Cognitive and gait outcomes after primary endoscopic third ventriculostomy in adults with chronic obstructive hydrocephalus

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  • 1 Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada;
  • | 2 Departments of Neurology and Neurological Surgery, University of Washington, Seattle, Washington;
  • | 3 Department of Pediatrics, University of Utah, Salt Lake City, Utah;
  • | 4 Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida;
  • | 5 Departments of Neurosurgery and
  • | 6 Neurology, Johns Hopkins University, Baltimore, Maryland;
  • | 7 Department of Neurosurgery, Center for Neurological Restoration, Cleveland Clinic, Cleveland, Ohio;
  • | 8 Departments of Neurosurgery and
  • | 9 Neurology, New York University School of Medicine, New York, New York;
  • | 10 Department of Neurological Surgery, Columbia University Irving Medical Center, New York, New York;
  • | 11 Department of Neurosurgery, Southmead Hospital, Bristol, United Kingdom; and
  • | 12 Department of Clinical Neurosciences, Division of Neurosurgery, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
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OBJECTIVE

The object of this study was to determine the short- and long-term efficacy of primary endoscopic third ventriculostomy (ETV) on cognition and gait in adults with chronic obstructive hydrocephalus.

METHODS

Patients were prospectively accrued through the Adult Hydrocephalus Clinical Research Network patient registry. Patients with previously untreated congenital or acquired obstructive hydrocephalus were included in this study. Gait velocity was assessed using a 10-m walk test. Global cognition was assessed with the Montreal Cognitive Assessment (MoCA). Only patients with documented pre- and post-ETV gait analysis and/or pre- and post-ETV MoCA were included.

RESULTS

A total of 74 patients had undergone primary ETV, 42 of whom were analyzed. The remaining 32 patients were excluded, as they could not complete both pre- and post-ETV assessments. The mean age of the 42 patients, 19 (45.2%) of whom were female, was 51.9 ± 17.1 years (range 19–79 years). Most patients were White (37 [88.1%]), and the remainder were Asian. Surgical complications were minor. Congenital etiologies occurred in 31 patients (73.8%), with aqueductal stenosis in 23 of those patients (54.8%). The remaining 11 patients (26.2%) had acquired cases. The gait short-term follow-up cohort (mean 4.7 ± 4.1 months, 35 patients) had a baseline median gait velocity of 0.9 m/sec (IQR 0.7–1.3 m/sec) and a post-ETV median velocity of 1.3 m/sec (IQR 1.1–1.4 m/sec). Gait velocity significantly improved post-ETV with a median within-patient change of 0.3 m/sec (IQR 0.0–0.6 m/sec, p < 0.001). Gait velocity improvements were sustained in the long term (mean 14 ± 2.8 months, 12 patients) with a baseline median velocity of 0.7 m/sec (IQR 0.6–1.3 m/sec), post-ETV median of 1.3 m/sec (IQR 1.1–1.7 m/sec), and median within-patient change of 0.4 m/sec (IQR 0.2–0.6 m/sec, p < 0.001).

The cognitive short-term follow-up cohort (mean 4.6 ± 4.0 months, 38 patients) had a baseline median MoCA total score (MoCA TS) of 24/30 (IQR 23–27) that improved to 26/30 (IQR 24–28) post-ETV. The median within-patient change was +1 point (IQR 0–2 points, p < 0.001). However, this change is not clinically significant. The cognitive long-term follow-up cohort (mean 14 ± 3.1 months, 15 patients) had a baseline median MoCA TS of 23/30 (IQR 22–27), which improved to 26/30 (IQR 25–28) post-ETV. The median within-patient change was +2 points (IQR 1–3 points, p = 0.007), which is both statistically and clinically significant.

CONCLUSIONS

Primary ETV can safely improve symptoms of gait and cognitive dysfunction in adults with chronic obstructive hydrocephalus. Gait velocity and global cognition were significantly improved, and the worsening of either was rare following ETV.

ABBREVIATIONS

AHCRN = Adult Hydrocephalus Clinical Research Network; ETV = endoscopic third ventriculostomy; ICP = intracranial pressure; iNPH = idiopathic normal pressure hydrocephalus; MMSE = Mini-Mental State Examination; MoCA = Montreal Cognitive Assessment; MoCA TS = MoCA total score; SDMT = Symbol Digit Modalities Test.

Supplementary Materials

    • Supplementary Tables 1-3 (PDF 378 KB)

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