Long-term operative failure of endoscopic third ventriculostomy in pediatric patients: the role of cine phase-contrast MR imaging

Abstract

<jats:sec> <jats:title>Object</jats:title> <jats:p>Although a rarely reported occurrence, late failure of endoscopic third ventriculostomy (ETV) may occur in children as a result of a variety of factors. Delay in recognition of symptoms can lead to harmful deterioration in the patient's condition. The authors undertook this study to assess the capacity of cine phase-contrast MR imaging to identify late failure in asymptomatic pediatric patients treated with ETV for hydrocephalus.</jats:p></jats:sec> <jats:sec> <jats:title>Methods</jats:title> <jats:p>This study was a retrospective evaluation of cases involving patients who underwent ETV between January 1, 1999, and December 31, 2008, at the pediatric neurological surgery service of the University of Padua. Before 2004, patients were routinely followed up with cine MR imaging at 3, 6, and 12 months after ETV. In 2004, a protocol of annual cine MR follow-up was instituted as a result of a case of fatal late failure. The authors evaluated all cases of late failure identified through cine MR imaging and performed a statistical analysis to investigate the relationship between ETV failure and several variables, including the cause of hydrocephalus for which ETV was originally indicated.</jats:p></jats:sec> <jats:sec> <jats:title>Results</jats:title> <jats:p>In a series of 84 patients (age range 6 days–16 years), 17 patients had early ETV failure. Of the remaining 67 patients, 5 (7%) were found to have no CSF flow through the fenestration and recurrent ventriculomegaly when assessed with cine MR imaging at 1, 2, 3, 4, and 7 years after ETV. The patient in whom ETV failure was identified 1 year postoperatively had Dandy-Walker malformation. The patients in whom ETV failure was identified 2, 3, and 4 years postoperatively all had undergone ETV for treatment of postinfective hydrocephalus. The patient in whom ETV failure was identified 7 years postoperatively had a cystic arachnopathy in the fourth ventricle after cerebellar astrocytoma removal.</jats:p></jats:sec> <jats:sec> <jats:title>Conclusions</jats:title> <jats:p>Patients who undergo ETV for infective hydrocephalus and Dandy-Walker malformation should receive long-term follow-up, because late closure of the stoma may occur progressively and slowly. Intraoperative observation of thickened arachnoid membranes at the level of the interpeduncular cisterns at the first ETV and a progressive decreasing of CSF flow through the stoma on routine cine MR imaging should be considered unfavorable elements entailing a significant risk of deterioration.</jats:p></jats:sec>

Endoscopic third ventriculostomy and repeat endoscopic third ventriculostomy in pediatric patients: the Dutch experience

“…2,12,19,50,52,67,69 A thicker third ventricle floor has been negatively associated with ETV success, 59 but unfortunately we could not retrospectively analyze this aspect. The presence of cisternal scarring has been negatively associated with success of the first ETV.…”

“…40 Although the comfort of parents could be a reason to prefer ETV over shunting, it can also make parents less cautious (i.e., provide a false sense of security), as there is no certainty of a cure for hydrocephalus, and late failure of ETV does occur with potential devastating results. 14,19,27,60 In our study, the latest failures occurred 12 years after ETV and 8 years after re-ETV.…”

“…The median age at re-ETV was 6.1 years (IQR 1.0-12.4 years), and the mean ETVSS for re-ETV was 71 (SD 16). There were 5 patients older than 18 years at re-ETV (19,19,21,22, and 26 years).…”

Result of Endoscopic Third Ventriculostomy for Hydrocephalus Caused by Cerebral Aqueductal Stenosis in Infant Patients

“…Cine PC MRI may be used to determine the patency of the stoma and may be used in follow-up. 4,24,30,31 Determining the best candidates for ETV has been difficult, with conflicting reports on who are the best candidates, particularly regarding the effect of age and etiology. Reports have indicated that outcome is a function of age 23,32,33 independent of age, 1,34 a function of etiology, 1,35-37 or a function of both age and etiology.…”

“…23 Intraoperative observation of thickened arachnoid membranes at the level of the interpeduncular cisterns at the time of ETV should be considered a significant risk of stoma block. 24 Postoperative failures usually occur early; regular clinical and radiologic follow-up must be performed, especially in the first years after the ETV. 25 According to Mohanty et al, 26 reclosure of the stoma because of gliosis and scarring has been observed in 6 to 15% of ETV failures.…”