Endoscopic third ventriculostomy for treatment of adult hydrocephalus: long-term follow-up of 163 patients

Abstract

<jats:sec> <jats:title>OBJECTIVE</jats:title> <jats:p>The efficacy of endoscopic third ventriculostomy (ETV) for the treatment of pediatric hydrocephalus has been extensively reported in the literature. However, ETV-related long-term outcome data are lacking for the adult hydrocephalus population. The objective of the present study was to assess the role of ETV as a primary or secondary treatment for hydrocephalus in adults.</jats:p></jats:sec> <jats:sec> <jats:title>METHODS</jats:title> <jats:p>The authors performed a retrospective chart review of all adult patients (age ≥ 18 years) with symptomatic hydrocephalus treated with ETV in Calgary, Canada, over a span of 20 years (1994–2014). Patients were dichotomized into a primary or secondary ETV cohort based on whether ETV was the initial treatment modality for the hydrocephalus or if other CSF diversion procedures had been previously attempted respectively. Primary outcomes were subjective patient-reported clinical improvement within 12 weeks of surgery and the need for any CSF diversion procedures after the initial ETV during the span of the study. Categorical and actuarial data analysis was done to compare the outcomes of the primary versus secondary ETV cohorts.</jats:p></jats:sec> <jats:sec> <jats:title>RESULTS</jats:title> <jats:p>A total of 163 adult patients with symptomatic hydrocephalus treated with ETV were identified and followed over an average of 98.6 months (range 0.1–230.4 months). All patients presented with signs of intracranial hypertension or other neurological symptoms. The primary ETV group consisted of 112 patients, and the secondary ETV consisted of 51 patients who presented with failed ventriculoperitoneal (VP) shunts. After the initial ETV procedure, clinical improvement was reported more frequently by patients in the primary cohort (87%) relative to those in the secondary ETV cohort (65%, p = 0.001). Additionally, patients in the primary ETV group required fewer reoperations (p &lt; 0.001), with cumulative ETV survival time favoring this primary ETV cohort over the course of the follow-up period (p &lt; 0.001). Fifteen patients required repeat ETV, with all but one experiencing successful relief of symptoms. Patients in the secondary ETV cohort also had a higher incidence of complications, with one occurring in 8 patients (16%) compared with 2 in the primary ETV group (2%; p = 0.010), although most complications were minor.</jats:p></jats:sec> <jats:sec> <jats:title>CONCLUSIONS</jats:title> <jats:p>ETV is an effective long-term treatment for selected adult patients with hydrocephalus. The overall ETV success rate when it was the primary treatment modality for adult hydrocephalus was approximately 87%, and 99% of patients experience symptomatic improvement after 2 ETVs. Patients in whom VP shunt surgery fails prior to an ETV have a 22% relative risk of ETV failure and an almost eightfold complication rate, although mostly minor, when compared with patients who undergo a primary ETV. Most ETV failures occur within the first 7 months of surgery in patients treated with primary ETV, but the time to failure is more prolonged in patients who present with failed previous shunts.</jats:p></jats:sec>

Age-specific global epidemiology of hydrocephalus: Systematic review, metanalysis and global birth surveillance

“…The only current treatment for hydrocephalus is surgical intervention typically with an implanted shunt system or in a limited patient subpopulation, an endoscopic third ventriculostomy (ETV). [ 74 ] With only 50% efficacy for shunts in the first two years after surgical placement, hydrocephalus continues to be a major global health problem, especially in countries with limited resources. [ 75 ] However, the lack of clarity regarding hydrocephalus epidemiology has negatively affected awareness and the proportionate allocation of resources to investigate and treat the disease.…”

Surgical treatment of long-standing overt ventriculomegaly in adults (LOVA)

“…headaches, cognitive decline, imbalance, gait disturbance, psychological disturbance, visual deterioration/diplopia2. Macrocephaly defined by head circumference >98th percentile in adulthood (male 53.8 cm; female 52.9 cm) [5, 14]3. Overt tri-ventriculomegaly (lateral and third ventricles) on neuroimaging, with cortical sulcal effacement and/or destruction of the sella turcica as evidence of long-standing ventriculomegaly4.…”

A review of common endoscopic intracranial approaches

“…demonstrated a 22% relative risk of ETV failure in patients in whom VP shunt surgery failed before an ETV, along with an almost eightfold complication rate. [ 14 ]…”