Intraoperative assessment of cerebral aqueduct patency and cisternal scarring: impact on success of endoscopic third ventriculostomy in 403 African children

Clinical article

Benjamin C. Warf Department of Neurosurgery, Children's Hospital Boston, Boston, Massachusetts; and

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 M.D.
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Abhaya V. Kulkarni Department of Neurosurgery, Hospital for Sick Children, Toronto, Ontario, Canada

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 M.D., Ph.D., F.R.C.S.C.
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Object

In the setting of a developing country where preoperative imaging may be limited, the authors wished to determine whether cisternal scarring or aqueduct patency at the time of surgery was sufficiently predictive of the failure of endoscopic third ventriculostomy (ETV) to justify shunt placement at the time of the initial operation.

Methods

The status of the prepontine cistern and aqueduct at the time of ventriculoscopy was prospectively recorded in 403 children in whom an ETV had been completed. Kaplan-Meier methods were used to construct survival curves. A Cox proportional hazards model was used to provide estimates of HRs for the time to ETV failure. Several independent variables were tested in a single multivariable model, including those previously shown to be associated with ETV survival, that is, age, hydrocephalus etiology, and extent of choroid plexus cauterization (CPC). In addition, intraoperative variables of particular interest were included in the analysis: status of the aqueduct at surgery (closed vs open) and status of the prepontine cistern at surgery (scarred vs clean/unscarred). Multicollinearity was not a concern since the variance inflation factors for all variables were < 2. The examination of stratified survival curves confirmed the appropriateness of the proportional hazards assumption for each variable.

Results

Overall actuarial 3-year success was 57%. Consistent with previous results, age, hydrocephalus etiology, and extent of CPC were significantly associated with ETV success. A closed aqueduct and an unscarred cistern were each independently associated with significantly better ETV success (HRs of 0.66 and 0.44, respectively). The presence of cisternal scarring more than doubled the risk of ETV failure, and an open aqueduct increased the risk of failure by 50%.

Conclusions

Intraoperative observations of the aqueduct and prepontine cistern are independent predictors of the risk of ETV failure and can be used to further refine outcome predictions based on age, hydrocephalus etiology, and extent of CPC. Further studies will test validity in several African centers and determine what threshold of failure risk should prompt shunt placement at the initial operation.

Abbreviations used in this paper:

CCHU = CURE Children's Hospital of Uganda; CPC = choroid plexus cauterization; ETV = endoscopic third ventriculostomy; PIH = postinfectious hydrocephalus.
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  • 1

    Casey AT, , Kimmings EJ, , Kleinlugtebeld AD, , Taylor WA, , Harkness WF, & Hayward RD: The long-term outlook for hydrocephalus in childhood. A ten-year cohort study of 155 patients. Pediatr Neurosurg 27:6370, 1997

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Drake J, , Chumas P, , Kestle J, , Pierre-Kahn A, , Vinchon M, & Brown J, et al.: Late rapid deterioration after endoscopic third ventriculostomy: additional cases and review of the literature. J Neurosurg 105:2 Suppl 118126, 2006

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Drake JM, , Kestle JR, , Milner R, , Cinalli G, , Boop F, & Piatt J Jr, et al.: Randomized trail of cerebrospinal fluid shunt valve design in pediatric hydrocephalus. Neurosurgery 43:294305, 1998

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Gangemi M, , Buonamassa S, , Colella G, & de Divitiis E: Endoscopic third ventriculostomy in idiopathic normal pressure hydrocephalus. Neurosurgery 55:129134, 2004

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Greenfield JP, , Hoffman C, , Kuo E, , Christos PJ, & Souweidane MM: Intraoperative assessment of endoscopic third ventriculostomy success. J Neurosurg Pediatr 2:298303, 2008

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Greitz D: Paradigm shift in hydrocephalus research in legacy of Dandy's pioneering work: rationale for third ventriculostomy in communicating hydrocephalus. Childs Nerv Syst 23:487489, 2007

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Hailong F, , Guangfu H, , Haibin T, , Hong P, , Yong C, & Wiedong L, et al.: Endoscopic third ventriculostomy in the management of communicating hydrocephalus: a preliminary study. J Neurosurg 109:923930, 2008

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Jonathan A, & Rajshkahar V: Endoscopic third ventriculostomy for chronic hydrocephalus after tuberculous meningitis. Surg Neurol 63:3235, 2005

  • 9

    Kehler U, & Gliemroth J: Extraventricular intracisternal obstructive hydrocephalus—a hypothesis to explain successful 3rd ventriculostomy in communicating hydrocephalus. Pediatr Neurosurg 38:98101, 2003

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Kleinbaum DG, , Kupper LL, & Muller KE: Collinearity concepts. Applied Regression Analysis and Other Multivariable Methods ed 2 Belmont, CA, Wadsworth Publishing Co, 1988. 209214

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Kulkarni AV, , Drake JM, , Armstrong DC, & Dirks PB: Measurement of ventricular size: reliability of the frontal and occipital horn ratio compared to subjective assessment. Pediatr Neurosurg 31:6570, 1999

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Madsen JR, , Egnor M, & Zou R: Cerebrospinal fluid pulsatility and hydrocephalus: the fourth circulation. Clin Neurosurg 53:4852, 2006

  • 13

    Meier U, , Zeilinger FS, & Schönherr B: Endoscopic ventriculostomy versus shunt operation in normal pressure hydrocephalus: diagnosis and indication. Acta Neurochir Suppl 76:563566, 2000

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Mitchell P, & Mathew B: Third ventriculostomy in normal pressure hydrocephalus. Br J Neurosurg 13:382385, 1999

  • 15

    Piatt JH Jr, & Cosgriff M: Monte Carlo simulation of cerebrospinal fluid shunt failure and definition of instability among shunt-treated patients with hydrocephalus. J Neurosurg 107:6 Suppl 474478, 2007

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    Stein SC, & Guo W: A mathematical model of survival in a newly inserted ventricular shunt. J Neurosurg 107:6 Suppl 448454, 2007

  • 17

    Warf BC: Combined Endoscopic Third Ventriculostomy and Choroid Plexus Cauterization (ETV/CPC) for Hydrocephalus in Infants and Children With Special Emphasis on the Developing World Tuttlingen, Germany, Endo-Press, 2006

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    Warf BC: Comparison of 1-year outcomes for the Chhabra and Codman-Hakim Micro Precision shunt systems in Uganda: a prospective study in 195 children. J Neurosurg 102:4 Suppl 358362, 2005

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Warf BC: Comparison of endoscopic third ventriculostomy alone and combined with choroid plexus cauterization in infants younger than 1 year of age: a prospective study in 550 African children. J Neurosurg 103:6 Suppl 475481, 2005

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    Warf BC: Hydrocephalus in Uganda: the predominance of infectious origin and primary management with endoscopic third ventriculostomy. J Neurosurg 102:1 Suppl 115, 2005

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21

    Warf BC, & Campbell JW: Combined endoscopic third ventriculostomy and choroid plexus cauterization as primary treatment of hydrocephalus for infants with myelomeningocele: long-term results of a prospective intent-to-treat study in 115 East African infants. J Neurosurg Pediatr 2:310316, 2008

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22

    Warf BC, , Mugamba J, & Kulkarni AV: Endoscopic third ventriculostomy in the treatment of childhood hydrocephalus in Uganda: report of a scoring system that predicts success. Clinical article. J Neurosurg Pediatr 5:143148, 2010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation

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