Treatment of post-thalamic hemorrhage hydrocephalus: ventriculoperitoneal shunt or endoscopic third ventriculostomy? A retrospective observational study.

BACKGROUND: The aim of this study was to compare the efficacy of ventriculoperitoneal shunt (VPS) and endoscopic third ventriculostomy (ETV) for the treatment of hydrocephalus after thalamic hemorrhage (TH) where external ventricular drainage (EVD) could not be removed after hematoma absorption, and to provide a theoretical basis for the clinical treatment of hydrocephalus after TH. METHODS: The clinical data of patients with hydrocephalus after TH whose EVD could not be removed after hematoma absorption were retrospectively analyzed. According to the patients' surgical methods, the patients were divided into the VPS group and ETV group. The operative time, length of hospital stay, complications, and reoperation rates of the two groups were compared. RESULTS: There was no statistically significant difference in intraoperative bleeding, length of hospital stay between the two groups. The EVD tubes were successfully removed in all patients after surgery. There were 4 (9.5%) complications in the ETV group and 3 (6.7%) complications in the VPS group, with no statistically significant difference in postoperative complications between the two groups. During the 1-year follow-up, 7 patients (16.7%) in the ETV group and 3 patients (6.7%) in the VPS group required reoperation. In the subgroup analysis of TH combined with fourth ventricular hemorrhage, 6 patients (14.3%) in the ETV group and 1 patient (2.2%) in the VPS group required reoperation, and the difference between the two groups was statistically significant. CONCLUSIONS: ETV had good efficacy in treating hydrocephalus caused by TH and TH that broke into the lateral ventricle and the third ventricle. However, if hydrocephalus was caused by TH with the fourth ventricular hematoma, VPS was a better surgical method because the recurrence rate of hydrocephalus in ETV was higher than that in VPS. Therefore, the choice of surgical method should be based on the patient's clinical features and hematoma location.

Giant tumefactive mesencephalothalamic Virchow-Robin space with triventricular hydrocephalus: a case-based systematic literature review.

BACKGROUND: The perivascular spaces of the brain are also known as Virchow-Robin spaces (VRSs). Dilated Virchow-Robin spaces in the brainstem are rare and mainly cause symptoms due to obstructive hydrocephalus, less frequently because of their size, mass effect, and impact on eloquent structures. CASE ILLUSTRATION: We present a patient with giant tumefactive VRS with hydrocephalus and neurological symptoms who was treated with endoscopic third ventriculostomy (ETV) followed by microscopic cyst fenestration. On the basis of this observation, we performed a thorough review of the literature to evaluate different treatment options. RESULTS: An 11-year-old girl presented with a headache for 3 months. The patient had a giant tumefactive mesencephalothalamic VRS with triventricular hydrocephalus. She was initially treated with endoscopic third ventriculostomy and multiple cyst fenestration. Symptomatic cyst regrowth required multiple cyst fenestrations via transcallosal transchoroidal (N = 2) and subtemporal approaches (N = 1) at the 2- and 4-year follow-ups. A literature review of these conditions allowed the detection of 12 cases (including our index case), and only 25% (3/12) of the patients underwent cyst fenestration 16.7% (2/12) required endoscopic fenestration and 8.3% (1/12) required microscopic fenestration. CONCLUSION: Giant mesencephalothalamic dVRSs are rare in the pediatric population. These patients are usually symptomatic due to obstructive hydrocephalus. Surgical options are endoscopic third ventriculostomy, ventricular shunt procedures, or direct cyst fenestration (microscopic or endoscopic). Close follow-up is mandatory owing to the risk of progression of the disease. Cyst fenestration resolves symptoms immediately, as it addresses both hydrocephalus and mass effects due to the cystic lesion in the same setting.

Beyond traditional predictors: the impact of the pulsatility index and cortical subarachnoid space diameter on endoscopic third ventriculostomy success.

OBJECTIVE: Determining the long-term success of endoscopic third ventriculostomy (ETV) remains challenging. This study aimed to investigate the impact of clinical and radiological factors on ETV success in pediatric patients with hydrocephalus. METHODS: The study included patients < 18 years old with hydrocephalus who underwent ETV between March 2014 and May 2021. Data including patient age, gender, history of previous shunt surgery, previous external ventricular drain placement, intraventricular hemorrhage history, and postoperative meningitis were extracted from medical records. Imaging features such as aqueductal stenosis, third ventricle floor bowing, displaced lamina terminalis, pulsatility index (PI), and maximum diameter of the cortical subarachnoid space (CSAS) were recorded for each patient using preoperative CT scans. Two independent neurosurgeons measured the CSAS maximum diameter and the PI. CSAS measurements were obtained on axial slices of the preoperative CT scans, whereas the PI was based on intraoperative third ventricle pulsatility. Patients were followed up for 1 year after surgery, with failure defined as the need for ventriculoperitoneal shunt (VPS) placement or death attributable to hydrocephalus. RESULTS: Ninety-eight children with a mean age of 16.39 ± 19.07 months underwent ETV for hydrocephalus. No deaths were recorded, but over 6 months and 1 year of follow-up, 12.2% and 22.4% of patients, respectively, experienced documented ETV failure requiring VPS placement. At the 6-month follow-up, a smaller maximum diameter of the CSAS was significantly associated with ETV failure; multivariate analysis revealed that CSAS maximum diameter was a predictor of 6-month ETV failure. At the 1-year follow-up, a lower PI was significantly associated with ETV failure, and multivariate analysis confirmed the PI as a significant predictor of ETV failure within 1 year after surgery. CSAS and PI measurements were repeated to assess interrater reliability: the intraclass correlation coefficients were 0.897 and 0.669 for CSAS and PI, respectively. CONCLUSIONS: This study found that the CSAS maximum diameter and the PI are predictors of ETV failure at 6 months and 1 year, respectively. These findings highlight the importance of considering specific factors such as the CSAS and PI when assessing the likelihood of ETV success in pediatric patients with hydrocephalus. Further research and consideration of these factors may help optimize patient selection and improve outcomes for those undergoing ETV as a treatment for hydrocephalus.

Levodopa-resistant parkinsonism developing after ventriculoperitoneal shunting for obstructive hydrocephalus and improving after endoscopic third ventriculostomy, with specific consideration of brainstem morphology: illustrative case.

BACKGROUND: Parkinsonism has been reported in patients with obstructive hydrocephalus (OH) following ventriculoperitoneal shunting (VPS). While levodopa works well, some cases are drug resistant. A few case series have reported that endoscopic third ventriculostomy (ETV) is beneficial, though its mechanism remains unclear. The use of a pathophysiology-reflected marker can aid in the diagnosis and treatment strategy. The authors report a case of parkinsonism due to OH after VPS that improved after ETV in a patient taking levodopa, which was subsequently discontinued. OBSERVATIONS: A 52-year-old man who had undergone VPS for OH caused by aqueductal stenosis with a tectal tumor presented with severe consciousness disturbance due to acute hydrocephalus and levodopa-refractory parkinsonism after multiple episodes of shunt malfunction. Magnetic resonance imaging showed an elevation of the floor of the third ventricle. ETV was performed to stabilize the pressure imbalance across the stenosis, and his parkinsonism symptoms improved after long-term rehabilitation, resulting in levodopa discontinuation. His pontomesencephalic angle, the angle between the anterior surface of the midbrain and upper surface of the pons in the midline of the sagittal plane, was significantly decreased. LESSONS: The focus in such cases should be on the essence of the pathophysiology for improving the symptoms rather than on easy-to-understand indicators such as ventricle size. https://thejns.org/doi/10.3171/CASE2429.

Symptomatic central nervous system tuberculosis and human herpesvirus-6 coinfection with associated hydrocephalus managed with endoscopic third ventriculostomy: A case report and review of human herpesvirus-6 neuropathology.

Background: Human herpesvirus 6 (HHV-6) is a double-stranded DNA virus well established in the clinical literature to cause the near-universal childhood infection roseola infantum (exanthema subitum/sixth disease). Primary HHV-6 infection has been reported to cause meningoencephalitis in pediatric patients, although generally in the immunocompromised. Case Description: The authors treated an immunocompetent 18-month-old female who transferred to our institution for a higher level of care given concerns for meningitis in the setting of decreased level of arousal (Glasgow Coma Scale 12), and bradycardia 9 days after the onset of nasal congestion, fatigue, and repeated bouts of emesis. Outside hospital cerebrospinal fluid (CSF) studies were notable for hypoglycorrhachia, elevated protein, elevated nucleated cells with a mononuclear predominance, and a meningitis polymerase chain reaction panel that was positive only for HHV-6. Brain magnetic resonance imaging with and without contrast revealed a basal cistern predominant leptomeningeal enhancement pattern as well as moderate ventriculomegaly with associated periventricular edema concerning acute communicating hydrocephalus. Considering the CSF studies, neuroimaging, and recent travel history to Mexico, central nervous system (CNS) tuberculosis (TB) was the leading suspicion, and antimicrobial therapy was initiated for this presumptive diagnosis with culture data only proving the TB suspicion correct after nearly 2 months in culture. Anti-viral therapy was initially not felt to be necessary as the HHV-6 was interpreted as incidental and not a cause of symptomatic meningitis in our immunocompetent host. The patient's hydrocephalus was treated with temporary CSF diversion followed by performance of an endoscopic third ventriculostomy. Despite appropriate hydrocephalus management, clinical improvement ultimately seemed to correlate with the initiation of antiviral therapy. Conclusion: The authors present this case and review the literature on HHV-6-associated CNS infections with the goal of informing the neurosurgeon about this often clinically underestimated pathogen.

Neuroanatomical refinement of Kocher's point for enhanced precision in ventriculostomy: A technical note and a literature review.

Background: This study was designed to assess the effectiveness and safety of using a modified Kocher's point for ventriculostomy using endoscopic third ventriculostomy (ETV) and external ventricular drainage (EVD) in 200 patients at PAR Private Hospital in Erbil, Iraqi Kurdistan. Methods: In this retrospective analysis, a total of 200 patients who were diagnosed with obstructive hydrocephalus and underwent ETV and EVD utilizing a modified entry site were included. The revised Kocher point was located 11.5 cm posterior and superior to the nasion, 3 cm laterally, and 0-1 cm before the coronal suture. Results: The use of this modified Kocher's point has brought much improvement in surgical precision and safety. This would minimize incidences of bleeding and misplacement of the catheters. The anatomical structure was well organized, and nothing was challenging in the process of traversing through the foramen of Monro into the third ventricle. It was easily introduced through the modified Kocher point with increasing efficacy and near zero possibility of sustaining injury to the limiting cerebral region. Conclusion: Using the modified point of Kocher provides added reliability and accuracy to ventriculostomy, thereby reducing complications and increasing the overall outcome of surgeries. It overcomes all the drawbacks of classical entry sites and, further, helps in increasing the productivity of ETV and EVD. More research must be done to support the benefits of this modification in other clinical settings.

Congenital Obstructive Hydrocephalus With Status Post-endoscopic Third Ventriculostomy Bilateral Subdural Hygroma and Pneumocephalus: A Case Report.

Pediatric neurosurgery faces a major difficulty in the treatment of hydrocephalus, a condition marked by an abnormal build-up of cerebrospinal fluid (CSF) in the brain. Its prevalence varies between 0.5 and 0.8 per 1,000 live births worldwide, with different etiologies, including congenital abnormalities and acquired diseases. With benefits including a lower risk of infection and avoiding issues due to the shunt, endoscopic third ventriculostomy (ETV) has become a beneficial surgical technique in certain instances. Bypassing clogged ventricular channels, ETV creates a new channel for CSF drainage. Despite its effectiveness, a thorough examination of underlying disease and anatomical variables is necessary for positive outcomes in patient selection. To give patients, the best possible care, this article attempts to summarize the prevalence of hydrocephalus and the part that ETV plays in managing it. It also emphasizes the significance of customized surgical techniques. It is critical to comprehend the incidence of hydrocephalus and available treatment choices to enhance the infant's quality of life and long-term outcomes.

Chronic Subdural Hematoma after Endoscopic Third Ventriculostomy for Chronic Obstructive Hydrocephalus: A Case Report.

Endoscopic third ventriculostomy (ETV) is a safe treatment option for chronic obstructive hydrocephalus. However, we encountered a case of chronic subdural hematoma (CSDH) with bilateral large hematoma volumes after ETV for chronic obstructive hydrocephalus. We herein report a rare complication of ETV. The patient was a 53-year-old woman who had been diagnosed with asymptomatic ventricular enlargement with aqueductal stenosis 5 years previously. However, over the course of 5 years, her gait and cognitive function gradually declined. ETV was administered to relieve symptoms. Head Magnetic resonance imaging performed 1 week after ETV indicated bilateral subdural hygroma. Three weeks after ETV, she presented with headache and left incomplete paralysis, and head Computed tomography (CT) demonstrated bilateral CSDH with a large volume hematoma. Burr-hole evacuation and drainage of the bilateral CSDH were performed, after which the symptoms resolved. However, 7 weeks after ETV, she again presented with headache and incomplete right paralysis, and CT revealed bilateral CSDH re-enlargement. After the second burr-hole evacuation and drainage of bilateral CSDH, her symptoms resolved. The bilateral CSDH continued to shrink following the second hematoma evacuation surgery and completely disappeared on CT scan performed 3 months after ETV. Ventricular enlargement due to chronic obstructive hydrocephalus stretches the brain mantle for several years. This long-term stretching may have diminished the brain compliance and led to the development, growth, and recurrence of CSDH. In ETV for chronic obstructive hydrocephalus, surgeons should consider the risk of postoperative CSDH with a high hematoma volume and tendency to recur.

Presentation, management, and outcomes of pediatric hydrocephalus in Africa: a systematic review and meta-analysis of 12,355 patients.

OBJECTIVE: The prevalence, management, and outcomes of hydrocephalus remain underexplored in Africa. This study aimed to analyze demographic and clinical features, evaluate treatment strategies, and assess neurological outcomes of pediatric hydrocephalus in Africa. METHODS: A systematic review of the literature using the PubMed, Google Scholar, and Web of Science electronic databases was completed according to the PRISMA guidelines to identify articles describing pediatric patients in Africa with hydrocephalus. RESULTS: Seventy-four retrospective and prospective studies and 33 case reports involving 12,355 patients were included. In 54 retrospective articles reporting patient demographics, 53.8% (3926/7297) were male with a mean age of 12.3 months. Nineteen studies reported macrocephaly (80.2%, 1639/2043) as the most common presentation. The etiology of hydrocephalus was reported as postinfectious (41.0%, 2303/5614) across 27 articles and congenital (48.6%, 1246/2563) in 10 articles. Eleven articles reported 46.7% (609/1305) of patients had communicating hydrocephalus while 53.3% (696/1305) had obstructive hydrocephalus. Diagnostic imaging included CT (76.1%, 2435/3202; n = 29 articles), ultrasonography (72.9%, 2043/2801; n = 15 articles), and MRI (44.8%, 549/1225; n = 11 articles). In 51 articles, 83.1% (7365/8865) of patients had ventriculoperitoneal shunting (VPS) while 33 articles described 54.1% (2795/5169) receiving endoscopic third ventriculostomy (ETV) for hydrocephalus surgical management. Postoperative complications included sepsis (6.9%, 29/421; n = 4 articles), surgical site infections (5.1%, 11/218; n = 4 articles), and CSF leaks (2.0%, 15/748; n = 8 articles). Shunt-related complications included infections (4.3%, 117/2717; n = 21 articles) and blockages (4.1%, 34/829; n = 6 studies). In 15 articles, 9.0% (301/3358) of patients with shunts had revisions. The mean follow-up duration was 18.9 ± 16.7 months with an overall mortality rate of 7.4% (397/5383; n = 29 articles). In the analysis of comparative studies, the 160 patients undergoing ETV demonstrated significantly higher odds of a successful operation (OR 1.54, 95% CI 0.51-4.69; p = 0.03) and neurological improvement at last follow-up (OR 3.36, 95% CI 0.46-24.79; p < 0.01) compared with the 158 who received VPS, but no significant differences were observed for complications and mortality between the two groups (p > 0.05). CONCLUSIONS: This review offers a comprehensive summary of pediatric hydrocephalus in Africa, highlighting shunting as the primary treatment. However, the observed variations across studies highlight the need to establish standardized guidelines for reporting patient characteristics, management strategies, and outcomes to ensure consistency and comparability in articles.

Stented endoscopic third ventriculostomy: technique, safety, and indications-a multicenter multinational study.

PURPOSE: Endoscopic third ventriculostomy (ETV) is an effective treatment for obstructive hydrocephalus. Secondary stoma closure may be life threatening and is the most common reason for late ETV failure, mostly secondary to local scarring. Local stents intended to maintain patency are rarely used. In this study, we summarize our experience using stented ETV (sETV), efficacy, and safety. MATERIAL AND METHODS: Data was retrospectively collected from all consecutive patients who underwent ETV with stenting at four centers. Collected data included indications for using sETV, hydrocephalic history, surgical technique, outcomes, and complications. RESULTS: Sixty-seven cases were included. Forty had a primary sETV, and 27 had a secondary sETV (following a prior shunt, ETV, or both). The average age during surgery was 22 years. Main indications for sETV included an adjacent tumor (n = 15), thick or redundant tuber cinereum (n = 24), and prior ETV failure (n = 16). Fifty-nine patients (88%) had a successful sETV. Eight patients failed 11 ± 8 months following surgery. Reasons for failure included obstruction of the stent, reabsorption insufficiency, and CSF leak (n = 2 each), and massive hygroma and tumor spread (n = 1 each). Complications included subdural hygroma (n = 4), CSF leak (n = 2), and stent malposition (n = 1). There were no complications associated with two stent removals. CONCLUSION: Stented ETV appears to be feasible and safe. It may be indicated in selected cases such as patients with prior ETV failure, or as a primary treatment in cases with anatomical alterations caused by tumors or thickened tuber cinereum. Future investigations are needed to further elucidate its role in non-communicating hydrocephalus.

Thirty-day outcomes of surgery for hydrocephalus: metrics in a large cohort from the National Surgical Quality Improvement Program-Pediatric.

OBJECTIVE: Hydrocephalus is a lifelong condition punctuated in most cases by unpredictable hospital admissions for surgical maintenance. It occupies more of the attention of the pediatric neurosurgeon than any other condition. Benchmarks for the measurement of outcomes are of interest to patients, their families, and the healthcare system. Compared to other metrics, 30-day outcomes require modest resources to collect, are conceptually transparent, and are responsive to process improvement. METHODS: The National Surgical Quality Improvement Program-Pediatric of the American College of Surgeons was queried for operations for hydrocephalus in the years 2013 through 2020. Demographic data and data regarding comorbidities were collected. Thirty-day rates of return to the operating room, of shunt infection, and of readmission to hospital were analyzed on a univariate basis and in multivariate models. RESULTS: There were 29,098 surgical procedures in the sample, including 10,135 shunt insertions, 16,420 shunt revisions, and 2543 endoscopic third ventriculostomies. The overall 30-day reoperation rate was 10.3%. The most powerful associations were with the nature of the index procedure and with a history of extreme prematurity. The 30-day shunt infection rate was 1.80%. The major associations were with young age, major cardiac risk factors, nutritional support, and ventilator dependence. The 30-day readmission rate was 17.2%. The nature of the index procedure, current malignancy, nutritional support, and recent steroid administration were major associations. Comorbidities negatively associated with these outcomes were highly prevalent. CONCLUSIONS: Precise benchmarks for important 30-day outcomes have been calculated from a very large sample of operations for hydrocephalus in childhood.

Trends in the corpus of literature on endoscopic third ventriculostomy: a bibliometric analysis spanning 3 decades.

OBJECTIVE: The objective of this study was to report the results of a bibliometric analysis on the modern corpus of literature pertaining to endoscopic third ventriculostomy (ETV). Prior bibliometrics studies on ETV have focused on highly cited articles, but an advanced bibliometric analysis has not yet been conducted. METHODS: The authors queried the Web of Science (WoS) for (ALL = (endoscopic third ventriculostomy)) OR (ALL = (ETV) AND ALL = (neurosurgery)). Articles or reviews published in English were included. Articles, along with their metadata, were exported. Statistical, bibliometric, and network analyses were performed using the Bibliometrix R package and various Python packages. Reference publication year spectroscopy (RPYS), a method that analyzes the frequency with which references are cited in terms of these references' publication years, was employed to explore the historical roots of the field. RESULTS: Between 1994 and 2023, 1663 documents were identified (1382 articles) from 5457 authors. The mean annual growth rate of publications was 4.9%. International coauthorship increased 4-fold over this time period and was noted for 18.95% of published studies from 2011 to 2023. We observed that Child's Nervous System published the most articles, Journal of Neurosurgery (JNS) articles were cited most frequently, and JNS: Pediatrics articles had the highest impact. Female coauthorship increased from < 1% of published studies before 2000 to 19% by 2022, with an increase in female first authorship from 2% in 2005 to 22% in 2022 and at least 1 female coauthor rising from 3% in 2000 to 68% in 2022. Likewise, minority authorship has increased, as in the early ETV literature > 75% of authors were White while currently only 43% are White. The authors of this study also identified the most prolific authors on the subject. Early in the publication record, etiological and technical terms such as "aqueductal stenosis" and "technical note" predominated. More recently, "complications," "failure," "success," "neuroendoscopy," and "choroid plexus cauterization" were prominent. Utilizing RPYS, the authors identified 32 articles that comprise the foundational articles on ETV, published between 1966 and 2010. CONCLUSIONS: Interest in ETV increased in the 1990s with the advent of advanced endoscopic technologies-particularly digital video. The focus of research has shifted from etiology to outcomes, complication management, and technical mastery.

Prognostic factors for endoscopic third ventriculostomy success in hydrocephalus with myelomeningocele.

PURPOSE: Myelomeningocele (MMC) is a prevalent neural tube closure defect often associated with hydrocephalus, necessitating surgical intervention in a significant proportion of cases. While ventriculoperitoneal shunting (VPS) has been a standard treatment approach, endoscopic third ventriculostomy (ETV) has emerged as a promising alternative. However, factors influencing the success of ETV in MMC patients remain uncertain. This retrospective observational study aimed to identify clinical and radiological factors correlating with a higher success rate of ETV in MMC patients. METHODS: Medical records of MMC patients who underwent ETV at a tertiary care center between 2015 and 2021 were reviewed. Demographic, clinical, and radiological data were analyzed. ETV success was defined as the absence of further hydrocephalus treatment during follow-up. RESULTS: Of 131 MMC patients, 21 met inclusion criteria and underwent ETV. The overall success rate of ETV was 57.1%, with a six-month success rate of 61.9%. Age ≤ 6 months was significantly associated with lower ETV success (25%) compared to older patients (76.9%) (OR: 0.1; 95% CI 0.005-2.006; p = 0.019). Radiological factors, including posterior fossa dimensions and linear indices, did not exhibit statistically significant associations with ETV success. CONCLUSION: Age emerged as a significant factor affecting ETV success in MMC patients, with younger patients exhibiting lower success rates. Radiological variables did not significantly influence ETV outcomes in this study. Identifying predictors of ETV success in MMC patients is crucial for optimizing treatment strategies and improving patient outcomes.

Purely Endoscopic Supracerebellar Infratentorial Approach to the Pineal Region in Pediatric Population.

Pineal lesions represent less than 1% of all brain tumors (Villani et al., Clin Neurol Neurosurg 109:1-6, 2007). The abysmal location and critical neurovascular structures remain a surgical challenge, despite the advent of microneurosurgery. The classical wide surgical suboccipital craniotomy with the supracerebellar infratentorial approach, described by Sir Victor Horsley (Victor, Proc R Soc Med 3:77-78, 1910), is infamous for its considerable surgical morbidity and mortality. This was later upgraded microneurosurgically by Stein to improve surgical outcomes (Stein, J Neurosurg 35:197-202, 1971).Ruge et al. reported the first purely endoscopic fenestration of quadrigeminal arachnoid cysts via this corridor (Ruge et al., Neurosurgery 38:830-7, 1996). A cadaver-based anatomical study by Cardia et al. demonstrated the viability for endoscope-assisted techniques (Cardia et al., J Neurosurg 2006;104(6 Suppl):409-14). However, the first purely endoscopic supracerebellar infratentorial (eSCIT) approach to a pineal cyst was performed in 2008 by Gore et al. (Gore PA et al., Neurosurgery 62:108-9, 2008).Unlike transventricular endoscopy, eSCIT approach poses no mechanical risk to the fornices and can be utilized irrespective of ventricular size. More vascular control and resultant reduction in uncontrolled hemorrhage improve the feasibility of attaining complete resection, especially around corners (Zaidi et al,, World Neurosurg 84, 2015). Gravity-dependent positioning and cerebrospinal fluid (CSF) diversion aid cerebellar relaxation, creating the ideal anatomical pathway. Also, angle of the straight sinus, tentorium, and tectal adherence can often influence the choice of approach; thus direct endoscopic visualization not only counteracts access to the engorged Galenic complex but also encourages sharp dissection of the arachnoid (Cardia et al., J Neurosurg 104:409-14, 2006). These tactics help provide excellent illumination with magnification, making it less fatiguing for the surgeon (Broggi et al., Neurosurgery 67:159-65, 2010).The purely endoscopic approach thwarts the dreaded risk of air embolisms, via simple copious irrigation from a small burr hole (Shahinian and Ra, J Neurol Surg B Skull Base 74:114-7, 2013). The tiny opening and closure are rapid to create, and the smaller wound decreases postoperative pain and morbidity. Recent literature supports its numerous advantages and favorable outcomes, making it a tough contender to traditional open methods.

Treatment of hydrocephalus following fetal repair of myelomeningocele: comparing endoscopic third ventriculostomy with choroid plexus cauterization to ventricular shunting.

OBJECTIVE: The aim of this study was to compare clinical and craniometric outcomes of patients treated for hydrocephalus following fetal myelomeningocele repair (fMMR) via a ventriculoperitoneal shunt (VPS) or endoscopic third ventriculostomy with choroid plexus cauterization (ETV/CPC). METHODS: This was a retrospective cohort study of children who were treated for hydrocephalus following fMMR via VPS or ETV with or without CPC (ETV ± CPC) at Vanderbilt between 2012 and 2021. The primary outcomes were treatment failure and time to failure (TTF). Secondary outcomes included changes in hydrocephalus metrics (fronto-occipital horn ratio [FOHR] and head circumference measurements) and healthcare resource utilization (number of hospital admissions, clinic visits, and neuroimaging findings). RESULTS: Among 88 patients who underwent fMMR, 37 (42%) required permanent CSF diversion, of whom 19 received treatment at the authors' institution. Twelve patients underwent ETV ± CPC, and 7 underwent VPS placement at a median corrected age of 23 weeks versus 1 week (p = 0.002). The preoperative median head circumference percentiles and z-scores for patients in the ETV ± CPC cohort were similar to those of the VPS cohort (percentiles: 98.5 vs 94.0, p = 0.064; z-scores: 2.32 vs 1.60, p = 0.111). There was no difference in preoperative median FOHR measurements between the two cohorts (0.57 vs 0.59, p = 0.53). At 6 months postoperatively, the median head circumference percentile and z-score for the ETV ± CPC cohort remained similar between the two cohorts (percentiles: 98.0 vs 67.5, p = 0.315; z-scores: 2.12 vs 0.52, p = 0.307). There was no difference in the change in FOHR (-0.06 vs -0.09, p = 0.37) and change in head circumference percentile (-1.33 vs -28.6, p = 0.058) between the cohorts 6 months after the index CSF diversion procedure. One patient in the ETV ± CPC cohort experienced a seizure and a nonoperative subdural hemorrhage postoperatively; no other complications were observed. Six of the 7 patients in the VPS cohort required shunt revision with a median TTF of 9.8 months while 2 of the 12 ETV ± CPC patients required a repeat ETV at a median of 17.5 months (86% vs 17%, p = 0.013). The median number of hydrocephalus-related hospital readmissions was significantly lower in the ETV ± CPC cohort than in the VPS cohort (0 vs 1, p = 0.006). The ETV ± CPC cohort had fewer CT scans (0 vs 2, p = 0.004) and radiographs (0 vs 2, p < 0.001) than the VPS cohort. CONCLUSIONS: In a single-center cohort, hydrocephalic fMMR patients treated via ETV ± CPC remained shunt free, while a majority of patients receiving an upfront shunt required revision. This is the first study comparing ETV ± CPC with VPS in the fMMR hydrocephalus population. While larger, multicenter studies are needed, these results suggest that ETV/CPC may be a preferred means of CSF diversion following fMMR.

The Landscape of Pediatric Hydrocephalus in the Province of KwaZulu-Natal: A Comparative Analysis of the Referral Pattern, Etiology, and Management Outcomes in 4 Distinct 5-Year Periods.

BACKGROUND: Pediatric hydrocephalus is a significant health burden globally, particularly in low- and middle-income countries. Data from specific regions such as KwaZulu-Natal, South Africa, are lacking. This study aimed to investigate pediatric hydrocephalus by comparing 4 distinct 5-year periods. METHODS: Data were collected retrospectively (2003-2007, 2008-2012, and 2013-2017) and prospectively (2018-2022). Children (≤18 years old) treated for hydrocephalus were included. Data on demographics, referral patterns, etiology, treatment modalities, and outcomes were collected and analyzed. RESULTS: A total of 3325 children were treated. The peak period was 2008-2012 (35.3%). Most children (51.4%) were from rural areas (P = 0.013), and 47.9% were referred from regional hospitals (P < 0.001). Boys (56.4%) and infants (60.2%) were predominant groups (P < 0.001). Postinfectious etiology (32.7%) was predominant (P < 0.001), particularly tuberculous meningitis (54.1%). Ventriculoperitoneal shunts were the mainstay treatment (84.2%), with notable complication rates (20.4%), including infections (9.6%). Human immunodeficiency virus co-infection was diagnosed in 2.5% of cases. Weekend procedures were associated with ventriculoperitoneal shunt complications (hazard ratio [HR] = 1.3, 95% confidence [CI]1.03-1.66, P = 0.03). Mortality rate was 7.9%, and age ≥1 year (HR = 2.43, 95% CI 1.87-3.17, P < 0.001), tertiary hospital referral (HR = 1.48, 95% CI 1.06-2.04, P = 0.019), ventriculoperitoneal shunt infection (HR = 3.63, 95% CI 2.66-4.95, P < 0.001), acute abdomen (HR = 2.17, 95% CI 1.11-4.25, P = 0.024), and pneumonia (HR = 7.32, odds ratio = 4.84-11.06, P < 0.001) were associated with mortality. CONCLUSIONS: This study provides comprehensive insights into pediatric hydrocephalus in KwaZulu-Natal. Monitoring temporal trends and predictors of outcomes will guide future interventions to mitigate the burden of pediatric hydrocephalus in the region.

Huge hydrocephalus: a rare case series with insights into management and outcomes of this neglected cohort.

PURPOSE: This study aims to discuss the management challenges of huge hydrocephalus (HH), a severe subset of hydrocephalus, presenting predominantly in underprivileged backgrounds. Insights into the condition's characteristics, factors affecting outcomes, and associated morbidity are discussed. METHODS: A retrospective review of all operated cases of hydrocephalus with head circumference greater than body length (HC>L) was conducted (January 2019-January 2023). Data on epidemiological parameters, associated cranial abnormalities, cortical mantle thickness, peri-conceptional folic acid intake, surgical interventions, age-appropriate milestones, and complications were collected. Follow-up was conducted for at least 12 months or until expiration. RESULTS: The cohort consisted of 7 males and 5 females with age ranging from 3 to 48 months. 33% of them had associated neurological abnormalities, and 18 surgical interventions were needed for these 12 cases, including ventriculoperitoneal shunt or endoscopic diversion. A 17% wound breakdown rate requiring re-suturing was present, and 33% of cases had postoperative CSF infection, with 33% mortality, with only one case having age-appropriate development seen. The average hospital stay was 11.9 days, six times our center's average. All cases with an Evans index with an average of 0.7 expired within 12 months. None of the 12 mothers took peri-conceptional folic acid, and no case agreed to reduction cranioplasty. CONCLUSION: Huge hydrocephalus is a rare cohort with significant management challenges and poor prognosis even after treatment. Factors such as delayed intervention and low socioeconomic status contribute to adverse outcomes. Prevention through peri-conceptual folic acid intake and addressing socioeconomic disparities is crucial in reducing disease burden and improving prognosis.

A Single-Centre Experience of the Management and Surgical Outcomes of Late-Onset Idiopathic Aqueductal Stenosis.

Background Although idiopathic aqueductal stenosis is a congenital disorder, some patients present in adulthood. Many theories have tried to account for the late-onset presentation; however, the aetiology remains uncertain. This study aimed to investigate the clinical presentation, management, and outcomes of patients with late-onset idiopathic aqueductal stenosis (LIAS) managed at our centre. Methodology A retrospective study of patients with a diagnosis of LIAS managed at our centre between 1996 and 2018 was undertaken. Data on clinical presentation, imaging, management, and outcomes were retrieved from patient records and radiology reports. Results A total of 20 patients were diagnosed with LIAS during the study period. Endoscopic third ventriculostomy (ETV) was the initial modality of treatment for nine patients, ventriculoperitoneal shunt (VPS) for four patients, and conservative management in seven patients, in four of them intracranial pressure (ICP) was found to be normal following a period of ICP monitoring. The median follow-up period was three years (1 month to 24 years). One patient was lost to follow-up. One ETV failed in the first six months necessitating VPS insertion. Two cases that were initially managed conservatively required a VPS three and nine years following the initial presentation. Of the patients undergoing VPS insertion, all subsequently required valve adjustment or surgical revision. Conclusions The majority of patients with LIAS undergoing ETV were managed successfully, whereas VPS insertion was associated with a high rate of revision surgery in this cohort. ETV should be considered as the treatment of choice to avoid the long-term complications of shunting for patients with LIAS.

Is endoscopic third ventriculostomy a viable treatment option for normal pressure hydrocephalus? A systematic review.

Background: Endoscopic third ventriculostomy (ETV) is considered an alternative treatment for hydrocephalus and has become a standard of care for obstructive hydrocephalus. Recent studies have also explored its role in normal pressure hydrocephalus (NPH). We conducted a systematic review aiming to assess the outcomes of this minimally invasive endoscopic technique as a viable treatment option for NPH. Methods: A systematic literature search was performed using PubMed and Scopus databases, using iterations of search terms "Endoscopic third ventriculostomy," "Idiopathic normal pressure hydrocephalus," and "Normal pressure hydrocephalus." To be eligible for inclusion in the review, articles had to report the usage of ETV as a primary treatment modality for NPH, report its outcomes, and be published in the English language. Results: Out of the 13 studies selected for qualitative synthesis, nine supported the use of ETV for NPH as an effective treatment option with improvement in the preoperative symptoms. Two studies favored shunt over ETV, stating that quality of life is better with VP shunt insertion. One study reported that ETV has higher perioperative mortality rates that outweigh its benefits. One study reported it to be an ineffective surgical option. Conclusion: The current review of evidence does not support the use of ETV for the treatment of NPH, except perhaps in a small subset of patients. These patients have a shorter duration of symptoms and a better preoperative neurological status. The lumbar infusion test and ventricular infusion test are modalities useful for selecting these candidates.

Ventriculoperitoneal shunt placement following endoscopic third ventriculostomy failure in the treatment of pediatric hydrocephalus.

OBJECTIVE: The goal of this study was to evaluate the impact of endoscopic third ventriculostomy (ETV) failure on subsequent risk of ventriculoperitoneal shunt (VPS) placement. METHODS: A retrospective chart review was performed to identify pediatric patients receiving ETV followed by a VPS at Oklahoma Children's Hospital between January 1, 2016, and December 31, 2021. A control group of patients receiving a VPS alone was also gathered. Complication and shunt failure rates were compared between the 2 groups at 12 months postoperatively. RESULTS: A total of 222 patients were included in this study. The VPS placement after ETV failure (VPSEF) group included 21 patients; 53% were male and 47% were female, with a mean age of 2.2 years and standard deviation of 4.3 years. The etiology of hydrocephalus was chiefly intraventricular hemorrhage (43%) and neural tube defects (19%). At 12 months after VPS placement, the complication rate was 24%, predominantly including infection (19%) or CSF leakage (10%). The VPS-only (VPSO) group included 201 patients; 51% were male and 49% were female, with a mean age of 4.2 years and standard deviation of 6.5 years. The etiology of hydrocephalus was chiefly intraventricular hemorrhage (26%) and neural tube defects (30%). At 12 months postoperatively, the complication rate was 10%, predominantly including infection (6%) or catheter-associated hemorrhage (3%). The difference in complication rates between the VPSEF and VPSO groups was not significant at 12 months postoperatively (p = 0.07); however, on subgroup analysis there was a significantly higher rate of CSF leakage at 12 months in the VPSEF group compared to the VPSO group (p = 0.0371). CONCLUSIONS: There was no difference in overall complication rates for the treatment of pediatric hydrocephalus by VPS following failed ETV compared to VPS placement alone, yet prior ETV may predispose patients to a higher rate of CSF leaks within 12 months of VPS placement. Further study is indicated to determine whether a prior ETV procedure predisposes patients to a higher complication rate on VPS placement.