Aqueductal stenosis in pediatric patients: An outcome analysis

Abstract

Ventriculo-peritoneal (VP) shunt and endoscopic third ventriculostomy (ETV), both are well-established therapeutic modalities for the management of hydrocephalus. However, the treatment of choice is still controversial due to non-uniformity of the pre-existing data. It was a single institute retrospective cum prospective study enrolling 68 pediatric patients of congenital aqueductal stenosis (neonate to 18-year-old, mean age 48.2 ± 67.9 mo). The present study dealt with a uniform population of congenital aqueductal stenosis excluding secondary causes like post-infectious, post-hemorrhagic and tumor-related aqueductal stenosis. There were 54 patients in the VP shunt group and 14 in the ETV group. In the VP shunt group, there was no intra-operative or post-operative mortality and none had cerebrospinal fluid leak. Technical failure rate (shunt malfunction within 5 days of surgery) was 1.8% after primary shunting procedure and 4.5% after shunt revisions. Among 38 patients witha minimum available follow-up of 6m o (mean 34.5± 29.3 mo), the overall incidence of shunt obstruction after primary VP shunt was 36.8% out of which 21.1% blocked within a year. The shunt infection rate was 5.3%, which presented clinically within 3 mo of surgery. Two (5.3%) patients developed symptomatic slit ventricles and 13.2% patients had new-onset seizures. In the ETV group, there was one (7.1%) technical failure where the stoma could not be made due to severe bleeding. Two (14.2%) patients had intra-operative bleeding and the post-operative mortality was 7.1% (cause of death: ventriculitis). Follow-up ranging from 6-52 mo (mean 15.4 ± 13.6 mo) was available in 10 patients. Stoma blocked in 50% patients and all of them presented by around 1 mo period. Although precise statistical comparison could not be done due to small and disparate number of cases in the two groups, the data is still valuable in the Indian context. After ETV, there was no long-term morbidity whereas 61% patients of VP shunt continued to have some or other problem in the form of shunt obstruction, infection, new-onset seizures or slit ventricle syndrome. We conclude that depending on the expertise, ETV should be offered as the treatment of choice in congenital aqueductal stenosis because of its less frequent association with long-term morbidities.