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Kahle KT, Klinge PM, Koschnitzky JE, Kulkarni AV, MacAulay N, Robinson S, Schiff SJ, Strahle JM. Paediatric hydrocephalus. Nat Rev Dis Primers 2024; 10:35. [PMID: 38755194 DOI: 10.1038/s41572-024-00519-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/11/2024] [Indexed: 05/18/2024]
Abstract
Hydrocephalus is classically considered as a failure of cerebrospinal fluid (CSF) homeostasis that results in the active expansion of the cerebral ventricles. Infants with hydrocephalus can present with progressive increases in head circumference whereas older children often present with signs and symptoms of elevated intracranial pressure. Congenital hydrocephalus is present at or near birth and some cases have been linked to gene mutations that disrupt brain morphogenesis and alter the biomechanics of the CSF-brain interface. Acquired hydrocephalus can develop at any time after birth, is often caused by central nervous system infection or haemorrhage and has been associated with blockage of CSF pathways and inflammation-dependent dysregulation of CSF secretion and clearance. Treatments for hydrocephalus mainly include surgical CSF shunting or endoscopic third ventriculostomy with or without choroid plexus cauterization. In utero treatment of fetal hydrocephalus is possible via surgical closure of associated neural tube defects. Long-term outcomes for children with hydrocephalus vary widely and depend on intrinsic (genetic) and extrinsic factors. Advances in genomics, brain imaging and other technologies are beginning to refine the definition of hydrocephalus, increase precision of prognostication and identify nonsurgical treatment strategies.
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Affiliation(s)
- Kristopher T Kahle
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
- Broad Institute of Harvard and MIT, Cambridge, MA, USA.
- Department of Neurosurgery and Division of Genetics and Genomics, Boston Children's Hospital, Boston, MA, USA.
| | - Petra M Klinge
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Jenna E Koschnitzky
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Abhaya V Kulkarni
- Division of Paediatric Neurosurgery, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Nanna MacAulay
- Department of Neuroscience, University of Copenhagen, Copenhagen, Denmark
| | - Shenandoah Robinson
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Paediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Steven J Schiff
- Department of Neurosurgery, Yale University, New Haven, CT, USA
- Department of Epidemiology of Microbial Diseases, Yale University, New Haven, CT, USA
| | - Jennifer M Strahle
- Department of Neurosurgery, Washington University School of Medicine, Saint Louis, MO, USA
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Sohail A, Bajwa MH, Virani QUA, Tariq A, Hussain N, Shamim SM. Is endoscopic third ventriculostomy a viable treatment option for normal pressure hydrocephalus? A systematic review. Surg Neurol Int 2024; 15:154. [PMID: 38840608 PMCID: PMC11152536 DOI: 10.25259/sni_127_2024] [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: 02/21/2024] [Accepted: 04/22/2024] [Indexed: 06/07/2024] Open
Abstract
Background Endoscopic third ventriculostomy (ETV) is considered an alternative treatment for hydrocephalus and has become a standard of care for obstructive hydrocephalus. Recent studies have also explored its role in normal pressure hydrocephalus (NPH). We conducted a systematic review aiming to assess the outcomes of this minimally invasive endoscopic technique as a viable treatment option for NPH. Methods A systematic literature search was performed using PubMed and Scopus databases, using iterations of search terms "Endoscopic third ventriculostomy," "Idiopathic normal pressure hydrocephalus," and "Normal pressure hydrocephalus." To be eligible for inclusion in the review, articles had to report the usage of ETV as a primary treatment modality for NPH, report its outcomes, and be published in the English language. Results Out of the 13 studies selected for qualitative synthesis, nine supported the use of ETV for NPH as an effective treatment option with improvement in the preoperative symptoms. Two studies favored shunt over ETV, stating that quality of life is better with VP shunt insertion. One study reported that ETV has higher perioperative mortality rates that outweigh its benefits. One study reported it to be an ineffective surgical option. Conclusion The current review of evidence does not support the use of ETV for the treatment of NPH, except perhaps in a small subset of patients. These patients have a shorter duration of symptoms and a better preoperative neurological status. The lumbar infusion test and ventricular infusion test are modalities useful for selecting these candidates.
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Affiliation(s)
| | | | | | | | | | - Shahzad M. Shamim
- Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan
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3
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The effect of shunt removal on the quality of life in patients with congenital hydrocephalus. Childs Nerv Syst 2023; 39:1261-1266. [PMID: 36637471 DOI: 10.1007/s00381-023-05835-1] [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: 11/23/2022] [Accepted: 01/06/2023] [Indexed: 01/14/2023]
Abstract
BACKGROUND Although there have been reports investigating the quality of life of patients who underwent ventriculoperitoneal shunting or endoscopic third ventriculostomy (ETV) for congenital hydrocephalus, there have been no studies of the quality of life of patients after ventriculoperitoneal shunt (VPS) removal. In the present study, a survey of pediatric and congenital hydrocephalus patients was conducted to compare the quality of life of patients with a remaining VPS with that of patients who had the shunt removed. METHODS Between February 2020 and November 2021, an outpatient survey was administered to patients 8 years of age and older who had undergone VPS due to a diagnosis of congenital hydrocephalus. The Hydrocephalus Outcome Questionnaire (HOQ) was used to assess the quality of life for this study. The HOQ scores (overall health score, physical health score, cognitive health score, and social-emotional health score) were compared among three groups: a VPS-remaining group, VPS-removed with endoscopic third ventriculostomy (ETV) group, and VPS-removed without ETV group. RESULTS The total number of patients who underwent VPS for hydrocephalus was 71, with 47 in the VPS-remaining group, 14 in the shunt-removed with ETV group, and 10 in the shunt-removed without ETV group. The HOQ overall health score was 0.68 for the VPS-remaining group, 0.74 for the shunt-removed with ETV group, and 0.74 for the shunt-removed without ETV. There were no significant differences between the VPS-remaining group and the VPS-removed with or without ETV groups (p = 0.3255, 0.4178, respectively). CONCLUSION There was no significant difference in the quality of life between patients with a remaining VPS and those who had their VPS removed with or without ETV.
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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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Long-term quality of life after ETV or ETV with consecutive VP shunt placement in hydrocephalic pediatric patients. Childs Nerv Syst 2022; 38:1885-1894. [PMID: 35790573 PMCID: PMC9522746 DOI: 10.1007/s00381-022-05590-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 06/16/2022] [Indexed: 11/05/2022]
Abstract
PURPOSE Endoscopic third ventriculostomy (ETV) and ventriculoperitoneal shunting are well-established treatments of obstructive hydrocephalus (HCP) in adult and pediatric patients. However, there is a lack of data with regard to the quality of life (QoL) of these patients during long-term follow-up METHODS: Inclusion criteria were pediatric patients with endoscopic treatment of hydrocephalus at the University Medicine Greifswald between 1993 and 2016. Patients older than 14 years at present were assessed with the Short Form-12 (SF-12) questionnaire. Patients younger than 14 years of age were assessed with the KINDL-R questionnaire that was completed by their parents. Patients' values were compared with the scores of a corresponding age-matched group of the healthy population and with patients who received later shunt treatment. Information about comorbidities, current symptoms, and educational level were gained by an additional part. Comparative analysis between patients with ETV success and failure (defined as shunt implantation after ETV) was performed. RESULTS A total of 107 patients (53 m, 54f) were included. Fifty-seven/107 patients (53.3%) were considered as ETV success. Mean age at ETV was 6.9 ± 5.9 years. Fifty-four statements of 89 patients that are still alive were gained (response rate 63%). Of these, 49 questionnaires were complete and evaluable (23 m, 26f; mean age 19.8 ± 10.0 years with an average follow-up period of 13.7 ± 7.2 years). Twenty-six/49 patients (53.1%) are considered ETV success. No statistically significant differences could be obtained between patients with ETV success and ETV failure. Patients older 14 years show QoL within normal range, patients younger than 14 years show significantly lower result regarding their environment of peers and social contacts. Patients younger than 6 months at the time of ETV and patients with posthemorrhagic HCP show significantly lower physical QoL. Gait disturbance, fatigue, and seizures are associated with a lower QoL, and educational level is lower than in the normal population. CONCLUSIONS Patients who underwent ETV in childhood do not have a lower health-related QoL in general. Subsequent insertions of ventriculoperitoneal (vp) shunts do not lower QoL. Certain subgroups of the patients show lower results compared to the healthy population.
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Rowen D, Keetharuth AD, Poku E, Wong R, Pennington B, Wailoo A. A Review of the Psychometric Performance of Selected Child and Adolescent Preference-Based Measures Used to Produce Utilities for Child and Adolescent Health. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2021; 24:443-460. [PMID: 33641779 DOI: 10.1016/j.jval.2020.09.012] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 09/08/2020] [Accepted: 09/25/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVE This review examined the psychometric performance of 4 generic child- and adolescent-specific preference-based measures that can be used to produce utilities for child and adolescent health. METHODS A systematic search was undertaken to identify studies reporting the psychometric performance of the Child Health Utility (CHU9D), EQ-5D-Y (3L or 5L), and Health Utilities Index Mark 2 (HUI2) or Mark 3 (HUI3) in children and/or adolescents. Data were extracted to assess known-group validity, convergent validity, responsiveness, reliability, acceptability, and feasibility. Data were extracted separately for the dimensions and utility index where this was reported. RESULTS The review included 76 studies (CHU9D n = 12, EQ-5D-Y-3L n = 20, HUI2 n = 26,HUI3 n = 43), which varied considerably across conditions and sample size. EQ-5D-Y-3L had the largest amount of evidence of good psychometric performance in proportion to the number of studies examining performance. The majority of the evidence related to EQ-5D-Y-3L was based on dimensions. CHU9D was assessed in fewer studies, but the majority of studies found evidence of good psychometric performance. Evidence for HUI2 and HUI3 was more mixed, but the studies were more limited in sample size and statistical power, which was likely to have affected performance. CONCLUSIONS The heterogeneity of published studies means that the evidence is based on studies across a range of countries, populations and conditions, using different study designs, different languages, different value sets and different statistical techniques. Evidence for CHU9D in particular is based on a limited number of studies. The findings raise concerns about the comparability of self-report and proxy-report responses to generate utility values for children and adolescents.
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Affiliation(s)
- Donna Rowen
- School of Health and Related Research, University of Sheffield, Sheffield, England, UK.
| | - Anju D Keetharuth
- School of Health and Related Research, University of Sheffield, Sheffield, England, UK
| | - Edith Poku
- School of Health and Related Research, University of Sheffield, Sheffield, England, UK
| | - Ruth Wong
- School of Health and Related Research, University of Sheffield, Sheffield, England, UK
| | - Becky Pennington
- School of Health and Related Research, University of Sheffield, Sheffield, England, UK
| | - Allan Wailoo
- School of Health and Related Research, University of Sheffield, Sheffield, England, UK
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Ros-Sanjuán Á, Iglesias-Moroño S, Ros-López B, Rius-Díaz F, Delgado-Babiano A, Arráez-Sánchez MÁ. Quality of life in children with hydrocephalus treated with endoscopic third ventriculostomy. J Neurosurg Pediatr 2021; 27:503-510. [PMID: 33607611 DOI: 10.3171/2020.8.peds20384] [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: 05/08/2020] [Accepted: 08/27/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The objectives of this study were to determine the quality of life of a pediatric cohort with hydrocephalus treated by endoscopic third ventriculostomy (ETV), using the Hydrocephalus Outcome Questionnaire-Spanish version (HOQ-Sv), and study the clinical and radiological factors associated with a better or worse functional status. METHODS This cross-sectional study was undertaken between September 2018 and December 2019. It comprised a series of 40 patients ranging from 5 to 18 years old with hydrocephalus treated by ETV. ETV was considered to be successful if there was no need for surgery for the treatment of hydrocephalus after a minimum follow-up of 6 months. The clinical variables included gender, age at hydrocephalus diagnosis, age at the time of ETV, age at completion of the questionnaire, etiology and type of hydrocephalus (communicating or not), prior shunt, repeat ETV, number of neurosurgical procedures, number of epileptic seizures, presenting signs, and follow-up duration until last office revision. The radiological variables were the Evans Index and the pre- and posttreatment frontooccipital horn ratio. An analysis was conducted of the association between all these variables and the various dimensions on the HOQ-Sv, completed by the parents of the patients via telephone or in the outpatient offices. RESULTS The mean age of the children at ETV was 7 years (range 7-194 months), and on completing the questionnaire was 12 years (range 60-216 months). The mean HOQ scores were as follows: overall 0.82, physical domain 0.86, social-emotional (SE) domain 0.84, cognitive domain 0.75, and utility score 0.90. A history of epileptic crises was a predictive factor for a worse score overall and in the SE and cognitive domains. Factors related to a worse score in the physical domain were a previous shunt, the number of procedures, and the etiology and type of hydrocephalus. The mean follow-up duration from ETV to the last office visit was 5 years (64.5 months). No association was found between the degree of ventricular reduction and the quality of life. CONCLUSIONS The factors related to a worse score in the different dimensions of the HOQ were a history of epileptic seizures, the number of procedures, communicating hydrocephalus, and having had a previous valve. No association was found between the reduction in ventricular size and the quality of life as measured on the HOQ-Sv.
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8
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Reynolds RA, Dixon M, Gannon S, Zhao S, Bonfield CM, Naftel RP, Wellons JC, Shannon CN. The interaction between parental concern and socioeconomic status in pediatric hydrocephalus management. J Neurosurg Pediatr 2020; 27:16-22. [PMID: 33035994 DOI: 10.3171/2020.6.peds20191] [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: 03/17/2020] [Accepted: 06/08/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Parent or guardian involvement is implicit in the care of pediatric patients with hydrocephalus. Some parents and guardians are more engaged than others. The relationship between socioeconomic status (SES), the level of parental concern about their child's hydrocephalus management and future, and overall health status has not been clearly delineated. In this study, the authors sought to clarify this connection using hydrocephalus patient-reported health outcomes. METHODS This cross-sectional study included children with surgically managed hydrocephalus whose parent or guardian completed the validated Hydrocephalus Outcome Questionnaire (HOQ) and Hydrocephalus Concern Questionnaire for parents (HCQ-P) on a return visit to the pediatric neurosurgery clinic at Vanderbilt University Medical Center between 2016 and 2018. Patients were excluded if the questionnaires were not completed in full. The calculated Overall Health Score (OHS) was used to represent the child's global physical, emotional, cognitive, and social health. The HCQ-P was used to assess parental concern about their child. Type of insurance was a proxy for SES. RESULTS The HOQ and HCQ-P were administered and completed in full by 170 patient families. In the cohort, 91% of patients (n = 155) had shunt-treated hydrocephalus, and the remaining patients had undergone endoscopic third ventriculostomy. The mean (± SD) patient age was 12 ± 4 years. Half of the patients were male (n = 90, 53%), and most were Caucasian (n = 134, 79%). One in four patients lived in single-parent homes or with a designated guardian (n = 45, 26%). Public insurance and self-pay accounted for 38% of patients (n = 64), while the remaining 62% had private or military insurance. In general, parents with higher concern about their child's medical condition indicated that their son or daughter had a higher OHS (χ2 = 17.07, p < 0.001). Patients in families with a lower SES did not have different OHSs from those with a higher SES (χ2 = 3.53, p = 0.06). However, parents with a lower SES were more worried about management of their child's hydrocephalus and their child's future success (χ2 = 11.49, p < 0.001). In general, parents were not preoccupied with one particular aspect of their child's hydrocephalus management. CONCLUSIONS More engaged parents, regardless of their family's SES, reported a better OHS for their child. Parents with public or self-paid insurance were more likely to report higher concern about their child's hydrocephalus and future, but this was not associated with a difference in their child's current health status.
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Affiliation(s)
- Rebecca A Reynolds
- 1Department of Neurological Surgery, Division of Pediatric Neurosurgery, and.,2Surgical Outcomes Center for Kids (SOCKs), Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Makayla Dixon
- 2Surgical Outcomes Center for Kids (SOCKs), Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, Tennessee
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- 2Surgical Outcomes Center for Kids (SOCKs), Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Shilin Zhao
- 3Department of Biostatistics, Vanderbilt University Medical Center; and
| | - Christopher M Bonfield
- 1Department of Neurological Surgery, Division of Pediatric Neurosurgery, and.,2Surgical Outcomes Center for Kids (SOCKs), Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Robert P Naftel
- 1Department of Neurological Surgery, Division of Pediatric Neurosurgery, and.,2Surgical Outcomes Center for Kids (SOCKs), Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, Tennessee
| | - John C Wellons
- 1Department of Neurological Surgery, Division of Pediatric Neurosurgery, and.,2Surgical Outcomes Center for Kids (SOCKs), Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Chevis N Shannon
- 1Department of Neurological Surgery, Division of Pediatric Neurosurgery, and.,2Surgical Outcomes Center for Kids (SOCKs), Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, Tennessee
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International Infant Hydrocephalus Study (IIHS): 5-year health outcome results of a prospective, multicenter comparison of endoscopic third ventriculostomy (ETV) and shunt for infant hydrocephalus. Childs Nerv Syst 2018; 34:2391-2397. [PMID: 29987375 DOI: 10.1007/s00381-018-3896-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Accepted: 06/29/2018] [Indexed: 10/28/2022]
Abstract
INTRODUCTION One of the most important unanswered questions in pediatric hydrocephalus is determining whether treatment with endoscopic third ventriculostomy (ETV) versus shunt results in improved health status and quality of life (QOL). To answer this, the International Infant Hydrocephalus Study (IIHS) was started in 2005 as a prospective, multicenter study to compare ETV and shunt in infants (< 24 months old) with symptomatic triventricular hydrocephalus from aqueductal stenosis. Herein, we present the 5-year primary outcome results. METHODS IIHS utilized a prospective comprehensive cohort design, in which patients received ETV or shunt, based on either randomization or parental preference. For this analysis, we pooled the randomized arm and the parental preference arm, analyzing them together. At 5 years of age, children were assessed with the Health Utilities Index Mark 2 (HUI-2) (primary outcome) and the Hydrocephalus Outcome Questionnaire (HOQ), a measure of QOL. Results were compared in an analysis of covariance, adjusting for baseline variables including age at surgery and baseline development status. RESULTS From a total of 158 patients who met eligibility criteria, complete 5-year outcomes were available on 78 (19 treated initially with shunt, 61 treated initially with ETV), assessed at a mean age of 62.1 months (SD 6.3). The mean 5-year HUI-2 utility score was 0.90 (SD 0.19) for ETV and 0.94 (SD 0.10) for shunt (p = 0.21). The mean 5-year HOQ overall score was 0.81 (SD 0.15) for ETV and 0.85 (SD 0.12) for shunt (p = 0.42). Similarly, there were no significant differences noted between 5-year HOQ subscores (cognitive, social-emotional, physical) or developmental measures at 1, 2, and 3 years. CONCLUSIONS This is the first prospective direct comparison of long-term outcomes of ETV and shunt for infant hydrocephalus. These results suggest that overall health status and quality of life in this cohort of infants treated for aqueductal stenosis are high, with no significant difference between those treated initially with ETV or shunt. TRIAL REGISTRATION NCT00652470.
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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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Hong S, Hirokawa D, Usami K, Ogiwara H. The long-term outcomes of endoscopic third ventriculostomy in pediatric hydrocephalus, with an emphasis on future intellectual development and shunt dependency. J Neurosurg Pediatr 2018; 23:104-108. [PMID: 30497212 DOI: 10.3171/2018.7.peds18220] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Accepted: 07/10/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVEThe goal of this study was to clarify the long-term outcome of endoscopic third ventriculostomy (ETV) in pediatric hydrocephalus in light of the ETV Success Score (ETVSS), shunt dependency, and intellectual development.METHODSThe authors retrospectively analyzed pediatric patients with hydrocephalus who underwent ETV between 2002 and 2012 and who were followed for longer than 5 years as a single-center cohort. The data of the patients' pre- and postoperative status were collected. The relationships between ETVSS and the full-scale IQ as well as shunt dependency were analyzed. The usefulness of ETVSS for repeat ETV and the change of radiological parameters of ventricle size before and after ETV were also analyzed. The success of ETV was defined as no requirement for further CSF diversion procedures.RESULTSFifty ETVs were performed in 40 patients. The average ETVSS was 61 and the success rate at 6 months was 64%. The mean follow-up was 9.9 years (5.2-15.3 years), and the long-term success rate of ETV was 50%. The Kaplan-Meier survival curve continued to show a statistically significant difference among patients with a low, moderate, and high ETVSS, even after 6 months (p = 0.002). After 15 months from the initial ETV, no patients required additional CSF diversion surgery. There was no statistical significance between ETVSS and the long-term full-scale IQ or shunt dependency (p = 0.34 and 0.12, respectively). The radiological improvement in ventricle size was not associated with better future educational outcome.CONCLUSIONSThe ETVSS was correlated with the long-term success rate. After 15 months from the initial ETV, no patients required an additional CSF diversion procedure. The ETVSS was not considered to be correlated with long-term intellectual status.
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Karmur BS, Kulkarni AV. Medical and socioeconomic predictors of quality of life in myelomeningocele patients with shunted hydrocephalus. Childs Nerv Syst 2018; 34:741-747. [PMID: 29249073 DOI: 10.1007/s00381-017-3691-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Accepted: 12/04/2017] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Children with myelomeningocele (MMC) often develop hydrocephalus, and the combination of these conditions can lead to psychosocial, cognitive, and physical health issues that decrease their health-related quality of life (HRQOL). The goal of the present study was to understand the QOL in patients with MMC and shunted hydrocephalus. METHODS Data from the Toronto Hydrocephalus QOL Database was acquired between 2004 and 2009 using parent-completed questionnaires and, when appropriate, child-completed questionnaires: Hydrocephalus Outcome Questionnaire (HOQ) and the Health Utilities Index. We identified several medical and socioeconomic factors potentially relevant to the outcome measure (e.g., level of myelomeningocele, length of stay in hospital, and shunt-related hospital admissions; family functioning, income, parental education, employment status, etc.). Linear regression models were used to examine associations between potential predictor variables and HRQOL, with P < 0.05 in the multivariate model suggesting significance. RESULTS The analysis consisted of 131 patients (mean age = 12.6, SD = 3.7). The mean HUI score was 0.51, and the mean HOQ overall health score was 0.67. There was a significant association between lower age and higher HOQ social-emotional health (P = 0.03) and HUI scores (P = 0.03), lower anatomical level of myelomeningocele and higher HUI scores (P = 0.01), better family functioning and higher HOQ overall health scores (P = 0.004), and higher family income and higher HOQ overall health, physical health, and HUI scores (P = 0.001, P = 0.003, and P = 0.02, respectively). CONCLUSION Myelomeningocele patients with shunted hydrocephalus can have a poor health-related quality of life. Our results indicate a strong association of income and family functioning on quality of life, along with younger age and lower level of myelomeningocele.
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Affiliation(s)
- Brij S Karmur
- Division of Neurosurgery, Hospital for Sick Children, Faculty of Medicine, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Abhaya V Kulkarni
- Division of Neurosurgery, Hospital for Sick Children, Faculty of Medicine, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.
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Perdaens O, Koerts G, Nassogne MC. Hydrocephalus in children under the age of five from diagnosis to short-/medium-/long-term progression: a retrospective review of 142 children. Acta Neurol Belg 2018; 118:97-103. [PMID: 29435827 DOI: 10.1007/s13760-018-0888-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 01/22/2018] [Indexed: 11/24/2022]
Abstract
The aim of this study is to evaluate the clinical history and prognosis of children with early-onset hydrocephalus. The retrospective study's inclusion criteria were hydrocephalus diagnosis before the age of 5 years, independent of aetiology, and birth details, January 1, 2000 to December 31, 2014. Overall, 142 children were entered into the study, divided into 11 aetiological groups: premature-birth post-intraventricular haemorrhage (16%), brain tumours (16%), spina bifida (15%), aqueductal stenosis (8%), post-meningitis (8%), post-haemorrhage (8%), Dandy-Walker malformation (6%), unknown origin (6%), arachnoid cyst (5%), miscellaneous obstruction (4%), and various causes (8%). In total, 23 patients died, primarily from the tumour group. Ventriculostomy, performed 42 times, was successful in 20 patients. Overall, 226 internal shunts were placed in 99 children. Infectious complications affected 19% of children after shunt placement and 51% after mechanical complications. Mean follow-up was 4 years 10 months, with 61% of children progressing fairly well, especially those with aqueductal stenosis, cysts, and unknown or diverse obstructive causes. Post-meningitis hydrocephalus displayed the poorest outcome. Isolated obstructive hydrocephalus exhibited better prognosis, with most obstructive aetiologies effectively treated via ventriculostomy. Children treated by shunt placement were more at risk of complications. Aetiologies with associated abnormalities and neurological sequelae had poorer outcomes.
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Affiliation(s)
- Océane Perdaens
- Service de Neurologie Pédiatrique, Université catholique de Louvain, Cliniques universitaires Saint-Luc, Avenue Hippocrate 10/1062, B-1200, Brussels, Belgium
| | - Guus Koerts
- Service de Neurologie Pédiatrique, Université catholique de Louvain, Cliniques universitaires Saint-Luc, Avenue Hippocrate 10/1062, B-1200, Brussels, Belgium
| | - Marie-Cécile Nassogne
- Service de Neurologie Pédiatrique, Université catholique de Louvain, Cliniques universitaires Saint-Luc, Avenue Hippocrate 10/1062, B-1200, Brussels, Belgium.
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14
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Iglesias S, Ros B, Martín Á, Carrasco A, Rius F, Arráez MÁ. Functional outcome in pediatric hydrocephalus: results of applying the Spanish version of the Hydrocephalus Outcome Questionnaire. J Neurosurg Pediatr 2018; 21:224-235. [PMID: 29303455 DOI: 10.3171/2017.8.peds16700] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The aims of the study were to assess whether the Spanish version of the Hydrocephalus Outcome Questionnaire (HOQ) could be useful for the evaluation and comparison of outcomes in the patients in the authors' region with those in patients in other institutions and to analyze predictors of functional outcome in patients with a shunt. METHODS The authors performed this cross-sectional study between March 2015 and April 2016. All the parents of a pediatric patient with hydrocephalus who attended the Hospital Regional Universitario de Málaga neurosurgery outpatient clinic were invited to enroll in the study and complete the HOQ-Spanish version. Age at diagnosis and at the time of the study, clinical data, shunt complications, and socioeconomic factors were also recorded. A descriptive analysis was performed, and independent variables related to the HOQ scores were studied. RESULTS A total of 132 patients participated in the study (100% participation rate). The mean ages were 16.74 months (range 0-142 months) at diagnosis and 10.45 years (range 5-16 years) at the time of the study. The mean overall HOQ score was 0.68 (on a scale from 0 [worse] to 1.0 [best]). Factors related to a worse quality of life were seizures, motor or visual impairment, shunt infection, need for shunt revision, need for more than 2 shunt revisions (range 0-8 revisions), symptomatic overdrainage, and older age at the time of the study. CONCLUSIONS The HOQ-Spanish version is useful in the authors' region; the dimension scores found in this study were comparable to those previously reported by referral centers. Future goals should be to prevent shunt complications, routinely get children to reach functional status, and refer patients for adjuvant therapy promptly.
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Affiliation(s)
- Sara Iglesias
- 1Neurosurgery Department, Hospital Regional Universitario de Málaga; and
| | - Bienvenido Ros
- 1Neurosurgery Department, Hospital Regional Universitario de Málaga; and
| | - Álvaro Martín
- 1Neurosurgery Department, Hospital Regional Universitario de Málaga; and
| | - Antonio Carrasco
- 1Neurosurgery Department, Hospital Regional Universitario de Málaga; and
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15
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Breimer GE, Dammers R, Woerdeman PA, Buis DR, Delye H, Brusse-Keizer M, Hoving EW. Endoscopic third ventriculostomy and repeat endoscopic third ventriculostomy in pediatric patients: the Dutch experience. J Neurosurg Pediatr 2017; 20:314-323. [PMID: 28708018 DOI: 10.3171/2017.4.peds16669] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVE After endoscopic third ventriculostomy (ETV), some patients develop recurrent symptoms of hydrocephalus. The optimal treatment for these patients is not clear: repeat ETV (re-ETV) or CSF shunting. The goals of the study were to assess the effectiveness of re-ETV relative to initial ETV in pediatric patients and validate the ETV success score (ETVSS) for re-ETV. METHODS Retrospective data of 624 ETV and 93 re-ETV procedures were collected from 6 neurosurgical centers in the Netherlands (1998-2015). Multivariable Cox proportional hazards modeling was used to provide an adjusted estimate of the hazard ratio for re-ETV failure relative to ETV failure. The correlation coefficient between ETVSS and the chance of re-ETV success was calculated using Kendall's tau coefficient. Model discrimination was quantified using the c-statistic. The effects of intraoperative findings and management on re-ETV success were also analyzed. RESULTS The hazard ratio for re-ETV failure relative to ETV failure was 1.23 (95% CI 0.90-1.69; p = 0.20). At 6 months, the success rates for both ETV and re-ETV were 68%. ETVSS was significantly related to the chances of re-ETV success (τ = 0.37; 95% bias corrected and accelerated CI 0.21-0.52; p < 0.001). The c-statistic was 0.74 (95% CI 0.64-0.85). The presence of prepontine arachnoid membranes and use of an external ventricular drain (EVD) were negatively associated with treatment success, with ORs of 4.0 (95% CI 1.5-10.5) and 9.7 (95% CI 3.4-27.8), respectively. CONCLUSIONS Re-ETV seems to be as safe and effective as initial ETV. ETVSS adequately predicts the chance of successful re-ETV. The presence of prepontine arachnoid membranes and the use of EVD negatively influence the chance of success.
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Affiliation(s)
- Gerben E Breimer
- Department of Neurosurgery, University Medical Center Groningen.,Departments of 2 Pathology and
| | - Ruben Dammers
- Department of Neurosurgery, Erasmus MC, Sophia Children's Hospital, Rotterdam
| | - Peter A Woerdeman
- Department of Neurosurgery, Rudolf Magnus Institute of Neuroscience, University Medical Center, Utrecht
| | - Dennis R Buis
- Neurosurgery, Academic Medical Center Amsterdam.,Department of Neurosurgery, VU University Medical Center, Neurosurgical Center Amsterdam
| | - Hans Delye
- Department of Neurosurgery, Radboud University Nijmegen Medical Centre, Nijmegen; and
| | | | - Eelco W Hoving
- Department of Neurosurgery, University Medical Center Groningen
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16
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Gianaris TJ, Nazar R, Middlebrook E, Gonda DD, Jea A, Fulkerson DH. Failure of ETV in patients with the highest ETV success scores. J Neurosurg Pediatr 2017; 20:225-231. [PMID: 28686122 DOI: 10.3171/2016.7.peds1655] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- Thomas J Gianaris
- Department of Neurological Surgery, Division of Pediatric Neurosurgery, Goodman Campbell Brain and Spine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Ryan Nazar
- Department of Neurosurgery, University of Louisville, Kentucky
| | - Emily Middlebrook
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas; and
| | - David D Gonda
- Division of Neurosurgery, University of California at San Diego, Rady Children's Hospital, San Diego, California
| | - Andrew Jea
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas; and
| | - Daniel H Fulkerson
- Department of Neurological Surgery, Division of Pediatric Neurosurgery, Goodman Campbell Brain and Spine, Indiana University School of Medicine, Indianapolis, Indiana
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Isaacs AM, Bezchlibnyk YB, Yong H, Koshy D, Urbaneja G, Hader WJ, Hamilton MG. Endoscopic third ventriculostomy for treatment of adult hydrocephalus: long-term follow-up of 163 patients. Neurosurg Focus 2017; 41:E3. [PMID: 27581315 DOI: 10.3171/2016.6.focus16193] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The efficacy of endoscopic third ventriculostomy (ETV) for the treatment of pediatric hydrocephalus has been extensively reported in the literature. However, ETV-related long-term outcome data are lacking for the adult hydrocephalus population. The objective of the present study was to assess the role of ETV as a primary or secondary treatment for hydrocephalus in adults. METHODS The authors performed a retrospective chart review of all adult patients (age ≥ 18 years) with symptomatic hydrocephalus treated with ETV in Calgary, Canada, over a span of 20 years (1994-2014). Patients were dichotomized into a primary or secondary ETV cohort based on whether ETV was the initial treatment modality for the hydrocephalus or if other CSF diversion procedures had been previously attempted respectively. Primary outcomes were subjective patient-reported clinical improvement within 12 weeks of surgery and the need for any CSF diversion procedures after the initial ETV during the span of the study. Categorical and actuarial data analysis was done to compare the outcomes of the primary versus secondary ETV cohorts. RESULTS A total of 163 adult patients with symptomatic hydrocephalus treated with ETV were identified and followed over an average of 98.6 months (range 0.1-230.4 months). All patients presented with signs of intracranial hypertension or other neurological symptoms. The primary ETV group consisted of 112 patients, and the secondary ETV consisted of 51 patients who presented with failed ventriculoperitoneal (VP) shunts. After the initial ETV procedure, clinical improvement was reported more frequently by patients in the primary cohort (87%) relative to those in the secondary ETV cohort (65%, p = 0.001). Additionally, patients in the primary ETV group required fewer reoperations (p < 0.001), with cumulative ETV survival time favoring this primary ETV cohort over the course of the follow-up period (p < 0.001). Fifteen patients required repeat ETV, with all but one experiencing successful relief of symptoms. Patients in the secondary ETV cohort also had a higher incidence of complications, with one occurring in 8 patients (16%) compared with 2 in the primary ETV group (2%; p = 0.010), although most complications were minor. CONCLUSIONS ETV is an effective long-term treatment for selected adult patients with hydrocephalus. The overall ETV success rate when it was the primary treatment modality for adult hydrocephalus was approximately 87%, and 99% of patients experience symptomatic improvement after 2 ETVs. Patients in whom VP shunt surgery fails prior to an ETV have a 22% relative risk of ETV failure and an almost eightfold complication rate, although mostly minor, when compared with patients who undergo a primary ETV. Most ETV failures occur within the first 7 months of surgery in patients treated with primary ETV, but the time to failure is more prolonged in patients who present with failed previous shunts.
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Affiliation(s)
- Albert M Isaacs
- Division of Neurosurgery, Department of Clinical Neuroscience
| | | | - Heather Yong
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Geberth Urbaneja
- Adult Hydrocephalus Program, Department of Clinical Neuroscience
| | - Walter J Hader
- Division of Neurosurgery, Department of Clinical Neuroscience;,Pediatric Neurosurgery Program, Department of Clinical Neuroscience, University of Calgary, Alberta; and
| | - Mark G Hamilton
- Adult Hydrocephalus Program, Department of Clinical Neuroscience;,Division of Neurosurgery, Department of Clinical Neuroscience;,Pediatric Neurosurgery Program, Department of Clinical Neuroscience, University of Calgary, Alberta; and
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18
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Weil AG, Westwick H, Wang S, Alotaibi NM, Elkaim L, Ibrahim GM, Wang AC, Ariani RT, Crevier L, Myers B, Fallah A. Efficacy and safety of endoscopic third ventriculostomy and choroid plexus cauterization for infantile hydrocephalus: a systematic review and meta-analysis. Childs Nerv Syst 2016; 32:2119-2131. [PMID: 27613635 DOI: 10.1007/s00381-016-3236-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Accepted: 08/30/2016] [Indexed: 11/25/2022]
Abstract
PURPOSE Endoscopic third ventriculostomy/choroid plexus cauterization (ETV/CPC) has gained popularity in its treatment of infantile hydrocephalus over the past decade. In this manuscript, we perform a systematic review and meta-analysis to determine the efficacy and safety of ETV/CPC, and to compare the procedural outcomes between North American and sub-Saharan African cohorts. METHODS Systematic review was performed using four electronic databases and bibliographies of relevant articles, with no language or date restrictions. Cohort studies of participants undergoing ETV/CPC that reported outcome were included using MOOSE guidelines. The outcome was time to repeat CSF diversion or death. Forest plots were created for pooled mean and its 95 % CI of outcome and morbidity. RESULTS Of 78 citations, 11 retrospective reviews (with 524 total participants) were eligible. Efficacy was achieved in 63 % participants at follow-up periods between 6 months and 8 years. Adverse events and mortality was reported in 3.7 and 0.4 % of participants, respectively. Publication bias was detected with respect to efficacy and morbidity of the procedure. A large discrepancy in success was identified between ETV/CPC in six studies from sub-Saharan Africa (71 %), compared to three studies from North America (49 %). CONCLUSIONS The reported success of ETV/CPC for infantile hydrocephalus is higher in sub-Saharan Africa than developed nations. Large long-term prospective multi-center observational studies addressing patient-important outcomes are required to further evaluate the efficacy and safety of this re-emerging procedure.
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Affiliation(s)
- Alexander G Weil
- Division of Pediatric Neurosurgery, Department of Surgery, Sainte Justine Hospital, University of Montreal, Montreal, QC, Canada
| | - Harrison Westwick
- Division of Pediatric Neurosurgery, Department of Surgery, Sainte Justine Hospital, University of Montreal, Montreal, QC, Canada
| | - Shelly Wang
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Departments of Biostatistics and Epidemiology, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Naif M Alotaibi
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Lior Elkaim
- Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada
| | - George M Ibrahim
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Anthony C Wang
- Department of Neurosurgery, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, USA
| | - Rojine T Ariani
- Department of Global Medicine, Keck School of Medicine at University of Southern California, Los Angeles, CA, USA
| | - Louis Crevier
- Division of Pediatric Neurosurgery, Department of Surgery, Sainte Justine Hospital, University of Montreal, Montreal, QC, Canada
| | - Bethany Myers
- Louise M. Darling Biomedical Library, University of California Los Angeles, Los Angeles, CA, USA
| | - Aria Fallah
- Brain Research Institute, University of California Los Angeles, Los Angeles, CA, USA.
- Department of Neurosurgery, David Geffen School of Medicine at UCLA, Mattel Children's Hospital UCLA, 300 Stein Plaza, Suite 525, Los Angeles, CA, 90095-6901, USA.
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Kulkarni AV, Sgouros S, Constantini S. International Infant Hydrocephalus Study: initial results of a prospective, multicenter comparison of endoscopic third ventriculostomy (ETV) and shunt for infant hydrocephalus. Childs Nerv Syst 2016; 32:1039-48. [PMID: 27107887 DOI: 10.1007/s00381-016-3095-1] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2016] [Accepted: 03/12/2016] [Indexed: 11/25/2022]
Abstract
INTRODUCTION The IIHS is an international, prospective, multicenter study to compare endoscopic third ventriculostomy (ETV) and shunt in infants (<24 months old) with symptomatic triventricular hydrocephalus from aqueductal stensosis. Recruitment started in 2004, and here, we present the first results of IIHS. METHODS IIHS utilized a prospective comprehensive cohort design, which contained both a randomized and a non-randomized arm. Patients received either an ETV or shunt, based on randomization or parental preference. Patients were followed prospectively for time to treatment failure, defined as the need for repeat CSF diversion procedure (shunt or ETV) or death due to hydrocephalus. Survival analysis was used to compare time to failure for ETV versus shunt. The trial was registered at clinicaltrials.gov (NCT00652470). RESULTS A total of 158 patients met eligibility criteria (median age at surgery 3.6 months, IQR 1.6-6.6 months) across 27 centers in 4 continents. Since only 52 patients (32.9 %) were randomized, all 158 patients were analyzed together (115 ETV, 43 shunt). Actuarial success rates for ETV vs shunt at 3, 6, and 12 months were as follows: 68 vs 95 %, 66 vs 88 %, and 66 vs 83 %. The 6-month ETV success rate of 66 % was slightly higher than would have been predicted by the ETV Success Score (57 %).The hazard ratio for time to treatment failure favored shunt over ETV (3.17, 95 % CI 1.45-6.96, p = 0.004), after adjusting for age at surgery, history of previous hemorrhage or infection, continent, and randomization status. Patients younger than 6 months of age appeared to do relatively worse with ETV than older patients. CONCLUSIONS The IIHS has provided the first prospective direct comparison of ETV and shunt for infant hydrocephalus. These initial results suggest that shunting has a superior success rate compared to ETV, although the success rate for both was relatively high. This patient cohort continues to be followed, and we will await the results of the important primary outcome of health status at 5 years of age.
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Affiliation(s)
- Abhaya V Kulkarni
- The Hospital for Sick Children, University of Toronto, 555 University Avenue, Suite 1503, Toronto, Ontario, M5G 1X8, Canada
| | - Spyros Sgouros
- Department of Pediatric Neurosurgery, Mitera Children's Hospital, University of Athens Medical School, Athens, Greece
| | - Shlomi Constantini
- Department of Pediatric Neurosurgery, Dana Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel.
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Ladner TR, Westrick AC, Wellons JC, Shannon CN. Health-related quality of life in pediatric Chiari Type I malformation: the Chiari Health Index for Pediatrics. J Neurosurg Pediatr 2016; 17:76-85. [PMID: 26431245 DOI: 10.3171/2015.5.peds1513] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECT The purpose of this study was to design and validate a patient-reported health-related quality of life (HRQOL) instrument for pediatric Chiari Type I malformation (CM-I), the Chiari Health Index for Pediatrics (CHIP). METHODS The CHIP has 45 items with 4 components making up 2 domain scores, physical (pain frequency, pain severity, nonpain symptoms) and psychosocial; physical and psychosocial scores are combined to create an overall HRQOL score. Increasing scores (0 to 1) represent increasing HRQOL. Fifty-five patients with CM-I (mean age 12 ± 4 years, 53% male) were enrolled and completed the CHIP and Health Utilities Index Mark 3 (HUI3). Twenty-five healthy controls (mean age 11.9 ± 4 years, 40% male) also completed the CHIP. CHIP scores were compared between these groups via the Mann-Whitney U-test. For CHIP discriminative function, subscore versus presence of CM-I was compared via receiver operating characteristic curve analysis. CHIP scores in the CM-I group were stratified by symptomatology (asymptomatic, headaches, and paresthesias) and compared via Kruskal-Wallis test with Mann-Whitney U-test with Bonferroni correction (p < 0.0167). CHIP was compared with HUI3 (Health Utilities Index Mark 3) via univariate and multivariate linear regression. RESULTS CHIP physical and psychosocial subscores were, respectively, 24% and 18% lower in CM-I patients than in controls (p < 0.001); the overall HRQOL score was 23% lower as well (p < 0.001). The area under the curve (AUC) for CHIP physical subscore versus presence of CM-I was 0.809. CHIP physical subscore varied significantly with symptomatology (p = 0.001) and HUI3 pain-related quality of life (R(2) = 0.311, p < 0.001). The AUC for CHIP psychosocial subscore versus presence of CM-I was 0.754. CHIP psychosocial subscore varied significantly with HUI3 cognitive- (R(2) = 0.324, p < 0.001) and emotion-related (R(2) = 0.155, p = 0.003) quality of life. The AUC for CHIP HRQOL versus presence of CM-I was 0.820. Overall CHIP HRQOL score varied significantly with symptomatology (p = 0.001) and HUI3 multiattribute composite HRQOL score (R(2) = 0.440, p < 0.001). CONCLUSIONS The CHIP is a patient-reported, CM-I-specific HRQOL instrument, with construct validity in assessing pain-, cognitive-, and emotion-related quality of life, as well as symptomatic features unique to CM-I. It holds promise as a discriminative HRQOL index in CM-I outcomes assessment.
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Affiliation(s)
- Travis R Ladner
- Department of Neurological Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Ashly C Westrick
- Department of Neurological Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - John C Wellons
- Department of Neurological Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Chevis N Shannon
- Department of Neurological Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee
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21
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Nishiyama K, Yoshimura J, Fujii Y. Limitations of Neuroendoscopic Treatment for Pediatric Hydrocephalus and Considerations from Future Perspectives. Neurol Med Chir (Tokyo) 2015; 55:611-6. [PMID: 26226979 PMCID: PMC4628151 DOI: 10.2176/nmc.ra.2014-0433] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Neuroendoscopy has become common in the field of pediatric neurosurgery. As an alternative procedure to cerebrospinal fluid shunt, endoscopic third ventriculostomy has been the routine surgical treatment for obstructive hydrocephalus. However, the indication is still debatable in infantile periods. The predictors of late failure and how to manage are still unknown. Recently, the remarkable results of endoscopic choroid plexus coagulation in combination with third ventriculostomy, reported from experiences in Africa, present puzzling complexity. The current data on the role of neuroendoscopic surgery for pediatric hydrocephalus is reported with discussion of its limitations and future perspectives, in this review.
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22
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Limbrick DD, Baird LC, Klimo P, Riva-Cambrin J, Flannery AM. Pediatric hydrocephalus: systematic literature review and evidence-based guidelines. Part 4: Cerebrospinal fluid shunt or endoscopic third ventriculostomy for the treatment of hydrocephalus in children. J Neurosurg Pediatr 2014; 14 Suppl 1:30-4. [PMID: 25988780 DOI: 10.3171/2014.7.peds14324] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The objective of this systematic review was to examine the existing literature comparing CSF shunts and endoscopic third ventriculostomy (ETV) for the treatment of pediatric hydrocephalus and to make evidence-based recommendations regarding the selection of surgical technique for this condition. METHODS Both the US National Library of Medicine and the Cochrane Database of Systematic Reviews were queried using MeSH headings and key words specifically chosen to identify published articles detailing the use of CSF shunts and ETV for the treatment of pediatric hydrocephalus. Articles meeting specific criteria that had been determined a priori were examined, and data were abstracted and compiled in evidentiary tables. These data were then analyzed by the Pediatric Hydrocephalus Systematic Review and Evidence-Based Guidelines Task Force to consider treatment recommendations based on the evidence. RESULTS Of the 122 articles identified using optimized search parameters, 52 were recalled for full-text review. One additional article, originally not retrieved in the search, was also reviewed. Fourteen articles met all study criteria and contained comparative data on CSF shunts and ETV. In total, 6 articles (1 Class II and 5 Class III) were accepted for inclusion in the evidentiary table; 8 articles were excluded for various reasons. The tabulated evidence supported the evaluation of CSF shunts versus ETV. CONCLUSIONS Cerebrospinal fluid shunts and ETV demonstrated equivalent outcomes in the clinical etiologies studied. RECOMMENDATION Both CSF shunts and ETV are options in the treatment of pediatric hydrocephalus. STRENGTH OF RECOMMENDATION Level II, moderate clinical certainty.
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Affiliation(s)
- David D Limbrick
- Division of Pediatric Neurosurgery, Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | | | - Paul Klimo
- Department of Neurosurgery, University of Tennessee Health Science Center,5Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Jay Riva-Cambrin
- Division of Pediatric Neurosurgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Ann Marie Flannery
- Department of Neurological Surgery, Saint Louis University, St. Louis, Missouri
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23
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Ventricular endoscopy in the pediatric population: review of indications. Childs Nerv Syst 2014; 30:1625-43. [PMID: 25081217 DOI: 10.1007/s00381-014-2502-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Accepted: 07/14/2014] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Neuroendoscopy has greatly impacted pediatric neurosurgery over the past few decades. Improved optics and microsurgical tools have allowed neuroendoscopes to be used for a multitude of neurosurgical procedures. DISCUSSION In this review article, we present the breadth of intraventricular neuroendoscopic procedures for the treatment of conditions ranging from hydrocephalus and brain tumors to congenital cysts and other pathologies. We critically discuss treatment indications and reported success rates for neuroendoscopic procedures. We also present novel approaches, technical nuances, and variations from recently published literature and as practiced in the authors' institution.
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Endoscopic third ventriculocisternostomy in hydrocephalic children under 2 years of age: appropriate or not? A single-center retrospective cohort study. Childs Nerv Syst 2013; 29:419-23. [PMID: 23149591 DOI: 10.1007/s00381-012-1961-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2012] [Accepted: 10/26/2012] [Indexed: 02/07/2023]
Abstract
PURPOSE Treating hydrocephalus can be difficult in children under the age of 2 years because a high amount of uncertainty exists as to which treatment to perform. In this retrospective cohort study, we analyzed children under the age of 2 years with hydrocephalus undergoing an endoscopic third ventriculocisternostomy (ETV) with respect to ETV outcome. METHODS In 59 consecutive patients under the age of 2 years, an ETV was performed between 1999 and 2010 at the Erasmus MC, Sophia Children's Hospital. Demographics, etiology of hydrocephalus, and radiological data were extracted retrospectively from the patients' medical records and operative reports and related to outcome. ETV Success Score (ETVSS) was used to retrospectively calculate the probability of success related to the actual outcome. RESULTS In this series, 42.4 % of patients had a successful ETV. The only statistically significant finding concerned age. The failed ETV patients appeared to be younger (0.52 ± 0.60 vs. 0.86 ± 0.56 year, p = 0.005), and when using a cutoff age of 6 months only, five out of 32 infants had a successful ETV (p = 0.002). Of the children with an arachnoid cyst, 57.1 % were treated successfully with an ETV. Of the five patients with a high probability of ETV success, four (80 %) were indeed successfully treated with ETV (p = 0.049). CONCLUSIONS Our data confirm the overall ineffectiveness of an ETV in children under the age of 6 months. Nevertheless, using the ETVSS is recommended to aid in the decision-making process even in patients under the age of 6 months.
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Neuroendoscopy in the Youngest Age Group. World Neurosurg 2013; 79:S23.e1-11. [DOI: 10.1016/j.wneu.2012.02.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2011] [Accepted: 02/02/2012] [Indexed: 12/13/2022]
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Abstract
PURPOSE We assessed usability and applicability of a rigid, multidirectional steerable videoendoscope (EndActive, Karl Storz GmbH, Tuttlingen, Germany) for endoscopic third ventriculostomy and compared our experience with reports about other multidirectional endoscopes. METHODS The prototype is a 4-mm-diameter rigid videoendoscope with an integrated image sensor comprising an embedded light source, offering a free viewing direction in a range of 160° while the tip itself does not move. In five specimens (ten sides), we introduced the endoscope via precoronal burr holes through the lateral ventricle and foramen of Monro into the third ventricle. The endoscope's tip was positioned at the level of the mamillary bodies and the previously defined anatomical target structures; anteriorly, the optic chiasm, anterior commissure, infundibulum, tuber cinereum and posteriorly, the entrance to the mesencephalic aqueduct and posterior commissure were inspected. RESULTS A single insertion of the videoendoscope was sufficient to explore with the multiplanar viewing mechanism the entire third ventricle. The prototype videoendoscope may be held like a microsurgical instrument in one hand. It is feasible to control movements precisely due to the reduced weight and ergonomic shape of the device. CONCLUSIONS The prototype EndActive has the potential to fit in the current concept of ETV and enrich the setting adding working economy and viewing variability.
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Naftel RP, Reed GT, Kulkarni AV, Wellons JC. Evaluating the Children's Hospital of Alabama endoscopic third ventriculostomy experience using the Endoscopic Third Ventriculostomy Success Score: an external validation study. J Neurosurg Pediatr 2011; 8:494-501. [PMID: 22044376 DOI: 10.3171/2011.8.peds1145] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Endoscopic third ventriculostomy (ETV) success is dependent on patient characteristics including age, origin of hydrocephalus, and history of shunt therapy. Using these factors, an Endoscopic Third Ventriculostomy Success Score (ETVSS) model was constructed to predict success of therapy. This study reports a single-institution experience with ETV and explores the ETVSS model validity. METHODS A retrospective chart review identified 151 consecutive patients who underwent ETV at a pediatric hospital between August 1995 and December 2009. Of these 151, 136 patients had at least 6 months of clinical follow-up. Data concerning patient characteristics, operative characteristics, radiological findings, complications, and success of ETV were collected. The actual success rates were compared with those predicted by the ETVSS model. RESULTS The actual success rate of ETV at 6 months was 68.4% (93 of 136 patients), which compared well to the predicted ETVSS of 76.5% ± 12.5% (± SD). The C-statistic was 0.74 (95% CI 0.65-0.83), suggesting that the ability of the ETVSS to discriminate failures from successes was good. Secondary ETV was found to have a hazard ratio for failure of 4.2 (95% CI 2.4-7.2) compared with primary ETV (p < 0.001). The complication rate was 9.3% with no deaths. At the first radiological follow-up, the increased size of ventricles had a hazard ratio for failure of 3.0 (95% CI 1.5-6.0) compared with patients in whom ventricle size either remained stable or decreased (p = 0.002). CONCLUSIONS The ETVSS closely predicts the actual success of ETV, fitting the statistical model well. Shortcomings of the model were identified in overestimating success in patients with ETVSS ≤ 70, which may be attributable to the poor success of secondary ETVs in the authors' patient population.
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Affiliation(s)
- Robert P Naftel
- Section of Pediatric Neurosurgery, Division of Neurosurgery, University of Alabama, Children's Hospital, Birmingham, Alabama, USA.
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Abstract
PURPOSE Those with hydrocephalus view quality of life (QOL) as the most important of outcomes. The literature on QOL in hydrocephalus is growing, and we now recognize several of the factors that potentially influence outcome in these children. Neurosurgeons should be aware of the latest findings and how to critically analyze the QOL literature. METHODS This paper will attempt to review some general scientific concepts about QOL that neurosurgeons can apply to all patients. As well, we will describe, in some detail, what we currently understand about QOL issues in childhood hydrocephalus specifically, and where future research might take us. CONCLUSIONS Quality-of-life assessment is becoming important in advancing our scientific understanding of hydrocephalus.
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