Choroid plexus coagulation for hydrocephalus not due to CSF overproduction: a review

Objective

This study aims to review the role of choroid plexus coagulation (CPC) for hydrocephalus not due to CSF overproduction.

Methods

The literatures covering CPC/cauterization/extirpation and ablation searched through PubMed were reviewed.

Results

The history of CPC goes back to early 1900s by open surgery. It has evolved to mainly an endoscopic surgery since 1930s. With the development of other treatment methods and the understanding of CSF dynamics, the application of CPC dramatically decreased by 1970s. In late 2000, there was a resurgence of CPC in combination with endoscopic third ventriculostomy (ETV) performed in Africa.

Conclusions

CPC remains one of the options for the treatment of hydrocephalus in selected cases. CPC might provide a temporary reduction in CSF production to allow the further development of CSF absorption in infant. Adding CPC to ETV for infants with communicating hydrocephalus may increase the shunt independent rate thus avoiding the consequence of late complication related to the shunt device. This is important for patients who are difficult to be followed up, due to geographical and/or socioeconomic constrains. Adding CPC to ETV for obstructive hydrocephalus in infant may also increase the successful rate. Furthermore, CPC may be an option for cases with high chance of shunt complication such as hydranencephaly. In addition, CPC may act as an adjunct therapeutic measure for complex cases such as multiloculated hydrocephalus. In comparison with the traditional treatment of CSF shunting, the role of CPC needs to be further evaluated in particular concerning the neurocognitive development.     

Prior CSF shunting increases the risk of endoscopic third ventriculostomy failure in the treatment of obstructive hydrocephalus in adults

INTRODUCTION: Endoscopic third ventriculostomy (ETV) is accepted as an effective treatment for obstructive hydrocephalus (OHC); however, its benefit in patients previously treated with cerebrospinal fluid (CSF) shunting remains unclear. The value of concurrent ETV and ventriculoperitoneal (VP) shunting in patients with frequent shunt failure remains unstudied. METHODS: Outcomes were compared between OHC patients receiving ETV as initial CSF diversion treatment (n= 19) versus OHC patients receiving ETV for shunt failure (n= 11) by log-rank analysis and Kaplan-Meier plots of recurrence-free periods. To determine if the performance of ETV with concurrent shunt revision decreased the incidence of catastrophic treatment failure in patients experiencing frequent and emergent shunt failures (n = 8), the time to treatment failure after ETV and shunt revision was compared with the mean duration of their previous CSF shunts. RESULTS: ETV after shunt failure was 2.5-fold more likely to fail [risk ratio (RR): 2.48, p<0.05] versus ETV as initial CSF diversion treatment for OHC. Following ETV as initial CSF diversion treatment, 17 patients (89%) experienced immediate improvement and 65% remained recurrence-free at year 2. Following ETV after shunt failure, 16 patients (71%) experienced immediate improvement, but only 25% remained recurrence-free at year 2. In patients with a history of multiple shunt revisions and complications, concurrent use of ETV and VP shunt did not significantly decrease treatment failure. However, the incidence of catastrophic shunt failure requiring acute intervention decreased (43% versus 17%). CONCLUSION: In our experience with ETV for OHC, prior CSF shunting in patients with obstructive hydrocephalus was associated with the decreased time to treatment failure following conversion to ETV. ETV may be less effective for the treatment of OHC in previously shunted patients. ETV combined with concurrent CSF shunting may be an important strategy to prevent catastrophic treatment failure in OHC patients with a history of multiple shunt revisions and complications.     

Endoscopic third ventriculostomy in the treatment of hydrocephalus in posterior fossa tumors in children

OBJECT: The purpose of the present study is to assess the effectiveness of endoscopic third ventriculostomy (ETV) in children with hydrocephalus related to posterior fossa tumors. METHODS: Between September 1999 and December 2002, 63 children with posterior fossa tumors were treated at Santobono Hospital in Naples, Italy. Twenty-six patients had severe hydrocephalus. In order to relieve intracranial hypertension before tumor removal, 20 were treated with ETV, and 6 with ventriculo-peritoneal (VP) shunts. Twenty patients with mild hydrocephalus were treated with diuretics, corticosteroid agents, and early posterior fossa surgery, and 17 patients who did not have hydrocephalus were treated by elective posterior fossa surgery. Another 4 ETV were performed in the management of postoperative hydrocephalus. RESULTS: Preoperative ETV procedures were technically successful. One was complicated by intraventricular bleeding. The successful 19 preoperative ETV resolved intracranial hypertension before posterior fossa surgery in all cases. Three of these 19 patients developed postoperative hydrocephalus and were treated by VP shunt insertion after posterior fossa surgery. Out of the 4 ETV performed after posterior fossa surgery, only 2 were successful, both when the shunt malfunctioned. CONCLUSIONS: Endoscopic third ventriculostomy should be considered as an alternative procedure to ventriculo-peritoneal shunting and external ventricular draining for the emergency control of severe hydrocephalus caused by posterior fossa tumors, since it can quickly eliminate symptoms, and hence, can delay surgery scheduling if required. Even though ETV does not prevent postoperative hydrocephalus in all cases, it does protect against acute postoperative hydrocephalus due to cerebellar swelling. In addition, it eliminates the risks of cerebrospinal fluid (CSF) infection related to external drainage and minimizes the risk of overdrainage because it provides more physiological CSF drainage than the other procedures. Since postoperative hydrocephalus is very often physically obstructive, ETV should always be considered a possible treatment procedure.     

Endoscopic third ventriculostomy in obstructed hydrocephalus

Forty-three ETV were performed in 46 patients of obstructive hydrocephalus. Study was divided into two groups. Group 1 was with 29 children of less than two years age. Group 2 had seventeen patients of more than 2 years, adolescent and adults. Group 1 had 70% clinical and 63% radiological improvement whereas Group 2 showed 100% clinical and 73% radiological improvement. ETV failed in relieving the symptoms of hydrocephalus in eight patients. They were eventually benefited with VP Shunt. There was one postoperative death, which was not related to the procedure. ETV is an important alternative to VP Shunt in relieving hydrocephalus due to obstruction in CSF pathway.     

Endoscopic third ventriculostomy in children younger than 2 years of age

Introduction Endoscopic third ventriculostomy (ETV) for the treatment of hydrocephalus of different etiologies is still controversial in children younger than 2 years of age. The success rate of ETV in this group of patients is analyzed in this study. Materials and methods The series consisted of 21 patients treated with ETV. The mean age of the patients was 6.7 months, ranging from 9 days to 15 months (16 patients were younger than 1 year). The study included hydrocephalus due to idiopathic aqueductal stenosis (eight) and other congenital anomalies (four) as well as posthemorrhagic (three) and tumor-related occlusive hydrocephalus (three). Two patients presented with shunt infection and one with a shunt failure. ETV was considered to be successful when shunting could be avoided. Results ETV was successful in nine patients, with a mean follow-up period of 26.2 months. The procedure was successful in four patients with idiopathic aqueductal stenosis, in two with other congenital anomalies, in one posthemorrhagic, and in two with a tumor-related hydrocephalus. In 12 patients, the ETV was unsuccessful after a mean follow-up of 3.3 months. These patients required a shunt. Ten of them were less than 1 year old when ETV was performed. In one tumor-related hydrocephalus, a shunt was inserted after a meningitis after tumor removal. Conclusions The success of ETV in children younger than 2 years of age suffering from non-communicating hydrocephalus seems to be dependent on both age and etiology. Our results show an overall success rate of 43%. In 37.5% of the children younger than 1 year of age, ETV was successful. ETV in patients with hydrocephalus due to idiopathic aqueductal stenosis seems to be more beneficial than in other causes of hydrocephalus. Presented at the Third World Conference of the International Study Group on Neuroendoscopy (ISGNE), Marburg, Germany, 15–18 June 2005.     

Endoscopic third ventriculostomy for obstructive hydrocephalus in children younger than 6 months of age: is it a first-choice method?

INTRODUCTION: Endoscopic third ventriculostomy (ETV) is considered a safe procedure and is a method of choice in treatment of obstructive hydrocephalus nowadays. In case of Sylvian aqueduct stenosis, the success rate reaches 90%. In children younger than 6 to 24 months, respectively, however, some authors report lower effectiveness ranging between 0% and 64%. The reasons of ETV failure are discussed: hyporesorption in patients with obstruction as a consequence of hemorrhage or infection, suboptimal ETV performance, especially in premature newborns, or the theory of different cerebrospinal fluid circulation in newborn babies. MATERIALS AND METHODS: Between January 2005 and December 2006 in our clinic, 14 patients younger than 6 months having presented with obstructive hydrocephalus were treated endoscopically. Obstruction was revealed by preoperative magnetic resonance imaging. The etiology of hydrocephalus was congenital aqueduct stenosis in five patients, posthemorrhagic obstruction in eight patients, and combination of posthemorrhagic and postinfection etiology in one patient. ETV was considered successful when no shunt operation was needed in the patient. RESULTS: ETV was successful in eight patients who experienced regression of signs of intracranial hypertension and were not forced to undergo ventriculo-peritoneal (V-P) shunting. In one patient, a successful repeat ETV was performed. In the remaining six patients, V-P shunt implantation was necessary. Total success rate in our group of patients was 57%. The only complication was subdural hygroma in one patient requiring evacuation. CONCLUSION: Based on our experience, we recommend ETV as the method of choice in children younger than 6 month of age.     

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.     

Assessment of the influence of operative factors in the success of endoscopic third ventriculostomy in children

Objective To determine if operative factors correlate with success of endoscopic third ventriculostomy (ETV) in the treatment of hydrocephalus.Materials and methods The ETV procedure video of 33 hydrocephalic children was reviewed. Mean age at operation was 76 months (range: 1–196). Success was defined as no need for shunt in the long term. We calculated the relative size of stoma as the percentage of stoma diameter to the distance between posterior clinoid–basilar artery. Factors analysed were: intra-operative haemorrhage, stoma size, thick/double third ventricular floor, pre-pontine adhesions presence, brisk cerebro-spinal fluid (CSF) flow through the stoma as well as hydrocephalus cause, previous shunt presence, CSF infection or haemorrhage and previous ETV. Analysis was performed using chi-square, linear regression, and one-way ANOVA.Results Overall ETV success rate was 42%. Mean stoma size was 37%. For the entire group, none of the operative factors correlated statistically with success. Previous shunt presence adversely correlated with success (p=0.008). The highest success rate was in the aqueduct stenosis group. In patients without previous shunt (n=17), stoma size over 30% tended towards significance (p=0.094), CSF leak was adversely associated with ETV success (p=0.041) and mean stoma size was 41.3% in successful ETV and 27.8% in unsuccessful ETV (p=0.072). In patients with previous shunt (n=16), thin third ventricular floor was a negative predisposing factor (p=0.057).Conclusion This study did not demonstrate a correlation between the presence of pre-pontine adhesions, double or thickened floor of third ventricle and ETV success. In patients without previous shunt, stoma size may correlate with success. CSF leak was strongly associated with failure.     

第三脑室底造瘘治疗梗阻性脑积水

目的：探讨对梗阻性脑积水患者采用在神经内窥镜下进行第三脑室底造瘘的手术方法。分析手术成功与失败的原因,方法：对21例不同原因造成的梗阻性脑积水患者进行了23次神经内视镜下的第三脑室底造瘘手术。结果：随访1-33个月,平均19个月,显效15例,有效2例,4例无效患者改行V-P分流术,2例接受2次造瘘;手术并发症包括颅内感染2例,严重硬膜下积液1例,暂时性脑疝1例,暂时性动眼神经麻痹1例,中脑及丘脑出血各1例,无死亡病例,结论：神经内窥镜下的第三脑室底造瘘对治疗梗阻性脑积水是一种安全、有效的手术方法,但为了提高手术疗效,减少手术并发症,应采用良好的手术器械、熟练掌握手术方法,选择适当手术患者。     

神经内镜第三脑室底造瘘术治疗梗阻性脑积水及其术后颅内压的监测

目的探讨神经内镜第三脑室底造瘘术（ETV）治疗梗阻性脑积水的效果及其术后颅内压（ICP）监测的意义。方法采用ETV治疗梗阻性脑积水36例，其中术后行ICP动态监测9例。结果术后患者症状缓解33例（91．7％），复查头颅CT或MRI示脑室系统较术前缩小；3例（8.3％）肿瘤引起的梗阻性脑积水症状缓解不明显，改行脑室-腹腔分流术。本组无死亡病例。9例术后行ICP监测结果示：①ETV术后18h内平均ICP〈10mmHg，18h后平均ICP轻度上升，稳定于10-12mmHg之间，肿瘤引起的脑积水ICP上升较快；②4例单纯导水管梗阻性脑积水术后使用甘露醇，用药后1-2h ICP下降1-2mmHg，2h后ICP逐渐恢复至用药前水平。结论①ETV后18h内ICP稍低，可能与术中放出脑脊液过多有关，可暂不应用脱水药物；②肿瘤引起的梗阻性脑积水应积极治疗原发病变。     

脑室镜下三脑室底造瘘术治疗非交通性脑积水

目的探讨脑室镜下第三脑室底造瘘术方法。方法回顾性分析2001～2005年行脑室镜下第三脑室底造瘘术的30例非交通性脑积水患者临床资料。结果30例患者近期疗效满意,1例症状复发改行脑室-腹腔分流术,无严重并发症。结论脑室镜下第三脑室底造瘘术可迅速有效地改善症状,脑脊液通过瘘孔进入生理性循环,可避免感染和过度分流,且安全可靠。     

Endoscopic third ventriculostomy in tuberculous meningitis

INTRODUCTION: We report our preliminary experience with two cases of tuberculous meningitis (TBM) in which endoscopic third ventriculostomy (ETV) was performed to treat non-communicating hydrocephalus. For many years, the insertion of ventriculoperitoneal shunts has been the standard treatment for hydrocephalus in patients with TBM, although the indications for and timing of surgery are not uniformly accepted. Shunt insertion is associated with a high incidence of complications, particularly with long-term follow-up. An alternative treatment for hydrocephalus in this group of patients would clearly be of great benefit. The indications for ETV have increased in the last decade, and there are reports of some effectiveness of the procedure in patients with hydrocephalus due to bacterial meningitis. To our knowledge, ETV has not been described in the management of TBM. METHODS: We report the early results of our preliminary experience with ETV in two patients who presented with neurological compromise due to hydrocephalus and raised intracranial pressure. The clinical context and pre-operative investigation of these patients are presented. The emphasis is placed on the distinction between communicating and non-communicating pathologies as a guide to management options. We detail our surgical findings and the peculiar endoscopic challenges that the condition presented to us. Follow-up in these patients included clinical and investigational data suggesting early effectiveness of the procedure in converting non-communicating hydrocephalus into a communicating one, which can then be treated medically. DISCUSSION: Endoscopic third ventriculostomy is presented as a new application of a procedure accepted for other indications in the treatment of non-communicating hydrocephalus. There are particular aspects of the use of this procedure related to the unique pathology of TBM that are significantly different. We explain our rationale for endoscopy in these patients, and suggest a protocol in which endoscopy may play a role in the management of patients with raised intracranial pressure due to tuberculous hydrocephalus.     

Paradigm shift in hydrocephalus research in legacy of Dandy’s pioneering work: rationale for third ventriculostomy in communicating hydrocephalus

Objective This study aims to question the generally accepted cerebrospinal fluid (CSF) bulk flow theory suggesting that the CSF is exclusively absorbed by the arachnoid villi and that the cause of hydrocephalus is a CSF absorption deficit. In addition, this study aims to briefly describe the new hydrodynamic concept of hydrocephalus and the rationale for endoscopic third ventriculostomy (ETV) in communicating hydrocephalus. Critique The bulk flow theory has proven incapable of explaining the pivotal mechanisms behind communicating hydrocephalus. Thus, the theory is unable to explain why the ventricles enlarge, why the CSF pressure remains normal and why some patients improve after ETV. Hydrodynamic concept of hydrocephalus Communicating hydrocephalus is caused by decreased intracranial compliance increasing the systolic pressure transmission into the brain parenchyma. The increased systolic pressure in the brain distends the brain towards the skull and simultaneously compresses the periventricular region of the brain against the ventricles. The final result is the predominant enlargement of the ventricles and narrowing of the subarachnoid space. The ETV reduces the increased systolic pressure in the brain simply by venting ventricular CSF through the stoma. The patent aqueduct in communicating hydrocephalus is too narrow to vent the CSF sufficiently.     

Development of obstructive hydrocephalus with lumboperitoneal shunting following subarachnoid hemorrhage.

Hydrocephalus is a frequent complication of subarachnoid hemorrhage (SAH). The optimum method of treating hydrocephalus in this setting has not been determined. We review our experience with patients developing communicating hydrocephalus secondary to SAH and subsequently treated with lumboperitoneal (LP) shunts. Following hospitalization for the treatment of SAH, patients who developed clinical symptoms and radiologic signs of hydrocephalus were treated with (ventriculoperitoneal) VP or LP shunting. Eighteen patients received an LP shunt, of which seven (28%) developed a non-communicating or obstructive hydrocephalus. These seven patients underwent replacement with a VP shunt and have not had further complications. In the setting of post-SAH communicating hydrocephalus, obstructive hydrocephalus may develop after LP shunt placement. Patients who develop this complication and have their LP shunts converted to VP shunts have a favorable prognosis.     

Initial experience with endoscopic third ventriculostomy in Nigeria, West Africa

Objectives Endoscopic third ventriculostomy (ETV) as an alternative to traditional shunt surgery in the management of hydrocephalus of different etiologies is new in Nigeria and West Africa, with no published data till date. This initial study was done to determine the success rate and complication among our patient population. Materials and methods This series consists of a prospective study of the clinical and radiological features and outcome of the first 25 consecutive patients who underwent ETV. ETV was considered to be successful when there was no event occurring during surgery that resulted in the procedure being aborted, postoperative neurological deficit, or adverse event that resulted in a modification of the normal postoperative care. Patients follow-up was for a minimum of 2 months. Results There were 14 males and 11 females. The median age of the patients was 6 months, ranging from 1 month to 48 years. The study included obstructive hydrocephalus because of aqueductal stenosis, Dandy Walker malformation, and pineal region tumor. ETV was successful in 23 patients. Two patients had cerebrospinal fluid leak and superficial surgical site infection. There was no mortality. Conclusion ETV in this series is safe with comparable surgical outcomes to conventional ventriculoperitoneal shunt surgery, and minimal postoperative morbidity has been observed. A commentary on this paper is available at .     

Indications for shunt insertion or III ventriculostomy in hydrocephalic children, guided by lumbar and intraventricular infusion tests

The best therapeutic management for infantile hydrocephalus is not always obvious. Traditionally, shunt insertion has been performed when CSF dynamics have been considered abnormal. However, in cases of noncommunicating hydrocephalus endoscopic III ventriculostomy (ETV) has become a well-established treatment modality, but despite clinical and radiological information clinical improvement is not obtained in all cases. A reliable preoperative investigative procedure helping to select hydrocephalic children for ETV, shunt insertion or no operation, is urgently needed. We report three cases of infantile hydrocephalus, in which our operative management was guided by the results of cerebrospinal (CSF) infusion tests. With a lumbar infusion test we assessed the CSF resorption capacity, and thus whether shunting was indicated. Comparing the results with those of an intraventricular infusion test, we assessed the presence of any structural blockage of the CSF circulation between the ventricles and the subarachnoid compartment, which would indicate a possible effect of an ETV. Performance of both a lumbar infusion test and a subsequent intraventricular infusion test in hydrocephalic children seems to provide valuable information for the decision-making on surgery. Received: 31 August 1998     

Death in consequence of late failure of endoscopic third ventriculostomy

Introduction Late failure of originally successful endoscopic third ventriculostomy (ETV) is considerably less common than failure of ventriculo-peritoneal (V-P) shunt in treatment of hydrocephalus. Death in consequence of late ETV failure is a very rare complication, so far having been mentioned in literature in 13 patients only. Case report We present the case of an 11-year-old girl who died in consequence of ETV failure 26 months after the endoscopic procedure. Histopathology proved the closure of stoma by gliotic tissue. Conclusion We can assume that reduced compliance of the ventricular wall in long-term V-P shunt, aqueductal stenosis as a cause of hydrocephalus as well as rapid onset of clinical symptoms prior to ETV might be the cause of acute onset of intracranial hypertension after late ETV failure. Potential prevention of sudden death seems to be the implantation of subcutaneous reservoir during the endoscopic procedure, which allows simple and rapid reduction of intraventricular pressure.     

Factors affecting surgical outcome of endoscopic third ventriculostomy in congenital hydrocephalus

Endoscopic third ventriculostomy (ETV) is an accepted modality of treatment for obstructive hydrocephalus, with good results in adult patients. However in the pediatric age group results vary from poor to similar to the adult population. This study evaluates the outcome of ETV in congenital hydrocephalus of both early and delayed presentation, and investigates factors that determine the outcome. Patients with congenital hydrocephalus who underwent ETV between January 2006 and December 2011 were retrospectively analyzed. Any conditions potentially influencing the need for redo surgery (persistent cerebrospinal fluid [CSF] leak not responding to local measures, tense fontanelle, increased ventricular size, recurrence of symptoms or radiological evidence of failure) were analyzed. A total of 102 patients with a mean age of 7.45 years were included. Presenting features were increasing head circumference and delayed milestones. Ninety-eight patients had triventricular hydrocephalus due to aqueductal stenosis. Procedures performed were ETV only (n = 74), ETV with aqueductoplasty (n = 22), ETV with cystoventriculostomy (n = 2) and aqueductoplasty only (n = 2). Failure of ETV occurred in 11 patients and all were managed with a ventriculoperitoneal shunt. CSF leak in the perioperative period was the only factor that was significantly associated with failure of ETV. ETV is a safe procedure with a good success rate and can be offered to children with aqueductal stenosis. There is a higher chance of failure if there is a CSF leak in the early or late postoperative period.     

Third ventriculostomy vs ventriculoperitoneal shunt in pediatric obstructive hydrocephalus: results from a Swiss series and literature review

Introduction Few series compare endoscopic third ventriculostomies (ETV) and ventriculoperitoneal shunts (VPS). To avoid the complications after a shunt insertion, there is an increased tendency to perform a third ventriculostomy. We reviewed all pediatric patients operated in the French-speaking part of Switzerland for a newly diagnosed obstructive hydrocephalus since 1992 and compared the outcome of patients who benefited from ETV to the outcome of patients who benefited from VPS. There were 24 ETV and 31 VPS. Discussion At 5 years of follow-up, the failure rate of ETV was 26%, as compared to 42% for the VPS group. This trend is also found in the pediatric series published since 1990 (27 peer-reviewed articles analyzed). Conclusion In accordance to this trend, although a statistical difference cannot be assessed, we believe that ETV should be the procedure of choice in pediatric obstructive hydrocephalus.