Letter to the Editor. Infantile hydrocephalus treated by choroid plexus coagulation

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TO THE EDITOR: We read with keen interest the article by Okano and Ogiwara2 (Okano A, Ogiwara H: Long-term follow-up for patients with infantile hydrocephalus treated by choroid plexus coagulation. J Neurosurg Pediatr 22:638–645, December 2018). We commend the authors for analyzing this clinically relevant issue. They concluded that choroid plexus coagulation (CPC) with or without endoscopic third ventriculostomy (ETV) can be a safe and effective treatment in children with infantile hydrocephalus and that long-term control of hydrocephalus and normal intellectual development can be achieved. However, there are a few important points that we would like to bring to the attention of the readers of this journal.

The authors observed that the mean ETV success score (ETVSS)1 of the patients who had undergone CPC alone was 46 ± 12.9 and that of the patients who had undergone combined CPC and ETV was 51.1 ± 7.0. There was no statistically significant difference between the ETVSSs of those who had undergone CPC only and those who had undergone CPC plus ETV (p = 0.71). Of the 5 children treated with CPC alone, only 1 (20%) required a shunt. Of the 9 children treated with CPC and ETV, 5 (55.55%) required a shunt (p = 0.12). Of the 5 children treated with CPC alone, only 1 (20%) required a second surgery. Of the children treated with CPC and ETV, since 1 patient underwent repeat ETV, a total of 6 (66.67%) of the 9 children required a second surgery (p = 0.09). Although they did not reach statistical significance as defined by the authors (p < 0.05), these observed differences tend to convey the message that despite similar preoperative characteristics, CPC alone may have a better outcome than CPC with ETV. We believe that these observations are attributable to significant heterogeneity among these two groups. A comparison of preoperative status on the basis of ETVSS alone should not be done. The authors should compare the demographics of the two groups, which could clarify the skew toward the CPC-alone group. It is relevant to read the authors’ comments on this pertinent issue.

The authors divided the patients who underwent CPC with or without ETV into shunt-dependent and shunt-independent groups. Six of 14 patients underwent ventriculoperitoneal (VP) shunt placement. Eight patients remained shunt independent, although 1 patient required repeat ETV. The authors included only 7 patients in the shunt-independent category in their description in Table 1 and Fig. 5. We believe that since the authors have categories of patients as shunt dependent or not, all 8 should be included in the shunt-independent category and reanalyzed accordingly.

Disclosures

The authors report no conflict of interest.

References

  • 1

    Kulkarni AVDrake JMKestle JRMallucci CLSgouros SConstantini S: Predicting who will benefit from endoscopic third ventriculostomy compared with shunt insertion in childhood hydrocephalus using the ETV Success Score. J Neurosurg Pediatr 6:3103152010

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  • 2

    Okano AOgiwara H: Long-term follow-up for patients with infantile hydrocephalus treated by choroid plexus coagulation. J Neurosurg Pediatr 22:6386452018

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Response

We appreciate very much the interest in our work. As Drs. Sardana and Kedia pointed out, our findings may give readers the impression that CPC alone may have a better outcome than CPC with ETV. At this point, we do not think this is true, and the number of patients in our study was too small and their backgrounds too heterogeneous to draw any conclusions. However, we would like to emphasize that CPC with or without ETV can achieve long-term control of hydrocephalus and normal intellectual development in successful cases. In the future, a prospective randomized clinical trial in a large number of patients with homogeneous backgrounds will be required to determine which patients will benefit from CPC alone and which will benefit from CPC with ETV.

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Article Information

Contributor Notes

Correspondence Hardik Sardana: hardiksardana@yahoo.co.in.INCLUDE WHEN CITING Published online June 21, 2019; DOI: 10.3171/2019.3.PEDS19130.Disclosures The authors report no conflict of interest.

© AANS, except where prohibited by US copyright law.

Headings
References
  • 1

    Kulkarni AVDrake JMKestle JRMallucci CLSgouros SConstantini S: Predicting who will benefit from endoscopic third ventriculostomy compared with shunt insertion in childhood hydrocephalus using the ETV Success Score. J Neurosurg Pediatr 6:3103152010

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

    Okano AOgiwara H: Long-term follow-up for patients with infantile hydrocephalus treated by choroid plexus coagulation. J Neurosurg Pediatr 22:6386452018

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