Endoscopic Third Ventriculostomy before Posterior Fossa Tumor Surgery in Adult Patients

Objective Obstructive hydrocephalus in patients with posterior fossa tumors is frequently seen. Treatment options include immediate tumor removal or prior cerebrospinal fluid (CSF) diversion procedures. The necessity and feasibility of an ETV in these situations has not yet been proven in adult patients. Methods We retrospectively reviewed our prospectively maintained database for ETVs before surgery of posterior fossa tumors in adults. The primary focus of data analyses was the question of whether the ETV was suitable to treat the acute situation of hydrocephalus without an increased rate of complications due to the special anatomical situation with a posterior fossa tumor. We also analyzed whether any further CSF diverting procedures were necessary. Results A total of 40 adult patients who underwent an ETV before posterior fossa tumor surgery were analyzed. Overall, 33 patients (82.5%) had clinical signs of hydrocephalus, and all of them improved in their clinical course after ETV. Seven patients (17.5%) did not demonstrate clinical signs of hydrocephalus, but ETV was performed with prophylactic or palliative intent in six patients and one patient, respectively. No complications were observed due to ETV itself. No permanent shunting procedure was necessary in a mean follow-up of 76.5 months. Early additional CSF diverting procedures (redo ETV, external ventricular drain) were performed in five patients (12.5%). Conclusion The present series confirms the feasibility and safety of ETV before posterior fossa tumor surgery in adult patients. If patients had symptomatic hydrocephalus before tumor surgery, an ETV can be performed, followed by early elective tumor surgery. A prophylactic ETV in asymptomatic patients is not advised. Early elective tumor surgery should be performed in these patients.

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Ventriculoperitoneal Shunt versus Endoscopic Third Ventriculostomy in the treatment of Obstructive Hydrocephalus in Pediatric Midline Posterior Fossa tumors

QJM ◽

10.1093/qjmed/hcab108.011 ◽

2021 ◽

Vol 114 (Supplement_1) ◽

Author(s):

Mohammed Tarek ◽

Hamdy Ibrahim ◽

H Jalalod'din ◽

SR Tawadros

Keyword(s):

Posterior Fossa ◽

Ventriculoperitoneal Shunt ◽

Endoscopic Third Ventriculostomy ◽

Obstructive Hydrocephalus ◽

Clinical Findings ◽

Third Ventriculostomy ◽

Posterior Fossa Tumors ◽

Shunt Insertion ◽

Vp Shunt ◽

Csf Diversion

Abstract Background Treatment of secondary hydrocephalus due to posterior fossa tumors in these children is still a matter of controversy, although preoperative ventriculo-peritoneal shunt (VP shunt) insertion before tumor excision is widely accepted among neurosurgeons but many attempts are rising to minimize permanent VP shunt insertion and associated complications and introducing third endoscopic ventriculostomy (ETV) as one of the options of 2ry hydrocephalus. Objectives Comparing the post-operative clinical success with resolution of the manifestations and post-operative complications between endoscopic third ventriculostomy and ventriculoperitoneal shunt as different modes of CSF diversion in children with 2ry hydrocephalus due to midline posterior fossa tumors. Methods The following electronic databases were searched from June 2009 to june2019: PubMed, Google scholar search engine. Cochrane database of systematic reviews, EMBASE and science Direct, using the keywords ―hydrocephalus; posterior fossa tumors; pediatrics; ventriculoperitoneal shunt; endoscopic third ventriculostomy‖. Studies were eligible if they contain the target keywords in title or abstract, addressing the Pediatric age group with 2ry hydrocephalus due to de novo posterior fossa tumor manifested by signs of increase the intra cranial tension including persistent headache and vomiting, blurred vision, 6th nerve palsy, papilledema in fundus examination, acute DCL and 2ry hydrocephalus confirmed by brain imaging. Exclusion criteria included studies including age group below 1yr or above 18 yr, or patients with recurrent post fossa tumors and operated before or patients presented by failed previously attempt of CSF diversion. Results: A total of 1255 citations were screened for eligibility,6 studies were included in our systematic review discussing, comparing and evaluating the durability of ETV versus VP shunt in treatment the 2ry hydrocephalusdue to pediatric posterior fossa tumor.. Overall study population reached 474 patients. the overall clinical findings at presentation and postoperative outcomes regarding the clinical findings improvement, radiological improvement and postoperative complications between ETV and VP shunt are compared and showing that ETV should be considered as an alternative procedure to VP shunt in controlling severe hydrocephalus related to posterior fossa tumors to relieve symptoms quickly during the preoperative period when patients should wait for their definite tumor excision. Conclusion The shorter duration of surgery, the lower incidence of morbidity, the absence of mortality, the lower incidence of procedure failure of endoscopic third ventriculostomy as compared to ventriculoperitoneal shunt, and the significant advantage of not becoming shunt dependent make endoscopic third ventriculostomy to be recommended as the first choice in the treatment of pediatric patients with marked obstructive hydrocephalus due to posterior fossa tumors. It is a preliminary, simple, safe, effective, physiological, minimally invasive procedure for the relief of elevated intracranial pressure before direct tumor removal.

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