Erratum: Predicting who will benefit from endoscopic third ventriculostomy compared with shunt insertion in childhood hydrocephalus using the ETV Success Score
Abhaya V. Kulkarni
Editorial: Pineal cyst resection
Abhaya V. Kulkarni
Letter to the Editor: Endoscopic third ventriculostomy success
Mostafa El Khashab
Editorial: Combined choroid plexus coagulation and endoscopic third ventriculostomy: is North America ready?
Mark S. Souweidane
Editorial: Shunt failure
Abhaya V. Kulkarni
Editorial. Neurodevelopmental outcome and sagittal synostosis
Abhaya V. Kulkarni and Ruth Donnelly
Quality of life in children with hydrocephalus: results from the Hospital for Sick Children, Toronto
Abhaya V. Kulkarni and Iffat Shams
Children with hydrocephalus face several quality of life (QOL) issues that have been poorly studied. The authors' aim was to quantify the QOL for children with hydrocephalus and identify predictors of long-term outcome, using a reliable and validated outcome measure: the Hydrocephalus Outcome Questionnaire (HOQ).
All children (5–18 years old) with treated hydrocephalus attending the neurosurgery outpatient clinic at the Hospital for Sick Children were asked to participate. The patient's QOL was measured by the parent-completed HOQ. Predictor variables were extracted from the medical records. Multivariable linear regression was used to identify those predictor variables that were significantly associated with outcome.
There was an 89% participation rate, with a total of 346 children participating (mean age 11.7 years, mean duration since diagnosis 9.9 years). Their mean HOQ Overall Health score was 0.68 (on a scale of 0 [worst QOL] to 1.0 [best QOL]). On multivariable analysis, the following predictors were associated with a worse overall QOL: increased seizure frequency, increased length of stay (LOS) in the hospital for the initial treatment of hydrocephalus, increased LOS for treatment of shunt infection and shunt overdrainage, increased number of proximal shunt catheters in situ, and increased distance of the family residence from the pediatric neurosurgical center.
For the first time, these results establish baseline QOL values for a typical large group of children many years after their diagnosis of hydrocephalus, by using a validated and reproducible outcome measure. Many of the factors that adversely impact QOL appear to be related to shunt complications and might, therefore, be modifiable.
Detection of important venous collaterals by computed tomography venogram in multisutural synostosis
Case report and review of the literature
Merdas Al-Otibi, Andrew Jea, and Abhaya V. Kulkarni
✓The authors describe the novel use of computed tomography (CT) venography in the preoperative evaluation of a child with Crouzon syndrome who was being considered for Chiari decompression. This 18-month-old girl presented with hydrocephalus (treated with a ventriculoperitoneal shunt) and persistent symptomatic Chiari malformation and associated syrinx. A CT venogram was obtained because of the well-described relationship between multisutural craniosynostosis and abnormal intracranial-to-extracranial venous drainage. The CT venogram showed widely dilated vertebral and paravertebral veins located in the paraspinous muscles of the craniocervical junction. Because of the risk of massive intraoperative blood loss and/or occlusion of important collateral draining veins leading to intracranial venous hypertension and intractably raised intracranial pressure, the planned posterior fossa decompression was not performed. Computed tomography venography is an easily obtained study that we recommend in the evaluation of children with multisutural craniosynostosis prior to cranial surgical interventions.
Clinical practice guidelines
Shobhan Vachhrajani, Abhaya V. Kulkarni, and John R. W. Kestle
In the era of evidence-based medicine, clinical practice guidelines (CPGs) have become an integral part of many aspects of medical practice. Because practicing neurosurgeons rarely have the time or, in some cases, the methodological expertise, to assess and assimilate the totality of primary research, CPGs can in theory provide a vehicle through which neurosurgeons could more efficiently integrate the most current evidence into patient management. Clinical practice guidelines have been met with some skepticism, however, particularly within the neurosurgical community. Some have expressed concerns that the promise of CPGs has not been matched by the reality. Others who oppose CPGs fear that they hinder the art of medicine, and limit physician and patient autonomy. The purpose of this paper is to provide the practicing neurosurgeon with an up-to-date review of CPGs. The authors discuss some of the complexities and recent advancements in CPG development, appraisal, and publication. An overview of the various systems for grading medical evidence and issuing CPG recommendations, each of which has its advantages and disadvantages, is included, and the current knowledge on the impact of CPGs in 2 important realms, patient care and medicolegal issues, is discussed.
The purpose of this review is to provide a balanced, current synopsis of what CPGs are, how they are developed, and what they can and cannot do. The authors hope that this will allow neurosurgeons to make more informed decisions about the many CPGs that will inevitably become an essential component of medical practice in the years to come.
Intraoperative assessment of cerebral aqueduct patency and cisternal scarring: impact on success of endoscopic third ventriculostomy in 403 African children
Benjamin C. Warf and Abhaya V. Kulkarni
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.
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.
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%.
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.