Complications Of Endoscopic Third Ventriculostomy Research Articles

Complications of Endoscopic Third Ventriculostomy in Previously Shunted Patients

Complications of Endoscopic Third Ventriculostomy in Previously Shunted Patients

Complications of endoscopic third ventriculostomy

Although endoscopic third ventriculostomy (ETV) is considered as the first choice in the management of noncommunicating hydrocephalus, it is not without risk or complication. The patients who had undergone ETV only between 1998 and 2005 were retrospectively reviewed. There were 85 males and 70 females, and 173 ETVs were performed in 155 patients. The patients' age ranged from 2 months to 77 years. Complications were categorized as (1) intraoperative, (2) early postoperative (<1 month), and (3) late postoperative (>1 month). Follow-up of the patients ranged from 1 to 86 months. Overall complication rate per patient was 15.4%, and complication per procedure was 18%. Complication rate significantly varied with the etiology of hydrocephalus (P = 0.013). The patients with Chiari type I malformation and tumor had no or very low complication rates. The complication risk was significantly higher in repeat endoscopic procedure (55.5%) than in the first procedure (10%; P = 0.0001). ETV should be the first choice in the management of noncommunicating hydrocephalus. Training, experience, and meticulous technique will decrease the complication rate. Patients undergoing ETV should be followed in a similar manner to patients with cerebrospinal fluid shunts.

Endoscopic third ventriculostomy in treatment of obstructive hydrocephalus

To explore the effects, influencing factors, and complications of endoscopic third ventriculostomy for obstructive hydrocephalus. The clinical data of 55 patients with obstructive hydrocephalus, 29 males and 26 females, aged 18.4 (6 months - 59 years), who underwent endoscopic third ventriculostomy were analyzed retrospectively. Endoscopic third ventriculostomy was performed successfully in 54 patients, and one patient failed to undergo endoscopic third ventriculostomy because of densely distributed blood vessels at the bottom of the third ventricle. Satisfying post-operative results were obtained in 50 cases and no effect was seen in 4 cases that underwent V-P shunt 3 months later. Subdural hygroma occurred in 4 of the 55 cases, subscale hydrops in 8 cases, post-operative fever in 4 cases, epilepsy in 1 case, and epidural hemorrhage in 1 case. Endoscopic third ventriculostomy is safe and effective in the treatment of obstructive hydrocephalus.

Outcomes in patients undergoing single-trajectory endoscopic third ventriculostomy and endoscopic biopsy for midline tumors presenting with obstructive hydrocephalus

The primary aim of this study was to evaluate the success of endoscopic third ventriculostomy (ETV) as a treatment for obstructive hydrocephalus secondary to midline tumors (midbrain, pontine, pineal, tectal plate, thalamic, and third ventricular regions). In addition, the study examined the role and value of endoscopic tumor biopsy (ETB) in the management of such cases. All surgical procedures were performed through a single-trajectory approach. A retrospective analysis of clinical notes, operation records, and pre- and postventriculostomy neuroimaging data was performed to determine the success or failure and complications of ETV and ETB in 42 patients presenting with tumor-induced obstructive hydrocephalus. Patient data were derived from an endoscopy database initiated in 1998. The study population included 21 female and 21 male patients (mean age 37 years, range 5-77 years). All 42 patients underwent an ETV; 33 of the 42 underwent an ETV and an ETB (single-trajectory). One patient was excluded from the follow-up analysis due to rapid deterioration of his condition from tumor progression. The duration of follow up ranged from 3 to 84 months (mean 32 months). At the last follow up, 11 patients with ETVs had undergone shunt placement and two patients had undergone repeated ETVs, giving a long-term success rate of 68% (28 of 41 cases) for single ETV as a treatment for hydrocephalus at presentation. Statistical analysis revealed no significant relationship (p > 0.92) between tumor location and ETV success or failure. The mean time to ETV failure was 32 weeks. Histological examination of biopsy specimens was non-diagnostic in eight (24%) of the 33 cases in which ETB was performed. Seven of these cases involved pineal region tumors and one involved a tectal plate tumor. There was no death or major morbidity associated with ETV and ETB in this series. Endoscopic third ventriculostomy is a safe and durable means of controlling hydrocephalus in tumor cases. Its success rate is high--comparable to that reported in aqueduct stenosis cases. Although ETB is probably not as accurate for diagnosis as biopsy with frame-based stereotactic guidance, it is associated with a lower mortality rate and, in the correct clinical setting, may be justifiably attempted as an initial biopsy procedure at the same time as ETV via a single-trajectory approach.

Death after Late Failure of Endoscopic Third Ventriculostomy: A Potential Solution

To the Editor: The article of Mobbs et al. (1) describes an interesting approach to prevention of a fearful complication of endoscopic third ventriculostomy (ETV): rapid deterioration leading to sudden death. The authors suggest that placement of a ventricular catheter and subcutaneous reservoir at the conclusion of the procedure may offer the potential to sample cerebrospinal fluid, measure intracranial pressure, and, in the case of deterioration, aspirate cerebrospinal fluid to decrease pressure. In our opinion, if a reservoir is to be placed after every ETV, it might as well be inserted in every shunted patient. After all, shunted patients have a similar or even higher risk of malfunction and are associated with a significantly higher danger of “sudden” death throughout their lifetime. We agree with other commentators that subcutaneous reservoir placement undoubtedly increases the risk (and cost) of ETV. In addition, placement of a permanent foreign body compromises the core rationale for ETV: avoiding reliance on a foreign body. ETV-associated infections occur in more than 5% of patients (2). When a foreign body remains in situ, antibiotics are not enough to clear the infection in most patients and another operation is required. Furthermore, the reservoir placement may prolong the operation and compromise wound healing, especially in infants. Insisting on regular clinical follow-up of our post-ETV population, and taking seriously any clinical changes that may occur in this group, seems to be a more rational and overall safer approach to confront the ETV failures that are bound to happen, whether early or late. Shlomi Constantini Vitaly Siomin Tel Aviv, Israel

Chronic subdural hematoma as a complication of endoscopic third ventriculostomy

Background Endoscopic third ventriculostomy has become a popular alternative to ventricular shunts for noncommunicating hydrocephalus. Although endoscopic third ventriculostomy is a safe procedure, several complications related to this procedure have been reported in the literature. The authors present a rare case of symptomatic bilateral subdural hematomas after an uneventful endoscopic third ventriculostomy. Case description A 51-year-old male patient presented with symptoms of obstructive hydrocephalus, headaches and memory disturbance. Magnetic resonance imaging demonstrated hydrocephalus secondary to aqueductal stenosis. An endoscopic third ventriculostomy was performed. The patient was discharged home in several days without complication. He then presented with headaches 3 weeks following surgery. A computed tomography study demonstrated bilateral subdural hematomas. These were treated with burr hole evacuation and drainage. Postoperatively, his headaches improved. At last follow-up he remains symptom-free and has radiographic evidence of a patent ventriculostomy. Conclusion This case confirms chronic subdural hematoma formation is a possible complication following third ventriculostomy. Patients should be followed closely for possible subdural hematoma formation.

Complications of endoscopic third ventriculostomy.

The purpose of this prospective investigation was to determine the rate of complications associated with endoscopic third ventriculostomy (ETV). Between March 1993 and October 2001, 193 ETVs were performed in 188 patients at a single institution. The age of the patients ranged from 1 month to 85 years (mean age 39 years). One procedure had to be abandoned because a severe venous hemorrhage blurred the surgeon's view; however, third ventriculostomy was successfully accomplished in that patient 14 days later. In addition, there were two cases in which significant venous hemorrhages could be controlled endoscopically by using irrigation. Postoperative imaging revealed three subdural collections, one tiny thalamic contusion, one cortical hemorrhage at the puncture site, and one severe subarachnoid hemorrhage (SAH). There were two deaths (1% mortality rate) related to the endoscopic procedure; causes of death were one SAH from a torn basilar perforating artery and one wound infection leading to meningitis and septic multiorgan failure. Three permanent deficits occurred (confusion, oculomotor palsy, and diabetes insipidus [1.6% permanent morbidity rate]). Transient deficits included four cases of meningitis, three cases of cerebrospinal fluid leak, two cases of herniation syndrome, two cases of confusion, one case in which there was a decrease of consciousness, two cases of oculomotor palsy, and one case in which there was loss of thirst (7.8% transient morbidity rate). Misplacement of the fenestration was the main reason for severe complications. During the course of the study, the complication rate dropped significantly (no incidences of mortality or permanent morbidity occurred during the last 100 procedures). All permanent and fatal complications occurred during the authors' very early experience, indicating that a steep learning curve was associated with the procedure. Endoscopic third ventriculostomy, if performed correctly, is a safe, simple, and effective treatment option for various forms of noncommunicating hydrocephalus.

A Near-Fatal Complication of Endoscopic Third Ventriculostomy

A Near-Fatal Complication of Endoscopic Third Ventriculostomy

A Near-Fatal Complication of Endoscopic Third Ventriculostomy

The authors treated a 14-year-old girl with posthemorrhagic hydrocephalus and an infected ventriculopleural shunt. She was taken for endoscopic third ventriculostomy with the hope of removing the hardware entirely, but she developed an arrhythmia and hypertension, followed rapidly by complete cardiac arrest. She was resuscitated successfully, made a complete recovery, and subsequently underwent a conventional shunt replacement. This is a newly reported life-threatening complication of neuroendoscopy that must be anticipated by any surgeon undertaking such a procedure.