Pineal Region Gliomas: A Systematic Review of Clinical Features and Treatment Outcomes.

BACKGROUND/AIM: To review the current literature on pineal region gliomas, summarizing the clinical characteristics and treatment outcomes. MATERIALS AND METHODS: PubMed, Scopus, and Cochrane databases were used to identify relevant articles. Comprehensive clinical characteristic review and survival analysis were conducted. RESULTS: Twelve studies describing 81 patients were included. The median age was 39 years (male=54.3%). Fifty patients (61.7%) had obstructive hydrocephalus requiring cerebrospinal fluid diversion with either ventriculoperitoneal shunt (VPS) (40.0%) or endoscopic third ventriculostomy (ETV) (24.0%). Patients who underwent VPS had significant survival benefits compared to ETV (p<0.05). All patients in our review underwent surgery, and gross-total resection (≥98%) was achieved in 34.6%. The supracerebellar infratentorial approach was the most employed surgical approach (62.3%). Chemotherapy was administered in 32.1% of cases, and radiotherapy in 40.7%. The median overall survival (OS) was 12 months, and the overall one-year survival rate was 60%. CONCLUSION: This study could not establish a correlation between the extent of tumor resection and positive treatment outcomes. However, among cases with hydrocephalus, patients who underwent VPS placement had better survival as compared to ETV.

Endoscopic versus stereotactic biopsies of intracranial lesions involving the ventricles.

Stereotactic biopsies of ventricular lesions may be less safe and less accurate than biopsies of superficial lesions. Accordingly, endoscopic biopsies have been increasingly used for these lesions. Except for pineal tumors, the literature lacks clear, reliable comparisons of these two methods. All 1581 adults undergoing brain tumor biopsy from 2007 to 2018 were retrospectively assessed. We selected 119 patients with intraventricular or paraventricular lesions considered suitable for both stereotactic and endoscopic biopsies. A total of 85 stereotactic and 38 endoscopic biopsies were performed. Extra procedures, including endoscopic third ventriculostomy and tumor cyst aspiration, were performed simultaneously in 5 stereotactic and 35 endoscopic cases. In 9 cases (5 stereotactic, 4 endoscopic), the biopsies were nondiagnostic (samples were nondiagnostic or the results differed from those obtained from the resected lesions). Three people died: 2 (1 stereotactic, 1 endoscopic) from delayed intraventricular bleeding and 1 (stereotactic) from brain edema. No permanent morbidity occurred. In 6 cases (all stereotactic), additional surgery was required for hydrocephalus within the first month postbiopsy. Rates of nondiagnostic biopsies, serious complications, and additional operations were not significantly different between groups. Mortality was higher after biopsy of lesions involving the ventricles, compared with intracranial lesions in any location (2.4% vs 0.3%, p = 0.016). Rates of nondiagnostic biopsies and complications were similar after endoscopic or stereotactic biopsies. Ventricular area biopsies were associated with higher mortality than biopsies in any brain area.

Extent of resection predicts risk of progression in adult pilocytic astrocytoma.

Object: Pilocytic astrocytomas are rare tumours in adults. Presentation, management and prognostic factors are poorly characterised. Methods: Retrospective single centre study from 2000 to 2016. Results: 50 cases were identified (median age 29 years; range 16-76). Symptoms at presentation were neurological deficit (n = 21), headache (n = 18) and seizures (n = 6). Five were incidental findings. Five patients had hydrocephalus at presentation and required emergent management, two by endoscopic third ventriculostomy and three by external ventricular drain. Symptoms were present for a median of 16 weeks (range 1 week to 34 years). Surgery consisted of gross total resection (n = 23), subtotal resection (n = 21) or biopsy (n = 6). Progression occurred in 20 patients at a median time of 7 years following surgery and was asymptomatic in just over half of these cases. A greater degree of resection (complete vs. subtotal) was associated with longer time to progression (Kaplan-Meier analysis, log rank test = 3.58, p = 0.059). At their first progression 12 patients underwent re-resective surgery and the remainder received radiotherapy. The median 5-year survival was 80%. Conclusions: In adult patients with a pilocytic astrocytoma, a macroscopic resection should be the aim at the first resective operation. Emergency management of hydrocephalus may be required in the first instance.

Tratamiento endoscópico de quistes coloideos del tercer ventrículo / Third ventricle colloid cysts endoscopic approach

Introducción: los quistes coloideos (QC) son tumores benignos de crecimiento lento, que comprenden menos del 1% de los tumores intracraneales. Se presentan en adultos jóvenes y se ubican más frecuentemente en el techo del tercer ventrículo. El objetivo de este trabajo es presentar una serie de pacientes con QC del tercer ventrículo operados por vía endoscópica, analizar la técnica quirúrgica, ventajas y desventajas. Desarrollo: se realizó una búsqueda retrospectiva de pacientes operados por vía endoscópica, en el Servicio de Neurocirugía del Hospital Italiano de Buenos Aires, de tumores del tercer ventrículo en un período de 2 años (2013-2015), con diagnóstico de QC confirmado por anatomía patológica . Se identificaron cinco pacientes, tres mujeres y dos hombres, cuyo promedio de edad fue de 50 años. No hubo complicaciones perioperatorias y ninguno mostró recidiva en el lapso de observación. Conclusión: la vía endoscópica es una vía técnicamente simple y con muy baja morbilidad. Si bien no siempre puede realizarse una exéresis completa, los trabajos prospectivos permitirán definir si esto resulta suficiente para el control de la enfermedad. (AU)

Colloid cysts are benign, slow-growing tumors, comprising less than 1% of intracranial tumors. They occur in young adults and are more frequently located on the roof of the third ventricle. The objective of this study is to present a series of patients with Colloid cysts operated endoscopically and analyze advantages and disadvantages of this surgical technique. We performed a retrospective review of Colloid Cysts operated on endoscopically, at the Neurosurgical Department of Hospital Italiano de Buenos Aires in a period of 2 years (2013-2015). Five patients were identified, three women and two men whose average age was 50 years. No perioperative complications were observed, with no recurrences during the follow up period. Conclusion: the endoscopic approach is technically simple and has very low morbidity. Although a complete excision can not always be performed, prospective studies will allow us to define whether if is sufficient to control the disease. (AU)

Ten-year survival of Ugandan infants after myelomeningocele closure.

OBJECTIVE Myelomeningocele (MM) is a neural tube defect complicated by neurological deficits below the level of the spinal lesion and, in many cases, hydrocephalus. Long-term survival of infants treated for MM in a low- and middle-income country has never been reported. This retrospective cohort study reports 10-year outcomes and factors affecting survival for infants undergoing MM repair at CURE Children's Hospital of Uganda. METHODS Patients were traced by telephone or home visit. Survival was estimated using the Kaplan-Meier method. Multivariate survival was analyzed using the Cox proportional hazards model, investigating the following variables: sex, age at surgery, weight-for-age at surgery, motor level, and presence and management of hydrocephalus. RESULTS A total of 145 children underwent MM repair between 2000 and 2004; complete data were available for 133 patients. The probability of 10-year survival was 55%, with 78% of deaths occurring in the first 5 years. Most of the deaths were not directly related to MM; infection and neglect were most commonly described. Lesions at motor level L-2 or above were associated with increased mortality (HR 3.176, 95% CI 1.557-6.476). Compared with repair within 48 hours of birth, surgery at 15-29 days was associated with increased mortality (HR 9.091, 95% CI 1.169-70.698). CONCLUSIONS Infants in low- and middle-income countries with MM can have long-term survival with basic surgical intervention. Motor level and age at surgery were significant factors influencing outcome. Education of local health care workers and families to ensure both urgent referral for initial treatment and subsequent access to basic medical care are essential to survival.

Low-Cost Interactive Image-Based Virtual Endoscopy for the Diagnosis and Surgical Planning of Suprasellar Arachnoid Cysts.

OBJECTIVE: To investigate the feasibility and reliability of virtual endoscopy (VE) as a rapid, low-cost, and interactive tool for the diagnosis and surgical planning of suprasellar arachnoid cysts (SACs). METHODS: Eighteen patients with SACs treated with endoscopic ventriculocystostomy were recruited, and 18 endoscopic patients treated with third ventriculostomy were randomly selected as a VE reconstruction control group. After loading their DICOM data into free 3D Slicer software, VE reconstruction was independently performed by 3 blinded clinicians and the time required for each reconstruction was recorded. Another 3 blinded senior neurosurgeons interactively graded the visibility of VE by watching video recordings of the endoscopic procedures. Based on the visibility scores, receiver operating characteristic curve analysis was used to investigate the reliability of VE to diagnose SACs, and Bland-Altman plots were used to assess the reliability of VE for surgical planning. In addition, the intraclass correlation coefficient was calculated to estimate the consistency among the results of 3 reconstruction performers. RESULTS: All 3 independent reconstructing performers successfully completed VE simulation for all cases, and the average reconstruction time was 10.2 ± 9.7 minutes. The area under the receiver operating characteristic curve of the cyst visibility score was 0.96, implying its diagnostic value for SACs. The Bland-Altman plot indicated good agreement between VE and intraoperative viewings, suggesting the anatomic accuracy of the VE for surgical planning. In addition, the intraclass correlation coefficient was 0.81, which revealed excellent interperformer consistency of our simulation method. CONCLUSIONS: This study substantiated the feasibility and reliability of VE as a rapid, low-cost, and interactive modality for diagnosis and surgical planning of SACs.

Síndrome de corazón contundido fulminante tras ventriculostomía endoscópica en una paciente con hidrocefalia crónica / Fulminant stunned myocardium following endoscopic ventriculostomy in a patient with chronic hydrocephalus

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Greater fluctuations in serum sodium levels are associated with increased mortality in children with externalized ventriculostomy drains in a PICU.

OBJECTIVES: Dysnatremia is common in critically ill children due to disruption of hormonal homeostasis. Children with brain injury are at risk for syndrome of inappropriate antidiuretic hormone, cerebral salt wasting, and sodium losses due to externalized ventricular drain placement. We hypothesized that among PICU patients managed with an externalized ventricular drain, hyponatremia is common, hyponatremia is associated with seizures and in-hospital mortality, and greater sodium fluctuations are associated with in-hospital mortality. DESIGN: Retrospective observational study. SETTING: Tertiary care PICU. PATIENTS: All pediatric patients treated in the PICU with an externalized ventricular drain from January 2005 to December 2009. Patients were identified by searching the physician order entry database for externalized ventricular drain orders. Hyponatremia was defined as the minimum sodium during patients' externalized ventricular drain time and was categorized as mild (131-134 mEq/L) or moderate to severe (≤ 130 mEq/L). Magnitude of sodium fluctuation was defined as the difference between a patient's highest and lowest sodium during the time in which an externalized ventricular drain was in use (up to 14 d). Seizure was defined as a clinically evident convulsion during externalized ventricular drain presence. A priori confounders were age, history of epilepsy, and externalized ventricular drain indication. Multivariable regression was performed to test the association between sodium derangements and outcomes. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Three hundred eighty patients were eligible. One hundred nine (29%) had mild hyponatremia, and 30 (8%) had moderate to severe hyponatremia. Twenty-eight patients (7%) had a seizure while hospitalized. Eighteen patients died (5%) prior to discharge. Survivors had a median daily sodium fluctuation of 1 mEq/L [0-5] vs non-survivors 9 mEq/L [6-11] (p < 0.001) and a median sodium fluctuation of 5 mEq/L [2-8] vs non-survivors 15 mEq/L [9-24] (p < 0.001) during externalized ventricular drain management. After controlling for a priori covariates and potential confounders, hyponatremia was not associated with an increased odds of seizures or in-hospital mortality. However, greater fluctuations in daily sodium (odds ratio, 1.38; 95% CI, 1.06-1.8) and greater fluctuations in sodium during externalized ventricular drain management were associated with increased odds of in-hospital mortality (odds ratio, 1.59; 95% CI, 1.2-2.11). CONCLUSIONS: Hyponatremia was common in PICU patients treated with externalized ventricular drains but not associated with seizures or in-hospital mortality. Greater sodium fluctuations during externalized ventricular drain management were independently associated with increased odds of in-hospital mortality.

Complications of endoscopic third ventriculostomy.

BACKGROUND: The treatment of choice for several types of obstructive hydrocephalus is endoscopic third ventriculostomy (ETV). However, in certain cases ETV is not clearly superior to shunt placement, and a question of choice arises. Apart from the possibility of success in each case, knowledge of complication rates is of major importance as well. MATERIAL: Several series of ETVs have been published by various specialized centers. The reported overall complication rate is usually between 5% and 15%, and related permanent morbidity lower than 3%. The reported mortality of ETV is lower than 1%. RESULTS: The most frequent intraoperative complications of ETV are hemorrhage (the most severe being due to basilar rupture) and injury of neural structures. In the immediate postoperative period, hematomas, infections, and cerebrospinal fluid leaks may present. Morbidity can be neurological and/or hormonal. Systemic complications are related more to the patient's general status and less to the procedure itself. Late sudden deterioration, leading as a rule to a patient's death, has been reported. Its incidence is not exactly known, but probably is lower than 0.1%. Nevertheless, the severity of this complication necessitates alertness and informing the patient. CONCLUSIONS: The complication rate of ETV is low, and rarely is a reason for choosing shunt placement instead. However, as a method it requires considerable experience, and several studies report a relation of experience not only with success rates but also with complication avoidance.

Seizures do not increase in-hospital mortality after intracerebral hemorrhage in the nationwide inpatient sample.

BACKGROUND: Seizures are common after intracerebral hemorrhage (ICH) but their impact on outcome is uncertain and prophylactic anti-convulsant use is controversial. We hypothesized that seizures would not increase the risk of in-hospital mortality in a large administrative database. METHODS: The study population included patients in the 2006 Nationwide Inpatient Sample over the age of 18 with a principal diagnosis of ICH (ICD9 = 431). Subjects with a secondary diagnosis of aneurysm, arterio-venous malformation, brain tumor, or traumatic brain injury were excluded. Seizures were defined by ICD9 codes (345.0x-345.5x, 345.7x-345.9x, 780.39). Logistic regression was used to quantify the relationship between seizures and in-hospital mortality. Pre-specified subgroups included age strata, length of stay, and invasive procedures. RESULTS: 13,033 subjects met all eligibility criteria, of which 1,430 (11.0 %) had a secondary diagnosis of seizure. Subjects with seizure were younger (64 vs. 70 years, p < 0.001), more likely to get craniectomy (2.1 vs. 1.2 %, p = 0.006), ventriculostomy (8.5 vs. 6.0 %, p < 0.001), intubation (32.2 vs. 25.9 %, p < 0.001), and tracheostomy (6.4 vs. 4.2 %, p < 0.001). Seizure patients had lower in-hospital mortality (24.3 vs. 28.0 %, p = 0.003). In a multivariable model incorporating patient and hospital level variables, seizures were associated with reduced odds of in-hospital death (OR = 0.62, 95 % CI 0.52-0.75). CONCLUSIONS: A secondary diagnosis of seizure after ICH was not associated with increased in-hospital death overall or in any of the pre-specified subgroups; however, there may be residual confounding by severity. These findings do not support a need for routine prophylactic anti-epileptic drug use after ICH.

Shunt survival after failed endoscopic treatment of hydrocephalus.

OBJECT: It is not known whether previous endoscopic third ventriculostomy (ETV) affects the risk of shunt failure. Different epochs of hydrocephalus treatment at the CURE Children's Hospital of Uganda (CCHU)-initially placing CSF shunts in all patients, then attempting ETV in all patients, and finally attempting ETV combined with choroid plexus cauterization (CPC) in all patients-provided the opportunity to assess whether prior endoscopic surgery affected shunt survival. METHODS: With appropriate institutional approvals, the authors reviewed the CCHU clinical database to identify 2329 patients treated for hydrocephalus from December 2000 to May 2007. Initial ventriculoperitoneal (VP) shunt placement was performed in 900 patients under one of three circumstances: 1) primary nonselective VP shunt placement with no endoscopy (255 patients); 2) VP shunt placement at the time of abandoned ETV attempt (with or without CPC) (370 patients); 3) VP shunt placement subsequent to a completed but failed ETV (with or without CPC) (275 patients). We analyzed time to shunt failure using the Kaplan-Meier method to construct survival curves, Cox proportional hazards regression modeling, and risk-adjusted analyses to account for possible confounding differences among these groups. RESULTS: Shunt failure occurred in 299 patients, and the mean duration of follow-up for the remaining 601 was 28.7 months (median 18.8, interquartile range 4.1-46.3). There was no significant difference in operative mortality (p = 0.07 by log-rank and p = 0.14 by Cox regression adjusted for age and hydrocephalus etiology) or shunt infection (p = 0.94, log-rank) among the 3 groups. There was no difference in shunt survival between patients treated with primary shunt placement and those who underwent shunt placement at the time of an abandoned ETV attempt (adjusted hazard ratio [HR] 1.14, 95% CI 0.86-1.51, p = 0.35). Those who underwent shunt placement after a completed but failed ETV (with or without CPC) had a lower risk of shunt failure (p = 0.008, log-rank), with a hazard ratio (adjusted for age at shunting and etiology) of 0.72 (95% CI 0.53-0.98), p = 0.03, compared with those who underwent primary shunt placement without endoscopy; but this was observed only in patients with postinfectious hydrocephalus (PIH) (adjusted HR 0.55, 95% CI 0.36-0.85, p = 0.007), and no effect was apparent for hydrocephalus of noninfectious etiologies (adjusted HR 0.98, 95% CI 0.64-1.50, p = 0.92). Improved shunt survival after failed ETV in the PIH group may be an artifact of selection arising from the inherent heterogeneity of ventricular damage within that group, or a consequence of the timing of shunt placement. The anticipated benefit of CPC in preventing future ventricular catheter obstruction was not observed. CONCLUSIONS: A paradigm for infant hydrocephalus involving intention to treat by ETV with or without CPC had no adverse effect on mortality or on subsequent shunt survival or infection risk. This study failed to demonstrate a positive effect of prior ETV or CPC on shunt survival.

Endoscopic third ventriculostomy in the treatment of childhood hydrocephalus: validation of a success score that predicts long-term outcome.

OBJECT: The goal of this study was to externally validate the proposed Endoscopic Third Ventriculostomy Success Score (ETVSS), which predicts successful treatment for hydrocephalus on the basis of a child's individual characteristics. METHODS: The authors retrospectively identified 181 cases of consecutive endoscopic third ventriculostomy (ETV) performed in children at a single neurosurgery center in the United Kingdom. They compared actual success at both 6 and 36 months, with mean predicted probabilities for low, moderate, and high chance of success strata based on the ETVSS. Long-term success was calculated using Kaplan-Meier methods and comparisons were made by means of unpaired t-tests. RESULTS: Overall, 166 primary ETVs were performed; ETV success was 72.9% at 6 and 64.5% at 36 months. At long-term follow-up, the mean predicted probability of success was significantly higher in those with a successful ETV (99 patients) than in those with a failed ETV (67 patients) (p = 0.001). The ETVSS accurately predicted outcome at 36 months; the low, medium, and high chance of success strata had mean predicted probabilities of success of 82%, 63%, and 36%, and actual success of 76%, 66%, and 42%, respectively. The overall complication rate was 6%. CONCLUSIONS: The ETVSS closely predicted the overall long-term success rates in high-, moderate-, and low-risk groups. The results of this study suggest that the ETVSS will aid clinical decision making in predicting outcome of ETV.

Predicting who will benefit from endoscopic third ventriculostomy compared with shunt insertion in childhood hydrocephalus using the ETV Success Score.

OBJECT: The authors recently developed and internally validated the ETV Success Score (ETVSS)--a simplified means of predicting the 6-month success rate of endoscopic third ventriculostomy (ETV) for a child with hydrocephalus, based on age, etiology of hydrocephalus, and presence of a previous shunt. A high ETVSS predicts a high chance of early ETV success. In this paper, they assess the clinical utility of the ETVSS by determining whether long-term survival outcomes for ETV versus shunt insertion are different within strata of ETVSS (low, moderate, and high scores). METHODS: A multicenter, international cohort of children (≤ 19 years old) with newly diagnosed hydrocephalus treated with either ETV (489 patients) or shunt insertion (720 patients) was analyzed. The ETVSS was calculated for all patients. Survival analyses with time-dependent modeling of the hazard ratios were performed. RESULTS: For the High-ETVSS Group (255 ETV-treated patients, 117 shunt-treated patients), ETV appeared to have a lower risk of failure right from the early postoperative phase and became more favorable with time. For the Moderate-ETVSS Group (172 ETV-treated patients, 245 shunt-treated patients), ETV appeared to have a higher initial failure rate, but after about 3 months the instantaneous risk of ETV failure became slightly lower than shunt failure (that is, the hazard ratio became < 1). For the Low-ETVSS Group (62 ETV-treated patients, 358 shunt-treated patients), the early risk of ETV failure was much higher than the risk of shunt failure, but the instantaneous risk of ETV failure became lower than the risk of shunt failure at about 6 months following surgery (the hazard ratio became < 1). CONCLUSIONS: Across all ETVSS strata, the risk of ETV failure becomes progressively lower compared with the risk of shunt failure with increasing time from the surgery. In the best ETV candidates (ETVSS ≥ 80), however, the risk of ETV failure is lower than the risk of shunt failure very soon after surgery, while for less-than-ideal ETV candidates (ETVSS ≤ 70), the risk of ETV failure is initially higher than the risk of shunt failure and only becomes lower after 3-6 months from surgery. These results need to be confirmed by larger, prospective, and preferably randomized studies.

Endoscopic third ventriculostomy vs cerebrospinal fluid shunt in the treatment of hydrocephalus in children: a propensity score-adjusted analysis.

BACKGROUND: Endoscopic third ventriculostomy (ETV) has preferentially been offered to patients with more favorable prognostic features compared with shunt. OBJECTIVE: To use advanced statistical methods to adjust for treatment selection bias to determine whether ETV survival is superior to shunt survival once the bias of patient-related prognostic factors is removed. METHODS: An international cohort of children (< or = 19 years of age) with newly diagnosed hydrocephalus treated with ETV (n = 489) or shunt (n = 720) was analyzed. We used propensity score adjustment techniques to account for 2 important patient prognostic factors: age and cause of hydrocephalus. Cox regression survival analysis was performed to compare time-to-treatment failure in an unadjusted model and 3 propensity score-adjusted models, each of which would adjust for the imbalance in prognostic factors. RESULTS: In the unadjusted Cox model, the ETV failure rate was lower than the shunt failure rate from the immediate postoperative phase and became even more favorable with longer duration from surgery. Once patient prognostic factors were corrected for in the 3 adjusted models, however, the early failure rate for ETV was higher than that for shunt. It was only after about 3 months after surgery did the ETV failure rate become lower than the shunt failure rate. CONCLUSIONS: The relative risk of ETV failure is initially higher than that for shunt, but after about 3 months, the relative risk becomes progressively lower for ETV. Therefore, after the early high-risk period of ETV failure, a patient could experience a long-term treatment survival advantage compared with shunt. It might take several years, however, to realize this benefit.

Surgery for hydrocephalus in sub-Saharan Africa versus developed nations: a risk-adjusted comparison of outcome.

PURPOSE: Surgery for children in developing nations is challenging. Endoscopic third ventriculostomy (ETV) is an important surgical treatment for childhood hydrocephalus and has been performed in developing nations, but with lower success rates than in developed nations. It is not known if the lower success rate is due to inherent differences in prognostic factors. METHODS: We analyzed a large cohort of children (≤20 years old) treated with ETV in developed nations (618 patients from Canada, Israel, United Kingdom) and developing nations of sub-Saharan Africa (979 patients treated in Uganda). Risk-adjusted survival analysis was performed. RESULTS: The risk of an intra-operative ETV failure (an aborted procedure) was significantly higher in Uganda regardless of risk adjustment (hazard ratio (HR), 95% confidence interval (CI), 11.00 (6.01 to 19.84) P<0.001). After adjustment for patient prognostic factors and technical variation in the procedure (the use of choroid plexus cauterization), there was no difference in the risk of failure for completed ETVs (HR, 95% CI, 1.04 (0.83 to 1.29), P=0.74). CONCLUSIONS: Three factors account for all significant differences in ETV failure between Uganda and developed nations: patient prognostic factors, technical variation in the procedure, and intra-operatively aborted cases. Once adjusted for these, the response to completed ETVs of children in Uganda is no different than that of children in developed nations.

The role of endoscopic third ventriculostomy in adult patients with hydrocephalus.

OBJECT: Endoscopic third ventriculostomy (ETV) is the treatment of choice for hydrocephalus, but the outcome is dependent on the cause of this disorder, and the procedure remains principally the preserve of pediatric neurosurgeons. The role of ETV in adult patients with hydrocephalus was therefore investigated. METHODS: One hundred ninety adult patients underwent ETV for hydrocephalus. Cases were defined as primary ETV (newly diagnosed, without a previously placed shunt) and secondary ETV (performed for shunt malfunctions due to infection or mechanical blockage). Causes of hydrocephalus included tumor, long-standing overt ventriculomegaly (LOVA), Chiari malformation Types I and II (CM-I and -II), aqueduct stenosis, spina bifida, and intraventricular hemorrhage (IVH). Successful ETV was defined as resolution of symptoms with shunt independence. Operative complications and ETV failure rate were investigated according to the causes of hydrocephalus and between the primary and secondary ETV groups. RESULTS: In the primary group, ETV was successful in 107 (83%) of 129 patients, including those with tumors (52 of 66), LOVA (21 of 24), CM-I (11 of 11 cases), CM-II (8 of 9), aqueduct stenosis (8 of 9), and IVH (2 of 2). In the secondary group, ETV was successful in 41 (67%) of 61 patients and was equally successful in cases of mechanical shunt malfunction (35 of 52 patients) and infected shunt malfunction (6 of 9 patients). The median time to ETV failure was 1.7 months in the primary group and 0.5 months in the secondary group. The majority of ETV failures occurred within the first 3 months, and thereafter, the Kaplan-Meier survival curves plateaued. There were no procedure-related deaths, and complications were seen in only 5.8% of cases. CONCLUSIONS: The success rate of ETVs in adults is comparable, if not better, than in children. In addition to the well-defined role of ETV in the treatment of hydrocephalus caused by tumors and aqueduct stenosis, ETV may also have a role in the management of CM-I, LOVA, persistent shunt infection, and IVH resistant to other CSF diversion procedures.

Endoscopic third ventriculostomy versus ventriculoperitoneal shunt in pediatric patients: a decision analysis.

INTRODUCTION: Uncertainty persists on the best treatment for patients with obstructive hydrocephalus: endoscopic third ventriculostomy (ETV) or shunt, particularly in the younger age groups. We performed decision analysis for quality of life (QOL) outcomes comparing these two procedures. MATERIALS AND METHODS: Frequency of outcome events for ETV was obtained from the Canadian Pediatric Neurosurgery Study Group (368 patients) and for shunts from two prospective randomized trials, the Shunt Design Trial and the Endoscopic Shunt Insertion Trial (647 patients combined). Quality-adjusted life year (QALY) estimates for various outcomes were obtained from the literature. Decision analysis was performed at 1 year of follow-up for specific age groups, e.g., <1 month, 1-6 months, etc. RESULTS: Failure from cerebrospinal fluid (CSF) diversion from either procedure was a function of age with higher failures rates in younger patients. Expected QALY at 1 year were marginally higher for ETV for all age groups, but the outcomes were similar enough to be regarded as equivalent. The results, however, were highly sensitive to the assigned health utility value estimates for patients who are well with a functioning ETV or shunt and the severe complication rate from ETV. CONCLUSION: Age is a major determinant of outcome from CSF diversion with worse outcomes in young patients. QALY estimates for either ETV or shunt are similar at 1 year.