Endoscopic Third Ventriculostomy Success Research Articles

759 Revisiting the ETV Success Score Using Machine Learning Can We Do Better?

INTRODUCTION: The endoscopic third ventriculostomy (ETV) success score (ETVSS) is a useful decision-making heuristic when considering the probability of surgical success, defined as no repeat CSF diversion surgery needed within six months. Nonetheless, the original dataset published in 2009 was relatively small (n = 618) and logistic regression (LR) model performance modest. METHODS: We queried the MarketScan national database for the years 2005-2020 to identify patients <18 years of age who underwent a first-time ETV and subsequently had at least 6 months of continuous enrollment in the database. We collected data on predictors matching the original ETVSS—age, etiology of hydrocephalus, and history of any previous shunt placement. Next, we used six ML algorithms—LR, support vector classifier, random forest, k-nearest neighbors, XGBoost, and Naive Bayes—to develop predictive models. Finally, we used nested cross-validation to assess models’ comparative performances on unseen data. RESULTS: We identified 1698 patients that met inclusion criteria, and 1139 (67%) had successful ETVs. Performance of all models exceeded that of the original ETVSS, with the LR model still performing best with area under the receiver operating characteristic curve (AUROC) 0.90 (95% confidence interval, 0.86-0.94), sensitivity 0.79 (0.70-0.88), and specificity 0.91 (0.87-0.95) at Youden’s index. The random forest was the second-best ML algorithm following closely behind. This compares favorably to the original ETVSS with AUROC 0.80 (0.76-0.84, p < 0.01), sensitivity 0.65 (0.47-0.85, p < 0.01), and specificity 0.71 (0.65-0.75, p < 0.01). CONCLUSIONS: Our predictions for ETV success outperform the current gold standard. Logistic regression may still be the most interpretable and predictive algorithm; further work is underway to externally validate these models.

A re-evaluation of the Endoscopic Third Ventriculostomy Success Score: a Hydrocephalus Clinical Research Network study.

The Hydrocephalus Clinical Research Network (HCRN) conducted a prospective study 1) to determine if a new, better-performing version of the Endoscopic Third Ventriculostomy Success Score (ETVSS) could be developed, 2) to explore the performance characteristics of the original ETVSS in a modern endoscopic third ventriculostomy (ETV) cohort, and 3) to determine if the addition of radiological variables to the ETVSS improved its predictive abilities. From April 2008 to August 2019, children (corrected age ≤ 17.5 years) who underwent a first-time ETV for hydrocephalus were included in a prospective multicenter HCRN study. All children had at least 6 months of clinical follow-up and were followed since the index ETV in the HCRN Core Data Registry. Children who underwent choroid plexus cauterization were excluded. Outcome (ETV success) was defined as the lack of ETV failure within 6 months of the index procedure. Kaplan-Meier curves were constructed to evaluate time-dependent variables. Multivariable binary logistic models were built to evaluate predictors of ETV success. Model performance was evaluated with Hosmer-Lemeshow and Harrell's C statistics. Seven hundred sixty-one children underwent a first-time ETV. The rate of 6-month ETV success was 76%. The Hosmer-Lemeshow and Harrell's C statistics of the logistic model containing more granular age and etiology categorizations did not differ significantly from a model containing the ETVSS categories. In children ≥ 12 months of age with ETVSSs of 50 or 60, the original ETVSS underestimated success, but this analysis was limited by a small sample size. Fronto-occipital horn ratio (p = 0.37), maximum width of the third ventricle (p = 0.39), and downward concavity of the floor of the third ventricle (p = 0.63) did not predict ETV success. A possible association between the degree of prepontine adhesions on preoperative MRI and ETV success was detected, but this did not reach statistical significance. This modern, multicenter study of ETV success shows that the original ETVSS continues to demonstrate good predictive ability, which was not substantially improved with a new success score. There might be an association between preoperative prepontine adhesions and ETV success, and this needs to be evaluated in a future large prospective study.

Combined Predictive Model for Endoscopic Third Ventriculostomy Success in Adults and Children

The selection of patients in whom endoscopic third ventriculostomy (ETV) can be effective remains poorly defined. The endoscopic third ventriculostomy success score (ETVSS) and the presence of bowing of the third ventricle have been identified as independent factors for predicting success, each with limitations. The objective of this study is to elaborate a combined predictive model to predict ETV success in a mixed cohort of patients. Demographic, intraoperative, postoperative, and radiological variables were analyzed in all ventriculostomies performed consecutively at a single institution from December 2004 to December 2022. Qualitative and quantitative measurements of preoperative, immediate and late postoperative MRI were conducted. Univariate analysis and logistic regression models were performed. 118 ETV were performed in the selected period. 106 procedures met inclusion criteria. The overall success rate was 71.7%, with a median follow-up of 3.64 years [1.06;5.62]. The median age was 36.1 years [11.7;53.5]. 35.84% were children (median=7.81 years). Among the 80 patients with third ventricle bowing, success rate was 88.8% (p<0.001). Larger third ventricle dimensions on preoperative mid-sagittal MRI were associated with increased ETV success. The model with the best receiver operating characteristic (ROC) curves, with an area under the curve (AUC) of 0.918 (95% CI 0.856;0.979) includes sex, ETVSS, presence of complications and third ventricle bowing. The presence of bowing of the third ventricle is strongly associated with a higher ETV success rate. However, a combined predictive model that integrates it with the ETVSS is the most appropriate approach for selecting patients for ETV.

Endoscopic Third Ventriculostomy: long term results

Objective:  Hydrocephalus is a major cause of morbidity in the pediatric population, with potentially severe consequences if left untreated hydrocephalus.&#x0D; Endoscopic third ventriculostomy (ETV) has become the method of choice in the treatment of obstructive hydrocephalus. However, age, ventricular anatomy, and etiology could determine success rates (SR) of ETV. The aim of this study was to identify putative factors that could influence the outcome of ETV in children.&#x0D; Methods: Clinical data of 148 consecutive patients under 18 years of age who underwent 150 consecutive ETVs from January 2000 to January 2019 were reviewed. Data were analyzed with regards to clinical and radiological SR. The actual long-term SR was compared to that predicted by the ETV Success Score (ETVSS) model.&#x0D; Results/Discussion: The study group included 63 males (43%) and 85 females (57%) ranging in age from 11 days to 18 years (mean age of, 6.17 ± 1.02 years; median age 4.5 years) at surgery. Concerning the etiology of hydrocephalus, tumors and aqueductal stenosis (AS) were the most frequently observed, with each occurring in 43 cases (29%), followed by malformations in 31 (21%), cystic lesions in 7 (5%) and other etiologies in 67 patients (16%). The overall SR at the first ETV attempt was 80% (118/148), compared to 74.8% (variance 14.35, 95% CI 69.37–78.22) predicted by the ETVSS. Regarding age, SR was 58% in patients under 6 months of age, 65% in children between 6 months and 1 year, and 86% in children older than 1 year. SR for AS and hydrocephalus associated with posterior fossa tumors were 88 and 90%, respectively. Unsatisfactory results were related to previous intraventricular hemorrhage and infection. The overall complication rate in this series was 13%.&#x0D; The lower SR after ETV in young children may be explained by the poor CSF reabsorption capacity of newborn infants due to immaturity of the arachnoid granulations;&#x0D; Univariate and multivariate analysis showed in our series that both the etiology of hydrocephalus and patient´s age group were relevant factors predicting success.&#x0D; A literature review showed that SR in children under 6 months of age ranged from 32% to 45%, and in children older than one year it ranged from 56% to 71%. A few studies have analyzed the postoperative course and SR after a period of 3 years.&#x0D; Conclusion: ETV is safe and effective in children. In this series, the age of the patient and etiology of hydrocephalus were related to SR. Also, the ETVSS was accurate to predict outcome. Intraventricular hemorrhage, previous CNS infection, myelomeningocele, prematurity and recurrent shunt revisions have been associated with high failure rates of ETV in all age groups, particularly in infants under 6 months of age. In a long-term follow-up, surgical experience was statistically significant in reducing complications.

Factors affecting endoscopic third ventriculostomy success in adults.

Endoscopic third ventriculostomy (ETV) is a standard treatment in hydrocephalus of certain aetiologies. The most widely used predictive model is the ETV success score. This is frequently used to predict outcomes following ETV in adult patients; however, this was a model developed in paediatric patients with often distinct aetiologies of hydrocephalus. The aim of this study was to assess the predictive value of the model and to identify factors that influence ETV outcomes in adults. A retrospective study design was used to analyse consecutive patients who underwent ETV at a tertiary neurosurgical centre between 2012 and 2020. Observed ETV outcomes at 6months were compared to pre-operative predicted ETV success scores. A multivariable Bayesian logistic regression analysis was used to determine the factors that best predicted ETV success and those factors that were redundant. A total of 136 patients were analysed during the 9-year study. Thirty-one patients underwent further cerebrospinal fluid diversion within 6months. The overall ETV success rate was 77%. Observed ETV outcomes corresponded well with predicted outcomes using the ETV success score for the higher scores, but less well for lower scores. Location of obstruction at the aqueduct irrespective of aetiology was the best predictor of success with odds of 1.65 of success. Elective procedures were also associated with higher success compared to urgent ones, whereas age under 70, nature and location of obstructive lesion (other than aqueductal) did not influence ETV success. ETV was successful in three-quarters of adult patient with hydrocephalus within 6months. Obstruction at the level of the aqueduct of any aetiology was a good predictor of ETV success. Clinicians should bear in mind that adult hydrocephalus responds differently to ETV compared to paediatric hydrocephalus, and more research is required to develop and validate an adult-specific predictive tool.

Evaluation of the ETV success score to improve decision making on the management of hydrocephalus secondary to pediatric posterior fossa tumors: A feasibility study

Introduction: Hydrocephalus is frequently seen in children with posterior fossa tumors (PFT), and endoscopic third ventriculostomy (ETV) prior to tumor resection can improve surgical conditions by treating the hydrocephalus. Moreover, a scoring system predicting the success of ETV could aid in decision-making for this procedure.&#x0D; Objective: This study aims to evaluate the efficacy of ETV in the treatment of hydrocephalus related to PFT and to evaluate the accuracy of the ETV success score in predicting ETV success.&#x0D; Methods: Patients under 18 years of age who underwent ETV before PFT resection between 1996 and 2021 were included in a retrospective study. The ETV success score was retrospectively obtained for all patients, and its predictive capacity was compared to the actual success observed.&#x0D; Results: Of the 59 surgical cases, a global success rate of 62.7% was observed in the first 6 months following ETV. This rate dropped to 50.8% for those patients reassessed one year after surgery. There was no correlation between the success rate and the histological grade of the tumor or the age of the patient. The ETV success score presented acceptable accuracy at both time points (AUC = 0.671 at 6 months, AUC = 0.649 at one year).&#x0D; Conclusion: ETV proved be a safe procedure, capable of treating hydrocephalus in patients with PFT, and the ETV success score is useful for indicating probable success of the endoscopic procedure.

Predicting endoscopic third ventriculostomy success in pediatric shunt dysfunction: a monocentric retrospective case series of 70 consecutive children, systematic review, and meta-analysis.

The outcome of endoscopic third ventriculostomy (ETV) in children who had previously received shunts and who were experiencing shunt dysfunction is still discussed in terms of efficacy (success rate from 40% to 80%) and safety (0%-32.5% of complications). Reported predictive factors of secondary ETV failure are age, early onset of hydrocephalus, and prematurity. The best surgical strategy in the different subgroups of patients with shunt dysfunction is still debated. Therefore, the authors aimed to identify subgroups of patients in whom shunt treatment was associated with favorable outcome of ETV, to define the role of ETV in patients with global rostral midbrain dysfunction syndrome. This study was a monocentric retrospective case series and a meta-analysis of children who had previously received shunts and who underwent secondary ETV for shunt dysfunction between 2012 and 2022. Clinical and MRI features were examined, along with surgical outcome, etiology of hydrocephalus, and preoperative ETV Success Score. Univariate and multivariate analyses were performed to find predictors of outcome of secondary ETV. Youden's J index was calculated on age distribution to find an optimal age cutoff. Systematic review of the literature and a meta-analysis were performed according to the PRISMA statement. Seventy consecutive patients were included. The overall success rate of secondary ETV was 63%. Primary obstructive hydrocephalus, age ≥ 36 months, and the presence of aqueductal obstruction were predictors of ETV success. Multivariate analysis found that age < 36 months, primary inflammatory hydrocephalus, and presence of fourth ventricular obstruction were associated with ETV failure. All patients with global rostral midbrain dysfunction syndrome experienced clinical and radiological improvement after ETV. The meta-analysis showed that postinflammatory etiology and age < 36 months were predictors of ETV failure. ETV is safe and effective for children with obstructive hydrocephalus experiencing shunt dysfunction, notably in cases of primary obstructive hydrocephalus with aqueductal stenosis, and among children whose age was ≥ 36 months who had postinflammatory hydrocephalus.

Compare the safety and efficacy of endoscopic third ventriculostomy and ventriculoperitoneal shunt placement in infants and children with hydrocephalus: a systematic review and meta-analysis

Purpose Endoscopic third ventriculostomy (ETV) and ventriculoperitoneal shunt placement are two surgical options used for treatment of non-communicating hydrocephalus. The purpose of this study was to compare the efficiency and safety of these techniques in pediatric patients. Materials and methods An extensive literature review regarding the clinical outcome, safety and efficiency of ETV and shunting in treatment of hydrocephalus was conducted in Medline, PubMed, Cochrane and Google Scholar databases up to 27 November 2015. Patient demographics, ETV and shunting success and failure rates were extracted. Results A total of seven two-arm studies were included for quantitative analysis and 25 single-arm studies were included for systematic review. The two-arm studies recruited a total of 6995 patients: 1046 in the ETV group and 5949 in the shunt group. The pooled results showed that the 1 year success rate of ETV and shunt-placement procedure were similar (pooled RR = 0.870, 95% CI = 0.680–1.112, P = 0.266). The failure rate in the ETV treatment group was 0.9 times higher than in the shunt group; however, the results did not reach statistical significance (pooled RR = 0.893, 95% CI = 0.576–1.383, P = 0.611). Conclusions Both ETV and shunts are associated with similar 1 year success and failure rates. Therefore, there are no current indications to recommend one mode of treatment over the other. Future studies designed to assess the effectiveness of ETV and shunt procedures depending on patient’s age and etiology are warranted.

A comparative study of Outcome in Ventriculoperitoneal Shunt and Endoscopic Third Ventriculostomy in Cases of Tubercular Meningitis with Hydrocephalus in Pediatric Patients

Introduction: Tuberculous meningitis (TBM) is becoming a rare illness in industrialized nations, but it is still widespread in underdeveloped nations. Ventriculoperitoneal shunt surgery is the GOLD Standard and is time tested procedure. Shunts, however, are associated with multiple problems. Material and Method: This is an observational study that compares the outcome of Endoscopic Third Ventriculostomy (ETV) with Ventriculoperitoneal shunt in patients of TBM with hydrocephalus at a 6-month follow-up. This study was done at a single tertiary care center.  Data was collected from the patient records as per selection criteria. 100 consecutive cases in each ETV and Shunt group fulfilling selection criteria were included in the study.  The two procedures were compared for their clinical outcome based on modified Vellore grade at 6 months of follow-up. Discussion: Evaluation of outcome at 6 months revealed an overall success rate of 68.5%. The success rate was higher for shunt (71%) as compared to ETV (66 %).  However, the difference between the two groups was not significant statistically. For children with advanced TBM and elevated ICP, shunt surgery may not be necessary. While some authors have considered the potential of delaying surgery for these kids, others have argued that even a single positive outcome warrants shunt placement for every kid with tuberculous hydrocephalus. Conclusion:  In pediatric cases of TBM with Hydrocephalus ETV should be considered as a first-line treatment in lower grades of TBM. Though for definitive comparison, a long-term randomized study is needed, and the study to look into factors responsible for the failure of ETV in TBM cases needs to be identified to formulate an ETV success score.

Endoscopic third ventriculostomy for shunt malfunction in the pediatric population: a systematic review, meta-analysis, and meta-regression analysis.

Despite growing published evidence of the merits of endoscopic third ventriculostomy (ETV) instead of shunt revision at the time of shunt malfunction (secondary ETV), concerns about its efficacy and complications remain and ETV is still not used widely in this context. This study aimed to carry out a comprehensive meta-analysis and reports on the success and safety of secondary ETV in the pediatric age group. In accordance with the PRISMA guidelines, systematic searches of Medline, Embase, and Cochrane Central were undertaken from database inception to September 7, 2022. ETV success was defined as the lack of need for a shunt and was the primary outcome measure. Secondary outcome measures were the rates of complications and mortality. A random-effects model was used. Summary-level meta-regression was performed to identify predictors for success in accordance with the ETV Success Score (ETVSS). Sixteen studies reporting on 584 patients who underwent secondary ETV for shunt malfunction were included in the meta-analysis. The overall pooled mean (95% CI) age was 6.1 (3-9) years, and 57.0% of patients were male. The pooled prevalence rates of the hydrocephalus etiologies were as follows: aqueduct stenosis (39.3%); myelomeningocele (27.6%); postinfectious (17.1%); posthemorrhagic (13.0%); neoplasm (13.0%); and malformation (11.3%). The overall pooled success rates of ETV for shunt malfunction at 3 months, 6 months, and 12 months were 65.69% (95% CI 52%-77%, prediction interval 47%-81%, I2 = 0, p = 0.775); 63.25% (95% CI 54%-72%, prediction interval 38%-83%, I2 = 65, p < 0.001); and 53.37% (95% CI 24%-81%, prediction interval 1%-99%, I2 = 47, p = 0.154). The overall pooled prevalence of intraoperative bleeding was 4.96% (95% CI 0%-64%, prediction interval 0%-99%, I2 = 85, p < 0.001). The overall rates of complications were low, with new neurological deficit (transient or permanent) having the highest rate at 1.61% (95% CI 0.68%-3.72%, prediction interval 0.67%-3.78%, I2 = 0, p > 0.999). On meta-regression, age (p = 0.138), proportion of patients with postinfectious hydrocephalus (p = 0.8736), and number of shunt revisions (p = 0.1775) were not statistically significant predictors of secondary ETV success at 6 months. This meta-analysis demonstrates that secondary ETV after shunt malfunction in pediatric patients is a feasible option with acceptable success rates and low complication rates. Clinical trial registration no.: CRD42022359573 (PROSPERO).

Endoscopic Third Ventriculostomy and Cortical Biopsy in Patients With Normal Pressure Hydrocephalus.

Introduction Normal pressure hydrocephalus (NPH) has conventionally been treated by placement of a ventriculoperitoneal shunt. However, it can also be treated with a less invasive technique, an endoscopic third ventriculostomy (ETV). Unfortunately, there is a lack of evidence on the characteristics of NPH patients who are most likely to benefit from ETV. This study seeks to identify if patients at risk of dementia with NPH should be candidates for an ETV. Methodology Thirty-six NPH patients who underwent ETV at two institutions between July 2007 and December 2014 were pre-surgically assessed for various risk factors. At the time of ETV, a cortical biopsy was obtained and assessed for plaques consistent with dementia. Post-procedure, patients were followed and assessed for symptoms such as gait improvement, headache, memory problems, incontinence, and dementia. ETV success was defined as an improvement in gait. Results The mean age of patients with successful ETVs was 65.8 ± 6.0 versus 74.5 ± 7.0 for failed ETVs. Sixty-seven percent of patients with negative biopsies showed gait improvement by the final follow-up appointment as compared to only 33% of patients with positive biopsies (p>0.05). Younger age was correlated with successful ETV (p=.003). Memory disturbance (p<0.05) and incontinence (p<0.05) after surgery were both associated with a lack of gait improvement at the final follow-up. Conclusion Biopsy was not a significant predictor of ETV success; however, there was a correlation between younger age and ETV success. Additional studies are required to determine if there is a relationship between cortical biopsy findings and ETV success.

Surgical Outcome of Endoscopic Third Ventriculostomy in Patients Having High ETV Success Score: One-Year Experience at a Tertiary Care Hospital

Background &amp; Objective:  Endoscopic third Ventriculostomy (ETV) is an accepted alternative to VP shunt in patients with obstructive hydrocephalus. We will share our experience and outcome.&#x0D; Materials &amp; Methods:  Thirty consecutive ETV cases performed by a single surgeon during 1 year in patients with an ETV success score of 60 or higher were included in this study. Patients’ demographics, outcomes, and complications are reported.&#x0D; Results:  (60%) were male and 12 (40%) were female. The mean age in our study was 6.1 years ± 9 (mean ± SD). Posterior fossa tumor was the most common etiology in our series (46.6%) followed by aqueductal stenosis (23.3%). Eighty percent of our patients did not experience an ETV failure. The complication rate was 20%. Inadequate ventriculostomy in 6.6% of the patients was the commonest complication.&#x0D; Conclusion:  ETV is safe and effective in patients with high ETV success scores.

Neuroendoscopy in the management of pineal region tumours in children.

Pineal region tumours (PRTs) are more common in children and represent a wide variety of lesions. The practise of a radiation test dose is obsolete and a biochemical/histological diagnosis is recommended before further therapy. Many patients present with hydrocephalus. Advances in neuroendoscopic techniques have allowed safe and effective management of this obstructive hydrocephalus with an opportunity to sample cerebrospinal fluid (CSF) and obtain tissue for histopathology. Definitive surgery is required in less than a third. Endoscopic visualisation and assistance is increasingly used for radical resection, where indicated. Our experience of endoscopic surgery for paediatric PRTs from 2002 to 2021 is presented. All patients underwent MRI with contrast. Serum tumour markers were checked. If negative, endoscopic biopsy and endoscopic third ventriculostomy (ETV) were performed; and CSF collected for tumour markers and abnormal cells. For radical surgery, endoscope-assisted microsurgery procedures were performed to minimise retraction, visualise the extent of resection and confirm haemostasis. M:F ratio was 2:1. The median age of presentation was 11years. Raised ICP (88.88%) was the commonest mode of presentation. Nineteen patients had pineal tumours, one had a suprasellar and pineal tumour, one had disseminated disease, while six had tectal tumours. The ETB diagnosis rate was 95.45%, accuracy rate was 83.3% and ETV success rate was 86.96%. Neuroendoscopy has revolutionised the management of paediatric PRTs. It is a safe and effective procedure with good diagnostic yield and allows successful concurrent CSF diversion, thereby avoiding major surgeries and shunt implantation. It is also helpful in radical resection of lesions, where indicated.

Failure of Endoscopic Third Ventriculostomy.

Endoscopic third ventriculostomy (ETV) is an alternative to cerebrospinal fluid (CSF) shunting in the treatment of hydrocephalus. Careful patient selection is critical as patient age, etiology of hydrocephalus, and previous shunting have been shown to influence ETV success rates. Intraoperatively, patient anatomy and medical stability may prevent or limit the completion of the ventriculostomy procedure, and findings such as a patulous third ventricular floor or cisternal scarring may portend a lower chance of successful hydrocephalus treatment. Patients in whom a ventriculostomy is completed may still experience continued symptoms of hydrocephalus or CSF leak, representing an early ETV failure. In other patients, the ETV may prove a durable treatment of hydrocephalus for several months or even years before recurrence of hydrocephalus symptoms. The failure pattern for ETV is different than that of shunting, with a higher early failure rate but improved long-term failure-free survival rates. The risk factors for failure, along with the presentation and management of failure, deserve review.

Prediction of 6 months endoscopic third ventriculostomy success rate in patients with hydrocephalus using a multi-layer perceptron network

ObjectiveDiscrimination between patients most likely to benefit from endoscopic third ventriculostomy (ETV) and those at higher risk of failure is challenging. Compared to other standard models, we have tried to develop a prognostic multi-layer perceptron model based on potentially high-impact new variables for predicting the ETV success score (ETVSS). MethodsClinical and radiological data of 128 patients have been collected, and ETV outcomes were evaluated. The success of ETV was defined as remission of symptoms and not requiring VPS for six months after surgery. Several clinical and radiological features have been used to construct the model. Then the Binary Gravitational Search algorithm was applied to extract the best set of features. Finally, two models were created based on these features, multi-layer perceptron, and logistic regression. ResultsEight variables have been selected (age, callosal angle, bifrontal angle, bicaudate index, subdural hygroma, temporal horn width, third ventricle width, frontal horn width). The neural network model was constructed upon the selected features. The result was AUC:0.913 and accuracy:0.859. Then the BGSA algorithm removed half of the features, and the remaining (Age, Temporal horn width, Bifrontal angle, Frontal horn width) were applied to construct models. The ANN could reach an accuracy of 0.84, AUC:0.858 and Positive Predictive Value (PPV): 0.92, which was higher than the logistic regression model (accuracy:0.80, AUC: 0.819, PPV: 0.89). ConclusionThe research findings have shown that the MLP model is more effective than the classic logistic regression tools in predicting ETV success rate. In this model, two newly added features, the width of the lateral ventricle's temporal horn and the lateral ventricle's frontal horn, yield a relatively high inter-observer reliability.

Endoscopic third ventriculostomy with or without choroid plexus coagulation for myelomeningocele-associated hydrocephalus: systematic review and meta-analysis.

While ventriculoperitoneal shunt (VPS) insertion is the standard treatment for myelomeningocele-associated hydrocephalus (MAH), it can be complicated by infection and shunt malfunction. As such, endoscopic third ventriculostomy (ETV), with or without choroid plexus coagulation (CPC), has been proposed as an alternative. The aim of this review was to determine the success, technical failure, and complication rates of ETV with or without CPC in patients with MAH. PubMed, Scopus, and Cochrane Central Register of Controlled Trials databases were searched from inception to June 2020 for case series, cohort studies, or randomized controlled trials reporting success, technical failure, or complication rates. Random-effects analysis was performed to determine the estimates for these outcome measures. Studies were evaluated using the Newcastle-Ottawa Scale for quality and risk of bias. Thirteen studies with a total of 325 patients who underwent either ETV or ETV+CPC were included in the review. Using random-effects modeling, the pooled estimate of the success rate was 56% (95% CI 44%-68%, I2 = 78%), while the technical failure rate was 2% (95% CI 0%-6%, I2 = 32%). The estimate for the success rate had high heterogeneity, due to the type of surgical intervention (ETV vs ETV+CPC, p < 0.001). Random-effects analysis of 9 studies with 117 patients who underwent ETV alone yielded an estimated success rate of 48% (95% CI 0.39-0.57, I2 = 0%), while analysis of 4 studies with 166 patients who underwent ETV+CPC revealed a success rate of 75% (95% CI 67%-82%, I2 = 21%). The estimates for the mild/moderate, severe, and fatal complication rates were 0 (95% CI 0%-4%, I2 = 0%), 2% (95% CI 0%-10%, I2 = 52%), and 0 (95% CI 0%-1%, I2 = 0%), respectively. ETV+CPC was associated with a higher success rate than ETV alone for MAH in a meta-analysis of published studies. ETV, with or without CPC, was technically feasible and safe for this patient population.

An audit of endoscopic third ventriculostomy (ETV) in a regional paediatric neurosurgical centre assessing the accuracy and feasibility of the ETV success score.

Endoscopic third ventriculostomy success score (ETVss) is widely utilised to predict outcomes for ETV. Accurate prediction of success for a procedure is of vital importance both for selecting the optimal management plan and for obtaining informed consent. Existing literature demonstrates a variety of opinions on the accuracy of the currently utilised ETVss and recommends a range of techniques to reduce the number of subsequent ventriculo-peritoneal (VP)-shunt insertions, prompting the present study. We retrospectively analysed data for ETV cases since 2007 to review success rate in our regional paediatric neurosurgical centre and if the currently utilised ETVss successfully predicted outcomes. Failed ETV cases were defined as any patient who received a VP-shunt at any time following ETV. Data was analysed with MS ExcelR and RStudioR. 44 ETVs were performed over 13years with approximately equal distribution between male and female patients; median age 7years (IQR 4-13years). Overall, mean ETVss for these 44 procedures was 78%; actual success rate was 70% with no statistically significant difference between them (p = 0.286; Welch two sample t-test). Accuracy of ETVss varied with pathology: tectal gliomas (mean ETVss 75% and actual success 78%); cerebellar tumours (mean ETVss 85% and actual success 81%); other tumours (mean ETVss 75% and actual success 81%); aqueduct stenosis (mean ETVss 71% and actual success 69%); and other pathologies (mean ETVss 70% and actual success 60%). < 1month and 1-6months and 1-10years and > 10years contributed equally to the accuracy of ETVss. Non-telencephalon tumours and obstruction at the level of the mid-brain are most strongly associated with successful ETV outcome. These findings can be used to modify the currently utilised ETVss to further improve accuracy of outcome prediction. We recommend a modified-ETVss (m-ETVss) and a future larger adequately powered prospective study to validate this.

The Role of Early Postoperative Intracranial Pressure Monitoring in Predicting the Outcome of Endoscopic Third Ventriculostomy Performed in Infants With Congenital Hydrocephalus: A Prospective Analysis.

IntroductionHydrocephalus is an excessive accumulation of cerebrospinal fluid (CSF) in the cavity and spaces of the brain. To date, there is no single method to accurately assess the compliance of subarachnoid spaces after endoscopic third ventriculostomy (ETV).ObjectiveTo analyze the intracranial pressure (ICP) trends in the early postoperative period in infants undergoing ETV for congenital hydrocephalus and correlate them with the final outcome.Material and methodsThis is a single-center prospective study conducted at the Department of Neurosurgery of our institute from January 2019 to February 2020. Infants presented with congenital hydrocephalus mandating ETV were included in the study. ICP was continuously monitored for the first three days after the procedure. ICP values were recorded hourly, and 24 ICP values obtained daily were averaged to obtain a daily average value (DAV).ResultsForty patients were recruited in the study. The mean age of the study population was 4.7 ± 2.8 months; 80% of the infants were <6 months of age. The male/female ratio was 5.7:1. The most common etiology was congenital aqueductal stenosis, which was observed in 18 (45%) of the patients, followed by Dandy-Walker malformation (DWM) in 11 (27.5%) of the patients. On considering a difference of >1 mmHg between the first and third postoperative day, the ETV success rate was dropped from 50% in stable trend to 11% in progressive increase trend, which was statistically significant (p = 0.044). At DAV variation of >2 mmHg in progressive increase trend, the sensitivity of stable ICP trend increased to 100% in predicting ETV success. Also, the negative predictive value (the ability of a stable trend to rule out ETV failure) reached 100%. The overall success rates of ETV in our study at one, three, and six months were 62.5%, 40%, and 35%, respectively.ConclusionA progressive increase in the ICP trend (with a difference of >2 mmHg between postoperative days 1 and 3) was the best predictor of ETV failure in our study. It was superior to any other clinical or radiological variable in our study, which was affecting the outcome.

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

Abstract 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 &gt;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.

Preoperative Third Ventricle Floor Bowing is Associated with Increased Surgical Success Rate in Patients Undergoing Endoscopic Third Ventriculostomy - A Systematic Review and Meta-analysis.

Endoscopic third ventriculostomy (ETV) is a procedure that involves devising an opening in the third ventricle floor, allowing cerebrospinal fluid to flow into the prepontine cistern and the subarachnoid space. Third ventricular floor bowing (TVFB) serves as an indicator of intraventricular obstruction in hydrocephalus and existence of pressure gradient across third ventricular floor, which is the prerequisite of a successful ETV. In this systematic review and meta-analysis, we aimed to synthesize the latest evidence on the TVFB as a marker for surgical success in patients undergoing ETV. We performed a comprehensive search on topics that assesses the association of TVFB with the surgical success in patients undergoing ETV from several electronic databases. There was a total of 568 subjects from six studies. TVFB was associated with 85% (81-88%) ETV success. TVFB was associated with OR 4.13 [2.59, 6.60], P < 0.001; I2: 6% for ETV success. Subgroup analysis on pediatric patients showed 86% (82-91%) success rate. In terms of value for ETV success compared to ETV Success Score (ETVSS), a high ETVSS does not significantly differ (P = 0.31) from TVFB and TVFB was associated with OR 3.14 [1.72, 5.73], P < 0.001; I2: 69% compared to intermediate/moderate ETVSS. Funnel plot analysis showed an asymmetrical funnel plot due to the presence of an outlier. Upon sensitivity analysis by removing the outlier, the OR was 3.62 [2.22, 5.89], P < 0.001; I2: 0% for successful surgery in TVFB. TVFB was associated with an increased rate of successful surgery in adults and children undergoing ETV.