Endoscopic third ventriculostomy in adult patients

[Microsurgical ventriculostomy of the third ventricle with access through a burrhole in the treatment of midly located deep-seated brain tumors]

BACKGROUND

Currently, endoscopic third ventriculostomy and simultaneous biopsy of deep midline brain tumors are a generally accepted option in neurooncology. Nevertheless, effectiveness of this surgery and diagnostic accuracy of biopsy are not without drawbacks. An alternative to endoscopic surgery may be simultaneous microsurgical third ventriculostomy and biopsy of deep midline tumors.

OBJECTIVE

To evaluate effectiveness and safety of burr hole microsurgical third ventriculostomy in the treatment of deep midline brain tumors.

MATERIAL AND METHODS

We used transcortical (25 cases) and transcallosal (8 cases) approaches for microsurgical third ventriculostomy.

RESULTS

Initially scheduled biopsy was performed in 19 cases, partial resection in 6 cases, subtotal resection in 4 cases and total resection in 4 cases. All patients underwent microsurgical third ventriculostomy. In 12 cases, stenting of stoma was performed in addition to ventriculostomy. Biopsy was informative in all cases. Postoperative follow-up period ranged from 3 to 44 months (mean 29 months). There was no postoperative hydrocephalus and need for shunting procedure.

CONCLUSION

Burr hole microsurgery may be an alternative to endoscopic surgery for the treatment of pineal, periaqueductal and third ventricular tumors.

Failure of Endoscopic Third Ventriculostomy

Endoscopic third ventriculostomy (ETV) is an alternative to cerebrospinal fluid (CSF) shunting in the treatment of hydrocephalus. Careful patient selection is critical as patient age, etiology of hydrocephalus, and previous shunting have been shown to influence ETV success rates. Intraoperatively, patient anatomy and medical stability may prevent or limit the completion of the ventriculostomy procedure, and findings such as a patulous third ventricular floor or cisternal scarring may portend a lower chance of successful hydrocephalus treatment. Patients in whom a ventriculostomy is completed may still experience continued symptoms of hydrocephalus or CSF leak, representing an early ETV failure. In other patients, the ETV may prove a durable treatment of hydrocephalus for several months or even years before recurrence of hydrocephalus symptoms. The failure pattern for ETV is different than that of shunting, with a higher early failure rate but improved long-term failure-free survival rates. The risk factors for failure, along with the presentation and management of failure, deserve review.

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.

The effect and evolution of patient selection on outcomes in endoscopic third ventriculostomy for hydrocephalus: A large-scale review of the literature

Endoscopic third ventriculostomy (ETV) has become a popular technique for the treatment of hydrocephalus, but small sample size has limited the generalizability of prior studies. We performed a large-scale review of all available studies to help eliminate bias and determine how outcomes have changed and been influenced by patient selection over time. A systematic literature search was performed for studies of ETV that contained original, extractable patient data, and a meta-analytic model was generated for correlative and predictive analysis. A total of 130 studies were identified, which included 11,952 cases. Brain tumor or cyst was the most common hydrocephalus etiology, but high-risk etiologies, post-infectious or post-hemorrhagic hydrocephalus, accounted for 18.4%. Post-operative mortality was very low (0.2%) and morbidity was only slightly higher in developing than in industrialized countries. The rate of ETV failure was 34.7% and was higher in the first months and plateaued around 20months. As anticipated, ETV is less successful in high-risk etiologies of hydrocephalus and younger patients. Younger patient age and high-risk etiologies predicted failure. ETVs were performed more often in high-risk etiologies over time, but, surprisingly, there was no overall change in ETV success rate over time. This study should help to influence optimal patient selection and offer guidance in predicting outcomes.

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.

Outcomes of endoscopic third ventriculostomy in adults

Endoscopic third ventriculostomy (ETV) is an alternative to ventriculoperitoneal shunting for treatment of hydrocephalus. Studies have reported favorable outcomes for up to three-quarters of adult patients. We performed the first ETV outcomes study using an administrative claims database, examining current practice for adult patients in the United States. We interrogated the Truven Health MarketScan® database for Current Procedural Terminology codes corresponding to ETV and ventriculoperitoneal shunt from 2003- to 2011, including patients over 18years and data from initial and subsequent hospitalizations. ETV failure was defined as any subsequent ETV or shunt procedure. Five hundred twenty-five patients underwent ETV with 6months minimum follow-up. Mean age was 45.9years (range: 18-86years). Mean follow-up was 2.2years (SD: 1.6years, range: 0.5-8.4years). Etiology of hydrocephalus was 21.3% tumor, 9.0% congenital/aqueductal stenosis, 15.8% hemorrhage, and 53.9% others. ETV was successful in 74.7% of patients. Of 133 who failed, 25 had repeat ETV; 108 had shunt placement. Longer length of stay for index surgery was associated with higher risk of failure (hazard ratio (HR): 1.03, p<0.001), as was history of previous shunt (HR: 2.45, p<0.001). Among patients with repeat surgeries, median time to failure was 25days. This study represents a longitudinal analysis of nationwide ETV practice over 9years. Success rate in this large cohort is similar to that published by other single-center retrospective studies. Age and geographic variation may be associated with surgeon choice of ETV or shunt placement after failure of the initial ETV.

Endoscopic Third Ventriculostomy in 250 Adults With Hydrocephalus

BACKGROUND:

Endoscopic third ventriculostomy (ETV) has been used predominantly in the pediatric population in the past. Application in the adult population has been less extensive, even in large neurosurgical centers. To our knowledge, this report is one of the largest adult ETV series reported and has the consistency of being performed at 1 center.

OBJECTIVE:

To determine the efficacy, safety, and outcome of ETV in a large adult hydrocephalus patient series at a single neurosurgical center. In addition, to analyze patient selection criteria and clinical subgroups (including those with ventriculoperitoneal shunt [VPS] malfunction or obstruction and neurointensive care unit patients with extended ventricular drainage before ETV) to optimize surgical results in the future.

METHODS:

We conducted a retrospective review of adult ETV procedures performed at our center between 2000 and 2014.

RESULTS:

The overall rate of success (no further cerebrospinal fluid diversion procedure performed plus clinical improvement) of 243 completed ETVs was 72.8%. Following is the number of procedures with the success rate in parentheses: aqueduct stenosis, 56 (91%); communicating hydrocephalus including normal pressure hydrocephalus, nonnormal pressure hydrocephalus, and remote head trauma, 57 (43.8%); communicating hydrocephalus in postoperative posterior fossa tumor without residual tumor, 14 (85.7%); communicating hydrocephalus in subarachnoid hemorrhage without intraventricular hemorrhage, 23 (69.6%); obstruction from tumor/cyst, 42 (85.7%); VPS obstruction (diagnosis unknown), 23 (65.2%); intraventricular hemorrhage, 20 (90%); and miscellaneous (obstructive), 8 (50%). There were 9 complications in 250 intended procedures (3.6%); 5 (2%) were serious.

CONCLUSION:

Use of ETV in adult hydrocephalus has broad application with a low complication rate and reasonably good efficacy in selected patients.

Endoscopic third ventriculostomy in the management of hydrocephalus: Outcome analysis of 168 consecutive procedures

BACKGROUND

Endoscopic third ventriculostomy (ETV) is the treatment of choice for obstructive hydrocephalus, but the outcome is still controversial in terms of age and aetiology.

METHODS

Between 1998 and 2011, 168 consecutive procedures were performed in 164 patients, primarily children (56%<18 years of age and 35%<2 years of age). The causes of obstructive hydrocephalus included tumoural pathology, Chiari malformation, congenital obstruction of the aqueduct, post-infectious and post-haemorrhagic membranes, and ventriculo-peritoneal shunt (VPS) malfunctions. Successful ETV was defined by the resolution of symptoms and the avoidance of a shunt.

RESULTS

ETV was successful in 75.6% of patients, but 19% of the patients required VPS in the first month after ETV, and 5.4% required a VPS more than one month after ETV. Four patients were ultimately submitted for second ETVs. In this series, no major permanent morbidity or mortality was observed.

CONCLUSIONS

ETV is a safe procedure and an effective treatment for obstructive hydrocephalus even following the dysfunction of previous VPSs and in children younger than two years.

A Novel Protocol of Continuous Navigation Guidance for Endoscopic Third Ventriculostomy

BACKGROUND:

Although considered a standard neurosurgical procedure, endoscopic third ventriculostomy (ETV) is associated with a relatively high complication rate that is predominantly related to malpositioning of the trajectory.

OBJECTIVE:

To develop an advanced navigation protocol for ETV, assess its possible benefits over commonly used ETV trajectories, and apply this protocol during surgery.

METHODS:

After development of our advanced protocol, the imaging data of 59 patients who underwent ETV without navigation guidance was transferred to our navigation software. An individualized endoscope trajectory was created according to our protocol in all cases. This trajectory was compared with 2 standard trajectories, especially with regard to the distance to relevant neuronal structures: a trajectory manually measured on preoperative radiological images, as performed in all 59 cases, and a trajectory resulting from a commonly used fixed coronal burr hole. Subsequently, we applied the protocol in 15 ETVs to assess the feasibility and procedural complications.

RESULTS:

Our individualized trajectory resulted in a significantly greater distance to the margins of the foramen of Monro, and the burr hole was located more posteriorly from the coronal suture in comparison with the standard trajectories. The advanced ETV technique was feasible in all 15 procedures, and no major complications occurred in any procedure. In 1 patient, a fornix contusion without clinical correlation was observed.

CONCLUSION:

Our data indicate that the proposed navigation protocol for ETV optimizes the distance of the endoscope to important neuronal structures. Continuous endoscope and puncture device guidance may further add to the safety of this procedure.

Endoscopic 3rd ventriculocisternostomy: procedural complications and long-term dysfunctions?

BACKGROUND AND PURPOSE

The endoscopic third ventriculostomy (ETV) has become the treatment of choice for managing non-communicating hydrocephalus. The aim of this study was to evaluate the efficacy and the morbi-mortality of this procedure and its long-term outcome.

PATIENTS AND METHODS

This retrospective study involved 82 consecutive patients treated for non-communicating hydrocephalus by ETV, in a single centre, between June 1999 and November 2008. The main criterion of efficacy was clinical improvement with shunt independence. The secondary criteria were the ventricular size (third and lateral ventricles) outcome and the procedural morbidity and mortality. In order to determine the predictive factors of dysfunction, a uni- and multivariate analysis was conducted.

RESULTS

Divided in two groups, the overall success rate was 65.4% in the paediatric group (n=26) and 83.9% in the adult group (n=56), after respectively a mean follow-up of 59.1±36.7 and 49.3±27.7 months. A procedural complication occurred in 5 patients (6.1%), with no procedure-related death. The predictive factors of ETV failure were an infectious aetiology and an age less than 16. Changes in ventricular size and success rate were independent.

CONCLUSIONS

ETV is an effective procedure at long-term for the management of non-communicating hydrocephalus with low morbidity. Therefore, it should be considered as first-line treatment. Cerebrospinal meningitis infection and young age both expose patients to possible dysfunction.

Microsurgical third ventriculostomy with stenting in intrinsic brain tumors involving anterior third ventricle

OBJECTIVE

Microsurgical fenestration of the third ventricular floor performed in one session with resection of deep seated tumors has been recently demonstrated as an approach to specifically address the concomitant obstructive hydrocephalus. As with endoscopic third ventriculostomy, occlusion of the stoma may result in progression of the obstructive hydrocephalus. In order to provide reliable communication between the basal cisterns and ventricles, we propose stenting of the stoma in cases of direct surgical approach to deep seated tumors.

METHODS

After performing tumor resection through the anterior transcallosal approach, premamillar and Liliequist's membranes were identified and fenestrated. A silicon stent was inserted into the prepontine cistern through the fenestrated floor of the third ventricle; the stent connected the third and lateral ventricles with the basal cisterns.

RESULTS

Microsurgical ventriculostomy of the third ventricle and stenting of the stoma was performed in 9 patients simultaneously with tumor resection (5 cases), open biopsy (3 cases), or microsurgical dissection of severe adhesions at the level of Monro foramina (1 case). In 7 cases, the third ventricular floor was infiltrated with the tumor and obstruction of the aqueduct persisted after tumor surgery; in 2 patients, high risk of reocclusion at the level of Monro foramen was expected. Stenting of the ventricular system provided patency of the stoma and Monro foramen. None of the patients required a shunt postoperatively. The follow-up time ranged from 3 to 22 months.

CONCLUSION

Microsurgical fenestration of the third ventricle floor combined with stoma stenting can be a viable option for hydrocephalus control.

A Review of Neuroendoscopy and Potential Applications in Veterinary Medicine

The endoscope was first developed over 200 yr ago. Endoscopy has since been applied to many disciplines of medicine. Its application to the nervous system was initially slow and not widely accepted and mainly involved the biopsy of tumors and the treatment of hydrocephalus. Several reasons for neuroendoscopy's limited use include inadequate endoscope technology, high skill level required, the advent of the surgical microscope, and the development of other treatments such as ventricular shunting. Over the past 50 yr, improvements in optical glass lenses, fiber optics, and electrical circuitry has led to better equipment and a revival of neuroendoscopy. Neuroendoscopy is now used in many diseases in human medicine including hydrocephalus, neoplasia, and intracranial cysts. This review presents the history of neuroendoscopy, the equipment and technology used, and the possible translation of techniques currently used in human medicine to veterinary medicine.

Minimally invasive neurosurgery for cerebrospinal fluid disorders

This article focuses on minimally invasive approaches used to address disorders of cerebrospinal fluid (CSF) circulation. The author covers the primary CSF disorders that are amenable to minimally invasive treatment, including aqueductal stenosis, fourth ventricular outlet obstruction (including Chiari malformation), isolated lateral ventricle, isolated fourth ventricle, multiloculated hydrocephalus, arachnoid cysts, and tumors that block CSF flow. General approaches to evaluating disorders of CSF circulation, including detailed imaging studies, are discussed. Approaches to minimally invasive management of such disorders are described in general, and for each specific entity. For each procedure, indications, surgical technique, and known outcomes are detailed. Specific complications as well as strategies for their avoidance and management are addressed. Lastly, future directions and the need for structured outcome studies are discussed.

Surgical management of adult hydrocephalus

The management of adult hydrocephalus spans a broad range of disorders and ages. Modern management strategies include endoscopic and adjustable cerebrospinal fluid shunt diversionary techniques. The assessment and management of the following clinical conditions are discussed: 1) the adult patient with congenital or childhood-onset hydrocephalus, 2) adult slit ventricle syndrome, 3) multicompartmental hydrocephalus, 4) noncommunicating hydrocephalus, 5) communicating hydrocephalus, 6) normal pressure hydrocephalus, and 7) the shunted patient with headaches. The hydrodynamics of cerebrospinal fluid shunt diversion are discussed in relation to mechanisms of under- and overdrainage conditions. A rationale for the routine implementation of adjustable valves for adult patients with hydrocephalus is provided based on objective clinical and experimental data. For the condition of normal pressure hydrocephalus, recommendations are offered regarding the evaluation, surgical treatment, and postoperative management of this disorder.