The role of endoscopic third ventriculostomy in adult patients with hydrocephalus

Clinical article

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Object

Endoscopic third ventriculostomy (ETV) is the treatment of choice for hydrocephalus, but the outcome is dependent on the cause of this disorder, and the procedure remains principally the preserve of pediatric neurosurgeons. The role of ETV in adult patients with hydrocephalus was therefore investigated.

Methods

One hundred ninety adult patients underwent ETV for hydrocephalus. Cases were defined as primary ETV (newly diagnosed, without a previously placed shunt) and secondary ETV (performed for shunt malfunctions due to infection or mechanical blockage). Causes of hydrocephalus included tumor, long-standing overt ventriculomegaly (LOVA), Chiari malformation Types I and II (CM-I and -II), aqueduct stenosis, spina bifida, and intraventricular hemorrhage (IVH). Successful ETV was defined as resolution of symptoms with shunt independence. Operative complications and ETV failure rate were investigated according to the causes of hydrocephalus and between the primary and secondary ETV groups.

Results

In the primary group, ETV was successful in 107 (83%) of 129 patients, including those with tumors (52 of 66), LOVA (21 of 24), CM-I (11 of 11 cases), CM-II (8 of 9), aqueduct stenosis (8 of 9), and IVH (2 of 2). In the secondary group, ETV was successful in 41 (67%) of 61 patients and was equally successful in cases of mechanical shunt malfunction (35 of 52 patients) and infected shunt malfunction (6 of 9 patients). The median time to ETV failure was 1.7 months in the primary group and 0.5 months in the secondary group. The majority of ETV failures occurred within the first 3 months, and thereafter, the Kaplan-Meier survival curves plateaued. There were no procedure-related deaths, and complications were seen in only 5.8% of cases.

Conclusions

The success rate of ETVs in adults is comparable, if not better, than in children. In addition to the well-defined role of ETV in the treatment of hydrocephalus caused by tumors and aqueduct stenosis, ETV may also have a role in the management of CM-I, LOVA, persistent shunt infection, and IVH resistant to other CSF diversion procedures.

Abbreviations used in this paper: CM-I = Chiari malformation Type I; CM-II = Chiari malformation Type II; ETV = endoscopic third ventriculostomy; EVD = external ventricular drain; ICP = intracranial pressure; IVH = intraventricular hemorrhage; LOVA = long-standing overt ventriculomegaly in adults; NPH = normal pressure hydrocephalus; VP = ventriculoperitoneal.

Article Information

Address correspondence to: Michael D. Jenkinson, Ph.D., Division of Neuroscience, Clinical Science Centre, Lower Lane, Liverpool, L9 7LJ, United Kingdom. email: michael.jenkinson@liv.ac.uk.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Kaplan-Meier curve plotted for time to ETV failure. For both the adult (smooth line) and pediatric (dashed line) groups there is a rapid decrease in the first 3 months, followed by a plateau.

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    Axial (left) and sagittal (right) T2-weighted MR images obtained in a woman with LOVA who underwent ETV. Marked ventriculomegaly is shown on the axial slice and satisfactory flow on the sagittal image.

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    Images obtained in a man with a 12-month history of global headache and cough-induced neck pain associated with left arm sensory disturbance. Examination revealed bilaterally diminished sensation in C6–T1 dermatomes. There was no papilledema. Magnetic resonance imaging revealed a CM with a 1.5 cm of tonsillar descent and triventriculomegaly with an open aqueduct (A), and a syrinx cavity extending from C-3 to T-3 (B). After ETV, his headaches and neck pain resolved, with improvement in upper limb sensory function. The follow-up MR image (C) revealed a flow void across the floor of the third ventricle but no change in ventricular size. The tonsillar herniation regressed to 8 mm, and the syrinx cavity reduced in length.

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    Images obtained in a man with a right thalamic and IVH. A: Axial CT scan demonstrating hydrocephalus. Mechanical blockage occurred in 5 EVDs and a VP shunt in this patient. B: Endoscopic third ventriculostomy was successfully performed, and a reduction in ventricle size is shown on postoperative imaging. C: Sagittal T2-weighted MR image obtained 12 months postoperatively shows a flow void through the floor of the third ventricle.

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