Endoscopic third ventriculostomy in patients with cerebrospinal fluid infection and/or hemorrhage

Success Rate of Endoscopic Third Ventriculostomy in Children Younger Than 1 Year With Idiopathic Congenital Aqueductal Stenosis and Long-term Follow-up

INTRODUCTION

The indication for endoscopic third ventriculostomy is often contested in children younger than 1 year. This study aims to establish the benefits of this modality in children with idiopathic congenital aqueductal stenosis.

METHODS

Retrospective analysis was performed on patients <1 year old with idiopathic congenital aqueductal stenosis undergoing endoscopic third ventriculostomy between 2004 and 2020. Preoperative cerebral imaging was performed in all cases. Endoscopic third ventriculostomy efficacy and overall patient outcome were evaluated over the entirety of the monitoring period averaging 146 months (range, 34-218 months). Outcome was assessed by modified Rankin Scale score. Treatment success was assessed in relation to the Endoscopic Third Ventriculostomy Success Score (ETVSS), patient age, and perioperative findings of membranes in the interpeduncular cistern.

RESULTS

The study comprised 14 children aged from 6 to 280 days, mean age 16 weeks, with 11 patients aged <6 months. The characteristic presentation was progressive macrocephaly, with the setting sun sign in 2 cases. The overall Endoscopic Third Ventriculostomy Success Score was 52.1%, whereas endoscopic third ventriculostomy was successful in 12 patients (85.7%) in the first year postoperation and in 11 cases (78.6%) in the long term. Endoscopic third ventriculostomy failure was not related to patient age (P > .99) or perioperative findings of interpeduncular cistern membranes (P = .51). Patient outcome averaged modified Rankin Scale score 1. Most children were without or with minimal disability.

CONCLUSIONS

We consider endoscopic third ventriculostomy a safe and effective modality for the initial treatment of patients aged <1 year presenting with congenital aqueductal stenosis-based hydrocephalus.

Treatment of post-thalamic hemorrhage hydrocephalus: ventriculoperitoneal shunt or endoscopic third ventriculostomy? A retrospective observational study

BACKGROUND

The aim of this study was to compare the efficacy of ventriculoperitoneal shunt (VPS) and endoscopic third ventriculostomy (ETV) for the treatment of hydrocephalus after thalamic hemorrhage (TH) where external ventricular drainage (EVD) could not be removed after hematoma absorption, and to provide a theoretical basis for the clinical treatment of hydrocephalus after TH.

METHODS

The clinical data of patients with hydrocephalus after TH whose EVD could not be removed after hematoma absorption were retrospectively analyzed. According to the patients' surgical methods, the patients were divided into the VPS group and ETV group. The operative time, length of hospital stay, complications, and reoperation rates of the two groups were compared.

RESULTS

There was no statistically significant difference in intraoperative bleeding, length of hospital stay between the two groups. The EVD tubes were successfully removed in all patients after surgery. There were 4 (9.5%) complications in the ETV group and 3 (6.7%) complications in the VPS group, with no statistically significant difference in postoperative complications between the two groups. During the 1-year follow-up, 7 patients (16.7%) in the ETV group and 3 patients (6.7%) in the VPS group required reoperation. In the subgroup analysis of TH combined with fourth ventricular hemorrhage, 6 patients (14.3%) in the ETV group and 1 patient (2.2%) in the VPS group required reoperation, and the difference between the two groups was statistically significant.

CONCLUSIONS

ETV had good efficacy in treating hydrocephalus caused by TH and TH that broke into the lateral ventricle and the third ventricle. However, if hydrocephalus was caused by TH with the fourth ventricular hematoma, VPS was a better surgical method because the recurrence rate of hydrocephalus in ETV was higher than that in VPS. Therefore, the choice of surgical method should be based on the patient's clinical features and hematoma location.

A challenging case of endoscopic third ventriculostomy

Background

Although controversial, endoscopic third ventriculostomy (ETV) in the management of Myelomeningocele and Chiari type II malformation-related hydrocephalous is gaining wider popularity and use. With variable success rates, it can be proposed as a first or second option after shunt malfunction. ETV in post-infectious hydrocephalus may also be considered as an alternative to shunting. With reported success rates of 50-60%, failure is attributed to anatomical reasons and/or to pathological subarachnoid space scarring that may result from infectious processes. Similarly, ETV in repeated shunt malfunctions is an acceptable option that may offer shunt independency. In all situations, case-by-case selection and discussion are to be considered.

Case Description

A 5-year-old boy with a history of surgically treated lumbosacral myelomeningocele and ventriculoperitoneal shunting at six months of age is presented. During the course following the initial surgery, he experienced multiple shunt malfunctions, with two episodes of meningitis, leading to 7 shunt revision surgeries. Lately, the patient presented a large peritoneal cyst formation that needed regular evacuations. With a magnetic resonance imaging (MRI)-scan showing a large bi-ventricular hydrocephalus and a trapped third ventricle with multiple septations, surgical options included either ventriculoatrial shunting or third ventriculostomy. The latter option, offering shunt independency, was chosen after family consent and risk explanation. The expected success rate of the procedure was discussed and evaluated to 40-60% on the ETV success score. The video describes a step-by-step procedure with detailed radiological and correlated anatomical annotations of a completely distorted anatomy of a multifactorial hydrocephalous. No scarring at the prepontine cistern was observed. Shunt independency was achieved. However, the patient died from late postoperative status epilepticus and pulmonary complications. Whether these postoperative events are directly related to the procedure is unclear, although technically and clinically successful in the short term.

Conclusion

We believe that ETV should be carefully indicated in selected patients with Chiari II, post-infectious hydrocephalus, by experienced hands, as the surgical anatomy can be extremely complex and misleading.

The Top 100 Most Cited Journal Articles on Hydrocephalus

Hydrocephalus represents a significant burden of disease, with more than 383,000 new cases annually worldwide. When the magnitude of this condition is considered, a centralized archive of pertinent literature is of great clinical value. From a neurosurgical standpoint, hydrocephalus is one of the most frequently treated conditions in the field. The focus of this study was to identify the top 100 journal articles specific to hydrocephalus using bibliometric analysis. Using the Journal of Citation Report database, 10 journals were identified. The Web of Science Core Collection was then searched using each journal name and the search term "hydrocephalus." The results were ordered by "Times Cited" and searched by the number of citations. The database contained journal articles from 1976 to 2021, and the following variables were collected for analysis: journal, article type, year of publication, and the number of citations. Journal articles were excluded if they had no relation to hydrocephalus, mostly involved basic science research, or included animal studies. Ten journals were identified using the above criteria, and a catalog of the 100 most cited publications in the hydrocephalus literature was created. Articles were arranged from highest to lowest citation number, with further classification by journal, article type, and publication year. Of the 100 articles referenced, 38 were review articles, 24 were original articles, 15 were comparative studies, 11 were clinical trials, six were multi-center studies, three were cross-sectional, and three were case reports with reviews. Articles were also sorted by study type and further stratified by etiology. If the etiology was not specified, studies were instead subcategorized by treatment type. Etiologies such as aqueductal stenosis, tumors, and other obstructive causes of hydrocephalus were classified as obstructive (n=6). Communicating (n=15) included idiopathic, normal pressure hydrocephalus, and other non-obstructive etiologies. The category "other" (n=3) was assigned to studies that included etiologies, populations, and/or treatments that did not fit into the classifications previously outlined. Through our analysis of highly cited journal articles focusing on different etiologies and the surgical or medical management of hydrocephalus, we hope to elucidate important trends. By establishing the 100 most cited hydrocephalus articles, we contribute one source, stratified for efficient referencing, to facilitate clinical care and future research on hydrocephalus.

Posthemorrhagic hydrocephalus management in patients with necrotizing enterocolitis: a monocentric experience

PURPOSE

Posthemorrhagic hydrocephalus (PHH) and necrotizing enterocolitis (NEC) are two comorbidities associated with prematurity. The management of patients with both conditions is complex and it is necessary to intercept them to avoid meningitis and multilocular hydrocephalus.

METHODS

In a single-center retrospective study, we analyzed 19 patients with NEC and PHH admitted from 2012 to 2022. We evaluated perinatal, imaging, and NEC-related data. We documented shunt obstruction and infection and deaths within 12 months of shunt insertion.

RESULTS

We evaluated 19 patients with NEC and PHH. Six cases (31.58%) were male, the median birth weight was 880 g (650-3150), and the median gestational age was 26 weeks (23-38). Transfontanellar ultrasound was performed on 18 patients (94.74%) and Levine classification system was used: 3 cases (15.79%) had a mild Levine index, 11 cases (57.89%) had moderate, and 5 cases (26.32%) were graded as severe. Magnetic resonance showed intraventricular hemorrhage in 14 cases (73.68%) and ventricular dilatation in 15 cases (78.95%). The median age at shunt insertion was 24 days (9-122) and the median length of hospital stay was 120 days (11-316). Sepsis was present in 15 cases (78.95%). NEC-related infection involved the peritoneal shunt in 4 patients and 3 of them had subclinical NEC. At the last follow-up, 6 (31.58%) patients presented with psychomotor delay. No deaths were reported.

CONCLUSIONS

Although recognition of subclinical NEC is challenging, the insertion of a ventriculoperitoneal shunt is not recommended in these cases and alternative treatments should be considered to reduce the risk of meningitis and shunt malfunction.

Application of LRG mechanism in normal pressure hydrocephalus

Normal pressure hydrocephalus (NPH) is a prevalent type of hydrocephalus, including secondary normal pressure hydrocephalus (SNPH) and idiopathic normal pressure hydrocephalus (INPH). However, its clinical diagnosis and pathological mechanism are still unclear. Leucine-rich α-2 glycoprotein (LRG) is involved in various human diseases, including cancer, diabetes, cardiovascular disease, and nervous system diseases. Now the physiological mechanism of LRG is still being explored. According to the current research results on LRG, we found that the agency of LRG has much to do with the known pathological process of NPH. This review focuses on analyzing the LRG signaling pathways and the pathological mechanism of NPH. According to the collected literature evidence, we speculated that LRG probably be involved in the pathological process of NPH. Finally, based on the mechanism of LRG and NPH, we also summarized the evidence of molecular targeted therapies for future research and clinical application.

Factors affecting endoscopic third ventriculostomy success in adults

BACKGROUND

Endoscopic third ventriculostomy (ETV) is a standard treatment in hydrocephalus of certain aetiologies. The most widely used predictive model is the ETV success score. This is frequently used to predict outcomes following ETV in adult patients; however, this was a model developed in paediatric patients with often distinct aetiologies of hydrocephalus. The aim of this study was to assess the predictive value of the model and to identify factors that influence ETV outcomes in adults.

METHODS

A retrospective study design was used to analyse consecutive patients who underwent ETV at a tertiary neurosurgical centre between 2012 and 2020. Observed ETV outcomes at 6 months were compared to pre-operative predicted ETV success scores. A multivariable Bayesian logistic regression analysis was used to determine the factors that best predicted ETV success and those factors that were redundant.

RESULTS

A total of 136 patients were analysed during the 9-year study. Thirty-one patients underwent further cerebrospinal fluid diversion within 6 months. The overall ETV success rate was 77%. Observed ETV outcomes corresponded well with predicted outcomes using the ETV success score for the higher scores, but less well for lower scores. Location of obstruction at the aqueduct irrespective of aetiology was the best predictor of success with odds of 1.65 of success. Elective procedures were also associated with higher success compared to urgent ones, whereas age under 70, nature and location of obstructive lesion (other than aqueductal) did not influence ETV success.

CONCLUSION

ETV was successful in three-quarters of adult patient with hydrocephalus within 6 months. Obstruction at the level of the aqueduct of any aetiology was a good predictor of ETV success. Clinicians should bear in mind that adult hydrocephalus responds differently to ETV compared to paediatric hydrocephalus, and more research is required to develop and validate an adult-specific predictive tool.

Clinical Outcome of Endoscopic Procedure in Patients with Shunt Malfunction

OBJECTIVE

The goal of this study was to analyze the clinical outcomes of endoscopic third ventriculostomy (ETV) and endoscopic septostomy when shunt malfunction occurs in a patient who has previously undergone placement of a ventriculoperitoneal shunt.

METHODS

From 2001 to 2020 at Seoul National University Children's Hospital, patients who underwent ETV or endoscopic septostomy for shunt malfunction were retrospectively analyzed. Initial diagnosis (etiology of hydrocephalus), age at first shunt insertion, age at endoscopic procedure, magnetic resonance or computed tomography image, subsequent shunting data, and follow-up period were included.

RESULTS

Thirty-six patients were included in this retrospective study. Twenty-nine patients, 18 males and 11 females, with shunt malfunction underwent ETV. At the time of shunting, the age ranged from 1 day to 15.4 years (mean, 2.4 years). The mean age at the time of ETV was 13.1 years (range, 0.7 to 29.6 years). Nineteen patients remained shunt revision free. The 5-year shunt revisionfree survival rate was 69% (95% confidence interval [CI], 0.54-0.88). Seven patients, three males and four females, with shunt malfunction underwent endoscopic septostomy. At the time of shunting, the age ranged from 0.2 to 12 years (mean, 3.9 years). The mean age at the time of endoscopic septostomy was 11.9 years (range, 0.5 to 29.5 years). Four patients remained free of shunt revision or addition. The 5-year shunt revision-free survival rate was 57% (95% CI, 0.3-1.0). There were no complications associated with the endoscopic procedures.

CONCLUSION

The results of our study demonstrate that ETV or endoscopic septostomy can be effective and safe in patients with shunt malfunction.

Challenges and Controversies in the Management of Tuberculous Meningitis with Hydrocephalus: A Systematic Review and Sarawak Institution's Experience

Introduction To date, there are no standard practice guidelines available and no universal consensus regarding treatment protocol in management of tuberculous meningitis (TBM) with hydrocephalus. Over the years, diverse views have existed in neurosurgical management of TBM with hydrocephalus. Some authors advocate ventriculo-peritoneal (VP) shunt, while others suggest that external ventricular drainage (EVD) may be the preferable neurosurgical procedure for a poor-grade patient.

Method We systematically reviewed published literature and presented our institution's experience. We performed a retrospective case study in our Sarawak neurosurgical center from 2018 to 2020. We tabulated the outcome according to preoperative classifications, which were Vellore Grading (VG), Modified Vellore Grading (MVG), British Medical Research Council Classification (MRC), and others: author-defined.

Result In our center, there were 20 cases of TBM with hydrocephalus treated by EVD and VP shunt from 2018 to 2020. We systematically searched published medical literature, and 23 articles were retrieved and analyzed. Poor outcomes were observed in poor-grade patients, especially VG/MVG 3/4 and MRC 3, from both institution and systemic review data. Shunt complication rate was lower in our center as compared with published literature.

Conclusion Unfortunately, morbidity and mortality were approximately twofold higher in poor-grade as compared with good-grade patients. However, about one-third of poor-grade patients achieved a good outcome. Cerebrospinal fluid (CSF) diversion would be an unavoidable treatment for hydrocephalus. Poor-grade patients tend to have cerebral infarcts in addition to hydrocephalus. An extended duration of EVD placement could be a potential measure to assess Glasgow coma scale recovery and monitor serial CSF samples.

Investigation of the Presence of Arachnoid Granulation in Fetuses and Early Infancy

The aim of our study is to investigate the importance of arachnoid granulation in cerebrospinal fluid physiology in fetuses and early infancy. Using the random sampling method, postmortem fetuses more than 26 weeks of gestation age and the children under the age of 1 year were chosen from the autopsy materials. Two male and two female intrauterine dead fetus; three male and three female, totally six children under the age of 1 year and one 3-year-old male were included in this study. In cases of intrauterine fetuses more than 26 weeks of gestation and children under the age of 1 year, complete invagination of arachnoid villi into the superior sagittal sinus was examined histologically. In the intrauterine period and in the first 6 months of life, arachnoid villi structures were not found in histologic preparations although in preparations taken after the 6 months of life samples showed similarities to arachnoid granulations. These structures were considered as arachnoid villi drafts after immunohistochemical analysis. In the control case who were 3 years old, maturation of arachnoid villi was complete and the arachnoid villi were invaginated into the superior sagittal sinus as fingerlike extensions. In our study, we think that the failure after E3V intervention in the treatment of hydrocephalus in cases under the age of 1 years may be related to the completion of arachnoid granulation development after the 18th month of life and the immature resorption capacity in this period.

Palliative endoscopic third ventriculostomy for pediatric primary brain tumors: a single-institution case series

OBJECTIVE

Children with nonoperative brain tumors, such as diffuse intrinsic pontine gliomas (DIPGs), often have life-threatening hydrocephalus. Palliative shunting is common in such cases but can be complicated by hardware infection and mechanical failure. Endoscopic third ventriculostomy (ETV) is a minimally invasive alternative to treat hydrocephalus without implanted hardware. Herein, the authors report their institutional experience with palliative ETV for primary pediatric brain tumors.

METHODS

The authors conducted a retrospective review of consecutive patients who had undergone palliative ETV for hydrocephalus secondary to nonresectable primary brain tumors over a 10-year period at Rady Children's Hospital. Collected variables included age, sex, tumor type, tumor location, presence of leptomeningeal spread, use of a robot for ETV, complications, ETV Success Score (ETVSS), functional status, length of survival, and follow-up time. A successful outcome was defined as an ETV performed without clinically significant perioperative complications or secondary requirement for a new shunt.

RESULTS

Fifteen patients met the study inclusion criteria (11 males, 4 females; average age 7.9 years, range 0.8-21 years). Thirteen patients underwent manual ETV, and 2 patients underwent robotic ETV. Preoperative symptoms included gaze palsy, nausea/vomiting, headache, lethargy, hemiparesis, and seizures. Tumor types included DIPG (3), intraventricular/thalamic glioblastoma (2), and leptomeningeal spread of medulloblastoma (2), anaplastic oligo-/astrocytoma (2), rhabdoid tumor (2), primitive neuroectodermal tumor (1), ganglioglioma (1), pineoblastoma (1), and embryonal carcinoma (1). The mean preoperative ETVSS was 79 ± 8.8. There was 1 perioperative complication, a wound breakdown consistent with refractory hydrocephalus. The mean follow-up was 4.9 ± 5.5 months overall, and mean survival for the patients who died was 3.2 ± 3.6 months. Two patients remained alive at a mean follow-up of 15.7 months. Palliative ETV was successful in 7 patients (47%) and unsuccessful in 8 (53%). While patients with successful ETV were significantly older (11.9 ± 5.6 vs 4.4 ± 4.1 years, p = 0.010), there were no significant differences in preoperative ETVSS (p = 0.796) or postoperative survival (p = 0.476) between the successful and unsuccessful groups. Overall, functional outcomes were similar between the two groups; there was no significant difference in posttreatment Karnofsky Performance Status scores (68.6 ± 19.5 vs 61.3 ± 16.3, p = 0.454), suggesting that including ETV in the treatment algorithm did not worsen outcomes.

CONCLUSIONS

Palliative ETV is a safe and potentially efficacious treatment option in selected pediatric patients with hydrocephalus from nonoperative brain tumors. Close follow-up, especially in younger children, is required to ensure that patients with refractory symptoms receive appropriate secondary CSF diversion.

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

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

Endoscopic third ventriculostomy inpatient failure rates compared with shunting in post-hemorrhagic hydrocephalus of prematurity

PURPOSE

Endoscopic third ventriculostomy (ETV) has gained traction as a method for treating post-hemorrhagic hydrocephalus of prematurity (PHHP) in an effort to obviate lifelong shunt dependence in neonates. However, data remains limited regarding inpatient failures.

METHODS

A retrospective analysis of the NIS between 1998 and 2014 was performed. Discharges with age < 1 year and ICD-9-CM codes indicating intraventricular hemorrhage of prematurity (772.1x) and ETV/shunt (02.22 and 02.3x) were included. Patients with ICD-9-CM codes for ventricular drain/reservoir (02.21) were excluded to prevent confounding. Time trend series plots were created. Yearly trends were quantified using logarithmic regression analysis. Kaplan-Meier curves were utilized to analyze time to treatment failure. Time to failure for each treatment was compared using log-rank.

RESULTS

A total of 11,017 discharges were identified. ETV was more likely to be utilized at < 29 weeks gestational age (p = 0.0039) and birth weight < 1000 g (p = 0.0039). Shunts were less likely to fail in older and heavier newborns (OR 0.836 p = 0.00456, OR 0.828 p = 0.0001, respectively). Those initially shunted had lower failure rates compared with ETV (OR 0.44, p < 0.0001) but time to failure was longer with ETV (p = 0.04562). 79.5% of ETVs that failed were shunted after the first failure. Shunts were much less likely to undergo ETV if they failed (OR 0.21, p < 0.0001). Higher grade IVH was predictive of shunt failure but not ETV (OR 2.36, p = 0.0129).

CONCLUSIONS

Although ETV can be effective in PHHP, it has a much higher initial failure rate than shunting and should thus be chosen based on a multifactorial approach.

ETV in infancy and childhood below 2 years of age for treatment of hydrocephalus

PURPOSE

Age and etiology play a crucial role in success of endoscopic third ventriculostomy (ETV) as a treatment of obstructive hydrocephalus. Outcome is worse in infants, and controversies still exist whether ETV is superior to shunt placement. We retrospectively analyzed 70 patients below 2 years from 4 different centers treated with ETV and assessed success.

METHODS

Children < 2 years who received an ETV within 1994-2018 were included. Patients were classified according to age and etiology; < 3, 4-12, and 13-24 months, etiologically; aqueductal stenosis, post-hemorrhagic-hydrocephalus (PHH), tumor-related, fourth ventricle outflow obstruction, with Chiari-type II and following CSF infection. We investigated statistically the predictors for ETV success through computing Kaplan-Meier estimates using patient's follow-up time and time to ETV failure.

RESULTS

We collected 70 patients. ETV success rate was 41.4%. The highest rate was in tumor-related hydrocephalus and fourth ventricle outlet obstruction (62.5%, 60%) and the lowest rate was in Chiari-type II and following infection (16.7%, 0%). The below 3 months age group showed relatively lower success rate (33.3%) in comparison to older groups which showed similar results (46.4%, 46.6%). Statistically, a previous VP shunt was a predictor for failure (p value < 0.05).

CONCLUSION

Factors suggesting a high possibility of failure were age < 3 months and etiology such as Chiari-type II or following infection. Altered CSF dynamics in patients with PHH and under-developed arachnoid villi may play a role in ETV failure. We do not recommend ETV as first line in children < 3 months of age or in case of Chiari II or following infection.

Converting Pediatric Patients and Young Adults From a Shunt to a Third Ventriculostomy: A Multicenter Evaluation

BACKGROUND

Endoscopic third ventriculostomy (ETV) is an effective primary treatment for certain forms of hydrocephalus. However, its use in children with an existing shunt is less well known.

OBJECTIVE

To report a multicenter experience in attempting to convert patients from shunt dependence to a third ventriculostomy and to determine predictors of success.

METHODS

Three participating centers provided retrospectively collected information on patients with an attempted conversion from a shunt to an ETV between December 1, 2008, and April 1, 2018. Demographic, clinical, and radiological data were recorded. Success was defined as shunt independence at the last follow-up.

RESULTS

Eighty patients with an existing ventricular shunt underwent an ETV. The median age at the time of the index ETV was 9.9 yr, and 44 (55%) patients were male. The overall success rate was 64% (51/80), with a median duration of follow-up of 2.0 yr (range, 0.1-9.4 yr). Four patients required a successful repeat ETV at a median of 1.7 yr (range, 0.1-5.7 yr) following the index ETV. Only age was predictive of ETV failure on multivariate analysis (odds ratio 0.86 [95% CI 0.78-0.94], P = .005). No patient less than 6 mo of age underwent an ETV, and of the 5 patients between 6 and 12 mo of age, 4 failed.

CONCLUSION

Although not every shunted patient will be a candidate for an ETV, nor will they be successfully converted, an ETV should at least be considered in every child who presents with a shunt malfunction or who has an externalized shunt.

TROPHY registry study design: a prospective, international multicenter study for the surgical treatment of posthemorrhagic hydrocephalus in neonates

INTRODUCTION

Among children with hydrocephalus, neonates with intraventricular hemorrhage (IVH) and posthemorrhagic hydrocephalus (PH) are considered a group with one of the highest complication rates of treatment. Despite continued progress in neonatal care, a standardized and reliable guideline for surgical management is missing for this challenging condition. Thus, further research is warranted to compare common methods of surgical treatment. The introduction of neuroendoscopic lavage has precipitated the establishment of an international registry aimed at elaborating key elements of a standardized surgical treatment.

METHODS

The registry is designed as a multicenter, international, prospective data collection for neonates aged 41 weeks gestation, with an indication for surgical treatment for IVH with ventricular dilatation and progressive hydrocephalus. The following initial temporizing surgical interventions, each used as standard treatment at participating centers, will be compared: external ventricular drainage (EVD), ventricular access device (VAD), ventricular subgaleal shunt (VSGS), and neuroendoscopic lavage (NEL). Type of surgery, perioperative data including complications and mortality, subsequent shunt surgeries, ventricular size, and neurological outcome will be recorded at 6, 12, 36, and 60 months.

RESULTS

An online, password-protected website will be used to collect the prospective data in a synchronized manner. As a prospective registry, data collection will be ongoing, with no prespecified endpoint. A prespecified analysis will take place after a total of 100 patients in the NEL group have been entered. Analyses will be performed for safety (6 months), shunt dependency (12, 24 months), and neurological outcome (60 months).

CONCLUSION

The design and online platform of the TROPHY registry will enable the collection of prospective data on different surgical procedures for investigation of safety, efficacy, and neurodevelopmental outcome of neonates with IVH and hydrocephalus. The long-term goal is to provide valid data on NEL that is prospective, international, and multicenter. With the comparison of different surgical treatment modalities, we hope to develop better therapy guidelines for this complex neurosurgical condition.

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.

Role of Secondary Endoscopic Third Ventriculostomy in Children: Review of an Institutional Experience

BACKGROUND

Endoscopic third ventriculostomy (ETV) has become a standard and safe procedure for obstructive hydrocephalus. ETV can also play an important role in children presenting with shunt malfunction with an added advantage of shunt independence. Secondary ETV can be defined as either a redo endoscopic ventriculostomy done after primary ETV stoma closure or that done in cases presenting with shunt malfunction.

OBJECTIVE

The aim of our study was to evaluate the role of secondary ETV in the pediatric age group patients.

METHODS

This is a retrospective analysis of 36 children (<18 years) who underwent ETV after shunt malfunction and 4 children with ETV done after previous ETV stoma closure from 2004 until 2018. In all patients, the obstructive pattern suggesting aqueduct outflow obstruction was observed on MRI. Patients were followed up for a mean period of 4.25 years.

RESULTS

ETV was considered successful if the patient avoided a shunt insertion later on in their life. Considering this definition, a success rate of 72% was observed with secondary ETV for shunt malfunction whereas a success rate of 75% was observed after primary ETV failure without any major side effects in any of the patients.

CONCLUSION

ETV can be considered a primary treatment modality in children with shunt malfunction and has a good success rate in cases presenting with closure of previously performed ETV stoma.

Neuroendoscopy for post-infective hydrocephalus in children

The treatment of hydrocephalus has changed in recent years with better imaging and introduction of endoscopic procedures as well as enhanced shunts. Indications of endoscopic third ventriculostomy (ETV) are now more refined with better quantification of outcome. This article reviews the current state of neuroendoscopy for infective hydrocephalus in children. The roles of third ventriculostomy as a primary procedure or after shunt malfunction, endoscopic interventions in multiloculated hydrocephalus and introduction of intraventricular lavage to salvage severely infected children are evaluated.

Successful endoscopic third ventriculostomy in children depends on age and etiology of hydrocephalus: outcome analysis in 51 pediatric patients

PURPOSE

Endoscopic third ventriculostomy (ETV) has become the method of choice in the treatment of hydrocephalus. Age and etiology could determine success rates (SR) of ETV. The purpose of this study is to assess these factors in pediatric population.

METHODS

Retrospective study on 51 children with obstructive hydrocephalus that underwent ETV was performed. The patients were divided into three groups per their age at the time of the treatment: < 6, 6-24, and > 24 months of age. All ETV procedures were performed by the same neurosurgeon.

RESULTS

Overall SR of ETV was 80% (40/51) for all etiologies and ages. In patients < 6 months of age SR was 56.2% (9/16), while 6-24 months of age was 88.9% (16/18) and > 24 months was 94.1% (16/17) (p = 0.012). The highest SR was obtained on aqueductal stenosis. SR of posthemorrhagic, postinfectious, and spina bifida related hydrocephalus was 60% (3/5), 50% (1/2), and 14.3% (1/7), respectively. While SR rate at the first ETV attempt was 85.3%, it was 76.9% in patients with V-P shunt performed previously (p = 0.000).

CONCLUSIONS

Factors indicating a potential failure of ETV were young age and etiology such as spina bifida, other than isolated aqueductal stenosis. ETV is the method of choice even in patients with former shunting. Fast healing, distensible skulls, and lower pressure gradient in younger children, all can play a role in ETV failure. Based on our experience, ETV could be the first method of choice for hydrocephalus even in children younger than 6 months of age.

Application of osteoinductive calcium phosphate ceramics in children's endoscopic neurosurgery: report of five cases

This work aimed at investigating the possibility and effectiveness of osteoinductive calcium phosphate (CaP) ceramics to close the drilled skull holes and prevent the postoperative cerebrospinal fluid (CSF) leaking in children’s endoscopic neurosurgery. Five children patients (four boys and one girl, 3- to 8-years old) underwent the surgery, in which the endoscopic third ventriculostomy (ETV) was operated in four cases of hydrocephalus, and biopsy and ETV were both performed in one case of pineal tumor. The drilled skull holes were filled with the commercial osteoinductive CaP ceramics. The patients were followed up by CT scan at 1, 7 days, 3 and 6 months postoperatively. All the five cases were successful, and the holes were closed well after filled with the ceramics. The follow-up survey showed that no CSF leaking or rejection reaction was found. The CT scan indicated that the drilled holes began healing at 7 days postoperatively, and a relatively complete healing happened at 6 months postoperatively. The excellent ability of the CaP ceramics to induce bone regeneration was also confirmed by repairing the skull defects in a monkey model. The results of μ-CT and histological analysis showed that a bony structure with irregular array occurred at the defect area, and the newly formed bone volume density reached 65.7%. In conclusion, the osteoinductive CaP ceramics could be an ideal material to treat the drilled skull holes in children’s endoscopic neurosurgery and prevent CSF leaking afterwards. However, further investigation with more cases and longer follow-up was required to evaluate the clinical effect.

The Results of Neuroendoscopic Surgery in Patients with Posttraumatic and Posthemorrhagic Hydrocephalus

BACKGROUND

Posttraumatic hydrocephalus (PTH) and posthemorrhagic hydrocephalus (PHH) were previously considered not suitable for neuroendoscopic treatment. New hydrocephalus theories support possible successful neuroendoscopy in such patients.

METHODS

This study presents the results of neuroendoscopy in PTH and PHH with a background analysis. From 130 hydrocephalic patients after neuroendoscopic surgeries, 35 cases with PTH (n = 11) or PHH (n = 24; acute: n = 9, subacute: n = 10, chronic: n = 5) were found. The success rate (Glasgow Outcome Scale [GOS] score 4 or 5 without shunt) and clinical outcome (GOS score) of endoscopic third ventriculostomy (ETV) were analyzed. During the study period, 34 patients had ventriculoperitoneal shunts implanted, including 2 PTH and 5 PHH patients (all chronic).

RESULTS

The success rate of ETV in PTH was 54.5%. In acute PHH, the success rate was 33.3%, 42.8% after excluding devastating hematomas. A post-ETV shunt was implanted in 1 patient (massive subarachnoid hemorrhage [SAH]) with final GOS score of 5. In subacute cases, the ETV success rate was 40% (no post-ETV shunts). In chronic PHH, only 1 patient with a GOS score of 5 was shunt-free (20%). The cause of ETV failure was massive SAH. Low final GOS score was caused by the extent of intracerebral bleeding or extracranial problems. The main indications for primary shunt implantation in PTH and PHH were infectious complications. The rate of good outcomes was 0% in PTH and 40% in PHH.

CONCLUSIONS

The best results of neuroendoscopy were achieved in PTH and acute PHH. ETV failures were associated with massive SAH; arachnoid cistern blockage and scarring precludes ETV success.

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.

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

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

Endoscopic Third Ventriculostomy: Success and Failure

Endoscopic third ventriculostomy (ETV) has now become an accepted mode of hydrocephalus treatment in children. Varying degrees of success for the procedure have been reported depending on the type and etiology of hydrocephalus, age of the patient and certain technical parameters. Review of these factors for predictability of success, complications and validation of success score is presented.

Markedly Improved Success Rate of Endoscopically Assisted Third Ventriculostomy Is Achieved by Routine Placement of External Lumbar Drain

Hydrocephalus is a major cause of patient decreased quality of life and high health care financial burden in the United States and throughout the world. The placement of ventricular shunts (ventriculoperitoneal shunt) has proven to be a safe treatment for hydrocephalus, but it is associated with a high complication rate leading to a lower quality of life and continued financial burden for patients, their families, and society as a whole. The endoscopically assisted third ventriculostomy (ETV) has been practiced as an alternative to ventricular shunting since the 1990s. Success rates vary widely and there are many factors which contribute to the varying success rates. The ETV procedure has the potential to alleviate much of the overall quality of life issues and some of the financial burdens associated with hydrocephalus provided success rates can be increased and the procedure and management techniques are adopted more widely. Common techniques have been published in the past which report associated improvements in success rates amongst individual surgeons. Here, we report a novel perioperative technique and management strategy that displays a higher than reported success rate. Our methods and results show potential to significantly improve overall ETV success rates if reproduced and subsequently adopted widely. We retrospectively studied records of 24 adult patients with hydrocephalus who were treated with an ETV procedure. Routinely, we placed an external lumbar drain postoperatively which was continued for a minimum of 2 days. There was a 95.8% success rate at 30 days. The overall success rate was 83.3%. This is significantly higher than the average of the predicted success scores calculated by the ETV success scoring system (71.8%). It is also significantly higher than previous studies' reported ETV success rates in adults. We propose additional similar studies to be performed to test the reproducibility of increased success rates using our technique, ideally through a prospective, randomized, multicenter trial.

Hydrocephalus in children

Imaging of hydrocephalus in utero, in infants and children is critically dependent on an understanding of the pathophysiology and treatment options for this condition in this age spectrum. For this reason, this chapter deals not only with the imaging modalities used to study hydrocephalus and how they are applied but also reviews key aspects of the pathophysiology and treatment of hydrocephalus in children. Imaging techniques to establish the diagnosis of chronic hydrocephalus fall into two categories: (1) tracer-type techniques that require an injection and observation of the transit of an injected substance through the ventricular system or subarachnoid space and (2) cross-sectional imaging, which allows for direct visualization of a point of obstruction within the ventricular system or subarachnoid space. For cross-sectional imaging, both magnetic resonance imaging (MRI) and computed tomography can be used, but MRI is usually preferred. Nomenclature has obscured the description of imaging findings in hydrocephalus. We suggest that most hydrocephalus is obstructive and propose to designate ventriculomegaly, the condition in which the ventricles are large on imaging, but there is no true obstruction to the outflow of cerebrospinal fluid.

Radiological Assessment of Hydrocephalus: New Theories and Implications for Therapy

It is almost a century since Dandy made the first experimental studies on hydrocephalus, but its underlying mechanism has been unknown up to now. The conventional view is that cerebrospinal fluid (CSF) malabsorption due to hindrance of the CSF circulation causes either obstructive or communicating hydrocephalus. Analyses of the intracranial hydrodynamics related to the pulse pressure show that this is an over-simplification. The new hydrodynamic concept presented here divides hydrocephalus into two main groups, acute hydrocephalus and chronic hydrocephalus. It is still accepted that acute hydrocephalus is caused by an intraventricular CSF obstruction, in accordance with the conventional view. Chronic hydrocephalus consists of two subtypes, communicating hydrocephalus and chronic obstructive hydrocephalus. The associated malabsorption of CSF is not involved as a causative factor in chronic hydrocephalus. Instead, it is suggested that increased pulse pressure in the brain capillaries maintains the ventricular enlargement in chronic hydrocephalus. Chronic hydrocephalus is due to decreased intracranial compliance, causing restricted arterial pulsations and increased capillary pulsations. The terms “restricted arterial pulsation hydrocephalus” or “increased capillary pulsation hydrocephalus” can be used to stress the hydrodynamic origin of both types of chronic hydrocephalus. The new hydrodynamic theories explain why third ventriculostomy may cure patients with communicating hydrocephalus, a treatment incompatible with the conventional view.

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.

Long-term results of endoscopic third ventriculostomy: an outcome analysis

OBJECT

Endoscopic third ventriculostomy (ETV) is the procedure of choice in the treatment of obstructive hydrocephalus. The excellent clinical and radiological success rates are well known. Nevertheless, very few papers have addressed the very long term outcomes of the procedure in very large series. The authors present a large case series of 113 patients who underwent 126 ETVs, and they highlight the initial postoperative outcome after 3 months and long-term follow-up with an average of 7 years.

METHODS

All patients who underwent ETV at the Department of Neurosurgery, Mainz University Hospital, between 1993 and 1999 were evaluated. Obstructive hydrocephalus was the causative pathology in all cases.

RESULTS

The initial clinical success rate was 82% and decreased slightly to 78% during long-term follow-up. Long-term success was analyzed using Kaplan-Meier curves. Overall, ETV failed in 31 patients. These patients underwent a second ETV or shunt treatment. A positive impact on long-term success was seen for age older than 6 months, and for obstruction due to cysts or benign aqueductal stenosis. The complication rate was 9% with 5 intraoperative and 5 postoperative events.

CONCLUSIONS

The high clinical success rate in short-term and long-term follow-up confirms ETV’s status as the gold standard for the treatment of obstructive hydrocephalus, especially for distinct pathologies. The patient’s age and underlying pathology may influence the outcome. These factors should be considered carefully preoperatively by the surgeon.

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.

Limitations of Neuroendoscopic Treatment for Pediatric Hydrocephalus and Considerations from Future Perspectives

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.

[Endoscopic ventriculocisternostomy complications in 108 hydrocephalic patients]

OBJECTIVES

Several reports have been published in relation to complications, sometimes fatal, associated to endoscopic ventriculocisternostomy (EVC). The objective of this study was to determine the range of complications using this surgical technique in a series of 108 patients.

METHODS

A retrospective and descriptive study was performed on 108 hydrocephalic patients: 76 children and 32 adults. All of them presented various forms of obstructive hydrocephalus.

RESULTS

In a total of 108 patients, 114 EVC were performed. The follow-up period ranged between 6 months and 10 years (mean 6.8 years). Age of patients ranged from 6 days to 75 years old (mean 18 years). Aqueductal stenosis was the most common aetiology, with 62 patients (57.4%). Significant complications occurred in 10 patients (9.2%). During the course of the study, the complication rate dropped significantly. No patient died because of the procedure (mortality 0%). We applied the Endoscopic Third Ventriculostomy Success Score (ETVSS) developed by Kulkarni and collaborators to our series to know if this score could be useful in predicting ETV results.

CONCLUSION

Like all minimally-invasive techniques, there is a steep learning curve for EVC. Correct patient selection and surgeon experience (which means not only familiarity with endoscopic techniques but also the performance of a minimum number of surgeries per year) are very important to avoid complications. The ETV Success Score devised closely approximates the predicted probability of ETV success.

Pediatric hydrocephalus: systematic literature review and evidence-based guidelines. Part 2: Management of posthemorrhagic hydrocephalus in premature infants

OBJECT

The objective of this systematic review and analysis was to answer the following question: What are the optimal treatment strategies for posthemorrhagic hydrocephalus (PHH) in premature infants?

METHODS

Both the US National Library of Medicine and the Cochrane Database of Systematic Reviews were queried using MeSH headings and key words relevant to PHH. Two hundred thirteen abstracts were reviewed, after which 98 full-text publications that met inclusion criteria that had been determined a priori were selected and reviewed.

RESULTS

Following a review process and an evidentiary analysis, 68 full-text articles were accepted for the evidentiary table and 30 publications were rejected. The evidentiary table was assembled linking recommendations to strength of evidence (Classes I-III).

CONCLUSIONS

There are 7 recommendations for the management of PHH in infants. Three recommendations reached Level I strength, which represents the highest degree of clinical certainty. There were two Level II and two Level III recommendations for the management of PHH. Recommendation Concerning Surgical Temporizing Measures: I. Ventricular access devices (VADs), external ventricular drains (EVDs), ventriculosubgaleal (VSG) shunts, or lumbar punctures (LPs) are treatment options in the management of PHH. Clinical judgment is required.

STRENGTH OF RECOMMENDATION

Level II, moderate degree of clinical certainty. Recommendation Concerning Surgical Temporizing Measures: II. The evidence demonstrates that VSG shunts reduce the need for daily CSF aspiration compared with VADs.

STRENGTH OF RECOMMENDATION

Level II, moderate degree of clinical certainty. Recommendation Concerning Routine Use of Serial Lumbar Puncture: The routine use of serial lumbar puncture is not recommended to reduce the need for shunt placement or to avoid the progression of hydrocephalus in premature infants.

STRENGTH OF RECOMMENDATION

Level I, high clinical certainty. Recommendation Concerning Nonsurgical Temporizing Agents: I. Intraventricular thrombolytic agents including tissue plasminogen activator (tPA), urokinase, or streptokinase are not recommended as methods to reduce the need for shunt placement in premature infants with PHH.

STRENGTH OF RECOMMENDATION

Level I, high clinical certainty. Recommendation Concerning Nonsurgical Temporizing Agents. II. Acetazolamide and furosemide are not recommended as methods to reduce the need for shunt placement in premature infants with PHH.

STRENGTH OF RECOMMENDATION

Level I, high clinical certainty. Recommendation Concerning Timing of Shunt Placement: There is insufficient evidence to recommend a specific weight or CSF parameter to direct the timing of shunt placement in premature infants with PHH. Clinical judgment is required.

STRENGTH OF RECOMMENDATION

Level III, unclear clinical certainty. Recommendation Concerning Endoscopic Third Ventriculostomy: There is insufficient evidence to recommend the use of endoscopic third ventriculostomy (ETV) in premature infants with posthemorrhagic hydrocephalus.

STRENGTH OF RECOMMENDATION

Level III, unclear clinical certainty.

Endoscopic third ventriculostomy for post-inflammatory hydrocephalus in pediatric patients: is it worth a try?

Hydrocephalus is a very common disease in developing countries. Congenital aqueductal obstruction and post-inflammatory hydrocephalus come on the top of the list of causes of hydrocephalus. Till the recent introduction of cranial endoscopy and despite their frequent complications, shunts were considered as the mainstream treatment for this disease. Endoscopic third ventriculostomy (ETV), especially for obstructive hydrocephalus, introduced a new era of treatment that is free of lifetime shunt dependency. This study was done to assess the efficacy of ETV for treating post-inflammatory hydrocephalus in a unique group of patients thus preventing—if possible—the lifetime shunt dependency and suffering. ETV was tried as a first-line therapy in 35 children (23 males and 12 females) with hydrocephalus proved to be secondary to intracranial infection. Mean age was 9.2 months (4-15). Twenty-four patients (68.6%) were below the age of 6 months while 11 patients (31.4%) were above 6 months. Twenty-five patients (71.4%) had a head circumference of 3 cm and 10 patients (28.6%) had a 5 cm or more increase in the head circumference above the 95th percentile. All the patients included were followed postoperatively with regular clinical, computerized tomography (CT), and magnetic resonance imaging (MRI) examinations as well as cerebrospinal fluid (CSF) analysis and culture. The overall success of ETV was 55.9% (19/34). Nine (81.9%) out of the 11 patients that were endoscopically documented to have aqueductal obstruction showed improvement. While out of the 23 patients with patent aqueduct, only 10 patients (43.4%) had improved. Procedure-related complications were not encountered. CSF leakage from the surgical wound occurred in three patients and mild CSF infection occurred in one patient. ETV is a simple, safe, and effective method in treating not only obstructive hydrocephalus due to non-inflammatory etiology, but also post-inflammatory hydrocephalus especially when the aqueduct is obstructed. An overall 50% improvement in our study and even more in other series encourage the trial of getting rid of the lifetime shunt complications and suffering.

[Treatment of child hydrocephalus by endoscopic third ventriculostomy in Senegal]

INTRODUCTION

Since its advent, endoscopic third ventriculostomy (ETV) has been an effective alternative to shunt placement for the treatment of hydrocephalus. The aim of this study was to report the results of our experience with this technique in children in Senegal.

MATERIALS AND METHODS

This was a retrospective study of 70 cases of children aged between 5 months to 15 years who were treated by ETV in the Neurosurgery Department of Fann Hospital in Dakar, between January 2010 to December 2012. The results were evaluated based on the clinical criteria of Drake and the Canadian Pediatric Neurosurgery Study Group. The mean follow-up duration was 24 months (9-32 months).

RESULTS

The mean age at diagnosis was 29 months. A male predominance (sex-ratio 1/3) was observed. We also noted a macrocephaly in 64.4 % of cases, psychomotor retardation in 40 % and decreased vision in 31.4 %. Headache and vomiting were found in 42.8 % and 61.4 % respectively. The main etiology was a stenosis of the mesencephalon aqueduct (30 %), followed by a Dandy-Walker malformation (25.7 %). Significant intraoperative bleeding was found in 2.8 % of patients. The most common postoperative complication was CSF leakage (18.6 %), followed by infections (14.2 %). The success rate according to the clinical criteria of Drake was 71.4 %. This success rate was influenced by the age of patients and the hydrocephalus etiology. No deaths occurred.

CONCLUSION

The endoscopic third ventriculostomy is a simple, safe and effective technique. Its advantages in terms of quality of life and morbidity compared with bypass valves makes it the technique of choice, particularly in developing countries.

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.

Endoscopic third ventriculostomy with/without choroid plexus cauterization for hydrocephalus due to hemorrhage, infection, Dandy-Walker malformation, and neural tube defect: a meta-analysis

OBJECT

Endoscopic third ventriculostomy (ETV) is a viable alternative to CSF shunting in hydrocephalic patients and is used with varying degrees of success dependent on age and etiology. The purpose of this meta-analysis is to analyze data on ETV and ETV/CPC (choroid plexus cauterization) outcomes in hopes of providing a clear understanding of their limitations in patients with hydrocephalus due to hemorrhage, infection, Dandy-Walker malformation, or neural tube disorders.

METHODS

An extensive PubMed search dating back 11 years was performed on primary ETV or ETV/CPC procedures for hydrocephalus due to infection, hemorrhage, neural tube defects, and Dandy-Walker malformation. ETV success was defined as no intraoperative or post-operative complications and no need for revision surgery at follow-up.

RESULTS

Ten studies were identified for analysis. The data represent 534 patients undergoing primary ETV and 167 patients undergoing primary ETV/CPC. The ETV group reached a 55 % success rate, while the ETV/CPC group reached a 67 % success rate. Success rates of ETV alone for hydrocephalus due to infection, neural tube defects, and intraventricular hemorrhage reached 54, 55, and 57 %, respectively. 84 % success was found in patients older than 2 years of age and 52 % success in patients less than 2 years of age.

CONCLUSIONS

ETV is a valid treatment for hydrocephalus of any etiology. There exists a small difference in success rates between infection, hemorrhage, and neural tube disorders, though not enough to discount ETV for these etiologies. Initial data utilizing ETV/CPC are promising, and additional studies will need to be done to verify such results.

Success rate of endoscopic third ventriculostomy in infants below six months of age with congenital obstructive hydrocephalus (a preliminary study of eight cases)

Aim:

In this study, we were assessing the outcome of Endoscopic Third Ventriculostomy (ETV) in infants below six months of age in cases of congenital obstructive hydrocephalus.

Materials and Methods:

The study was done prospectively on eight cases of obstructive hydrocephalus in infants younger than six months of age to assess the success rate of ETV as a primary treatment for hydrocephalus in this age group; in cases of evident failure, a ventriculo-peritoneal (VP) shunt was applied.

Results:

Despite eliminating the factors suggested as causes of ETV failure in infants below six months; the type, as with the communicating hydrocephalus, the thickness of the third ventricular floor, history of previous intracranial hemorrhage or central nervous system infection, still the success rate did not exceed 12.5%.

Conclusions:

The complication rate following ETV was low in comparison to the high frequency (20–80%) and seriousness of the possible postoperative complications following VP shunt with a significant decrease in the quality of patients’ lives. Hence the decision-making as well as the parental counselling were in a trial to estimate the ETV success or the need to perform a shunt in the treatment of obstructive hydrocephalus.

Current state and future development of intracranial neuroendoscopic surgery

Since the introduction of the modern, smaller endoscopes in the 1960s, neuroendoscopy has become an expanding field of neurosurgery. Neuroendoscopy reflects the tendency of modern neurosurgery to aim towards minimalism; that is, access and visualization through the narrowest practical corridor and maximum effective action at the target point with minimal disruption of normal tissue. Transventricular neuroendoscopy allows the treatment of several pathologies inside the ventricular system, such as obstructive hydrocephalus and intra-/paraventricular tumors or cysts, often avoiding the implantation of extracranial shunts or more invasive craniotomic approaches. Endoscopic endonasal transphenoidal surgery allows the treatment of pathologies of the sellar and parasellar region, with the advantage of a wider vision of the surgical field, less traumatism of the nasal structures, greater facility in the treatment of possible recurrences and reduced complications. However, an endoscope may be used to assist microsurgery in virtually any kind of neurosurgical procedures (endoscope-assisted microsurgery), particularly in aneurysm and tumor surgery. Basic principles of optical imaging and the physics of optic fibers are discussed, focusing on the neuroendoscope. The three main chapters of neuroendoscopy (transventricular, endonasal transphenoidal and endoscope-assisted microsurgery) are reviewed, concerning operative instruments, surgical procedures, main indications and results.

Endoscopic Transventricular Transaqueductal Magendie and Luschka Foraminoplasty for Hydrocephalus

BACKGROUND:

Routinely, hydrocephalus related to fourth ventricular outlet obstruction (FVOO) has been managed with ventriculoperitoneal (VP) shunting or endoscopic third ventriculostomy (ETV). Few reports on Magendie foraminoplasty exist, and Luschka foraminoplasty has not been described.

OBJECTIVE:

To present an alternative technique in the management of FVOO via an endoscopic transventricular transaqueductal Magendie and Luschka foraminoplasty and to discuss the indications, technique, findings, and outcomes.

METHODS:

Between 1994 and 2011, all patients who underwent endoscopic Magendie and Luschka foraminoplasty were analyzed.

RESULTS:

A total of 33 Magendie (28) and/or Luschka (5) foraminoplasties were performed in 30 patients. Twenty-three were adult and 7 were pediatric patients. The etiology of the FVOO was divided into primary etiologies (congenital membrane in 5 and atresia in 2) and secondary causes (neurocysticercosis in 14 patients, bacterial meningitis in 9). Fifteen (50%) had previously failed procedures. Intraoperative findings that led to Magendie/Luschka foraminoplasty were ETV not feasible to perform, nonpatent basal subarachnoid space, or primary FVOO. Minor postoperative complications were seen in 3 patients. Only 26 patients had long-term follow-up; 17 (65.3%) of these had clinical improvement and did not require further procedures. Nine (34.7%) did not improve. Eight required another procedure (7 shunts, and 1 endoscopic procedure). One patient died.

CONCLUSION:

Flexible neuroendoscopic transventricular transforaminal Magendie and Luschka foraminoplasty is feasible and safe. These procedures may prove to be viable alternatives to standard ETV and VP shunt in appropriate patients. Adequate intraoperative assessment of ETV success is necessary to identify patients who will benefit.