Endoscopic Third Ventriculostomy in Obstructive Infantile Hydrocephalus: Remarks about the So-Called ‘Unsuccessful Cases’

Abstract Purpose Intraventricular neuroendoscopic techniques, particularly third ventriculostomy, are employed increasingly in the management of infantile hydrocephalus. However, surgical access to the ventricular cavities is associated with a risk of post-operative cerebrospinal fluid (CSF) leak. Here, we describe a structured, multi-layered approach to wound opening and closure which aims to maximise the natural tissue barriers against CSF leakage. We present a series of patients undergoing this technique and subsequently review the literature regarding opening and closure techniques in paediatric intraventricular neuroendoscopic procedures. Methods We performed a retrospective case series analysis of patients under 1 year of age who underwent intraventricular neuroendoscopic procedures in a single institution over a 5-year period. Patients were identified from an institutional operative database, and operation notes and clinical records were subsequently reviewed. Results 28 patients fulfilled the inclusion criteria for this study. The mean age at operation was 9 weeks. 27 patients underwent endoscopic third ventriculostomy whilst 1 underwent endoscopic septostomy, and all patients underwent our structured, multi-layered opening and closure technique. Follow-up ranged from 4 months to 5 years. There were no cases of post-operative CSF leak, infection or wound breakdown. 12 patients remained shunt-free at the last follow-up, with the remaining 16 requiring shunt insertion for progressive hydrocephalus at a mean of 24 days post-operatively. Conclusion Various methods aiming to prevent post-operative CSF leak have been reported in the literature. We propose that our institutional technique may be of benefit in minimising this risk in infants undergoing endoscopic third ventriculostomy and similar intraventricular neuroendoscopic procedures.

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The importance of extent of choroid plexus cauterization in addition to endoscopic third ventriculostomy for infantile hydrocephalus: a retrospective North American observational study using propensity score–adjusted analysis

Journal of Neurosurgery Pediatrics ◽

10.3171/2017.7.peds16379 ◽

2017 ◽

Vol 20 (6) ◽

pp. 503-510 ◽

Cited By ~ 2

Author(s):

Aria Fallah ◽

Alexander G. Weil ◽

Kyle Juraschka ◽

George M. Ibrahim ◽

Anthony C. Wang ◽

...

Keyword(s):

Propensity Score ◽

Multivariate Regression ◽

Propensity Scores ◽

Endoscopic Third Ventriculostomy ◽

Third Ventriculostomy ◽

Infantile Hydrocephalus ◽

Multivariable Regression ◽

Csf Diversion ◽

Shunt Independence ◽

Choroid Plexus Cauterization

OBJECTIVECombined endoscopic third ventriculostomy (ETC) and choroid plexus cauterization (CPC)—ETV/CPC— is being investigated to increase the rate of shunt independence in infants with hydrocephalus. The degree of CPC necessary to achieve improved rates of shunt independence is currently unknown.METHODSUsing data from a single-center, retrospective, observational cohort study involving patients who underwent ETV/CPC for treatment of infantile hydrocephalus, comparative statistical analyses were performed to detect a difference in need for subsequent CSF diversion procedure in patients undergoing partial CPC (describes unilateral CPC or bilateral CPC that only extended from the foramen of Monro [FM] to the atrium on one side) or subtotal CPC (describes CPC extending from the FM to the posterior temporal horn bilaterally) using a rigid neuroendoscope. Propensity scores for extent of CPC were calculated using age and etiology. Propensity scores were used to perform 1) case-matching comparisons and 2) Cox multivariable regression, adjusting for propensity score in the unmatched cohort. Cox multivariable regression adjusting for age and etiology, but not propensity score was also performed as a third statistical technique.RESULTSEighty-four patients who underwent ETV/CPC had sufficient data to be included in the analysis. Subtotal CPC was performed in 58 patients (69%) and partial CPC in 26 (31%). The ETV/CPC success rates at 6 and 12 months, respectively, were 49% and 41% for patients undergoing subtotal CPC and 35% and 31% for those undergoing partial CPC. Cox multivariate regression in a 48-patient cohort case-matched by propensity score demonstrated no added effect of increased extent of CPC on ETV/CPC survival (HR 0.868, 95% CI 0.422–1.789, p = 0.702). Cox multivariate regression including all patients, with adjustment for propensity score, demonstrated no effect of extent of CPC on ETV/CPC survival (HR 0.845, 95% CI 0.462–1.548, p = 0.586). Cox multivariate regression including all patients, with adjustment for age and etiology, but not propensity score, demonstrated no effect of extent of CPC on ETV/CPC survival (HR 0.908, 95% CI 0.495–1.664, p = 0.755).CONCLUSIONSUsing multiple comparative statistical analyses, no difference in need for subsequent CSF diversion procedure was detected between patients in this cohort who underwent partial versus subtotal CPC. Further investigation regarding whether there is truly no difference between partial versus subtotal extent of CPC in larger patient populations and whether further gain in CPC success can be achieved with complete CPC is warranted.

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Endoscopic third ventriculostomy with choroid plexus cauterization for the treatment of infantile hydrocephalus in Haiti

Journal of Neurosurgery Pediatrics ◽

10.3171/2019.10.peds19433 ◽

2020 ◽

Vol 25 (4) ◽

pp. 411-416

Author(s):

Ashish H. Shah ◽

Yudy LaFortune ◽

George M. Ibrahim ◽

Iahn Cajigas ◽

Michael Ragheb ◽

...

Keyword(s):

Choroid Plexus ◽

Endoscopic Third Ventriculostomy ◽

Proportional Hazards ◽

Univariate Analysis ◽

Significant Risk ◽

Cox Proportional Hazards ◽

Third Ventriculostomy ◽

Infantile Hydrocephalus ◽

Middle Income ◽

Choroid Plexus Cauterization

OBJECTIVEUntreated hydrocephalus poses a significant health risk to children in the developing world. In response to this risk, global neurosurgical efforts have increasingly focused on endoscopic third ventriculostomy with choroid plexus cauterization (ETV/CPC) in the management of infantile hydrocephalus in low- and middle-income countries (LMICs). Here, the authors report their experience with ETV/CPC at the Hospital Bernard-Mevs/Project Medishare (HBMPM) in Port-au-Prince, Haiti.METHODSThe authors conducted a retrospective review of a series of consecutive children who had undergone ETV/CPC for hydrocephalus over a 1-year period at HBMPM. The primary outcome of interest was time to ETV/CPC failure. Univariate and multivariate analyses using a Cox proportional hazards regression were performed to identify preoperative factors that were associated with outcomes.RESULTSOf the 82 children who underwent ETV/CPC, 52.2% remained shunt free at the last follow-up (mean 6.4 months). On univariate analysis, the ETV success score (ETVSS; p = 0.002), success of the attempted ETV (p = 0.018), and bilateral CPC (p = 0.045) were associated with shunt freedom. In the multivariate models, a lower ETVSS was independently associated with a poor outcome (HR 0.072, 95% CI 0.016–0.32, p < 0.001). Two children (2.4%) died of postoperative seizures.CONCLUSIONSAs in other LMICs, ETV/CPC is an effective treatment for hydrocephalus in children in Haiti, with a low but significant risk profile. Larger multinational prospective databases may further elucidate the ideal candidate for ETV/CPC in resource-poor settings.

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The Efficacy Analysis of Endoscopic Third Ventriculostomy in Infantile Hydrocephalus

Journal of Korean Neurosurgical Society ◽

10.3340/jkns.2015.57.2.119 ◽

2015 ◽

Vol 57 (2) ◽

pp. 119 ◽

Cited By ~ 8

Author(s):

Zhenhua He ◽

Caixia An ◽

Xinding Zhang ◽

Xiaodong He ◽

Qiang Li

Keyword(s):

Endoscopic Third Ventriculostomy ◽

Third Ventriculostomy ◽

Infantile Hydrocephalus ◽

Efficacy Analysis

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Fungal Granuloma following Endoscopic Third Ventriculostomy for Infantile Hydrocephalus = الورم الفطري الحبيبي بعد عملية التجويف الثالث بالمنظار لإستسقاء الرأس في الرضع

Sultan Qaboos University Medical Journal [SQUMJ] ◽

10.12816/0003213 ◽

2013 ◽

Vol 13 (1) ◽

pp. 162-164 ◽

Cited By ~ 2

Author(s):

Rajeev Kariyattil ◽

Dilip Panikar

Keyword(s):

Endoscopic Third Ventriculostomy ◽

Third Ventriculostomy ◽

Infantile Hydrocephalus

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Endoscopic third ventriculostomy with choroid plexus cauterization outcome: distinguishing success from failure

Journal of Neurosurgery Pediatrics ◽

10.3171/2016.6.peds1675 ◽

2016 ◽

Vol 18 (6) ◽

pp. 655-662 ◽

Cited By ~ 9

Author(s):

Michael C. Dewan ◽

Jaims Lim ◽

Clinton D. Morgan ◽

Stephen R. Gannon ◽

Chevis N. Shannon ◽

...

Keyword(s):

Choroid Plexus ◽

Head Circumference ◽

Predictive Value ◽

Endoscopic Third Ventriculostomy ◽

Third Ventriculostomy ◽

Anterior Fontanel ◽

Infantile Hydrocephalus ◽

Predictive Values ◽

Choroid Plexus Cauterization ◽

Made In

OBJECTIVE Endoscopic third ventriculostomy with choroid plexus cauterization (ETV/CPC) offers an alternative to shunt treatment for infantile hydrocephalus. Diagnosing treatment failure is dependent on infantile hydrocephalus metrics, including head circumference, fontanel quality, and ventricle size. However, it is not clear to what degree these metrics should be expected to change after ETV/CPC. Using these clinical metrics, the authors present and analyze the decision making in cases of ETV/CPC failure. METHODS Infantile hydrocephalus metrics, including bulging fontanel, head circumference z-score, and frontal and occipital horn ratio (FOHR), were compared between ETV/CPC failures and successes. Treatment outcome predictive values of metrics individually and in combination were calculated. RESULTS Forty-four patients (57% males, median age 1.2 months) underwent ETV/CPC for hydrocephalus; of these patients, 25 (57%) experienced failure at a median time of 51 days postoperatively. Patients experiencing failure were younger than those experiencing successful treatment (0.8 vs 3.9 months, p = 0.01). During outpatient follow-up, bulging anterior fontanel, progressive macrocephaly, and enlarging ventricles each demonstrated a positive predictive value (PPV) of no less than 71%, but a bulging anterior fontanel remained the most predictive indicator of ETV/CPC failure, with a PPV of 100%, negative predictive value of 73%, and sensitivity of 72%. The highest PPVs and specificities existed when the clinical metrics were present in combination, although sensitivities decreased expectedly. Only 48% of failures were diagnosed on the basis all 3 hydrocephalus metrics, while only 37% of successes were negative for all 3 metrics. In the remaining 57% of patients, a diagnosis of success or failure was made in the presence of discordant data. CONCLUSIONS Successful ETV/CPC for infantile hydrocephalus was evaluated in relation to fontanel status, head growth, and change in ventricular size. In most patients, a designation of failure or success was made in the setting of discordant data.

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