Clinical Outcome, Cognitive Function, and Quality of Life after Endoscopic Third Ventriculostomy versus Ventriculo-Peritoneal Shunt in Non-Tumor Hydrocephalus

The Call for Neuroendoscopy Cadaveric Workshops in Lower-Middle Income Countries

OBJECTIVE

This study aims to assess the impact of the workshops organized during Neuroendocon 23 on the perspective and confidence of neurosurgeons toward endoscopy in a lower-middle income country.

METHODS

Neuroendocon 23 had cranial and spinal endoscopy cadaveric workshops with 30 delegates each. A pre and postworkshop survey was disseminated among the delegates, and statistical analysis was performed with SPSS (version 26) using P < 0.05.

RESULTS

A total of 24 delegates (40%) consented to participate in the study, with only 1 female respondent (4.17%). After the cranial endoscopy workshop, there was an increase in the level of confidence of delegates in cranial endoscopic approaches (P < 0.001). Similarly, after the spine endoscopy workshop, the respondents had increased confidence in managing spine conditions with the endoscopic approach (P = 0.040), to the extent that they preferred the endoscopic over the microsurgical technique (P < 0.001). All respondents (n = 24, 100%) believed that endoscopy should be promoted in lower-middle income countries and integrated into residency curricula.

CONCLUSIONS

Cranial and spinal endoscopy cadaveric workshops could be the first step in stimulating the interest of neurosurgeons in endoscopy.

Small Bowel Obstruction and Enterococcus Meningitis: Rare Complications of Ventriculoperitoneal Shunt Placement

A ventriculoperitoneal (VP) shunt is a commonly used mechanical device indicated for congenital and acquired hydrocephalus in children. Although VP shunt failure is not uncommon, the symptomatology and cause of failure can vary. In this case, we describe intestinal obstruction in a three-year-old Caucasian female with a history of Pilomyxoid Astrocytoma and VP shunt placement for the management of hydrocephalus. Surgical exploration revealed ischemia of the terminal ileum secondary to VP shunt tubing-induced adhesions requiring bowel resection. A secondary VP shunt infection due to Enterococcus faecalis was also noted. Our case highlights a unique presentation of intestinal obstruction and infection that should serve to increase provider suspicion when evaluating patients presenting with abdominal distention and pain with presence of a VP shunt.

Tetraventricular hydrocephalus with aqueductal flow void: an overlooked entity having consistent improvement following endoscopic third ventriculostomy

BACKGROUND

Tetraventricular Hydrocephalus (TetHCP) is a heterogeneous group of cerebrospinal fluid (CSF) flow disorders having varying success rates with Endoscopic third ventriculostomy (ETV). This is report on the efficacy and rationale of ETV in a specific subset of primary TetHCP with aqueductal CSF flow voids.

METHODS

Patients of primary acquired TetHCP presenting with increasing head size and/or headache having aqueductal CSF flow void on sagittal Magnetic Resonance Imaging (MRI) were included in this study. All of them underwent ETV. All patients were evaluated for clinical improvement & MRI at 3 months, and need for any additional procedure, in contrast to those without CSF flow void. The pathophysiology of hyperdynamic CSF circulation and its correlation to ETV was further reviewed.

RESULTS

Eleven patients had tetraventricular hydrocephalus and aqueductal flow void, with age ranging from 10 months to 59 years. Two patients who could undergo quantitative flow study confirmed the hyperdynamic flow across the aqueduct. Following ETV, all showed clinical improvement. MRI at 3 months showed CSF flow void across the third ventricular stoma in addition to across the aqueduct. None of these patients required any redo procedures for a mean follow-up of 39.2 months. In contrast, there was 30% failure rate after ETV among 10 patients of tetraventricular hydrocephalus without aqueductal flow void.

CONCLUSION

Tetraventricular hydrocephalus with aqueductal CSF flow void may be a unique entity with hyperdynamic CSF circulation and relative resistance at fourth ventricular outlets. ETV is highly efficacious in these patients, resulting in consistent clinico-radiological improvement.

Feasibility of awake endoscopic third ventriculostomy in selected patients of obstructive hydrocephalus

BACKGROUND

Endoscopic third ventriculostomy (ETV) is usually performed under general anesthesia (GA) with proper head immobilization. However a few patients with hydrocephalus (HCP) may not be suitable for GA. Once the surgeon is familiar with endoscopic ventricular anatomy and gains adequate surgical experience with the procedure, ETV can be attempted under local anesthesia (LA) in selected patients. Here we discuss our experience of treating 32 patients of HCP with ETV under LA.

METHODS

32 symptomatic HCP patients with in the age range of 13 and 65 years, conscious, alert, cooperative and at high risk for GA owing to deranged liver or renal function, associated co-morbidities, pregnancy were considered for ETV under scalp block. All patients were evaluated for any discomfort during the surgical intervention.

RESULT

All procedures were completed under LA. Four patients needed additional sedation prior to the scalp block to alleviate their apprehension. Four patients complained of bilateral orbital pain. In three it coincided with irrigation of fluid lower than body temperature. One patient had pain while touching the dorsum sella and needed analgesic supplement. All of them improved and none required additional CSF diversion within the average follow up of 9.5 months.

CONCLUSION

ETV can be performed under local anesthesia in conscious, alert and cooperative patients in experienced hands. Unnecessary stimulation of the painful structures should be avoided and fluid for irrigation should be at body temperature. This ensures patient comfort and safety of the procedure.

The effect of shunt removal on the quality of life in patients with congenital hydrocephalus

BACKGROUND

Although there have been reports investigating the quality of life of patients who underwent ventriculoperitoneal shunting or endoscopic third ventriculostomy (ETV) for congenital hydrocephalus, there have been no studies of the quality of life of patients after ventriculoperitoneal shunt (VPS) removal. In the present study, a survey of pediatric and congenital hydrocephalus patients was conducted to compare the quality of life of patients with a remaining VPS with that of patients who had the shunt removed.

METHODS

Between February 2020 and November 2021, an outpatient survey was administered to patients 8 years of age and older who had undergone VPS due to a diagnosis of congenital hydrocephalus. The Hydrocephalus Outcome Questionnaire (HOQ) was used to assess the quality of life for this study. The HOQ scores (overall health score, physical health score, cognitive health score, and social-emotional health score) were compared among three groups: a VPS-remaining group, VPS-removed with endoscopic third ventriculostomy (ETV) group, and VPS-removed without ETV group.

RESULTS

The total number of patients who underwent VPS for hydrocephalus was 71, with 47 in the VPS-remaining group, 14 in the shunt-removed with ETV group, and 10 in the shunt-removed without ETV group. The HOQ overall health score was 0.68 for the VPS-remaining group, 0.74 for the shunt-removed with ETV group, and 0.74 for the shunt-removed without ETV. There were no significant differences between the VPS-remaining group and the VPS-removed with or without ETV groups (p = 0.3255, 0.4178, respectively).

CONCLUSION

There was no significant difference in the quality of life between patients with a remaining VPS and those who had their VPS removed with or without ETV.

Children hydrocephalus in Togo: etiologies, treatment, and outcomes

Background

Hydrocephalus is frequent in sub-Saharan African countries. The postinfectious hydrocephalus tends to decrease. The objective of this study was to identify the etiologies and outcomes of hydrocephalus.

Methods

This was a retrospective study of hydrocephalus cases (0-15 years old) treated in the neurosurgery unit of the Sylvanus Olympio Hospital in Lomé over 10 years (2012-2021). At 1 year, the evolution distinguished in two categories: (1) Good psychomotor development: no delay in the acquisition of walking, language, and school. (2) Psychomotor delay: delay in the acquisition of walking, language, and school.

Results

We reported 305 children treated for hydrocephalus representing 1.8% of all neurosurgery unit patients and 34.2% of pediatric pathologies. There was a male predominance (60.6%). We noted second degree consanguinity in 8.5%. The positive maternal serologies were HIV (12.4%), syphilis (8.2%), and toxoplasmosis (2.6%). A malaria episode had been treated during the first trimester in 36.7% of the mothers. The main clinical sign of hydrocephalus was 91.5% of Macrocephalus. Congenital Malformafions were the most common etiologies of hydrocephalus (68.5%). Ventriculoperitoneal shunt was the main surgical method used and 16 deaths were recorded. The medium-term evolution (1 year) was evaluated in 36.1% and noted 61.8% of psychomotor retardation.

Conclusion

This study confirms the trend of the predominance of congenital causes of hydrocephalus in Africa, even if maternal infections can be involved in the development of some of them. The morbimortality of this pathology remains important, especially concerning neurocognitive outcomes.

Shunt Migration in Children: A Patient Level Systematic Review of Risk Factors and Outcome

Ventriculoperitoneal shunt insertion is one of the most common pediatric neurosurgical procedures performed. Shunt migration is one of the infrequent complications of shunt insertion and often requires a change of the shunt system. The objective of the study is to systematically review the sites of shunt migration and factors associated with mortality in children. Comprehensive search and review of the literature were done according to the PRISMA guidelines. Citations were selected using the following inclusion criteria: 1. Shunt migration in ventriculoperitoneal shunts was the primary inclusion criteria, 2. Age of the study participants <18 years, and 3. Patient-level data available in the study. Exclusion criteria were 1. Age >18 years, 2. Patient-level data not available, 3. Full text of the article not available, and 4. Article not in the English language. Sites of migration and risk factors for mortality were assessed. In total, 111 studies out of 161 studies were included in the final analysis. The scrotum was the most common site of shunt migration (30.67%), followed by anal migration, migration into the bowel, chest wall/thoracic migration, and intracranial/subgaleal migration. Univariate analysis showed the presence of infection and site of migration to be significantly associated with mortality. Multivariate analysis showed the presence of infection and age at presentation to be significant predictors of mortality. This study highlights that presence of infection is a significant predictor of mortality in cases of shunt migration. Infection should be managed expeditiously for optimum management of shunt migration.