Management Of Obstructive Hydrocephalus Research Articles

Endoscopic third ventriculostomy

Introduction. Endoscopic third ventriculostomy (ETV) is the treatment of choice in obstructive hydrocephalus. It has become the main standard choice in management since 1962. However, there is scant data regarding the complications from clinical or multi-centre trials. This study highlights the specific complications and prevention methods related to ETV in Neurosurgical Teaching Hospital, Baghdad, Iraq. Methods. It is a prospective case series study conducted on cases in the Neurosurgical Teaching Hospital in Baghdad, Iraq, from January 2014- October 2019. We selected ninety patients. The sample selection was convenient as any patients admitted in the study period who met the selection criteria were included. All included patients underwent a Computerized Tomography scan or Magnetic Resonance Imaging in the periprocedural management. Results. Ninety cases have 59 (65.5%) females and 31 (34.5%) males. The most common cause of hydrocephalus is congenital causes (51 cases (56.6%), especially within the first decade of life. Aqueduct stenosis is the leading cause in 37 cases (72%). ETV complications were found in 32 cases (35.5%). The most common cause of complications is congenital cases of 14 (15%). Intraoperative complications include bleeding (mild, moderate, and severe) in 18 cases (20%). Mild bleeding constitutes 15 cases (16.6%) of all complicated cases. Conclusion. ETV is a standard procedure in the management of obstructive hydrocephalus. The complication rate is found in around one-third of the cases in our study. Surgeons’ selection of indicated patients and better surgical experience decrease the failure rate of ETV and complications.

Endoscopic third ventriculostomy in the management of obstructive hydrocephalus: Success and failure.

Objective: To determine if endoscopic third ventriculostomy (ETV) is effective in the treatment of obstructive hydrocephalus. Study Design: Prospective study. Setting: Department of Neurosurgery, Hayatabad Medical Complex, Peshawar. Period: February 2018 to March 2021. Material & Methods: Eighty Five patients underwent endoscopic third ventriculostomy (ETV) for obstructive hydrocephalus all patients with obstructive hydrocephalus of any gender and age more than 6 months were included in the study. Patients age less than 6 months, recurrent cases and those refuse to opt for ETV were excluded from our study. The information regarding patient demographic, etiology, complications of procedure were documented in proforma. Data was analyzed using SPSS version 20.0 and presented in form of tables. Results: In the current study out of 85 patients, 48(56.4%) were male and 37(43.5%) were females with male to female ratio=1.23. ETV had successful outcome in 66(77.6%) patients. The sign and symptoms of raised intracranial pressure resolved in all patients after ETV. Overall complication rate in our study was 22(25.8%). The commonest complication was inadequate ventriculostomy in 10(11.7%), per operative significant bleeding in 4(4.7%) of patient, seizure in 3(3.5%) of patients, CSF leak and intraventricular hemorrhage in 2(2.35%) respectively. Conclusion: ETV is minimally invasive, safe, effective mode of treatment for obstructive hydrocephalus. Success rate is higher in children below 5 years of age. The overall success rate varies from 70-80% in various studies.

Endoscopic Third Ventriculostomy in the Management of Obstructive Hydrocephalus.

In the paper, “Early surgical outcome of endoscopic third ventriculostomy in the management of obstructive hydrocephalus: A randomized control trial,” the authors studied 1-month outcome of endoscopic third ventriculostomy (ETV) or ventriculoperitoneal (VP) shunting as the treatment for obstructive hydrocephalus. During 1½ years, sixty patients from 6 months to 70 years were enrolled in the study and allocated into two groups by simple random sampling. Postoperative outcome was evaluated by fontanel, head size, vomiting, and infection. They concluded that early outcome (1 month) subsequent to ETV was better than VP shunt (80% success rate in ETV and 40% in shunt cohort). They reported an infection rate of 26.67% in shunt group and 3.33% in ETV group.[[1]]

OBSTRUCTIVE HYDROCEPHALUS;

Introduction: Management of Hydrocephalus has always amazed and challenged clinicians throughout the history of medicine. The traditional treatment for all forms of hydrocephalus has been the implantation of Ventriculoperitoneal Shunt (VPS) system. Because of deployment of implant, this procedure inherently associated with certain common complications, infection approximately 24.6% of all shunt operations. Moreover, the risk of postoperative seizures is 25% and intracranial hemorrhage is 3.5%. Endoscopic Third Ventriculostomy (ETV) is a surgical procedure that allows the Cerebrospinal Fluid (CSF) to flow directly from the third ventricle to the basal cisterns and subarachnoid spaces, ETV has been established as a safe treatment for obstructive hydrocephalus because in this procedure there is no implant is deployed, that’s why rate of post operative complications is low as compare to VPS as intracranial infection found in 8% patient, intracranial hemorrhage in 5%and 1% patient developed seizure post ETV. Objectives: Objective of this study is to determine the frequency of short term complications of endoscopic third ventriculostomy in obstructive hydrocephalus. Study Design: Descriptive case series. Setting: Department of Neurosurgery, Lahore General Hospital, Lahore. Duration with Dates: Six months: from 01-07-2011 to 31-12-2011. Methods: This was a prospective study of in which 45 patients underwent Endoscopic third ventriculostomy for Obstructive hydrocephalus. The outcome of interest was to assess the frequency of complications like infection, hemorrhage and seizures following the ETV in patient with obstructive hydrocephalus. Data was collected on a specially designed Performa. Demographic details, signs and symptoms at presentation, details of post operative evaluation (mortality and neurological deficiency) were noted. Results: A total of 45 patients underwent in ETV for the treatment of obstructive hydrocephalus. Complications were observed in eight (17.8%) cases in which five patients had only one complication and three patients had multiple (two) complications. Regarding type of complication, Infection was observed in six (13.3%) cases, hemorrhage was observed in four (8.9%) cases and wound CSF leakages was seen in only one (2.2%) case. Conclusion: Endoscopic third ventriculostomy is recent advances in the management of obstructive hydrocephalus, it has lesser complications (Infection, Hemorrhage, seizures) and long term failure rate is low as compare to the traditional treatment of obstructive hydrocephalus.

Early Surgical Outcome of Endoscopic Third Ventriculostomy in the Management of Obstructive Hydrocephalus: A Randomized Control Trial.

Background:Management of obstructive hydrocephalus is an important issue for the reduction of mortality and morbidity.Objectives:The aim of the present study was to assess the early surgical outcome of endoscopic third ventriculostomy (ETV) in the management of obstructive hydrocephalus.Methodology:This randomized controlled trial was conducted at the Department of Neurosurgery at Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh, from April 2009 to September 2010 for 1½ years. All patients presenting with obstructive hydrocephalus with the obstruction at or distal to the third ventricle and age 6 months and above were included in the study population. All the patients were divided into two groups named as Group A (experimental group) who were treated with ETV and Group B (control group) who were treated with ventriculoperitoneal shunt (VPS). The early surgical outcome was defined as outcomes within 1 month following surgical interventions. Pre- and post-operative outcomes of this study were measured.Results:A total number of sixty patients were recruited from which thirty patients were in Group A and the rest thirty patients were in Group B. The mean postoperative head circumference was 43.4 ± 7.1 cm and 47.8 ± 5.6 cm in VPS and ETV surgery, respectively (P ≤ 0.01). Postoperative vomiting was improved 24 (92.3%) in Group A and 23 (88.5%) in Group B (P < 0.05). Postoperative infection occurred in 1 (3.3%) case in Group A and 8 (26.7%) cases in Group B (P < 0.05). The success of the operation in Group A and Group B included 25 (83.3%) cases and 12 (40%) cases, respectively (P < 0.05).Conclusion:Early surgical outcome following ETV is better than VPS surgery in patients with obstructive hydrocephalus.

Isolated third ventricle glioblastoma.

Introduction Glioblastoma is the most common and the most malignant type of gliomas. Cerebral hemispheres are usual locations for gliomas. Isolated third ventricular presentation is very rare for glioblastomas. A new case of isolated third ventricular glioblastoma has been presented in this report.Case descriptionA 36-year-old woman was admitted to outpatient clinic with headache, blurred vision and confusion. A head CT scan and MRI had showed third ventricular mass lesion with obstructive hydrocephalus. Previous to her admission to our clinic, a ventriculo-peritoneal shunt had been inserted and her hydrocephalus had been relieved to some extent in acute settings. In our clinic, stereotactic biopsy was performed and a second ventriculoperitoneal shunt was inserted from the opposite site. Histopathological diagnosis was glioblastoma. Radiotherapy and chemotherapy were started immediately after the surgery. Patient’s hydrocephalus has resolved and she was well at post-operative 6th month.Discussion and evaluationIn differential diagnosis list of the tumors presenting in the third ventricle, there are plenty of tumors such as colloid cyst, meningioma, germinoma, craniopharyngioma, lymphoma, choroid plexus papilloma, subependymal giant cell astrocytoma, chiasmatic and hypothalamic benign astrocytoma. Ring enhancement of this region pathology is a peculiar sign for glioblastoma, yet not pathognomonic. Tumor histology is crucial to yield the final diagnosis.ConclusionManagement of obstructive hydrocephalus, making histopathological diagnosis, starting adjuvant radiotherapy and chemotherapy in isolated third ventricular glioblastomas is a safe and effective approach when we consider malignant nature and intractable progress of glioblastomas.

Ventriculosubgaleal shunt in the management of obstructive hydrocephalus caused by cerebellar infarction

IntroductionCerebellar infarction is relatively uncommon. Small infarctions only cause cerebellar manifestations e.g. ataxia and nystagmus and are treated medically. Large cerebellar infarctions, however, can be life threatening. It cause brain stem compression and can obstruct the cerebrospinal fluid pathway causing obstructive hydrocephalus. It has to be treated promptly and may require besides the medical treatment surgical intervention as well. This is mainly in the form of posterior fossa decompression. In this study, we studied the beneficial effect of inserting a temporary ventriculoperitoneal shunt to relieve the supratentorial hydrocephalus in addition to posterior fossa decompression on the morbidity and mortality of patients in comparison to posterior fossa decompression alone. Aim of the workThe aim of this study was to evaluate the role of ventriculosubgaleal shunt in cerebellar infarction causing supratentorial ventricular dilatation. MethodsThis was a retrospective study that included ten patients having extensive cerebellar infarction causing spratentorial hydrocephalus. They were divided into two groups, group (1) was submitted to posterior fossa decompression alone and group (2) was submitted to posterior fossa decompression in addition to temporary ventriculosubgaleal shunt insertion. ResultsGroup (2) which had posterior fossa decompression in addition to temporary.ventriculosubgaleal shunt had much better results than group (1) which had only posterior fossa decompression. Group (2) had a lower morbidity and mortality and a shorter hospital stay than group (1). ConclusionTemporary insertion of ventriculosubgaleal shunt is recommended in patients having extensive cerebellar infarction causing supratentorial hydrocephalus in addition to posterior fossa decompression. It results in a lower morbidity and mortality and a shorter hospital stay.

Endoscopic Third Ventriculostomy: The Lebanese Experience

Background: Endoscopic third ventriculostomy (ETV) has gained wide popularity as a first-line treatment for obstructive hydrocephalus (OHC). We have been performing ETV since 1998. We report our experience with this technique in the management of OHC. Methods: Between 1998 and 2007, we performed 49 ETV procedures in 46 patients suffering from OHC. Medical records were retrospectively reviewed. Success was defined as shunt-free survival. Results: There were 29 males and 17 females with a mean age of 23 years (6 months–65 years). Aqueductal stenosis and tectal tumor were the most common etiologies (63%). Seven patients (15.6%) had early ETV failure. Of 38 patients with initial success and available follow-up, shunt independence was achieved in 29 patients (76.3%) after a mean follow-up of 37 months. Kaplan-Meier analysis yielded a 70% 5-year shunt-free survival rate. On multivariate analysis, no variables could predict early or late ETV failure. Transient complications occurred in 6 patients (13%), but there were no ETV-related deaths or permanent morbidity. Conclusion: ETV is a safe and effective treatment for OHC, resulting in a high rate of long-term shunt independence with a low risk of complications. ETV should be considered the treatment of choice for patients with OHC and its development as a substitute to shunt placement should be encouraged in neurosurgically developing countries.

Rational Management of Transient Obstructive Hydrocephalus Secondary to a Cerebellar Infarct

Cerebrovascular disease is a common occurrence in adults with immediate as well as long-term neurological effects. Sequelae are disabling for patients and lead to a greater demand for healthcare infrastructure and search for treatment options. The acute phase in a cerebellar infarction may become complicated with transient obstructive hydrocephalus, subsequent intracranial hypertension, and the need for surgical management. Although many patients respond well to medical treatment, clinical findings and neuroimaging methods must be considered to determine whether the hydrocephalus can be surgically treated in a timely fashion. A series of cases is presented and a proposal is made for adding endoscopic third ventriculostomy to the available treatment armamentarium. Fourteen patients with cerebellar strokes and their clinical course are reported. Six required surgery for hydrocephalus management. Three of the cases had an endoscopic third ventriculostomy without complications, the rest were managed conservatively. As an average, patency was re-established in the aqueduct three months post ictus. Management of obstructive hydrocephalus in the acute phase of a cerebellar stroke must be individualized. In cases with transient obstructive hydrocephalus, endoscopic third ventriculostomy is a good surgical treatment option that avoids the risks of a long-term ventricular shunt.

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.

Endoscopic third ventriculostomy in the management of obstructive hydrocephalus: an outcome analysis.

The purpose of this paper is to elucidate the safety and efficacy of, and indications and outcome prognosis for endoscopic third ventriculostomy (ETV) in 58 patients with obstructive hydrocephalus. Between September 1999 and April 2003, 58 ETVs were performed in 58 patients with obstructive hydrocephalus (36 male and 22 female patients) at the authors' institution. The ages of the patients ranged from 5 to 67 years (mean age 35 years) and the follow-up period ranged from 3 to 41 months (mean duration of follow up 24 months). Patients were divided into four subgroups based on the cause of the obstructive hydrocephalus: 21 with intracranial tumors; 11 with intracranial cysts; 18 with aqueductal stenosis: and eight with intracranial hemorrhage or infection. Both univariate and multivariate statistical analyses were performed to assess the prognostic relevance of the cause of the obstructive hydrocephalus, early postoperative clinical appearance, and neuroimaging findings in predicting the result of the ETV. The survival rate was 87% at the end of the 1st year and 84% at the end of the 2nd year post-ETV. One month after ETV an overall clinical improvement was observed in 45 (77.6%) of 58 patients. If we also consider the successful revision of ETV in two patients, a success rate of 78.3% (47 of 60 patients) was reached. The ETV was successful in 17 (81%) of 21 patients with intracranial tumors, nine (82%) of 11 with cystic lesions, 16 (88.9%) of 18 with aqueductal stenosis, and three (38%) of eight with intracranial hemorrhage or infection. A Kaplan-Meier analysis illustrates that the percentage of functioning ETVs stabilizes between 75 and 80% 1 year after the operation. In a comparison of results 1 year after ETV, the authors found that the aqueductal stenosis subgroup had the highest proportion of functioning ETV (89%). The proportions of the tumor and cyst subgroups were 84 and 82%, respectively, whereas the proportion was only 50% in the ventriculitis/intracranial hemorrhage subgroup (strata log-rank test: chi2 = 7.93, p = 0.0475). In the present study, ETV failed in eight patients (13.8%) and the time to failure after the procedure was a mean of 3.4 months (median 2 months, range 0-8 months). The logistic regression analysis confirmed an early postoperative improvement (within 2 weeks after ETV, significance [Sig] of log likelihood ratio [LLR] < 0.0001) and a patent stoma on cine phase-contrast magnetic resonance (MR) images (Sig of LLR = 0.0002) were significant prognostic factors for a successful ETV. The results demonstrated the multivariate model (B = -53.7309, standard error = 325.1732, Wald = 0.0273, Sig = 0.8688) could predict a correct result in terms of success or failure from ETV surgery in 89.66% of observed cases. The Pearson chi-square test demonstrated that little reliance could be placed on the finding of a reduced size of the lateral ventricle (chi2 = 5.305, p = 0.07) on neuroimaging studies within 2 weeks after ETV, but it became a significant predictive factor at 3 months (chi2 = 8.992, p = 0.011) and 6 months (chi2 = 10.586, p = 0.005) post-ETV. Major complications occurred in seven patients (12.1%), including intraoperative venous bleeding in three, arterial bleeding in one, and occlusion of the stoma in three patients. The overall mortality rate was 10.3% (six patients). One of these patients died of pulmonary infection and another of ventriculitis. Four additional patients died of progression of malignant tumor during the follow-up period. The results indicate that ETV is a most effective treatment in cases of obstructive hydrocephalus that is caused by aqueductal stenosis and space-occupying lesions. For patients with infections or intraventricular bleeding, ETV has considerable effects in selected cases with confirmed CSF dynamic studies. Early clinical and cine phase-contrast MR imaging findings after the operation play an important role in predicting patient outcomes after ETV. The predictive value of an alteration in ventricle size, especially during the early stage following ETV, is unsatisfactory. Seventy-five percent of ETV failures occur within 6 months after surgery. A repeated ventriculostomy should be considered to be a sufficient treatment option in cases in which stoma dysfunction is suspected.

The role of third ventriculostomy in the management of obstructive hydrocephalus.

Endoscopic third ventriculostomy (ETV) is an effective treatment for occlusive hydrocephalus caused by an obstruction of the CSF flow in the aqueduct or the posterior fossa. We evaluated the factors age, pathology and surgical technique on the results of the ETV. Between November 1992 and October 2000 171 ETV have been performed in 159 patients. The follow-up was evaluated in 150 patients. The age ranged from 10 days to 77 years (mean age 35 years). The hydrocephalus was caused by benign aqueductal stenosis in 77 patients, space-occupying lesions in 59, by intraventricular hemorrhages in 11, and by other causes in 3 patients. The trajectory was planned in 31 patients by frame-based and in 4 patients by frameless stereotaxy. The overall success rate of a single ETV was 71.3 % and including successful re-ETV 76.7 %. Best results were observed in adults and children older than 1 year. Infants demonstrated significantly worser outcomes. Patients with benign aqueductal stenosis and tumor compressing the aqueduct had the greatest profit from the ETV. The stereotactic guidance had no influence on the outcome and the number of severe complications. Complications were one arterial bleeding, three venous bleedings, and one ICB, all without permanent deficit, except one permanent hemiparesis. No mortality was observed.

The Treatment of Hydrocephalus by Ventriculo-Atrial Shunt1.

The operation of ventriculo-venous shunt in the management of obstructive hydrocephalus is discussed in the light of a series of 100 patients suffering from this condition who came under the care of a single neurological service over a six-year period, 79 being children, the remaindren adolescent or adult. Technical details of the operation, complications and results are discussed, consideration also being given to the factors influencing the decision whether in any given case this or some other procedure would appear to be in the best interests of the patient.