 0.066). Most clinical symptoms and signs at baseline improved after surgery (dizziness, lapse of concentration, gait instability, and headache).

CONCLUSION

Patients with non-communicated HO also showed classical hydrocephalus symptoms as communicated in iNPH patients. The iNPH Scale allows a structured neurological assessment over the disease's progress and surgical intervention. Further studies with a larger patient samples are necessary to support our results.

Risk of early failure of VP shunts implanted for hydrocephalus after craniotomies for brain tumors in adults

Risks and survival times of ventriculoperitoneal (VP) shunts implanted due to hydrocephalus after craniotomies for brain tumors are largely unknown. The purpose of this study was to determine the overall timing of VP shunting and its failure after craniotomy for brain tumors in adults. The authors also wished to explore risk factors for early VP shunt failure (within 90 days). A population-based consecutive patient cohort of all craniotomies for intracranial tumors leading to VP shunt dependency in adults (> 18 years) from 2004 to 2013 was studied. Patients with pre-existing VP shunts prior to craniotomy were excluded. The survival time of VP shunts, i.e., the shunt longevity, was calculated from the day of shunt insertion post-craniotomy for a brain tumor until the day of shunt revision requiring replacement or removal of the shunt system. Out of 4774 craniotomies, 85 patients became VP shunt-dependent (1.8% of craniotomies). Median time from craniotomy to VP shunting was 1.9 months. Patients with hydrocephalus prior to tumor resection (N = 39) had significantly shorter time to shunt insertion than those without (N = 46) (p < 0.001), but there was no significant difference with respect to early shunt failure. Median time from shunt insertion to shunt failure was 20 days (range 1–35). At 90 days, 17 patients (20%) had confirmed shunt failure. Patient age, sex, tumor location, primary/secondary craniotomy, extra-axial/intra-axial tumor, ventricular entry, post-craniotomy bleeding, and infection did not show statistical significance. The risk of early shunt failure (within 90 days) of shunts after craniotomies for brain tumors was 20%. This study can serve as benchmark for future studies.

CSF Dynamics for Shunt Prognostication and Revision in Normal Pressure Hydrocephalus

BACKGROUND

Despite the quantitative information derived from testing of the CSF circulation, there is still no consensus on what the best approach could be in defining criteria for shunting and predicting response to CSF diversion in normal pressure hydrocephalus (NPH).

OBJECTIVE

We aimed to review the lessons learned from assessment of CSF dynamics in our center and summarize our findings to date. We have focused on reporting the objective perspective of CSF dynamics testing, without further inferences to individual patient management.

DISCUSSION

No single parameter from the CSF infusion study has so far been able to serve as an unquestionable outcome predictor. Resistance to CSF outflow (Rout) is an important biological marker of CSF circulation. It should not, however, be used as a single predictor for improvement after shunting. Testing of CSF dynamics provides information on hydrodynamic properties of the cerebrospinal compartment: the system which is being modified by a shunt. Our experience of nearly 30 years of studying CSF dynamics in patients requiring shunting and/or shunt revision, combined with all the recent progress made in producing evidence on the clinical utility of CSF dynamics, has led to reconsidering the relationship between CSF circulation testing and clinical improvement.

CONCLUSIONS

Despite many open questions and limitations, testing of CSF dynamics provides unique perspectives for the clinician. We have found value in understanding shunt function and potentially shunt response through shunt testing in vivo. In the absence of infusion tests, further methods that provide a clear description of the pre and post-shunting CSF circulation, and potentially cerebral blood flow, should be developed and adapted to the bed-space.

The Third Eye Sees Double: Cohort Study of Clinical Presentation, Histology, Surgical Approaches, and Ophthalmic Outcomes in Pineal Region Germ Cell Tumors

BACKGROUND

Intracranial germ cell tumors (GCTs) predominantly occur in the adolescent and young adult population and are most frequently located at the pineal gland. Tumor masses in the pineal region may cause ophthalmic symptoms due to compression to the midbrain, frequently presenting with Parinaud syndrome and hydrocephalus due to aqueductal compression.

METHODS

We conducted a single-institution cohort study of primary, pineal region GCTs to characterize the clinical presentation, as well as associated ophthalmic and hydrocephalus outcomes.

RESULTS

Fifty-six primary pineal GCTs were identified. Among the 40 isolated pineal region GCTs, 15 were germinomas while 25 were nongerminomatous GCTs. Among 43 cases of hydrocephalus, endoscopic third ventriculostomy was the primary treatment in 27 cases, which was successful in 23 but failed and required additional treatment for the rest. Pineal tumor mass was significantly larger in cases with hydrocephalus compared with those without, and the 20-mm diameter of the tumor was the crucial point for obstructive hydrocephalus. Ophthalmic symptoms were commonly observed at presentation, which included diplopia (74.3%), upward-gaze palsy (69.7%), and Argyll Robertson pupil (40%). These symptoms tended to remain, and the existence of these symptoms at presentation predicted the remaining symptoms in the follow-up.

CONCLUSIONS

Intracranial GCTs presenting with ophthalmic abnormalities appear to be at increased risk of residual posttreatment symptoms, while second-look surgery presents a significant risk factor for the development of new deficits. Hydrocephalus often accompanies pineal region GCTs, and in most cases both cerebrospinal fluid diversion and tissue diagnosis can be successfully achieved via endoscopic third ventriculostomy.

Endoscopic Endonasal Transsphenoidal Approach for Third Ventriculostomy in the Management of Obstructive Hydrocephalus

ABSTRACT

Endoscopic third ventriculostomy (ETV) is a safe and effective method for the management of obstructive hydrocephalus. Traditional approach is a transfrontal trajectory through the foramen of Monro to access and open the third ventricle floor. Though endoscopic endonasal transsphenoidal approach (EETA) for pituitary and skull base tumors has become increasingly popular, no published literature has explored its utility in performing an ETV. Here, the authors reported a successful ETV for obstructive hydrocephalus through the EETA. A 57-year-old male presenting with progressive headache and gait disturbance for 3 months was diagnosed with obstructive hydrocephalus. Brain MRI revealed an obstruction of cerebrospinal fluid (CSF) flow at the cerebral aqueduct and supratentorial hydrocephalus, accompanied with dilatation and downward herniation of the third ventricle floor. Considering the displacement of the third ventricle floor and the indication for surgery, an ETV was successfully performed through the EETA. No postoperative complication was observed. Both radiological and clinical evaluation postoperatively confirmed ETV success with decreased ventricular size, increased CSF flow across the floor of the third ventricle, and improved clinical signs. EETA is a feasible approach for ETV in selected cases of obstructive hydrocephalus. This approach provides a short trajectory to directly visualize and open the Liliequist's membrane and the displaced floor of the third ventricle, while minimizes damage to normal brain tissue. Skull base repair with nasoseptal flap ensures the success rate by preventing postoperative CSF leak and infection.

Success and complication rates of endoscopic third ventriculostomy for tuberculous meningitis: a systematic review and meta-analysis

Because ventriculoperitoneal shunt (VPS) insertion for patients with hydrocephalus from tuberculous meningitis (TBM) can be complicated by shunt infection and malfunction, endoscopic third ventriculostomy (ETV) has been proposed as an alternative. The aim of this review was to determine the success, technical failure, and complication rates of ETV in TBM in a meta-analysis and determine which factors are predictive of outcome. The PubMed, Scopus, and CENTRAL databases were searched from inception to April 2020 for case series, cohort studies, or randomized controlled trials reporting success, technical failure, or complication rates. For studies with individual patient data available, logistic regression analysis was done to determine whether age, sex, clinical grade, and type of hydrocephalus on imaging was predictive of outcome. Eight studies with a total of 174 patients were included in the review. Using random-effects modeling, the pooled estimate of success rate was 59% (95% CI 50-68%), with low heterogeneity (I² = 30%). The technical failure and complication rates were 5% and 15%, respectively, but these variables had moderate heterogeneity. In 36 patients with individual patient data, a non-communicating type of hydrocephalus on imaging was associated with an odds ratio of 5.90 (95% CI 1.1-32.9, p = 0.043) for success. In summary, ETV for TBM had a pooled success rate of 59%, technical failure rate of 5%, and complication rate of 15%. An imaging finding of non-communicating hydrocephalus was associated with increased success. High-quality randomized, prospective studies using VPS insertion as control are needed to further define the role of ETV in TBM.

Predicting endoscopic third ventriculostomy success in adult hydrocephalus: preliminary assessment of a modified ETV success score for adults (ETVSS-A) in a series of 47 patients

BACKGROUND

Endoscopic third ventriculostomy is an established treatment for noncommunicating hydrocephalus. In carefully selected patients, it can be adopted for the management of communicating variant; however controversy exists in regards to the definition of the appropriate candidates. Predictive score of Endoscopic Third Ventriculostomy Success (ETVSS) has been reported for pediatric and mixed populations only. Our purpose was to define a ETV success score for adult population (ETVSS-A), measuring the strength of correlation between preoperative score retrospectively evaluated and the success rates achieved in a class of adult patients.

METHODS

A retrospective analysis of 47 cases which received ETV procedure at our Institution between 2015 and 2018 was run. Demographic data,clinical history,preoperative and postoperative signs were reviewed and ETVSS-A was calculated. Thereafter ETVSS-A results were compared with the actual success rates.

RESULTS

29 patients(61,7%) presented unchanged or improvedclinical status with a mean ETVSS-A of 54.5%;18 patients(38,3%) worsened with mean ETVSS-A of 37,7%. We found that age,type of hydrocephalus and symptoms of admission are each apart important factors in predicting ETV success:older patients and those with non-obstructive hydrocephalus had the lowest predicted ETV success. In patients in whom ETV was actually successful, the pre-operative ETVSS-A was significantly higher as compared to those patients in whom we observed a poor surgical outcome.

CONCLUSIONS

From the results of this series, though small and retrospectively analyzed, it seems that ETVSS-A can be considered as a useful instrument to help neurosurgeon in predicting the ETV success and though define a more accurate surgical strategy in cases of hydrocephalus. Wider series and prospective studies are attended to validate these preliminary results.

The 50 most cited publications in endoscopic third ventriculostomy: a bibliometric analysis

OBJECTIVEAlthough endoscopic third ventriculostomy (ETV) for the treatment of hydrocephalus was introduced in 1923, the method was relegated to the sidelines in favor of extracranial techniques. Since the 1990s to the beginning of the current century, however, ETV has undergone a remarkable resurgence to become the first-line treatment for obstructive hydrocephalus, and for some groups, the procedure has been applied for communicating hydrocephalus as well. In the present study, the authors identified the top 50 cited ETV works. These articles represent works of significance that document current practices and provide guidance for future inquiry.METHODSThe top 50 cited articles pertaining to ETV were identified using bibliometric data obtained with the Harzing's Publish or Perish software search engine. These high-impact works were evaluated for publication properties including year, country of authorship, category, and journal.RESULTSThe top 50 works were cited an average of 141.02 times with a mean of 9.45 citations per year. Articles published in 2005 were the most numerous in the top 50 group. These top articles were most frequently published in the Journal of Neurosurgery: Pediatrics. Most of the articles were clinical studies reporting on patients in the pediatric age group. The country of most authorship was the US, although many other countries were among the top 50 works.CONCLUSIONSThe present report discusses the bibliometric analysis of the top 50 ETV articles. This list may be useful to those interested in the progress and current status of this procedure.

Natural History of Endoscopic Third Ventriculostomy in Adults: Serial Evaluation with High-Resolution CISS

BACKGROUND AND PURPOSE

Endoscopic third ventriculostomy is a well-accepted treatment choice for hydrocephalus and is used most frequently with a known impediment to CSF flow between the third ventricle and basal cisterns. However, there are scarce data on the imaging evolution of the defect in the floor of the third ventricle and how this affects patency rates and clinical outcomes. The purpose of this study was to assess whether, and how, the endoscopic third ventriculostomy defect changes in size with time.

MATERIALS AND METHODS

All high-resolution endoscopic third ventriculostomy protocol MRIs performed between 2009 through 2014 were retrospectively identified. Two fellowship-trained neuroradiologists, blinded to clinical information, independently reviewed all retrospective cases.

RESULTS

A total of 98 imaging studies were included from 34 patients. The average change in the area throughout the studied period was 0.02 mm²/day (7.5 mm²/year), with a higher increase in size noted in the first 3 postsurgical months, with a gradual decrease in the degree of defect-size change. Use of the NICO Myriad device was correlated with the area of the endoscopic third ventriculostomy defect on the last follow-up, demonstrating a larger final defect size in patients in whom the surgical technique included debridement of the endoscopic third ventriculostomy defect walls with the NICO Myriad device (28.21 versus 11.25 mm, P < .05).

CONCLUSIONS

High-resolution MR imaging with sagittal CISS images is useful in the postoperative evaluation of endoscopic third ventriculostomies. Such findings may prove useful in determining the optimal duration of follow-up with MR imaging of patients who have undergone endoscopic third ventriculostomy.

Frequency and treatment of hydrocephalus prior to and after posterior fossa tumor surgery in adult patients

BACKGROUND

There is paucity of information about the frequency of hydrocephalus prior to and after posterior fossa tumor surgery in adult patients and about the best way it should be managed. The present study was conducted to determine the frequency of hydrocephalus prior to and after posterior fossa tumor surgery in adult patients as well as the value of an endoscopic third ventriculostomy (ETV) prior to posterior fossa tumor surgery with regard to the rate of perioperative complications and persistent hydrocephalus.

METHODS

A single-institution retrospective chart review of all posterior fossa tumor surgeries of our department in a 10-year period (2005 to 2014) has been done.

RESULTS

Fifty-two of 243 adult patients with posterior fossa tumors presented with hydrocephalus at the time of admission prior to tumor surgery. 39/52 received early tumor surgery, 11/52 an ETV prior to tumor surgery and in 2/52 an external ventricular drainage (EVD) was inserted prior to tumor surgery. 3/52 patients required a permanent cerebrospinal fluid (CSF) diverting procedure for persistent hydrocephalus after tumor removal. One hundred ninety-one patients did not demonstrate a hydrocephalus before surgical treatment and four of them developed a post-resection hydrocephalus.

CONCLUSION

The frequency of hydrocephalus prior to posterior fossa tumor surgery in adult patients is 21.4% and therefore much lower than in respective reports of pediatric patients. The risk of persistent hydrocephalus and newly developed hydrocephalus after tumor surgery was very low, too (5.7 and 2.1%, respectively). An ETV is not justified in every adult patient prior to posterior fossa tumor surgery.

Endoscopic third ventriculostomy and repeat endoscopic third ventriculostomy in pediatric patients: the Dutch experience

OBJECTIVE After endoscopic third ventriculostomy (ETV), some patients develop recurrent symptoms of hydrocephalus. The optimal treatment for these patients is not clear: repeat ETV (re-ETV) or CSF shunting. The goals of the study were to assess the effectiveness of re-ETV relative to initial ETV in pediatric patients and validate the ETV success score (ETVSS) for re-ETV. METHODS Retrospective data of 624 ETV and 93 re-ETV procedures were collected from 6 neurosurgical centers in the Netherlands (1998-2015). Multivariable Cox proportional hazards modeling was used to provide an adjusted estimate of the hazard ratio for re-ETV failure relative to ETV failure. The correlation coefficient between ETVSS and the chance of re-ETV success was calculated using Kendall's tau coefficient. Model discrimination was quantified using the c-statistic. The effects of intraoperative findings and management on re-ETV success were also analyzed. RESULTS The hazard ratio for re-ETV failure relative to ETV failure was 1.23 (95% CI 0.90-1.69; p = 0.20). At 6 months, the success rates for both ETV and re-ETV were 68%. ETVSS was significantly related to the chances of re-ETV success (τ = 0.37; 95% bias corrected and accelerated CI 0.21-0.52; p < 0.001). The c-statistic was 0.74 (95% CI 0.64-0.85). The presence of prepontine arachnoid membranes and use of an external ventricular drain (EVD) were negatively associated with treatment success, with ORs of 4.0 (95% CI 1.5-10.5) and 9.7 (95% CI 3.4-27.8), respectively. CONCLUSIONS Re-ETV seems to be as safe and effective as initial ETV. ETVSS adequately predicts the chance of successful re-ETV. The presence of prepontine arachnoid membranes and the use of EVD negatively influence the chance of success.

Failure of ETV in patients with the highest ETV success scores

OBJECTIVE Endoscopic third ventriculostomy (ETV) is a surgical alternative to placing a CSF shunt in certain patients with hydrocephalus. The ETV Success Score (ETVSS) is a reliable, simple method to estimate the success of the procedure by 6 months of postoperative follow-up. The highest score is 90, estimating a 90% chance of the ETV effectively treating hydrocephalus without requiring a shunt. Treatment with ETV fails in certain patients, despite their being the theoretically best candidates for the procedure. In this study the authors attempted to identify factors that further predicted success in patients with the highest ETVSSs. METHODS A retrospective review was performed of all patients treated with ETV at 3 institutions. Demographic, radiological, and clinical data were recorded. All patients by definition were older than 1 year, had obstructive hydrocephalus, and did not have a prior shunt. Failure of ETV was defined as the need for a shunt by 1 year. The ETV was considered a success if the patient did not require another surgery (either shunt placement or a repeat endoscopic procedure) by 1 year. A statistical analysis was performed to identify factors associated with success or failure. RESULTS Fifty-nine patients met the entry criteria for the study. Eleven patients (18.6%) required further surgery by 1 year. All of these patients received a shunt. The presenting symptom of lethargy statistically correlated with success (p = 0.0126, odds ratio [OR] = 0.072). The preoperative radiological finding of transependymal flow (p = 0.0375, OR 0.158) correlated with success. A postoperative larger maximum width of the third ventricle correlated with failure (p = 0.0265). CONCLUSIONS The preoperative findings of lethargy and transependymal flow statistically correlated with success. This suggests that the best candidates for ETV are those with a relatively acute elevation of intracranial pressure. Cases without these findings may represent the failures in this highly selected group.

Endoscopic management of a low-grade thalamic glioma: a safe alternative to open microsurgery?

BACKGROUND

Despite considerable advances in preoperative and intraoperative imaging and neuronavigation, resection of thalamic gliomas remains challenging. Although both endoscopic biopsy and third ventriculostomy (ETV) for the treatment of secondary hydrocephalus are commonly performed, endoscopic resection of thalamic gliomas has been very sparsely described.

METHOD

We report and illustrate the surgical procedure and patient's outcome after full endoscopic resection of a thalamic glioma and to discuss this approach as an alternative to open microsurgery.

RESULTS

In 2016, a 56-year-old woman presented with disorientation, dysphasia and right facial hypaesthesia in our department. Cranial magnetic resonance imaging revealed a left thalamic lesion and subsequent hydrocephalus. Initially, hydrocephalus was treated by ETV but forceps biopsy was not diagnostic. However, metabolism in ¹⁸F-fluoroethyl-L-tyrosine positron emission tomography indicated glioma. Subsequently, endoscopic and neuronavigation-guided tumour resection was performed using a <1 cm², trans-sulcal approach through the left posterior horn of the lateral ventricle. While visibility was poor using the intraoperative microscope, neuroendoscopy provided excellent visualisation and allowed safe tumour debulking. Neither haemorrhage from the tumour or collapse of the cavity compromised endoscopic resection.

CONCLUSIONS

In accordance with one previously published case of endoscopic resection of a thalamic glioma, no surgery-related complications were observed. Although this remains to be determined in larger series, endoscopic resection of these lesions might be a safe and feasible alternative to biopsy or open surgery. Future studies should also aim to identify patients specifically eligible for these approaches.

Prevention of Complications in Endoscopic Third Ventriculostomy

A variety of complications in endoscopic third ventriculostomy have been reported, including neurovascular injury, hemodynamic alterations, endocrinologic abnormalities, electrolyte imbalances, cerebrospinal fluid leakage, fever and infection. Even though most complications are transient, the overall rate of permanent morbidity is 2.38% and the overall mortality rate is 0.28%. To avoid these serious complications, we should keep in mind potential complications and how to prevent them. Proper decisions with regard to surgical indication, choice of endoscopic entry and trajectory, careful endoscopic procedures with anatomic orientation, bleeding control and tight closure are emphasized for the prevention of complications.

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

OBJECTIVE The efficacy of endoscopic third ventriculostomy (ETV) for the treatment of pediatric hydrocephalus has been extensively reported in the literature. However, ETV-related long-term outcome data are lacking for the adult hydrocephalus population. The objective of the present study was to assess the role of ETV as a primary or secondary treatment for hydrocephalus in adults. METHODS The authors performed a retrospective chart review of all adult patients (age ≥ 18 years) with symptomatic hydrocephalus treated with ETV in Calgary, Canada, over a span of 20 years (1994-2014). Patients were dichotomized into a primary or secondary ETV cohort based on whether ETV was the initial treatment modality for the hydrocephalus or if other CSF diversion procedures had been previously attempted respectively. Primary outcomes were subjective patient-reported clinical improvement within 12 weeks of surgery and the need for any CSF diversion procedures after the initial ETV during the span of the study. Categorical and actuarial data analysis was done to compare the outcomes of the primary versus secondary ETV cohorts. RESULTS A total of 163 adult patients with symptomatic hydrocephalus treated with ETV were identified and followed over an average of 98.6 months (range 0.1-230.4 months). All patients presented with signs of intracranial hypertension or other neurological symptoms. The primary ETV group consisted of 112 patients, and the secondary ETV consisted of 51 patients who presented with failed ventriculoperitoneal (VP) shunts. After the initial ETV procedure, clinical improvement was reported more frequently by patients in the primary cohort (87%) relative to those in the secondary ETV cohort (65%, p = 0.001). Additionally, patients in the primary ETV group required fewer reoperations (p < 0.001), with cumulative ETV survival time favoring this primary ETV cohort over the course of the follow-up period (p < 0.001). Fifteen patients required repeat ETV, with all but one experiencing successful relief of symptoms. Patients in the secondary ETV cohort also had a higher incidence of complications, with one occurring in 8 patients (16%) compared with 2 in the primary ETV group (2%; p = 0.010), although most complications were minor. CONCLUSIONS ETV is an effective long-term treatment for selected adult patients with hydrocephalus. The overall ETV success rate when it was the primary treatment modality for adult hydrocephalus was approximately 87%, and 99% of patients experience symptomatic improvement after 2 ETVs. Patients in whom VP shunt surgery fails prior to an ETV have a 22% relative risk of ETV failure and an almost eightfold complication rate, although mostly minor, when compared with patients who undergo a primary ETV. Most ETV failures occur within the first 7 months of surgery in patients treated with primary ETV, but the time to failure is more prolonged in patients who present with failed previous shunts.

Spontaneous subarachnoid haemorrhage

Subarachnoid haemorrhage is an uncommon and severe subtype of stroke affecting patients at a mean age of 55 years, leading to loss of many years of productive life. The rupture of an intracranial aneurysm is the underlining cause in 85% of cases. Survival from aneurysmal subarachnoid haemorrhage has increased by 17% in the past few decades, probably because of better diagnosis, early aneurysm repair, prescription of nimodipine, and advanced intensive care support. Nevertheless, survivors commonly have cognitive impairments, which in turn affect patients' daily functionality, working capacity, and quality of life. Additionally, those deficits are frequently accompanied by mood disorders, fatigue, and sleep disturbances. Management requires specialised neurological intensive care units and multidisciplinary clinical expertise, which is better provided in high-volume centres. Many clinical trials have been done, but only two interventions are shown to improve outcome. Challenges that remain relate to prevention of subarachnoid haemorrhage by improved screening and development of lower-risk methods to repair or stabilise aneurysms that have not yet ruptured. Multicentre cooperative efforts might increase the knowledge that can be gained from clinical trials, which is often limited by small studies with differing criteria and endpoints that are done in single centres. Outcome assessments that incorporate finer assessment of neurocognitive function and validated surrogate imaging or biomarkers for outcome could also help to advance the specialty.

Fourth Ventricle Outlet Obstruction with Expanding Space on the Surface of Cerebellum

BACKGROUND

Hydrocephalus is classified as noncommunicating and communicating based on whether all ventricular and subarachnoid spaces are communicating. Although the diagnosis between the two different states is crucial, it is difficult in certain conditions. In particular, communicating hydrocephalus and noncommunicating hydrocephalus owing to fourth ventricle outlet obstruction are highly misdiagnosed. We describe a case of fourth ventricle outlet obstruction of unknown origin that was initially misdiagnosed as communicating hydrocephalus.

CASE DESCRIPTION

A 66-year-old woman with gait disturbance and incontinence caused by hydrocephalus underwent ventriculoperitoneal shunt surgery. After 9 months, her fourth ventricle became enlarged and could not be controlled by lowering the shunt pressure. Magnetic resonance imaging (MRI) demonstrated obstruction at the foramen of Magendie, foramina of Luschka, and the cerebral aqueduct. Endoscopic surgery for aqueduct plasty with third ventriculostomy was planned. Because the aqueduct was observed to open spontaneously, only the standard third ventriculostomy was performed. When MRI findings were reviewed retrospectively, an unnatural space was observed between the lower cranial nerves and cerebellar hemisphere that grew along with the fourth ventricular enlargement. This space was determined by MRI cisternography to be the cystic membrane ballooning out from the foramen of Luschka. The primary hydrocephalus likely resulted from fourth ventricle outlet obstruction.

CONCLUSIONS

Enlargement of the whole ventricular system with an expanded space between the lower cranial nerves and cerebellar hemisphere can be caused by fourth ventricle outlet obstruction. In such cases, preoperative evaluation of anatomic architecture and cerebrospinal fluid obstruction using MRI cisternography is essential and leads to a successful endoscopic strategy.

Long-Term Follow-Up of Repeat Endoscopic Third Ventriculostomy in Obstructive Hydrocephalus

OBJECTIVE

Endoscopic third ventriculostomy (ETV) is a safe and less-invasive treatment strategy for patients with obstructive hydrocephalus and provides excellent outcome. Nevertheless, repeat ETV in cases of ETV failure is a controversial issue.

METHODS

Between 1993 and 1999, 113 patients underwent a total of 126 ETVs at the Department of Neurosurgery, Mainz University Hospital. Obstructive hydrocephalus was the causative pathology in all cases. A very long-term follow-up of up to 16 years could be achieved. All medical reports of patients who received ETV were reviewed and analyzed with focus on ETV failure with following repeat ETV and its initial as well as very long-term success.

RESULTS

Thirty-one events of ETV failure occurred during the follow-up period. Thirteen patients underwent repeat ETV: 3 patients during the first 3 months (early repeat ETV), the other 10 patients after 7-78 months (late repeat ETV, mean 33 months). All repeat ETV were performed without complications. Follow-up evaluation after successful repeat ETV ranged from <1 month up to 14 years (mean 7 years). Of the 3 early revisions, 2 failed and 1 other patient died during follow-up whereas only 2 of the late repeat ETV failed. Very long-term success rate of late repeat ETV up to 14 years yielded 80%.

CONCLUSIONS

Repeat ETV in cases of late ETV failures represents an excellent option for cerebrospinal fluid circulation restoration up to 14 years of follow-up. Repeat ETV in early ETV failure in contrast is not favored by the performing surgeons; and factors of ETV failure should be analyzed very carefully before a decision for repeat ETV is made.

Surgical management of arrested hydrocephalus: Case report, literature review, and 18-month follow-up

OBJECTIVE

Arrested hydrocephalus is stable ventriculomegaly without evidence of neurologic deterioration or symptoms. Management of arrested hydrocephalus in asymptomatic adults is controversial, with little clinical data. This case highlights the potential for decompensation in adults with arrested hydrocephalus and reviews the literature regarding pathophysiology and management of this clinical entity.

PATIENTS AND METHODS

A 39 year-old gentleman with arrested hydrocephalus incidentally found during work-up for new-onset seizure and managed conservatively for ten years presented with increasing headache, memory loss, gait instability and urinary and fecal incontinence. Stable massive triventriculomegaly was documented on serial brain imaging, and ophthalmologic exam revealed no papilledema.

RESULTS

The patient underwent endoscopic third ventriculostomy with immediate post-operative improvement of headache, resolution of incontinence, and cessation of seizures. At 15 months after surgery, neuropsychiatric testing demonstrated improvement in visuomotor skills, problem solving, verbal fluency and cognitive flexibility compared to his pre-operative baseline. At 18 months after surgery he remained seizure free with full continence and significant improvement in headaches.

CONCLUSION

Early recognition of arrested hydrocephalus and its potential for decompensation may prompt surgical treatment and prevent neurologic deterioration.

Evaluation of Ventriculoperitoneal Shunt-Related Complications in Intracranial Meningioma with Hydrocephalus

Objective Meningioma is a common intracranial tumor that predisposes patients to hydrocephalus which may require a permanent cerebrospinal fluid (CSF) diversion procedure such as ventriculoperitoneal (VP) shunts. We reviewed our long-term experience with VP shunts for the management of hydrocephalus in patients with meningioma. Methods and Materials A total of 48 Patients with meningioma who underwent VP shunt insertion for hydrocephalus from 1990 to 2013 was included in our case series. The study population was evaluated clinically and radiographically after VP shunt placement. Results Overall shunt failure was seen in 13 (27%) patients. Single and multiple shunt revisions were required in eight (16.7%) and five (10.4%) patients, respectively. The overall shunt revision within 6 months, 1 , and 5 years was 19, 23, and 27%, respectively. Male patient was significantly associated with the longer survival after shunt placement. Revisions free survival after 3, 5, 10, and 15 years of VP shunt placement were 70, 46, 30, and 20%, respectively. Finally, in regression analysis, age greater than 65 years (p = 0.02, 95% confidence interval (CI) = 0.1-0.13), tumor in posterior fossa (p < 0.0001, 95% CI = 0.1-0.23), tumor size (> 5 cm) (p = 0.3, 95% CI = 0.01-0.19), and Simpson resection grades II to IV (p = 0.04, 95% CI = 0.07-0.2) were identified as positive predictors of requirement of CSF flow diversion Conclusion The findings of the present study reveal that VP shunting is an important treatment option for the management of hydrocephalus in patients with meningioma. Further studies using less invasive techniques are warranted to compare the benefits of VP shunt for the management of hydrocephalus.