Predictors of success for combined endoscopic third ventriculostomy and choroid plexus cauterization in a North American setting: a Hydrocephalus Clinical Research Network study

Abstract

<jats:sec><jats:title>OBJECTIVE</jats:title><jats:p>Endoscopic third ventriculostomy combined with choroid plexus cauterization (ETV+CPC) has been adopted by many pediatric neurosurgeons as an alternative to placing shunts in infants with hydrocephalus. However, reported success rates have been highly variable, which may be secondary to patient selection, operative technique, and/or surgeon training. The objective of this prospective multicenter cohort study was to identify independent patient selection, operative technique, or surgical training predictors of ETV+CPC success in infants.</jats:p></jats:sec><jats:sec><jats:title>METHODS</jats:title><jats:p>This was a prospective cohort study nested within the Hydrocephalus Clinical Research Network’s (HCRN) Core Data Project (registry). All infants under the age of 2 years who underwent a first ETV+CPC between June 2006 and March 2015 from 8 HCRN centers were included. Each patient had a minimum of 6 months of follow-up unless censored by an ETV+CPC failure. Patient and operative risk factors of failure were examined, as well as formal ETV+CPC training, which was defined as traveling to and working with the experienced surgeons at CURE Children’s Hospital of Uganda. ETV+CPC failure was defined as the need for repeat ETV, shunting, or death.</jats:p></jats:sec><jats:sec><jats:title>RESULTS</jats:title><jats:p>The study contained 191 patients with a primary ETV+CPC conducted by 17 pediatric neurosurgeons within the HCRN. Infants under 6 months corrected age at the time of ETV+CPC represented 79% of the cohort. Myelomeningocele (26%), intraventricular hemorrhage associated with prematurity (24%), and aqueductal stenosis (17%) were the most common etiologies. A total of 115 (60%) of the ETV+CPCs were conducted by surgeons after formal training. Overall, ETV+CPC was successful in 48%, 46%, and 45% of infants at 6 months, 1 year, and 18 months, respectively. Young age (&lt; 1 month) (adjusted hazard ratio [aHR] 1.9, 95% CI 1.0–3.6) and an etiology of post–intraventricular hemorrhage secondary to prematurity (aHR 2.0, 95% CI 1.1–3.6) were the only two independent predictors of ETV+CPC failure. Specific subgroups of ages within etiology categories were identified as having higher ETV+CPC success rates. Although training led to more frequent use of the flexible scope (p &lt; 0.001) and higher rates of complete (&gt; 90%) CPC (p &lt; 0.001), training itself was not independently associated (aHR 1.1, 95% CI 0.7–1.8; p = 0.63) with ETV+CPC success.</jats:p></jats:sec><jats:sec><jats:title>CONCLUSIONS</jats:title><jats:p>This is the largest prospective multicenter North American study to date examining ETV+CPC. Formal ETV+CPC training was not found to be associated with improved procedure outcomes. Specific subgroups of ages within specific hydrocephalus etiologies were identified that may preferentially benefit from ETV+CPC.</jats:p></jats:sec>

Management of Pre-existing Ventriculoperitoneal Shunt in Posterior Vault Distraction for Lambdoid Craniosynostosis: A Case Report and Technical Note

“…Giving him a low chance of ETV success by stratified ETVSS (low is ≤ 40; moderate is 50-70; high is ≥80). This said, the addition of a choroid plexus coagulation could indeed increase the chances of ETV success [18].…”

Surgical resource utilization after initial treatment of infant hydrocephalus: comparing ETV, early experience of ETV with choroid plexus cauterization, and shunt insertion in the Hydrocephalus Clinical Research Network

“…The influence of formal training in ETV with CPC on outcomes has been studied previously by the HCRN, without a significant impact or relationship identified. 28 The types of surgical revisions following index treatment strategy followed expected trends. First-time CSF shunt insertion following ETV failure and CSF shunt revision following shunt malfunction (excluding infection) accounted for similarly high proportions of surgical revisions over 3 and 5 years following initial surgery (Tables 5 and 6).…”

Integrated understanding of hydrocephalus — a practical approach for a complex disease

“…Those forms of hydrocephalus will still account for the classic nomenclature of non-communicating hydrocephalus as introduced by Dandy and are having the implication that endoscopic treatment will be well indicated in order to reestablish communication of CSF flow [18]. Success of endoscopic ventriculo-cisternostomy (ETV), however, further depends mainly on age and the underlying disease leaing to hydrocephalus [43,47,67]. Recently, another form of non-communicating hydrocephalus was introduced, which is called either panventriculomegaly, external occlusive hydrocephalus, or prepontine occlusive hydrocephalus [3,25,35] and is defined mainly by a prepontine obstruction of CSF spaces in which the CSF communication toward the subarachnoid space of the convexity is blocked.…”

“…Among endoscopic techniques, ETV is well established in non-communicating hydrocephalus to reestablish communication between internal and external CSF spaces but may not be used under the age of 6 months due to higher failure rates. Especially in North America and Africa, ETV is combined with choroid plexus coagulation to enhance the success rate and avoid shunting [46,67]. This is still discussed controversially, especially if alternatively, more physiological shunt systems are used to optimally reach physiological CSF equilibrium in the calvarium and thereby keeping the choroid plexus intraventricularly intact.…”