Indications For Endoscopic Third Ventriculostomy Research Articles

Re-Do endoscopic third ventriculostomy. Retrospective analysis of 13 patients.

Indication for endoscopic third ventriculostomy (ETV) in the treatment for noncommunicating hydrocephalus is widely accepted. There is controversy regarding the indication of a second procedure (re-ETV) when the first has failed. The objective of this work is to revise ETV failures in a series in which re-ETV was performed and to describe the factors related to its prognosis. Retrospective study of pediatric patients with ETV failure treated by re-ETV between 2003 and 2018. Gender, age in first and second ETV, time to failure of first ETV, etiology of hydrocephalus, previous presence of shunt, ETV-SS in the first and second ETV, intraoperative findings, success of the second procedure and follow-up were collected. The ETV-SS result was grouped into high (≥80), moderate (50-70) or low (≤40) scores. Endoscopic procedure failure was considered clinical worsening or the absence of radiological criteria for improvement (reduction in ventricular size or presence of ETV flow artifact in the floor of third ventricle). Of 97 ETV carried out in this period, 47 failures were registered, with 13 re-ETV performed. Of these, 8 were classified as successful (61.53%). Re-ETV was successful in 4/4 cases in which etiology was tectal tumor or aqueduct stenosis. In the group with a high ETV-SS score there was a higher rate of success (75%) than in the group with a moderate score (40%). 9 patients presented shunt prior to first ETV and in them, success was 66.6% compared to 50% in the group without prior shunt. All re-ETV were performed without complications. In 11 of the 13 procedures a closed stoma was found and the remaining 2 cases, we found a punctate opening. The mean follow-up after re-ETV was 61.23 months. The selection of patients for re-VET should be cautious. Factors such as age, etiology, and previous shunt (ETV-SS factors) have prognostic influence. However, there are specific factors which indicate favorable prognostic for re-VET such as a longer time to failure of the first procedure, the finding of a closed/punctate stoma or the loss of flow artifact in the follow-up MRI.

Combined endoscopic third ventriculostomy and tumor biopsy in the management of pineal region tumors, safety considerations

BackgroundPineal region tumor is considered an ideal indication for endoscopic third ventriculostomy (ETV), with success rate up to 92%. The ultimate advantage is the ability to obtain tumor biopsy for histopathological diagnosis and for further treatment strategy plan design.ObjectivesTo investigate the safety considerations to minimize tumor biopsy-related bleeding, increase diagnostic accuracy, and establish a successful ETV procedure.MethodsRetrospective study including 25 patients of pineal region tumor with concomitant triventricular hydrocephalus. Preoperative planning to perform ETV and obtain tumor biopsy was achieved either through single more anteriorly located precoronal burr-hole (17 patients) or two separate burr-holes (eight patients). The patients’ age ranged from 9 months to 65 years with a mean age of 26.5 years. Preoperative MRI brain with coronal T2- and sagittal T1-weighted images was used to design trajectory.ResultsNo significant intraventricular bleeding reported. A diagnostic tumor biopsy yield was successful in 22 patients. Ventriculoperitoneal shunt insertion was required in 1 patient failed to improve.ConclusionEndoscopic tumor biopsy is relatively safe with high diagnostic yield that helps in management protocol plus shunt independent control of associated hydrocephalus.

Endoscopic third ventriculostomy as adjunctive therapy in the treatment of low-pressure hydrocephalus in adults.

Background:Treatment of low-pressure hydrocephalus (LPH) may require prolonged external ventricular drainage (EVD) at sub-zero pressures to reverse ventriculomegaly. Endoscopic third ventriculostomy (ETV) has been used in the treatment of noncommunicating hydrocephalus; however, indications for ETV are expanding.Methods:Patients with the diagnosis of LPH as defined by the Pang and Altschuler criteria who underwent sub-zero drainage treatment over an 8-year period were included. Patients were divided into two cohorts based on whether or not ETV was employed during their treatment. Time from EVD placement to internalization of shunt was recorded for both groups; time from ETV to placement of shunt was recorded for the patients undergoing ETV.Results:Sixteen adult patients with LPH were managed with sub-zero drainage method. Ten (62.5%) patients did not undergo ETV and the average time from first ventriculostomy to shunting was 73 days (range 14–257 days). Six (37.5%) patients underwent ETV during the course of their treatment; average time from initial ventriculostomy to shunt was 114 days (range 0–236 days) (P = 0.16). Time from development of LPH to ETV ranged from 28 days to 6.5 months. In the ETV group, of the 4 patients who underwent shunting, the average time to shunting following ETV was 15.25 days.Conclusions:ETV can be used successfully in the management of refractory LPH to decrease the duration of EVD.

ETV as a last resort

The field of neuroendoscopy is rapidly expanding with increasing indications for endoscopic third ventriculostomy (ETV). As a treatment for hydrocephalus, ETV has the advantage of providing a more physiological cerebrospinal fluid diversion without shunt hardware which reduces the risk of recurrent infection and malfunction. The success rate of ETV has been increasing with decreasing morbidity and mortality. Originally, ETV was indicated for cases of obstructive hydrocephalus, however the indications are expanding. To highlight this, we present a small series of cases were ETV is not traditionally indicated and was a treatment of last choice.

The role of endoscopic third ventriculostomy in the treatment of hydrocephalus

Hydrocephalus remains a major public health problem. Conventional treatment has relied on extracranial shunting of CSF to another systemic site, but this approach is associated with a high rate of complications. Endoscopic third ventriculostomy (ETV) is a novel treatment for select forms of hydrocephalus that can eliminate the need for implantation of a lifelong ventricular shunt system. However, the indications for ETV are contested and its long-term effectiveness is not well established. The authors selected 100 consecutive patients who underwent ETV for hydrocephalus beginning in 1994. Patients were enrolled and treated at a single institution by a single surgeon. The primary outcome was success of ETV, with success defined as no need for subsequent surgery for hydrocephalus. Ninety-five patients satisfied the inclusion criteria. The mean follow-up period was 5.1 years (median 4.7 years) with follow-up data available for as long as 17 years. Patients commonly presented with headache (85%), ataxia (34%), emesis (29%), and changes in vision (27%). The success rate for ETV was 75%. Twenty-one patients (22%) in the series had malfunctioning shunts preoperatively and 13 (62%) were successfully treated with ETV. Preoperative inferior bowing of the third ventricle floor on MRI was significantly associated with ETV success (p < 0.05). Endoscopic third ventriculostomy is an effective and durable treatment for select patients with hydrocephalus. When successful, the procedure eliminates the lifelong complications associated with implanted ventricular shunts.

Is there an indication for ETV in young infants in aetiologies other than isolated aqueduct stenosis?

The objective was to determine whether endoscopic third ventriculostomy (ETV) has a role in the management of obstructive hydrocephalus in aetiologies other than idiopathic aqueduct stenosis (AS) in infants. In addition to reviewing the literature, we performed a retrospective analysis of our endoscopy database, which was established in 1998, and analysed the outcome results of all cases of ETV in those under 1 year of age which were performed between 1998 and 2003. We included cases of idiopathic AS in the outcome analysis as a benchmark of successful outcome. Successful outcome was assessed by resolution of the presenting clinical features and shunt freedom. Aetiologies that were identified included, in addition to idiopathic AS, suprasellar arachnoid cysts, AS in association with post-haemorrhagic hydrocephalus (PHH), post-infectious hydrocephalus (PIH), tumour-related hydrocephalus and a heterogenous group including Dandy-Walker malformation and other developmental anomalies. Suprasellar arachnoid cysts had a 100% outcome success. Idiopathic AS had a 50% outcome success and the successful outcome of PHH cases was poor at 18%. A statistical analysis revealed no effect of age at the time of ETV on the outcome in the aetiological groups. The definitive initial neurosurgical management of suprasellar arachnoid cysts causing significant hydrocephalus is ETV, whereas that for PHH and PIH is probably that of a ventriculo-peritoneal shunt placement. We speculate that there may be a sub-group of AS cases, termed pure or idiopathic AS, which have a higher rate of successful outcome that may be durable from a younger age. The role of repeat ETV is controversial.

Why a Focus Session on endoscopic third ventriculostomy in infants?

Since its “renaissance” in the late 1980s, endoscopic third ventriculostomy (ETV) gained a growing acceptance and, eventually, an established place in the surgical treatment of obstructive hydrocephalus. It soon became clear, however, that a part of the patients undergoing that endoscopic procedure eventually failed and that the chance of curing the hydrocephalus by endoscopy alone (without a shunt) depended on several factors, from which patient’s age and etiology of hydrocephalus are the most important. Most pediatric neurosurgeons agree that ETV has a higher failure rate in infants as opposed to children, adolescents, or adults. As some of us (not all) have found very low success rates in the first months of life, the question of whether this procedure should be offered at all to our youngest patients or whether it should be reserved to infants beyond the first or second year of life was raised. Similar considerations concern the role of etiology: there is general consensus that patients with isolated aqueductal stenosis are “good candidates” for ETV, whereas newborns with hydrocephalus in the context of myelomeningocele should be treated with shunts. But what kind of treatment should be chosen in other etiologies? How should mixed forms of obstructive/absorptive hydrocephalus be dealt with? Which kind of preoperative imaging is indispensable? Are there differences between ETV and shunts in the first year of life, with respect to complications or neurologic long-term outcome? This series of articles is intended to give an actual overview over the different important aspects of ETV in infants, particularly in the first year of life. The role of preoperative imaging, frequency and type of complications, and neurologic development after ETV vs shunt are dealt with, as well as the impact of age on success rate, indications for ETV in pathologies different from isolated aqueductal stenosis, or the relevance of a “spectrum classification” of absorptive vs obstructive hydrocephalus for the choice of the appropriate treatment procedures. Of course, this Focus Session not only gives more or less established answers, but also addresses questions that still remain open. In particular, the important issue of final neurodevelopmental outcome of children treated by ETVor shunt can be dealt with only by a prospective and randomized study, following the patients over years, as is intended to be realized by the ongoing International Infant Hydrocephalus Study (IIHS). While this Focus Session reflects our present knowledge, we are optimistic that the future will clarify questions that at the moment must be left unanswered. Childs Nerv Syst (2006) 22:1527 DOI 10.1007/s00381-006-0188-2

Third Ventriculostomy for Treatment of Hydrocephalus: Results of 271 Procedures

Abstract: The indication for endoscopic third ventriculostomy(ETV) includes almost any hydrocephalus. Depending on theunderlying pathology, a highly variable outcome has beenreported. Here, the authors present their experience with ETV inthe treatment of hydrocephalus after application of thistechnique for 13 years. Between January 1993 and October2005, 271 third ventriculostomies were undertaken. Indicationsincluded obstructive hydrocephalus caused by tumor, aqueduc-tal stenosis, hemorrhage and brain infarction, and selected casesof communicating hydrocephalus. A standard endoscopicventriculostomy was performed at the floor of the thirdventricle, consisting of a blunt perforation and subsequentenlargement of the stomy with a balloon catheter. The mean ageof the patients was 41 years with a range from 1 day up to 85years. Overall, symptoms improved clinically in 69% and theventricular size decreased in 64%. In 1 case, the procedure hadto be abandoned. The success rate of the procedure dependedhighly on the underlying pathology (116 cases with obstructivehydrocephalus caused by tumor, 81% success rate; 56 cases withaqueductal stenosis, 73% success rate; 35 cases of intraven-tricular hemorrhage, 66% radiologic improvement; 15 caseswith cerebellar infarction and fourth ventricular malformationeach and a success rate of 86% and 53% respectively; 35%clinical improvement in 23 cases communicating hydrocephalus;50% improvement in 4 cases associated with myelomeningo-cele). Complications included 2 deaths (0.7%) and 4 permanentdeficits (1.5%). In all, ETV represents a safe and reliableprocedure for hydrocephalus treatment. It is the procedure ofchoice for obstructive hydrocephalus.Key Words: third ventriculostomy, hydrocephalus, neuroendo-scopy, aqueductal stenosis, pediatric neuroendoscopy(Neurosurg Q 2006;16:24–31)

Hydrocephalus in children with posterior fossa tumors: role of endoscopic third ventriculostomy

Controversy exists regarding the indication for endoscopic third ventriculostomy (ETV) in children with hydrocephalus caused by posterior fossa tumors. The authors present their treatment modalities and discuss the role of ETV in the management of hydrocephalus. The authors retrospectively reviewed the cases of 58 children who were admitted to their clinic consecutively with posterior fossa tumors between January 1999 and December 2003. Fifty-two patients presented with hydrocephalus. The mean age at the time of admission was 6 years and 3 months. The mean follow-up period was 25 months. The authors evaluated how many children required a cerebrospinal fluid (CSF) draining procedure (external ventricular drain [EVD], ventriculoperitoneal [VP] shunt, or ETV) prior to or following tumor removal. Only six patients (11.5%) required permanent treatment for hydrocephalus. Four patients received a VP shunt and two patients underwent ETV. A temporary EVD was placed in five patients (two required a shunt). Forty-six patients (88.5%) did not require a permanent CSF draining procedure. For children with posterior fossa tumors, ETV is not indicated as a standard operation either prior to or following tumor removal. Only six of 52 children presenting with hydrocephalus required a permanent CSF draining procedure. Endoscopic third ventriculostomy may be suitable for patients with fourth ventricle outflow obstruction and persisting or progressive hydrocephalus following tumor removal.

Endoscopic third ventriculostomy in patients with cerebrospinal fluid infection and/or hemorrhage.

In this study the authors evaluate the safety, efficacy, and indications for endoscopic third ventriculostomy (ETV) in patients with a history of subarachnoid hemorrhage or intraventricular hemorrhage (IVH) and/or cerebrospinal fluid (CSF) infection. The charts of 101 patients from seven international medical centers were retrospectively reviewed; 46 patients had a history of hemorrhage, 42 had a history of CSF infection, and 13 had a history of both disorders. All patients experienced third ventricular hydrocephalus before endoscopy. The success rate for treatment in these three groups was 60.9, 64.3, and 23.1%, respectively. The follow-up period in successfully treated patients ranged from 0.6 to 10 years. Relatively minor complications were observed in 15 patients (14.9%), and there were no deaths. A higher rate of treatment failure was associated with three factors: classification in the combined infection/hemorrhage group, premature birth in the posthemorrhage group, and younger age in the postinfection group. A higher success rate was associated with a history of ventriculoperitoneal (VP) shunt placement before ETV in the posthemorrhage group, even among those who had been born prematurely, who were otherwise more prone to treatment failure. The 13 premature infants who had suffered an IVH and who had undergone VP shunt placement before ETV had a 100% success rate. The procedure was also successful in nine of 10 patients with primary aqueductal stenosis. Patients with obstructive hydrocephalus and a history of either hemorrhage or infection may be good candidates for ETV, with safety and success rates comparable with those in more general series of patients. Patients who have sustained both hemorrhage and infection are poor candidates for ETV, except in selected cases and as a treatment of last resort. In patients who have previously undergone shunt placement posthemorrhage, ETV is highly successful. It is also highly successful in patients with primary aqueductal stenosis, even in those with a history of hemorrhage or CSF infection.

Clinical features of late-onset idiopathic aqueductal stenosis

BACKGROUND Although late-onset idiopathic aqueductal stenosis (LIAS) is considered a good indication for endoscopic third ventriculostomy (ETV), the characteristics of this clinical entity have seldom been reported in the magnetic resonance (MR) imaging era. The authors reviewed their patients with LIAS who were treated by ETV to confirm its clinical features and response to treatment. METHODS The study group was composed of 31 patients diagnosed with LIAS who were previously untreated. Both anatomic and cine phase-contrast MR studies were used to detect the obstruction of the aqueduct canal. The preoperative symptoms were statistically analyzed in relation to the age of the patients and the degree of preoperative ventriculomegaly. RESULTS The overall success rate of ETV was 83.9% with mean follow-up duration of 26.2 months. Only two patients had acute onset (within one month) without any predisposing chronic symptoms. The patients with chronic symptoms (longer than 6 months [ n = 25]) can be divided into two major groups: a headache group ( n = 12) and a normal pressure hydrocephalus (NPH)-symptom group ( n = 11), Two patients had both headaches and NPH symptoms. The patients in the headache group were significantly younger and had smaller ventricles than the patients in the NPH group. With multivariate regression analysis, age independently affected the type of chronic symptoms. CONCLUSIONS LIAS typically presents with chronic onset, with younger patients tending to have headaches, and older patients tending to have NPH symptoms. ETV is considered the best surgical option, with more than an 80% success rate.

Endoscopic third ventriculostomy for hydrocephalus.

The authors report on 125 patients who underwent endoscopic third ventriculostomy for obstructive hydrocephalus in three Italian Neurosurgical Centers. The series includes 77 cases of primary aqueductal stenosis, 33 with triventricular hydrocephalus due to external tumor compression, and 15 with tetraventricular hydrocephalus. The operations were carried out mainly under general anesthesia, using a flexible endoscope. Decrease of size of the third ventricle and the presence of a signal void at the level of the fenestration are the main postoperative MRI findings. Signs of intracranial hypertension, increased head circumference and Parinaud syndrome respond more frequently to the endoscopic treatment. The overall rate of good results (shunt-independent patients) in this series is 86.4%; primary aqueductal stenosis (93.5%) and triventricular hydrocephalus due to external compression (84.8%) are associated to the higher rate of good postoperative results than tetraventricular hydrocephalus (53.3%). Because of the very low invasivity of this technique, the absence of postoperative mortality and the scarce and usually transient postoperative complications, the authors advise to enlarge the indications for endoscopic third ventriculostomy to all patients with obstructive hydrocephalus when the third ventricle is large enough and there are no alterations of the CSF resorption.