Lower rates of symptom recurrence and surgical revision after primary compared with secondary endoscopic third ventriculostomy for obstructive hydrocephalus secondary to aqueductal stenosis in adults

Abstract

E ndoscopic third ventriculostomy (ETV) is considered the initial treatment of choice for obstructive hydrocephalus, with significant improvement reported in more than 75% of hydrocephalus secondary to aqueductal stenosis and approximately 95% of outflow obstruction of the third ventricle caused by space-occupying lesions. 10,16,23 ETV is also the preferred treatment for symptomatic congenital aqueductal stenosis, as well as a viable option for patients whose aqueductal stenosis is acquired. 16 Overall, the largest adult series have displayed success rates ranging from 66% to 88% in hydrocephalus management. 10 However, the success of ETV in patients obJective Endoscopic third ventriculostomy (ETV) is the treatment of choice for obstructive hydrocephalus; however, the success of ETV in patients who have previously undergone shunt placement remains unclear. The present study analyzed 103 adult patients with aqueductal stenosis who underwent ETV for obstructive hydrocephalus and evaluated the effect of previous shunt placement on post-ETV outcomes. methods This study was a retrospective review of 151 consecutive patients who were treated between 2007 and 2013 with ETV for hydrocephalus. One hundred three (68.2%) patients with aqueductal stenosis causing obstructive hydrocephalus were included in the analysis. Postoperative ETV patency and aqueductal and cisternal flow were assessed by high-resolution, gradient-echo MRI. Post-ETV Mini-Mental State Examination, Timed Up and Go, and Tinetti scores were compared with preoperative values. Univariate and multivariate analyses were performed comparing the post-ETV outcomes in patients who underwent a primary (no previous shunt) ETV (n = 64) versus secondary (previous shunt) ETV (n = 39). results The majority of patients showed significant improvement in symptoms after ETV; however, no significant differences were seen in any of the quantitative tests performed during follow-up. Symptom recurrence occurred in 29 (28.2%) patients after ETV, after a median of 3.0 (interquartile range 0.8-8.0) months post-ETV failure. Twenty-seven (26.2%) patients required surgical revision after their initial ETV. Patients who received a secondary ETV had higher rates of symptom recurrence (p = 0.003) and surgical revision (p = 0.003), particularly in regard to additional shunt placement/revision post-ETV (p = 0.005). These differences remained significant after multivariate analysis for both symptom recurrence (p = 0.030) and surgical revision (p = 0.043). coNclusioNs Patients with obstructive hydrocephalus due to aqueductal stenosis exhibit symptomatic improvement after ETV, with a relatively low failure rate. Patients with a primary history of shunt placement who undergo ETV as a secondary intervention are at increased risk of symptom recurrence and need for surgical revision post-ETV.

Endoscopic Third Ventriculostomy, Indications and Challenges

“…In a previous study, clinical improvement with identifiable success of the procedure was detected in 86.4% of cases [19], where the success rate was lower in secondary ETV after VP shunt (Figure 2). This would be better identified in patients with previous history of multiple VP shunt revisions where the ETV failure is relatively more encountered [19,20]. ETV is also preferred as the first-line management of hydrocephalus due to obstruction of the aqueduct of Sylvius with pineal tumors or tectal gliomas [21][22][23].…”

“…It is not considered as a stable condition as it can be tolerated for years, where stenosis is aggravated by trauma, subarachnoid hemorrhage, viral infection, or gradual accumulation of the CSF proximal to the aqueduct in partial obstruction [16][17][18]. In a previous study, clinical improvement with identifiable success of the procedure was detected in 86.4% of cases [19], where the success rate was lower in secondary ETV after VP shunt (Figure 2). This would be better identified in patients with previous history of multiple VP shunt revisions where the ETV failure is relatively more encountered [19,20].…”

“…The success of the secondary ETV after ventricular shunt insertion is still debatable, where some studies identified the previous shunting procedure as a weakening factor against the ETV success [19,41]. Other studies mentioned the success of the secondary ETV in hindering the shunt dependency [42,43].…”

Prevalence and Pattern of Initial Complications Following Endoscopic Third Ventriculostomy for Hydrocephalus Obstructor

“…CSF shunt patients experience drainage (obstruction, disconnection), drainage (overflow), and infection concerns. [12] Hydrocephalus therapy is moving away from shunts to endoscopic methods. [13] Small burr holes offer rapid access without brain retraction.…”

Clinical Impact of the Patient Age Following Endoscopic Third Ventriculostomy: A Review

“…The aim following third ventriculostomy is to manage obstructive hydrocephalus by diversion of abnormal intracranial cerebrospinal fluid with least possible complications (13)(14). (16,17). In case of aqueduct of Sylvius obstruction and tumors third ventriculostomy seems best treatment option (18)(19)(20).…”