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

Abstract

<jats:sec><jats:title>OBJECTIVE</jats:title><jats:p>Few studies have addressed surgical resource utilization—surgical revisions and associated hospital admission days—following shunt insertion or endoscopic third ventriculostomy (ETV) with or without choroid plexus cauterization (CPC) for CSF diversion in hydrocephalus. Study members of the Hydrocephalus Clinical Research Network (HCRN) investigated differences in surgical resource utilization between CSF diversion strategies in hydrocephalus in infants.</jats:p></jats:sec><jats:sec><jats:title>METHODS</jats:title><jats:p>Patients up to corrected age 24 months undergoing initial definitive treatment of hydrocephalus were reviewed from the prospectively maintained HCRN Core Data Project (Hydrocephalus Registry). Postoperative courses (at 1, 3, and 5 years) were studied for hydrocephalus-related surgeries (primary outcome) and hospital admission days related to surgical revision (secondary outcome). Data were summarized using descriptive statistics and compared using negative binomial regression, controlling for age, hydrocephalus etiology, and HCRN center. The study population was organized into 3 groups (ETV alone, ETV with CPC, and CSF shunt insertion) during the 1st postoperative year and 2 groups (ETV alone and CSF shunt insertion) during subsequent years due to limited long-term follow-up data.</jats:p></jats:sec><jats:sec><jats:title>RESULTS</jats:title><jats:p>Among 1090 patients, the majority underwent CSF shunt insertion (CSF shunt, 83.5%; ETV with CPC, 10.0%; and ETV alone, 6.5%). Patients undergoing ETV with CPC had a higher mean number of revision surgeries (1.2 ± 1.6) than those undergoing ETV alone (0.6 ± 0.8) or CSF shunt insertion (0.7 ± 1.3) over the 1st year after surgery (p = 0.005). At long-term follow-up, patients undergoing ETV alone experienced a nonsignificant lower mean number of revision surgeries (0.7 ± 0.9 at 3 years and 0.8 ± 1.3 at 5 years) than those undergoing CSF shunt insertion (1.1 ± 1.9 at 3 years and 1.4 ± 2.6 at 5 years) and exhibited a lower mean number of hospital admission days related to revision surgery (3.8 ± 10.3 vs 9.9 ± 27.0, p = 0.042).</jats:p></jats:sec><jats:sec><jats:title>CONCLUSIONS</jats:title><jats:p>Among initial treatment strategies for hydrocephalus, ETV with CPC yielded a higher surgical revision rate within 1 year after surgery. Patients undergoing ETV alone exhibited a nonsignificant lower mean number of surgical revisions than CSF shunt insertion at 3 and 5 years postoperatively. Additionally, the ETV-alone cohort demonstrated significantly fewer hospital admission days related to surgical management of hydrocephalus within 3 years after surgery. These findings suggest a time-dependent benefit of ETV over CSF shunt insertion regarding surgical resource utilization.</jats:p></jats:sec>

Treatment strategies for hydrocephalus related to Dandy-Walker syndrome: evaluating procedure selection and success within the Hydrocephalus Clinical Research Network

“…As the long-term health implications of shunt dependence increasingly gains attention, both neurosurgeons and parents may be more apt to consider ETV-based approaches as the initial treatment choice. [21][22][23][24] Our results suggest that North American surgeons may reasonably choose an ETV-based treatment for many children in an attempt to avoid shunt dependency and the potential longterm difficulties associated with shunt placement. However, the treating surgeon still might need to consider shuntbased treatment in specific subgroups that were too small for a separate analysis, particularly very young infants (age < 1 month) with comorbidities who were treated predominantly with shunt-based procedures in this cohort.…”

The choroid plexus maintains ventricle volume and adult subventricular zone neuroblast pool, which facilitates post-stroke neurogenesis

“…Our results show that once the ChP is ablated in adult brain, the loss of CSF is stable and irreversible for at least 20 months, suggesting that the ChP epithelial cells have minimal regenerative capacity in the adult mouse brain, which has not been specifically tested previously. Importantly, it may carry implications for patients who underwent surgical ChP cauterization as a treatment for hydrocephalus 32 , recognizing that there may be cross-species differences. Additionally, considering that damage to the ChP has been observed in ischemic and hemorrhagic stroke 55 , as well as in traumatic brain injury 56 , our finding raises a question on the role of the ChP in long-term sequelae of these conditions.…”

“…Additionally, regulation of CSF volume is thought to be important in brain homeostasis, however, while the deleterious effects of overproduction and/or insufficient drainage of CSF are well-characterized in hydrocephalus 15 , little is known about the effects of reduced CSF production and the lack of CSF volume, which is often seen in human CSF leak patients 29 . Clinically, an important intervention targeting the ChP is surgical ChP removal, which is used in treating children with ChP tumors 30 , and ChP cauterization is under clinical trials for treating neonatal hydrocephalus in combination with endoscopic third ventriculostomy 31,32 . Despite their perceived critical role in both homeostasis and disease, both the ChP and CSF remain among the most understudied areas in the central nervous system (CNS) 3 .…”

Cerebrospinal Fluid Homeostasis and Hydrodynamics: A Review of Facts and Theories

“…However, the employment of this method in hydrocephalus patients, presented disappointing results, with literature suggesting an overall production rate reduction of up to 40% in experimental animal models [34, 35], thus it was abandoned, at least as a single approach technique. Some authors point toward a potential beneficial effect when combined with endoscopic third ventriculostomy [36]; however, the most up to date systematic review with meta-analysis failed to provide supportive evidence [37], while the latest study of the Hydrocephalus Research Network goes one step further suggesting a potentially negative effect to the overall outcome in pediatric patients [38].…”