Comparing motor development in children with hydrocephalus after treatment with ventriculoperitoneal shunt and endoscopic third ventriculostomy: a cross-sectional study.

Introduction: Ventriculoperitoneal shunt insertion (VPSI) and endoscopic third ventriculostomy (ETV) are the major procedures for treating pediatric hydrocephalus. However, studies comparing motor development following the two treatments are limited. Objective: We aimed to determine motor development outcomes in children with hydrocephalus up to 2 years of age after undergoing VPSI or ETV, to identify which surgical approach yields better motor outcomes and may be more effective for Malawian children. Methods: This was a cross-sectional study where we recruited two groups of participants: one group consisted of children with hydrocephalus treated with VP shunt whilst the other group were treated with ETV, at least 6 months prior to this study. Participants were identified from the hospital records and were called to come for neurodevelopmental assessment using the Malawi Development Assessment Tool (MDAT). Results: A total 152 children treated for hydrocephalus within an 18-month period met the inclusion criteria. Upon follow up and tracing, we recruited 25 children who had been treated: 12 had VPSI and 13 had ETV. MDAT revealed delays in both assessed motor domains: 19 out of the 25 children had delayed gross motor whilst 16 of 25 had delayed fine motor development. There was no significant difference between the shunted and the ETV groups. Conclusion: Children with hydrocephalus demonstrate delays in motor development six to 18 months after treatment with either VPSI or ETV. This may necessitate early and prolonged intensive rehabilitation to restore motor function after surgery. Long-term follow-up studies with bigger sample sizes are required to detect the effect of the two treatment approaches.

Endoscopic third ventriculostomy (ETV) for Chiari 1 malformation: a systematic review and meta-analysis.

Meta-analysis and systematic review. To understand the role of endoscopic third ventriculostomy (ETV) for the treatment of concurrent Chiari Malformation Type I (CMI) and hydrocephalus in adults. A literature search on PubMed and Medline with MeSH terms relating to ETV and CMI identified 155 articles between 1988 and 2024. After excluding pediatric cases and other CNS pathologies with associated CMI, 11 articles met inclusion criteria. The Newcastle-Ottawa Scale was identified to assess heterogeneity and risk of bias among the 11 studies analyzed in this systematic-review and meta-analyses compared pre- and post-operative outcomes to examine the use of ETV as a treatment modality for CMI with hydrocephalus. From the 11 included studies, 35 cases of concurrent CMI and hydrocephalus treated with ETV were identified. ETV provided a pooled rate of symptom resolution or improvement of 66%. Additionally, meta-analysis discovered the following pooled rates: a reduction of tonsillar descent in 94% of patients, decreased ventriculomegaly in 94%, and ETV patency in 99%. Syringomyelia, nausea, papilledema and cerebellar dysfunction did not have sufficient numbers for meaningful statistical analyses. However, in each of these categories, more than 85% of the symptoms or radiographic findings improved. This review summarizes the safety and efficacy of ETV for the concurrent management of acquired CMI with hydrocephalus. Specifically, ETV improves radiological outcomes of both ventriculomegaly and tonsillar descent as well as the most prevalent neurological symptom, headaches.

Endoscopic Third Ventriculostomy and Pineal Biopsy from a Single Entry Point.

Pineal neoplasms have a significant impact on children although they are relatively uncommon. They account for approximately 3-11% of all childhood brain tumors, which is considerably higher than the <1% seen in adult brain tumors. These tumors can be divided into three main categories: germ cell tumors, parenchymal pineal tumors, and tumors arising from related anatomical structures. Obtaining an accurate and minimally invasive tissue diagnosis is crucial for selecting the most appropriate treatment regimen for patients with pineal gland tumors. This is due to the diverse treatment options available and the potential risks associated with complete resection. In cases where patients present with acute obstructive hydrocephalus caused by a pineal gland tumor, immediate treatment of the hydrocephalus is necessary. The urgency stems from the potential complications of hydrocephalus, including increased intracranial pressure and neurological deficits. To address these challenges, a minimally invasive endoscopic approach provides a valuable opportunity. This technique allows clinicians to promptly relieve hydrocephalus and obtain a histological diagnosis simultaneously. This dual benefit enables a more comprehensive understanding of the tumor and assists in determining the most effective treatment strategy for the patient.

Purely Endoscopic Treatment for Arachnoid Cysts.

Arachnoid cysts are benign, mostly congenital lesions that are asymptomatic in most patients. In some cases, due to their location or sheer size, they produce a mass effect or hydrocephalic obstruction of the cerebrospinal fluid (CSF) flow and thus might warrant surgical treatment. The goal of the surgery is usually to reduce pressure inside the cysts, to reduce the mass effect, or to restore the CSF pathway. Surgical treatment options are resection, fenestration, or shunting of the cyst. Over the past decades, treatment under sheer endoscopic control either through a tube or via craniotomy of arachnoid cysts has been studied thoroughly and replaced open microsurgical cyst surgery in the opinion of many neurosurgeons. Endoscopic treatment has proven to be a safe and feasible technique for both patients and surgeons. In the following chapter, the authors describe their indications for surgery and pre- and postoperative workup, where precautions should be taken, and discuss the different possibilities and techniques of endoscopic cyst fenestration. The aim is to give detailed instructions and present cases for ventriculocystostomy, cystocisternostomy, ventriculocystocisternostomy, and cystoventriculostomy and point out specifics deemed to be important to avoid complications and to ensure the best possible outcome for each patient.

Infant Hydrocephalus.

Hydrocephalus is a neurosurgical condition that is highly prevalent in pediatric medicine. In the infant population, there is a distinct set of features that all primary pediatricians would benefit from understanding. Infant hydrocephalus can present prenatally on imaging and postnatally with symptomatic enlargement of the head and associated skull features and raised intracranial pressures. The 2 major pathophysiology models of infant hydrocephalus are the bulk flow and the intracranial pulsatility models. The most common acquired forms of hydrocephalus include posthemorrhagic hydrocephalus, postinfectious hydrocephalus, and brain tumor. The most common congenital forms of hydrocephalus include those due to myelomeningocele, aqueductal stenosis, and posterior fossa malformations. There are various evaluation and treatment algorithms for these different types of hydrocephalus, including cerebrospinal fluid shunting and endoscopic third ventriculostomy. The aim of this review was to elaborate on those features of hydrocephalus to best equip primary pediatricians to diagnose and manage hydrocephalus in infants.

Use of intensive care, intracranial pressure monitoring, and external ventricular drainage devises in patients with bacterial meningitis, a cohort study.

BACKGROUND: Bacterial meningitis can cause a life-threatening increase in intracranial pressure (ICP). ICP-targeted treatment including an ICP monitoring device and external ventricular drainage (EVD) may improve outcomes but is also associated with the risk of complications. The frequency of use and complications related to ICP monitoring devices and EVDs among patients with bacterial meningitis remain unknown. We aimed to investigate the use of ICP monitoring devices and EVDs in patients with bacterial meningitis including frequency of increased ICP, drainage of cerebrospinal fluid (CSF), and complications associated with the insertion of ICP monitoring and external ventricular drain (EVD) in patients with bacterial meningitis. METHOD: In a single-center prospective cohort study (2017-2021), we examined the frequency of use and complications of ICP-monitoring devices and EVDs in adult patients with bacterial meningitis. RESULTS: We identified 108 patients with bacterial meningitis admitted during the study period. Of these, 60 were admitted to the intensive care unit (ICU), and 47 received an intracranial device (only ICP monitoring device N = 16; EVD N = 31). An ICP > 20 mmHg was observed in 8 patients at insertion, and in 21 patients (44%) at any time in the ICU. Cerebrospinal fluid (CSF) was drained in 24 cases (51%). Severe complications (intracranial hemorrhage) related to the device occurred in two patients, but one had a relative contraindication to receiving a device. CONCLUSIONS: Approximately half of the patients with bacterial meningitis needed intensive care and 47 had an intracranial device inserted. While some had conservatively correctable ICP, the majority needed CSF drainage. However, two patients experienced serious adverse events related to the device, potentially contributing to death. Our study highlights that the incremental value of ICP measurement and EVD in managing of bacterial meningitis requires further research.

Good clinical outcomes and the necessity of CSF drainage in patients undergoing simultaneous biopsy and endoscopic third ventriculostomy in the region of pineal tumors: A systematic review and meta-analysis.

INTRODUCTION: Due to their delicate and deep-seated location, tumors in the pineal region of the brain pose exceptional challenges in neurosurgical management. Highly precise procedures have become crucial to address these complexities, such as the simultaneous performance of biopsy and endoscopic third ventriculostomy (ETV). Our aim was to assess the feasibility, safety, and efficacy of simultaneous biopsy and ETV for treating patients with pineal region tumors. METHODS: Medline, Embase, and Web of Science were searched for English studies from January 2000 to February 2024, following Cochrane and PRISMA guidelines. Eligible studies encompassed a minimum of four patients and examined at least one of the following outcomes: good clinical outcomes and the necessity of shunt placement. Single proportion analysis with 95% confidence intervals was conducted under a random-effects model, employing the I2 statistic to assess heterogeneity. Additionally, publication bias was evaluated using the ROBINS-I tool. RESULTS: After a meticulous selection process, eighteen studies involving 390 patients were included in the analysis. Overall, good clinical outcomes were observed in 131 out of 147 patients, representing a rate of 92 % (95 % CI: 84 % to 100 %, I2 = 62 %) through random effects analysis. Subgroup analysis showed that children exhibited a notably high rate of good clinical outcomes, reaching 100 % (95 % CI: 96 % to 100 %, I2 = 0 %). Regarding the need for shunt placement, out of the 356 patients assessed, only 39 required shunt placement, yielding a rate of 8 % (95 % CI: 4 % to 12 %, I2 = 63 %). Further sub-analyses indicated shunt requirement rates of 12 % for children and 3 % for adults. Specifically focusing on adults, data from 46 patients who underwent biopsy revealed a success rate of 84 % (95 % CI: 62 % to 100 %, I2 = 81 %). Remarkably, no major complications were reported among adults, resulting in a rate of 0 % (95 % CI: 0 % to 6 %, I2 = 0 %). Additionally, low rates of mortality related to the procedure were observed in adults, with two deaths recorded among the 46 patients analyzed, resulting in a mortality rate of 1 % (95 % CI: 0 % to 7 %, I2 = 0 %). CONCLUSION: In conclusion, our study aimed to assess the feasibility, safety, and efficacy of performing simultaneous biopsy and ETV for patients with pineal region tumors. We meticulously examined clinical aspects and patient outcomes, including good clinical outcomes, the requirement for shunt placement after ETV, biopsy success rates, mortality, and complications.

Management of external ventricular drain: to wean or not to wean?

PURPOSE: External ventricular drain (EVD) is one of the most frequent procedures in neurosurgery and around 15 to 30% of these patients require a permanent cerebrospinal fluid (CSF) diversion. The optimal EVD weaning strategy is still unclear. Whether gradual weaning compared to rapid closure, reduces the rate of permanent CSF diversion remains controversial. The aim of this trial is to compare the rates of permanent CSF diversion between gradual weaning and rapid closure of an EVD. METHODS: This was a single-center, retrospective cohort study including patients between 2010 to 2020. Patients were divided into a weaning (WG) and non-weaning (NWG) group. The primary outcome was permanent CSF diversion rates, secondary outcomes included hospitalization time, EVD-related morbidity, and clinical outcome. RESULTS: Out of 412 patients, 123 (29.9%) patients were excluded due to early death or palliative treatment. We registered 178 (61.6%) patients in the WG and 111 (38.4%) in the NWG. Baseline characteristics were comparable between groups. The VPS rate was comparable in both groups (NWG 37.8%; WG 39.9%, p = 0.728). EVD related infection (13.5% vs 1.8%, p < 0.001), as well as non-EVD related infection rates (2.8% vs 0%, p < 0.001), were significantly higher in the WG. Hospitalization time was significantly shorter in the NWG (WG 24.93 ± 9.50 days; NWG 23.66 ± 14.51 days, p = 0.039). CONCLUSION: Gradual EVD weaning does not seem to reduce the need for permanent CSF diversion, while infection rates and hospitalization time were significantly higher/longer. Therefore, direct closure should be considered in the clinical setting.

The incidence of ventriculostomy-related infections as diagnosed by 16S rRNA polymerase chain reaction: A prospective observational study.

BACKGROUND: Ventriculostomy-related infections (VRIs) are reported in about 10 % of patients with external ventricular drains (EVDs). VRIs are difficult to diagnose due to clinical and laboratory abnormalities caused by the primary neurological injury which led to insertion of the EVD. Polymerase chain reaction (PCR) of the cerebrospinal fluid (CSF) may enable more accurate diagnosis of VRI. We performed a prospective cohort study to measure the incidence of VRI as diagnosed by 16S rRNA PCR. METHODS: Patients admitted to intensive care with a primary diagnosis of subarachnoid haemorrhage (SAH), traumatic brain injury (TBI), or intracerebral haemorrhage (ICH), who required an EVD, were assessed for inclusion in this study. Data were extracted from the electronic medical record, bedside charts, or from a prospectively collected database, the Neuroscience Outcomes in Intensive CarE database (NOICE). 16S rRNA PCR was performed on routinely collected CSF as per laboratory protocol. VRI was also diagnosed based on pre-existing definitions. RESULTS: 237 CSF samples from 39 patients were enrolled in the study. The mean patient age was 55.7 years, and 56.4 % were female. The most common primary neurological diagnosis was SAH (61.5 %). The incidence of a positive PCR was 2.6 % of patients (1 in 39) and 0.8 % of CSF samples (2 in 237). The incidence of VRI according to pre-published diagnostic criteria was 2.6 % - 41 % of patients and 0.4 % - 17.6 % of CSF samples. 28.2 % of patients were treated for VRI. Pre-published definitions which relied on CSF culture results had higher specificity and lower false positive rates for predicting a PCR result when compared to definitions incorporating non-microbiological markers of VRI. In CSF samples with a negative 16S rRNA PCR, there was a high proportion of non-microbiological markers of infection, and a high incidence of fever on the day the CSF sample was taken. CONCLUSIONS: The incidence of VRI as defined as a positive PCR was lower than the incidence of VRI according to several published definitions, and lower than the incidence of VRI as defined as treatment by the clinical team. Non-microbiological markers of VRI may be less reliable than a positive CSF culture in diagnosing VRI.

Risk factors and outcomes associated with external ventricular drain related hemorrhage.

OBJECTIVE: The objective of this study was to determine risk factors predictive of external ventricular drain (EVD)-related hemorrhage and the association of such hemorrhages with mortality, discharge disposition, length of stay (LOS), and total cost. METHODS: After Institutional Review Board approval, data was collected retrospectively for adult patients requiring EVD placement from 2015 to 2018 at the authors' institution. Collected data included demographic patient information, peri-procedural factors, and relevant post-procedural measures. Computerized tomography (CT) images and associated radiologic reports were independently reviewed, identifying hemorrhages accompanying EVD placement. RESULTS: From this 487-patient sample, 85 (17.5 %) patients had hemorrhages, including asymptomatic hemorrhages identified on imaging alone. A univariable analysis of patient parameters in the overall cohort was performed to identify possible predictors of hemorrhage. Age (p = 0.002), Charlson Comorbidity Index (CCI) (p < 0.001), platelet count (p = 0.002), presence of uremia (p = 0.035), and the number of times the EVD was replaced (p < 0.001) were associated with hemorrhage in univariable models. The experience of the resident surgeon based on post-graduate year (PGY level) and the number of attempts/passes needed for EVD placement were not associated with hemorrhage risk. Significant predictor of hemorrhage confirmed in a multivariable analysis only included the number of times the EVD was replaced (OR = 2.78, adjusted p < 0.001). Outcomes between EVD-related hemorrhage versus no hemorrhage groups, including mortality, discharge disposition, LOS, and cost, were compared. EVD-related hemorrhage was found to be associated with increased mortality (OR = 3.58, adjusted p < 0.001) and decreased likelihood of discharge home (OR = 0.13, adjusted p = 0.030) in the associated multivariable regressions. CONCLUSION: The number of times an EVD was replaced was associated with EVD-related hemorrhage outcome. EVD-related hemorrhage is associated with increased mortality and a decreased likelihood of being discharged home.

Neuroendoscopy-Assisted Entire-Process Visualization Technique of Ventricular Puncture for External Ventricular Drainage.

OBJECTIVE: This study aimed to investigate the feasibility, safety, and efficacy of the neuroendoscopy-assisted entire-process visualization technique (NEAEVT) of ventricular puncture for external ventricular drainage. METHODS: Eighty-eight patients with cerebral hemorrhage who underwent unilateral ventricular puncture for external ventricular drainage in our hospital from June 2021 to June 2023 were analyzed. Patients were grouped according to puncture technique: NEAEVT (30 patients), freehand (30 patients), and laser-navigation-assisted (28 patients). Operation time, drainage tube placement, and catheter-related hemorrhage incidence were compared between the groups. RESULTS: Mean operation time significantly differed between the freehand, NEAEVT, and laser-assisted groups (17.07, 18.37, and 34.04 min, respectively; P <0.0001). The position of the drainage tube was optimal or adequate in all patients of the NEAEVT group; optimal/adequate positioning was achieved in 80% of the freehand group. No catheter-related hemorrhage occurred in the NEAEVT group. Three freehand group patients and 2 laser-assisted group patients experienced catheter-related hemorrhage. CONCLUSION: The NEAEVT of ventricular puncture is accurate and achieves ventricular drainage without significantly increasing surgical trauma, operation time, or incidence of hemorrhage.

Prospects of CSF shunt independence among chronically shunted patients.

BACKGROUND AND OBJECTIVES: CSF shunt placement for hydrocephalus and other etiologies has arguably been the most life-saving intervention in pediatric neurosurgery in the past 6 decades. Yet, chronic shunting remains a source of morbidity for patients of all ages. Neuroendoscopic surgery has made shunt independence possible for newly diagnosed hydrocephalic patients. In this study, we examine the prospects of shunt independence with or without endoscopic third ventriculostomy (ETV) in chronically shunted patients. METHODS: After IRB approval, a retrospective analysis was completed on patients whose shunt was ligated or removed to achieve shunt independence, with or without ETV. Clinical and imaging data were collected. RESULTS: Eighty-eight patients with CSF shunts had their shunt either ligated or removed, 57 of whom had a concomitant ETV. Original reasons for shunting included: congenital hydrocephalus 20 (23%), post-hemorrhagic hydrocephalus (PHH) of prematurity 14 (16%), aqueductal stenosis 10 (11%), intracranial cyst 8 (9%), tumor 8 (9%), infantile subdural hematomas 8 (9%), myelomeningocele 7 (8%), post-traumatic hydrocephalus 7 (8%) and post-infectious hydrocephalus 6 (7%). The decision to perform a simultaneous ETV was made based on etiology. Forty-nine (56%) patients became shunt independent. The success rate was 46% in the ETV group and 73% in the no ETV group. Using multivariate analysis and Cox Proportional Hazards models, age > 4 months at shunt placement (p = 0.032), no shunt revisions (p = 0.01), select etiologies (p = 0.043), and ETVSS > 70 (in the ETV group) (p = 0.017), were protective factors for shunt independence. CONCLUSION: Considering the long-term complications of shunting, achieving shunt independence may provide hope for improved quality of life. While this study is underpowered, it provides pilot data identifying factors that predict shunt independence in chronically shunted patients, namely age, absence of prior shunt revision, etiology, and in the ETV group, the ETVSS.

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.

Ventricular Access Utilizing Cutaneous Reference Points: Statistical Analysis and Proposal of a New Ventricular Entry Point.

OBJECTIVES: Perform radiologic measurements and analysis of normal brain computed tomography (CT) scans; delineate a new ventricular entry point from cutaneous landmarks, highlighting the potential surgical implications of these findings. METHODS: Six radiologic distances (AR; BR; AL; BL, C, and D) were measured in normal brain CT scans using Horos software. Statistical analysis of the measurements was performed with minitab18 software based on age, sex, and side. RESULTS: 132 brain CT scans were analyzed, yielding the following mean results: AR distance: 2.1 cm; BR distance: 7 cm; AL distance: 2.1 cm; BL distance: 7.1 cm; C distance: 12.4 cm; D distance: 7 cm; new ventricular entry point: 12.4 cm posterior to the nasion, and 2.1 cm lateral to the midline. CONCLUSIONS: The freehand technique for accessing the lateral ventricles is a common neurosurgical procedure but is often accompanied by complications. To address this, we suggest a novel entry point for ventricular access, determined by cutaneous reference points. This point is situated 12.4 cm posterior to the nasion along the midline and 2.1 cm lateral to the midline. Although our findings may play a role in presurgical planning for ventricular pathologies, future prospective studies are warranted.

Paediatric hydrocephalus.

Hydrocephalus is classically considered as a failure of cerebrospinal fluid (CSF) homeostasis that results in the active expansion of the cerebral ventricles. Infants with hydrocephalus can present with progressive increases in head circumference whereas older children often present with signs and symptoms of elevated intracranial pressure. Congenital hydrocephalus is present at or near birth and some cases have been linked to gene mutations that disrupt brain morphogenesis and alter the biomechanics of the CSF-brain interface. Acquired hydrocephalus can develop at any time after birth, is often caused by central nervous system infection or haemorrhage and has been associated with blockage of CSF pathways and inflammation-dependent dysregulation of CSF secretion and clearance. Treatments for hydrocephalus mainly include surgical CSF shunting or endoscopic third ventriculostomy with or without choroid plexus cauterization. In utero treatment of fetal hydrocephalus is possible via surgical closure of associated neural tube defects. Long-term outcomes for children with hydrocephalus vary widely and depend on intrinsic (genetic) and extrinsic factors. Advances in genomics, brain imaging and other technologies are beginning to refine the definition of hydrocephalus, increase precision of prognostication and identify nonsurgical treatment strategies.

Comparison of endoscopic third ventriculostomy versus cerebrospinal fluid shunt procedures for the treatment of pediatric hydrocephalus in Taiwan.

PURPOSE: Pediatric hydrocephalus is the most common cause of surgically treatable neurological disease in children. Controversies exist whether endoscopic third ventriculostomy (ETV) or cerebrospinal fluid (CSF) shunt placement is the most appropriate treatment for pediatric hydrocephalus. This study aimed to compare the risk of re-operation and death between the two procedures. METHODS: We performed a retrospective population-based cohort study and included patients younger than 20-years-old who underwent CSF shunt or ETV for hydrocephalus from the Taiwan National Health Insurance Research Database. RESULTS: A total of 3,555 pediatric patients from 2004 to 2017 were selected, including 2,340 (65.8%) patients that received CSF shunt placement and 1215 (34.2%) patients that underwent ETV. The incidence of all-cause death was 3.31 per 100 person-year for CSF shunt group and 2.52 per 100 person-year for ETV group, with an adjusted hazard ratio (HR) of 0.79 (95% confidence interval [CI] = 0.66-0.94, p = 0.009). The cumulative incidence competing risk for reoperation was 31.2% for the CSF shunt group and 26.4% for the ETV group, with an adjusted subdistribution HR of 0.82 (95% CI = 0.70-0.96, p = 0.015). Subgroup analysis showed that ETV was beneficial for hydrocephalus coexisting with brain or spinal tumor, central nervous system infection, and intracranial hemorrhage. CONCLUSION: Our data indicates ETV is a better operative procedure for pediatric hydrocephalus when advanced surgical techniques and instruments are available.

Classification of the relationship between suprasellar arachnoid cyst and hydrocephalus based on treatment modalities: shunting versus neuroendoscopic approaches.

PURPOSE: Children diagnosed with suprasellar arachnoid cysts often concurrently have hydrocephalus. This study aims to classify the relationship between suprasellar arachnoid cysts and hydrocephalus, discussing surgical strategies-shunting or neuroendoscopic approaches-and their sequence, based on this classification. METHODS: A retrospective analysis was conducted on 14 patients diagnosed with suprasellar arachnoid cysts and hydrocephalus, treated surgically by the first author between January 2016 and December 2020. Clinical features, radiological findings, surgical strategies, and outcomes were reviewed. The classification of the relationship between the suprasellar arachnoid cysts and hydrocephalus was developed and illustrated with specific cases. Recommendations for future surgical management based on this classification are provided. RESULTS: We classified the relationship between suprasellar arachnoid cysts and hydrocephalus into three categories. SACH-R1, the direct type, represents cases where the cysts cause obstructive hydrocephalus. Here, neuroendoscopic ventriculocystocisternostomy (VCC) effectively treats both conditions. SACH-R2, the juxtaposed type, involves concurrent occurrences of cysts and hydrocephalus without a causative link. This is further subdivided into SACH-R2a, where acute progressive communicating hydrocephalus coexists with the cyst, initially managed with a ventriculoperitoneal shunt, followed by VCC upon stabilization of hydrocephalus; and SACH-R2b, where the cyst coexists with chronic stable communicating hydrocephalus, first addressed with VCC, followed by monitoring and potential secondary shunting if needed. Key factors differentiating SACH-R2a from SACH-R2b include the patient's age, imaging signs of fourth ventricle and cisterna magna enlargement, and the rapid progression or chronic stability and severity of hydrocephalus symptoms. SACH-R3, the reverse type, describes scenarios where shunting for hydrocephalus leads to the development or enlargement of the cyst, managed via neuroendoscopic VCC with precautions to prevent infections in existing shunt systems. CONCLUSION: The simultaneous presence of suprasellar arachnoid cysts and hydrocephalus requires a nuanced understanding of their complex relationship for optimal surgical intervention. The analysis and classification of their relationship are crucial for determining appropriate surgical approaches, including the choice and sequence of shunting and neuroendoscopic techniques. Treatment should be tailored to the specific type identified, rather than blindly opting for neuroendoscopy. Particularly for SACH-R2a cases, we recommend initial ventriculoperitoneal shunting.

Dynamic Workflow Proposal for Continuous Frameless Electromagnetic Neuronavigation in Rigid Neuroendoscopy.

BACKGROUND: Ventriculoscopic neuronavigation has been described in several articles. However, there are different ventriculoscopes and navigation systems. Due to these different combinations, it is difficult to find detailed neuronavigation protocols. We describe, step-by-step, a simple method to navigate both the trajectory until reaching the ventricular system, as well as the intraventricular work. METHODS: We use a rigid ventriculoscope (LOTTA, KarlStorz) with an electromagnetic stylet (S8-StealthSystem, Medtronic). The protocol is based on a modified or 3-dimensionally printed trocar for navigating the extraventricular step and on a modified pediatric nasogastric tube for the intraventricular navigation. RESULTS: This protocol can be set up in less than 10 minutes. The extraventricular part is navigated by introducing the electromagnetic stylet inside the modified or 3-dimensionally printed trocar. Intraventricular navigation is done by combining a modified pediatric nasogastric tube with the electromagnetic stylet inside the endoscope's working channel. The most critical point is to obtain a blunt-bloodless ventriculostomy while achieving perfect alignment of all targeted structures via pure straight trajectories. CONCLUSIONS: This protocol is easy-to-set-up, avoids head rigid-fixation and bulky optical-based attachments to the ventriculoscope, and allows continuous navigation of both parts of the surgery. Since we have implemented this protocol, we have noticed a significant enhancement in both simple and complex ventriculoscopic procedures because the surgery is dramatically simplified.