Neuroendoscopic third ventriculostomy for hydrocephalus in adults: report of a single unit’s experience with 63 cases

doi:10.1016/S0090-3019(01)00352-4

Surgical Neurology

Volume 55, Issue 2, February 2001, Pages 74-78

https://doi.org/10.1016/S0090-3019(01)00352-4 Get rights and content

Abstract

BACKGROUND

Neuroendoscopic third ventriculostomy (NTV) is becoming a first line treatment for hydrocephalus in this center. Its use in a consecutive series of adults is reported.

METHOD

Initially a retrospective data collection after 7 months becoming prospective studying all patients who underwent NTV in this center. The adults (17 years or older) have been studied.

RESULTS

Sixty-three patients met the criteria for inclusion: 38 male, 25 female. Mean age at first NTV 37.5 years. There was an 80% success rate (i.e., no further therapy for the hydrocephalus required). Follow-up was for a mean of 3.1 years. The largest subgroup were patients with third ventricular tumours (35%), of whom 86% were successfully treated. Mean time to failure for the whole series was 8.5 months (range immediate–30 months). Complications occurred in 17.5%; those deemed serious in 11%. There were three deaths (4.7%) within 30 days of the procedure. There were six other deaths during follow-up, five because of tumour progression and one because of pneumonia.

CONCLUSIONS

This procedure lends itself to the treatment of hydrocephalus in adults and appears to be more successful than in young children. It is efficacious in both previously shunted and non shunted patients. It is now the first-line treatment for noncommunicating hydrocephalus in this center and also for patients with shunt failure who are anatomically suitable, having cerebrospinal fluid spaces large enough to admit the endoscope. The complication and mortality rates compare favorably with those for shunts.

Section snippets

Method

All adult patients who underwent NTV for hydrocephalus between January 1994 and August 1999 have been reviewed. Some of the data was collected, retrospectively, but from August 1994 it has been collected prospectively in our departmental neuroendoscopy database.

The etiology and previous therapies for their hydrocephalus, the outcome of the NTV and subsequent clinical course have been studied.

A failed NTV is one in which the patient required subsequent treatment for their hydrocephalus.

The

Results

Sixty-three patients were identified who met the criteria for inclusion. There were 38 males and 25 females. Their mean age at first NTV was 37.5 years (median 32 years, range 17–77 years). Follow-up was for a mean of 3.1 years (range 0–7 years). Three patients died within 30 days of surgery.

Initially the procedure failed in 16 of 63 (25%). Of these 16, 3 underwent a second successful NTV having had membranes of Liliequist or occlusion of the fenestration demonstrated on imaging. Thus overall

Discussion

This paper is based on our first 5 years experience with NTV during which our learning curve has been steep and the number of surgeons able to perform the procedure has risen from 2 to 6. The majority of patients have been children 2, 3.

This series serves to confirm the efficacy of this mode of therapy with a success rate of 75% for NTV in an unselected series of mixed etiology hydrocephalic adult patients. When those who had a second successful NTV were included this rose to 80%. Repeat NTV is

Conclusion

NTV is a durable and safe procedure in this age group. There is a difference between adults and children in the time to failure; the reason is obscure. Efficacy is demonstrated in patients who have been previously shunted, and this series confirms the best results in noncommunicating hydrocephalus.

A randomised controlled clinical trial will answer the questions regarding long-term efficacy in a new era of development of this technique.

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Cited by (96)

Frame-Based Stereotactic Endoscopic Third Ventriculostomy—Toward Improved Precision and Minimizing Morbidities
2020, World Neurosurgery
Citation Excerpt :
Endoscopic third ventriculostomy (ETV) is an established treatment for several types of obstructive hydrocephalus and a viable alternative to shunting procedures.1-6
Endoscopic third ventriculostomy (ETV) is a widely accepted treatment for obstructive hydrocephalus. For most practitioners, this procedure will be performed without navigation guidance. Without such guidance, the complications associated with the procedure have ranged from 1% to 8%. We hypothesized that the discrepancy between the surface bony anatomy and internal cranial anatomy contributes to the morbidities associated with ETV. We tested this hypothesis by comparing the position of the entry point defined by the classic Kocher's point relative to the ideal entry point that would result in no manipulation of the endoscope defined by frame-based stereotaxis.
The cranial computed tomography scan of 58 patients who had undergone frame-based stereotactic ETV was reformatted into 3-dimensional renderings. The location of this entry point was compared with the Kocher point, as determined by the external bony anatomy.
Overall, >70% of the burr holes that provided an ideal trajectory to the third ventricle were ≥0.5 cm from the Kocher point in both the sagittal and the coronal planes. Median deviations of 0.74 and 0.81 cm in the coronal (P < 0.01) and sagittal (P < 0.0001) planes were observed.
The use of stereotactic endoscopic techniques increase the safety of third ventriculostomy by adding precision and reducing otherwise unnecessary surgical maneuvering.
Long-Term Outcomes of Endoscopic Third Ventriculostomy in Adults
2016, World Neurosurgery
To describe long-term outcomes of endoscopic third ventriculostomy (ETV) in adults with hydrocephalus.
Single-institution retrospective review of adults treated with ETV between 1998 and 2006. Patient demographic, treatment, and follow-up data were collected. The patients were divided into 2 groups: primary ETV for patients with previously untreated or newly diagnosed hydrocephalus and secondary ETV for patients with a previous shunt presenting with shunt malfunction. ETV outcome was deemed successful if the patient remained shunt-free after ETV. Multivariate analysis was performed using Cox regression.
The study population comprised 190 patients, with a median age of 43 years (range, 16–79 years). The median duration of follow-up was 112 months (range, 1–190 months). The primary ETV group contained 129 patients; the secondary ETV group, 61 patients. Operative complications occurred in 11 patients (6%). A successful outcome was obtained in 139 patients (73%). ETV failure occurred in 51 patients, with a median time to failure of 2 months (range, 0–124 months). Although the majority (86%) of ETV failures occurred within 2 years postoperatively, failure was noted in 3 cases between 5 and 10 years after intervention, including in 1 patient at a 124-month follow-up. In multivariate analysis, only previous shunt was found to influence outcomes (P = 0.021), with shorter ETV survival noted in patients with a previous shunt. Age, indication, and ETV success did not influence outcome.
ETV is a safe procedure with excellent rates of long-term efficacy; however, late failure can occur, and patients should be instructed to seek medical advice if symptoms recur. A previous shunt is associated with a higher ETV failure rate.
Outcomes of endoscopic third ventriculostomy in adults
2016, Journal of Clinical Neuroscience
Citation Excerpt :
Analysis was then based on initial and subsequent hospitalizations for ETV or shunt. ETV failure was defined as subsequent surgery for hydrocephalus after primary surgery (i.e. repeat ETV or placement of ventriculoperitoneal shunt [VP shunt]) [12]. Temporary CSF diversion measures, such as ventricular puncture, lumbar puncture, and external ventricular drain placement, were not included.
Endoscopic third ventriculostomy (ETV) is an alternative to ventriculoperitoneal shunting for treatment of hydrocephalus. Studies have reported favorable outcomes for up to three-quarters of adult patients. We performed the first ETV outcomes study using an administrative claims database, examining current practice for adult patients in the United States. We interrogated the Truven Health MarketScan® database for Current Procedural Terminology codes corresponding to ETV and ventriculoperitoneal shunt from 2003- to 2011, including patients over 18 years and data from initial and subsequent hospitalizations. ETV failure was defined as any subsequent ETV or shunt procedure. Five hundred twenty-five patients underwent ETV with 6 months minimum follow-up. Mean age was 45.9 years (range: 18–86 years). Mean follow-up was 2.2 years (SD: 1.6 years, range: 0.5–8.4 years). Etiology of hydrocephalus was 21.3% tumor, 9.0% congenital/aqueductal stenosis, 15.8% hemorrhage, and 53.9% others. ETV was successful in 74.7% of patients. Of 133 who failed, 25 had repeat ETV; 108 had shunt placement. Longer length of stay for index surgery was associated with higher risk of failure (hazard ratio (HR): 1.03, p < 0.001), as was history of previous shunt (HR: 2.45, p < 0.001). Among patients with repeat surgeries, median time to failure was 25 days. This study represents a longitudinal analysis of nationwide ETV practice over 9 years. Success rate in this large cohort is similar to that published by other single-center retrospective studies. Age and geographic variation may be associated with surgeon choice of ETV or shunt placement after failure of the initial ETV.
Anatomic Variations of the Floor of the Third Ventricle: An Endoscopic Study
2016, World Neurosurgery
Anatomical variations of the floor of the third ventricle are common in hydrocephalic patients and can significantly affect outcomes of endoscopic third ventriculostomy (ETV). We sought to categorize variations in third ventricle anatomy and to discuss the implications of these variations for ETV.
Intraoperative videos and pictures of 50 patients who underwent ETV between April 2001 and August 2010 were reviewed. Twenty-seven patients with clearly demonstrable third ventricular floors that satisfied our criteria were selected for the study.
Images of variations were organized into the following categories: 1) thinned floor, 2) thickened floor, 3) partially effaced floor, 4) ballooning/herniating floor, 5) small prepontine interval, 6) narrowed third ventricle, and 7) other significant anomalies.
The third ventricle is a common site for anatomical variations in hydrocephalic patients. A good knowledge of these variations is essential before performing ETV, because they have the potential to increase operative risk.
Aqueduct Stent Placement: Indications, Technique, and Clinical Experience
2015, World Neurosurgery
Complicated hydrocephalus, such as trapped fourth ventricle, is challenging. Aqueduct stent placement is a possible alternative to the conventional multiple shunts approach. This article discusses the indications, techniques, and clinical experiences of aqueduct stent placement.
We retrospectively analyzed a series of 10 consecutive patients with hydrocephalus and had aqueduct stent placement between February 2009 and May 2014. The clinical and imaging data were collected and the indications, technique, and clinical experience of aqueduct stent placement were analyzed and discussed.
Among the 10 patients (mean age, 38 years; range, 5 months–69 years), 8 patients harbored an obstructive hydrocephalus caused by aqueductal obstruction. The underlying pathology consisted of intraventricular tumor in 3 patients, intraventricular cysticercosis in 2, and membranous or inflammatory obstruction in 3 patients. Two patients presented with trapped fourth ventricle, which resulted from Dandy-Walker malformation and shunt placement, respectively. Aqueduct stents were placed endoscopically in 8 patients, whereas the other 2 were placed microscopically. There were no deaths due to aqueduct stent placement. Postoperatively, all of the patients showed improvement or resolution of their symptoms. After an average follow-up period of 27 months (range, 1–51 months), recurrence of aqueductal obstruction has not been observed. In 1 patient, there was a complication of transient oculomotor paralysis after aqueduct stent placement. A stent migration was observed in 1 patient after remaining stable for 4 years.
Aqueduct stent placement is technically feasible and can be useful in selected patients either with endoscopy or open surgery.
The management of residual or recurrent central neurocytoma
2015, Neurosurgery Clinics of North America

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HydrocephalusNeuroendoscopic third ventriculostomy for hydrocephalus in adults: report of a single unit’s experience with 63 cases

Abstract

Section snippets

Method

Results

Discussion

Conclusion

Neuroendoscopic third ventriculostomy

Neurosurg Focus

Neuroendoscopy in the premature population

Child’s Nerv Syst

Neuroendoscopic third ventriculostomy in patients less than 1 year old

Pediatr Neurosurg

Cerebral infarction after neuroendoscopic third ventriculostomy

Neurosurgery

Liliequist’s membrane in minimally invasive endoscopic neurosurgery

Clin Anat

The role of endoscopic third ventriculostomy in the management of shunt malfunction

Neurosurgery

Role of repeat neuroendoscopic third ventriculostomy (NTV)

Neurosurgery

Endoscopic third ventriculostomyoutcome analysis of 100 consecutive procedures

Neurosurgery

Late outcome of the surgical treatment of hydrocephalus

Child’s Nerv Syst

Hydrocephalus
Neuroendoscopic third ventriculostomy for hydrocephalus in adults: report of a single unit’s experience with 63 cases