Repeat endoscopic third ventriculostomy success rate according to ventriculostoma closure patterns in children.

PURPOSE: This study aimed to examine the success rate of repeat endoscopic third ventriculostomy (redo-ETV) according to pattern of ventriculostoma closure based on observations in 97 paediatric redo-ETV patients. METHODS: Clinical data and intraoperative video recordings of 97 paediatric hydrocephalus patients who underwent redo-ETV due to ventriculostoma closure at two institutions were retrospectively analysed. We excluded patients with a history of intraventricular haemorrhage, cerebrospinal fluid (CSF) infection or CSF shunt surgery and those with incompletely penetrated membranes during the initial ETV. RESULTS: Verification of ventriculostoma closure was confirmed with cine phase-contrast magnetic resonance imaging and classified into 3 types: type 1, total closure of the ventriculostoma by gliosis or scar tissue that results in a non-translucent/opaque third ventricle floor; type 2, narrowing/closure of the ventriculostoma by newly formed translucent/semi-transparent membranes; and type 3, presence of a patent ventriculostoma orifice with CSF flow blockage by newly formed reactive membranes or arachnoidal webs in the basal cisterns. The overall success rate of redo-ETV was 37.1%. The success rates of redo-ETV according to closure type were 25% for type 1, 43.6% for type 2 and 38.2% for type 3. The frequency of type 1 ventriculostoma closure was significantly higher in patients with myelomeningocele-related hydrocephalus. CONCLUSION: For patients with ventriculostoma closure after ETV, reopening of the stoma can be performed. Our findings regarding the frequencies of ventriculostoma closure types and the success rate of redo-ETV in paediatric patients according to ventriculostoma closure type are preliminary and should be verified by future studies.

Flow diversion of a recurrent, iatrogenic basilar tip aneurysm in a pediatric patient: case report.

Endoscopic third ventriculostomy (ETV) is a common treatment for noncommunicating hydrocephalus. Although rare, vascular injury and traumatic pseudoaneurysm development during ETV have been reported. The authors present the case of a 13-year-old boy who underwent repeat ETV (rETV) for shunt and ETV failure, and who suffered an intraoperative subarachnoid hemorrhage due to iatrogenic injury to the basilar tip, with subsequent development of a pseudoaneurysm. Despite initial primary coil embolization, the aneurysm recurred and was definitively treated with flow diversion. In this report, the authors review complication rates associated with ETV and rETV as well as the emerging use of flow diversion and its applications in vessel reconstruction within the pediatric population.

Long-Term Follow-Up of Repeat Endoscopic Third Ventriculostomy in Obstructive Hydrocephalus.

OBJECTIVE: Endoscopic third ventriculostomy (ETV) is a safe and less-invasive treatment strategy for patients with obstructive hydrocephalus and provides excellent outcome. Nevertheless, repeat ETV in cases of ETV failure is a controversial issue. METHODS: Between 1993 and 1999, 113 patients underwent a total of 126 ETVs at the Department of Neurosurgery, Mainz University Hospital. Obstructive hydrocephalus was the causative pathology in all cases. A very long-term follow-up of up to 16 years could be achieved. All medical reports of patients who received ETV were reviewed and analyzed with focus on ETV failure with following repeat ETV and its initial as well as very long-term success. RESULTS: Thirty-one events of ETV failure occurred during the follow-up period. Thirteen patients underwent repeat ETV: 3 patients during the first 3 months (early repeat ETV), the other 10 patients after 7-78 months (late repeat ETV, mean 33 months). All repeat ETV were performed without complications. Follow-up evaluation after successful repeat ETV ranged from <1 month up to 14 years (mean 7 years). Of the 3 early revisions, 2 failed and 1 other patient died during follow-up whereas only 2 of the late repeat ETV failed. Very long-term success rate of late repeat ETV up to 14 years yielded 80%. CONCLUSIONS: Repeat ETV in cases of late ETV failures represents an excellent option for cerebrospinal fluid circulation restoration up to 14 years of follow-up. Repeat ETV in early ETV failure in contrast is not favored by the performing surgeons; and factors of ETV failure should be analyzed very carefully before a decision for repeat ETV is made.

Endoscopic third ventriculostomy and repeat endoscopic third ventriculostomy in pediatric patients: the Dutch experience.

OBJECTIVE After endoscopic third ventriculostomy (ETV), some patients develop recurrent symptoms of hydrocephalus. The optimal treatment for these patients is not clear: repeat ETV (re-ETV) or CSF shunting. The goals of the study were to assess the effectiveness of re-ETV relative to initial ETV in pediatric patients and validate the ETV success score (ETVSS) for re-ETV. METHODS Retrospective data of 624 ETV and 93 re-ETV procedures were collected from 6 neurosurgical centers in the Netherlands (1998-2015). Multivariable Cox proportional hazards modeling was used to provide an adjusted estimate of the hazard ratio for re-ETV failure relative to ETV failure. The correlation coefficient between ETVSS and the chance of re-ETV success was calculated using Kendall's tau coefficient. Model discrimination was quantified using the c-statistic. The effects of intraoperative findings and management on re-ETV success were also analyzed. RESULTS The hazard ratio for re-ETV failure relative to ETV failure was 1.23 (95% CI 0.90-1.69; p = 0.20). At 6 months, the success rates for both ETV and re-ETV were 68%. ETVSS was significantly related to the chances of re-ETV success (τ = 0.37; 95% bias corrected and accelerated CI 0.21-0.52; p < 0.001). The c-statistic was 0.74 (95% CI 0.64-0.85). The presence of prepontine arachnoid membranes and use of an external ventricular drain (EVD) were negatively associated with treatment success, with ORs of 4.0 (95% CI 1.5-10.5) and 9.7 (95% CI 3.4-27.8), respectively. CONCLUSIONS Re-ETV seems to be as safe and effective as initial ETV. ETVSS adequately predicts the chance of successful re-ETV. The presence of prepontine arachnoid membranes and the use of EVD negatively influence the chance of success.

Reopening of an obstructed third ventriculostomy: long-term success and factors affecting outcome in 215 infants.

OBJECT: The role of reopening an obstructed endoscopic third ventriculostomy (ETV) as treatment for ETV failure is not well defined. The authors studied 215 children with ETV closure who underwent successful repeat ETV to determine the indications, long-term success, and factors affecting outcome. METHODS: The authors retrospectively reviewed the CURE Children's Hospital of Uganda database from August 2001 through December 2012, identifying 215 children with failed ETV (with or without prior choroid plexus cauterization [CPC]) who underwent reopening of an obstructed ETV stoma. Treatment survival according to sex, age at first and second operation, time to failure of first operation, etiology of hydrocephalus, prior CPC, and mode of ETV obstruction (simple stoma closure, second membrane, or cisternal obstruction from arachnoid scarring) were assessed using the Kaplan-Meier survival method. Survival differences among groups were assessed using log-rank and Wilcoxon methods and a Cox proportional hazards model. RESULTS: There were 125 boys and 90 girls with mean and median ages of 229 and 92 days, respectively, at the initial ETV. Mean and median ages at repeat ETV were 347 and 180 days, respectively. Postinfectious hydrocephalus (PIH) was the etiology in 126 patients, and nonpostinfectious hydrocephalus (NPIH) in 89. Overall estimated 7-year success for repeat ETV was 51%. Sex (p = 0.46, log-rank test; p = 0.54, Wilcoxon test), age (< vs > 6 months) at initial or repeat ETV (p = 0.08 initial, p = 0.13 repeat; log-rank test), and type of ETV obstruction (p = 0.61, log-rank test) did not affect outcome for repeat ETV (p values ≥ 0.05, Cox regression). Those with a longer time to failure of initial ETV (> 6 months 91%, 3-6 months 60%, < 3 months 42%, p < 0.01; log-rank test), postinfectious etiology (PIH 58% vs NPIH 42%, p = 0.02; log-rank and Wilcoxon tests) and prior CPC (p = 0.03, log-rank and Wilcoxon tests) had significantly better outcome. CONCLUSIONS: Repeat ETV was successful in half of the patients overall, and was more successful in association with later failures, prior CPC, and PIH. Obstruction of the original ETV by secondary arachnoid scarring was not a negative prognostic factor, and should not discourage the surgeon from proceeding. Repeat ETV may be a more durable solution to failed ETV/CPC than shunt placement in this context, especially for failures at more than 3 months after the initial ETV. Some ETV closures may result from an inflammatory response that is less robust at the second operation.