Endoscopic Third Ventriculostomy: Our Experience of Consecutive 50 Cases at a Tertiary Care Center

Objective The aim of this study was to do a retrospective analysis of the various neurosurgical pathologies where endoscopic third ventriculostomy (ETV) was used and to evaluate the outcome and prognosis. Methods The retrospective data collection was done for the patients who underwent ETV with or without other adjunct procedures; the results were prepared for clinical presentation, diagnosis, surgical approach, and surgical goal; and success rate and prognosis were analyzed and compared with other studies. Results A total of 50 patients were included in the study, with overall success rate of ETV as 88%; aqueductal stenosis was the most common indication where ETV was used; headache and vomiting were the most common presenting complaints followed by ataxia and visual blurring; and ETV provided flexibility in its use with biopsy, abscess drainage, temporary external ventricular drain placement, etc. Conclusion ETV being superior to ventriculo-peritoneal shunt for obstructive hydrocephalus provides flexibility in its use and possibly is a useful adjunct to prevent postoperative hydrocephalus after endoscopic intraventricular surgery; proper case selection in accordance to ETV success score yields a better success rate. In experienced hands with proper precautions, perioperative complications can be kept at minimum. Wherever possible, in cases of obstructive hydrocephalus, especially in patients >1 year of age, ETV should be the treatment of choice. We recommend a proper case selection, including preoperative detailed reading of sagittal magnetic resonance imaging scan, to improve the success rate with less complication.

Clinical Impact of the Patient Age Following Endoscopic Third Ventriculostomy: A Review

Background: Clinically erratic cerebrospinal fluid (CSF) outflow within brain ventricles was described as non-communicating and communicating hydrocephalous. Neurosurgical patients are commonly seen with increased intracranial pressure due to increased CSF accumulation. (1) Initially scientists followed ventriculoperitoneal shunt an inexpensive and available technique to treat hydrocephalous disorders. Due to least successful outcomes, Scientists used other alternative endoscopic techniques. These endoscopic techniques include aqueductal endoscopic stenting, aqueductoplasty and third ventriculostomy (2). Defining success rate of Endoscopic third ventriculostomy clinical and radiographic analysis are considered gold standard. Objectives: Our review aims to assess comparative role of patient age, patient selection, hydrocephalus etiology, surgical advancement and epigenetic treatment strategies following endoscopic third ventriculostomy focusing hydrocephalous. The main objectives of current study, to critically analyze available literature till to date and a step forward for the development of standard surgical protocols. Methodology: Clinical studies from Level I-IV published in English language focusing human subject only were only considered by retrieving NCBI/PubMed, Medline databases. Studies purely focusing third ventriculostomy in subject of patient age, hydrocephalus etiology and age associated complications were processed further. Objective based data inspection approach was followed. From each included study focusing third ventriculostomy detailed information demographic information was collected. Further data analysis was done by using SAS and multiple tools of Microsoft Excel Version 2010. Outcomes: From total 11 included studies specifically focusing hydrocephaly treatment via endoscopic third ventriculostomy, 757 patients with equal 1:1 male and female gender ratio and 125 cases of unknown gender were considered. Current study highlighting efficacy of Endoscopic third ventriculostomy at the rate of 77% effective treating obstructive hydrocephalus. On basis of etiological concerns about 36.32 % cases hydrocephalous cases were linked with encephalitis, underweight birth and nonspecific etiology. However, 24 % cases of hydrocephalus were led by group of tumors including, Ependymoma, Medulloblastoma, Meningioma, Cerebella pontine angle Tumors and Pineal gland carcinomas as well. 154 (20%) cases of obstructive hydrocephalus were associated with aqueduct stenosis, 16% cases reporting hemorrhage and only 23 cyst cases. Conclusion and future recommendations: Endoscopic third ventriculostomy (ETV) is a safe and effective (77%) treatment option for the treatment of obstructive hydrocephalus among all age groups. However, specifically highest efficacy was noted among patients of 15-30-year age group. Understanding disease etiology and patient selection criteria both are considered potential components following successful endoscopic third ventriculostomy. We highly recommend further research following a universal age criteria and reporting results in distinct age category to standardize ETV treating hydrocephaly efficiently. Key words: Endoscopic third ventriculostomy, ETV, hydrocephalous, aqueductal endoscopic stenting, aqueductoplasty.

Successful management of symptomatic hydrocephalus using a temporary external ventricular drain with or without endoscopic third ventriculostomy in pediatric patients with germinoma

OBJECTIVE The objective of this study was to describe the management of hydrocephalus in a cohort of pediatric patients with germinoma. METHODS The authors conducted a retrospective chart review of patients with germinoma and symptomatic hydrocephalus treated at the Hospital for Sick Children between 2002 and 2020. Descriptive data included tumor location, CSF diversion procedure (external ventricular drain [EVD], endoscopic third ventriculostomy [ETV], ventriculoperitoneal [VP] shunt) and outcomes. The frontooccipital horn ratio (FOR) method was used to determine the presence of ventriculomegaly. RESULTS Of 39 patients with germinoma, 22 (73% male) had symptomatic hydrocephalus at diagnosis (11 pineal, 4 suprasellar, and 7 bifocal). Management of hydrocephalus included EVD (n = 5, 22.7%), ETV (n = 5, 22.7%), and combination ETV and EVD (n = 7, 31.8%), whereas 5 patients (22.7%) did not undergo surgical intervention. The median FOR at diagnosis was 0.42 (range 0.38–0.58), which correlated with moderate to severe ventriculomegaly. Carboplatin and etoposide–based chemotherapy induced fast tumor shrinkage, avoiding CSF diversion (n = 5) and resolving hydrocephalus with a transient EVD (n = 5). The median duration until EVD removal was 7 days (range 2–10 days). Two of 12 patients with EVD ultimately required a VP shunt. Kaplan-Meier overall survival was 100% and progression-free survival was 96.4% at a median follow-up of 10.4 years. CONCLUSIONS Timely initiation of chemotherapy is imperative to rapidly reduce tumor bulk in children with germinoma and limits the need for VP shunt insertions. In children in whom CSF diversion is required, hydrocephalus may be successfully managed with a temporary EVD ± ETV.

Hydrocephalus in achondroplasia: efficacy of endoscopic third ventriculostomy

OBJECTIVE Ventriculoperitoneal shunts (VPSs) for hydrocephalus in patients with achondroplasia are known to have a higher failure rate than in other hydrocephalus populations. However, the etiology of hydrocephalus in this group is considered “communicating,” and, therefore, potentially not amenable to endoscopic third ventriculostomy (ETV). ETV has, nonetheless, been reported to be successful in a small number of patients with achondroplasia. The authors aimed to investigate the long-term results of ETV in this population. METHODS Patients with achondroplasia who had undergone surgical treatment for hydrocephalus (ETV or VPS placement) were identified. In patients who had undergone ETV, medical records and neuroimages were reviewed to determine ventricular volumes and frontal and occipital horn ratios (FOHRs) pre- and postoperatively, as well as the incidence of surgical complications and reoperation. Patients who underwent VPS placement were included for historical comparison, and their medical records were reviewed for basic demographic information as well as the incidence of surgical complications and reoperation. RESULTS Of 114 pediatric patients with achondroplasia referred for neurosurgical consultation, 19 (17%) were treated for hydrocephalus; 10 patients underwent ETV only, 7 patients underwent VPS placement only, and 2 patients had a VPS placed followed by ETV. In patients treated with ETV, ventricular volume and FOHRs were normal, if measured at birth, and increased significantly until the time of the ETV. After ETV, all patients demonstrated significant and sustained decreases in ventricular measurements with surveillance up to 15 years. There was a statistically significant difference in rates of repeat CSF surgery between the ETV and VPS cohorts (0/12 vs 7/9, p < 0.001). CONCLUSIONS ETV was efficacious, safe, and durable in the treatment of hydrocephalus in patients with achondroplasia. Although many studies have indicated that hydrocephalus in these patients is “communicating,” a subset may develop an “obstructive” component that is progressive and responsive to ETV.

A bi-foraminal craniometric-guided approach to endoscopic third ventriculostomy and biopsy of a pineal tumour

Background: Pineal tumors are very rarely encountered, with an incidence of <1% of intracranial lesions in adults. Life-threatening hydrocephalus due to obstruction of the third ventricle can result from the location of these tumours. Endoscopic third ventriculostomy (ETV) and tumor biopsy is a safe and feasible strategy, particularly if the tumor appears benign. This mitigates the high risks of uncontrollable venous bleeding from open and stereotactic biopsies. While typically performed using either ipsilateral single or dual bur holes, the location of the tumor may require modifications to the standard endoscopic techniques. Case Description: A 55-year-old male presented with signs of intracranial hypertension and was found to have obstructive hydrocephalus due to a pineal tumour. The tumour displayed a right-sided dominance when the pre-operative imaging was assessed, which would risk forniceal injury if biopsied via a right-sided burr hole. Craniometric measurements revealed a superior trajectory to the tumour via the left foramen of Monro. A biforaminal approach was performed, with a traditional ETV using a right coronal bur hole and biopsy via a left frontal bur hole. This minimized forniceal stretching and allowed a safe biopsy. Conclusion: The bi-foraminal approach has not been widely described in the literature but can potentially avoid morbidity with biopsy in patients with right-sided pineal tumours. We believe this technique should be considered, particularly in low-resource settings where neuroendoscopy is not commonly done, and where the use of ipsilateral single or dual-bur holes may lead to forniceal injury.

Frequency of success and complications of primary endoscopic third ventriculostomy in infants with obstructive hydrocephalous

Objectives: To determine the success rate and complications of primary endoscopic third ventri-culostomy (ETV) in infants with obstructive hydrocephalous. Methods: This case series was conducted at the Department of Neurosurgery, Medical and Teaching Institute, Lady Reading Hospital Peshawar from July 2016 to June 2018. All consecutive patients with age less than one year who underwent ETV for primary obstructive hydrocephalous, of both gender, were included in the study. The patients were followed up to six months after surgery. The data was entered in a specially designed Performa. Patients’ data was analyzed using SPSS version 21.0. Results: We had total 21 patients with age less than one year during the study period. Male patients were 11 (52.4%). Success rate of ETV at six months of follow up was 12 (57.1%). Post-op complications observed were in 9.52% (2/21) cases. One patient had cerebrospinal fluid CSF) leak and the other had significant bleed. Conclusion: ETV is successful in 57.1% of infants with obstructive type of hydrocephalous. The post op complications in case of ETV are lower than Ventriculo-peritoneal shunts. Therefore, ETV can be offered to infants having obstructive hydrocephalous. doi: https://doi.org/10.12669/pjms.38.1.4097 How to cite this:Sharafat S, Khan Z, Azam F, Ali M. Frequency of success and complications of primary endoscopic third ventriculostomy in infants with obstructive hydrocephalous. Pak J Med Sci. 2022;38(1):---------. doi: https://doi.org/10.12669/pjms.38.1.4097 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.