Outcomes of Endoscopic Third Ventriculostomy in Pediatric Patients With Hydrocephalus

Background

Endoscopic third ventriculostomy (ETV) is used to deal with sufferers with obstructive hydrocephalus in infants. This research evaluated the postoperative outcomes of ETV amongst pediatric sufferers.

Methodology

A retrospective research was undertaken on the Mardan Medical Complex between June 2018 and June 2021. All pediatric sufferers who underwent the process of ETV in each the absence and presence of choroid plexus cauterization (CPC) at our heart had been included in the research. Using medical historical past information, a complete survey questionnaire was designed. The findings and results had been evaluated both as a hit or failure.

Results

A complete of 90 circumstances had been reviewed through the research. The fee of in-hospital mortality was 1.1% whereas probably the most generally recognized causes of hydrocephalus had been myelomeningocele and aqueductal stenosis. A complete of 39 (43.33%) sufferers had a profitable surgical procedure. In sufferers the place hydrocephalus was secondary to aqueductal stenosis, the success fee was the best, whereas the success fee was fairly low for post-infectious hydrocephalus and intraventricular hemorrhage (p < 0.0001). The postoperative complication fee was 55.56% in our research. The fee of in-hospital mortality was 1.1%.

Conclusions

We discovered that the success fee of ETV was dependent upon components such because the trigger of hydrocephalus, kind of hydrocephalus, and the age of the affected person. Therefore, ETV shouldn’t be appropriate for all sufferers, and vigilance should be undertaken in deciding on sufferers for the process. The fee of postoperative infections in our establishment was alarmingly excessive which is a regarding matter for the establishment.

Introduction

Hydrocephalus is a severe neurological situation affecting infants most often [1]. The sickness is distinguished by an irregular build-up of cerebrospinal fluid (CSF), which induces ventricular dilatation and enhanced intracranial strain, in addition to subsequent mind parenchymal atrophy [2]. Two of the usual remedies for hydrocephalus are the location of a shunt or an endoscopic third ventriculostomy (ETV) [3].

The ventriculoperitoneal shunt (VPS) stays a regular strategy towards hydrocephalus resulting from its protected profile [4]. Other shunting methods, such because the ventricular atrial shunt and the lateral ventricle-cisterna magna shunt, have been advisable in solely chosen conditions [4]. However, in case of problems, these are very effectively managed in developed international locations. However, the state of affairs shouldn’t be the identical in much less developed international locations like Pakistan. Bakhsh reported that infants who developed problems resulting from CSF shunting usually offered very late to the healthcare amenities resulting from socioeconomic situations and ignorance [5]. The writer additional highlighted that as much as 40% of deaths occurred in infants who had congenital hydrocephalus.

ETV has lately gained recognition amongst neurosurgeons. It is another process in which a bypass is created on the ground of the third ventricle [6]. It is helpful for sufferers who’ve obstructive hydrocephalus. ETV is a remedy of selection in circumstances of hydrocephalus as a result of it takes away the necessity for shunt placement [7]. Over the previous few years, important developments in neuroimaging, endoscopic expertise, processing gear, and a stereotaxic neuronavigation system have resulted in the widespread use of endoscopy for a spread of interventions, notably obstructive hydrocephalus, in addition to in some chosen speaking hydrocephalus [7-9].

Although ETV has already been acknowledged as a substitute for shunt placement, particularly for younger sufferers with non-communicating hydrocephalus [10], its effectiveness stays questionable, relying on the age and pathophysiology of the hydrocephalus. Therefore, contemplating the dearth of native literature, this research was performed to judge the surgical outcomes in a cohort of a pediatric inhabitants with hydrocephalus.

Materials & Methods

A retrospective research was undertaken on the Mardan Medical Complex between June 2018 and June 2021. After acquiring moral approval from the institutional evaluation board of Mardan Medical Complex (IRB # NEU-25565), the information acquisition was began.

All information for pediatric sufferers who underwent ETV in the absence and presence of choroid plexus cauterization (CPC) at our heart had been included in the research. During the research, 90 circumstances of hydrocephalus had been reviewed who had been managed with ETV. Over the interval of research, sufferers had been adopted up by way of information obtained from medical information. The paperwork had been evaluated for demographic traits, etiology and kind of hydrocephalus, general ETV success fee, related points, follow-up, and failure of remedy.

A versatile endoscope telecam and a Bugbee electrocautery wire and a monitor had been used for the process. The fundamental causes of hydrocephalus had been recognized. A historical past of meningitis, ventriculitis, or sickness earlier than the event of hydrocephalus; radiographic scans indicating division or partitions in the ventricles; or postoperative observations of hemosiderin or the presence of yellowish deposits had been all thought to be post-infectious hydrocephalus. Hydrocephalus secondary to myelomeningocele was outlined as the event of the Chiari II malformation. Patients had been additional subcategorized on the occasion of ventriculoscopy based mostly on their age and the standing of aqueduct.

A standard ETV by way of the frontal horn was carried out, together with fenestration of the third ventricle’s ground. Using electrocautery, brief pulses had been delivered on the floor. A blunt penetration that fenestrated by way of Bugbee wire behind the dorsum sellae was carried out. By gently stretching the tissues, the wire was employed to finally dilate the aperture. After ETV, CPC was carried out relying on the origin of hydrocephalus. The choroid plexus of the lateral ventricle was utterly sealed using the Bugbee wire and a low-voltage monopolar coagulating present, originating on the foramen of monro and subsequently advancing posteriorly.

Followed by process, sufferers had been discharged from the hospital after three days and additional monitored for one, three, and 6 months. The affected person’s head circumference, fontanel options, indicators, neurological evaluation, and developmental progress had been all evaluated. When thought of applicable, cranial ultrasonography or computed tomography (CT) scans of head had been additionally performed in sure circumstances.

The remedy was thought of profitable if any of the next standards had been met: (i) discount in development fee of head circumference development to regular or lower than regular fee, (ii) decompression of the anterior fontanel, (iii) aid from signs of elevated intracranial strain, (iv) decision of eye findings, and (v) a lower in ventriculomegaly as recognized on neuroimaging. SPSS model 25 (IBM Corp., Armonk, NY, USA) was employed to investigate the retrieved information. For dichotomized variables, a chi-square check was carried out. The degree of significance was set at 5%.

Results

A complete of 90 circumstances had been reviewed through the research interval. Out of these, 11 (12.22%) sufferers underwent mixed ETV and CPC was carried out. The majority of the sufferers had been females with a imply age of 12.56 ± 10.12 months. The imply head circumference was discovered to be 63.44 ± 12.42 cm. Demographic and medical parameters are illustrated in Table 1. The most typical trigger of hydrocephalus was myelomeningocele. Other causes included post-infectious hydrocephalus, Dandy-Walker malformation, and space-occupying lesions. The least widespread trigger of hydrocephalus was intraventricular hemorrhage. The most typical kind of hydrocephalus was non-communicating with a frequency of 58 (64.4%) sufferers.

  N (%)
Age
Less than 6 months 41 (45.6%)
6–12 months 17 (18.9%)
More than 1 yr 32 (35.6%)
Gender
Female 41 (45.6%)
Male 49 (54.4%)
Causes of hydrocephalus
Myelomeningocele 34 (37.8%)
Dandy-Walker malformation 8 (8.9%)
Aqueductal stenosis 32 (35.6%)
Space-occupying lesion 5 (5.6%)
Post-infectious hydrocephalus 10 (11.1%)
Intraventricular hemorrhage 1 (1.1%)
Type of hydrocephalus
Non-communicating 58 (64.4%)
Communicating 19 (21.1%)
Undefined 13 (14.4%)

A complete of 39 (43.33%) sufferers had a profitable surgical procedure. In sufferers the place hydrocephalus was secondary to aqueductal stenosis, the success fee was the best, whereas the success fee was fairly low for post-infectious hydrocephalus and intraventricular hemorrhage (p < 0.0001). Some sufferers with speaking hydrocephalus had been managed with ETV as effectively. However, the success fee amongst sufferers with non-communicating hydrocephalus was considerably better in comparison with speaking kind (79.49% versus 20.51%; p < 0.0001), as illustrated in Table 2.

Causes of hydrocephalus Success (n = 39) Failure (n = 51) Total P-value
Myelomeningocele 9 (23.1%) 25 (49%) 34 (37.7%) <0.0001
Dandy-Walker malformation 5 (12.8%) 3 (5.9%) 8 (8.9%)  
Aqueductal stenosis 17 (43.6%) 15 (29.4%) 32 (35.6%)  
Space-occupying lesion 5 (12.8%) 0 (0%) 5 (5.6%)  
Post-infectious hydrocephalus 3 (7.7%) 7 (13.7%) 10 (11.1%)  
Intraventricular hemorrhage 0 (0%) 1 (2%) 1 (1.1%)  
Type of hydrocephalus       <0.0001
Non-communicating 31 (79.49%) 25 (49.02%) 56 (62.22%)  
Communicating 8 (20.51%) 26 (50.98%) 34 (37.78%)  

All sufferers had been discharged with a median size of keep of 5 days. In our research, the postoperative complication fee was 55.56%. Postoperative an infection was detected in 70% of circumstances (35/50). Postoperative bleeding occurred in 13 (26%) circumstances whereas two sufferers had a seizure (Table 3). The fee of in-hospital mortality was 1.1%.

Complication (n = 50) Incidence
Postoperative an infection 35 (70%)
Postoperative bleeding 13 (26%)
Postoperative seizure 2 (4%)

Patients aged fewer than one yr who had been receiving a mix of ETV and CPC had a significantly higher success fee (53%) than sufferers present process ETV alone (25%) in (p = 0.0001) (Table 4). Furthermore, the speed of loss to follow-up at three months was very excessive at 111 (55.2%).

Patient final result Age of affected person Total P-value
<1 yr (n = 61) >1 yr (n = 29) 90  
Successful 20 (32.8%) 21 (72.4%) 41 (45.6%) <0.0001
Unsuccessful 61 (67.2%) 8 (27.6%) 49 (54.4%)  

Discussion

According to the findings, probably the most generally reported causes of hydrocephalus had been myelomeningocele and aqueductal stenosis, which is in accordance with prior research [11,12]. Biluts et al. concluded that ETV was carried out with passable surgical outcomes and fewer mortality and morbidity. Similar to our research, Biluts et al. additionally revealed myelomeningocele and aqueductal stenosis to be the most typical causes of hydrocephalus. Furthermore, the authors additionally discovered that success charges had been considerably increased amongst one-year-old sufferers who underwent ETV alone (23%) in comparison with these present process each ETV and CPC (53%) [12]. However, some a long time earlier, the literature revealed a unique pattern in sufferers with hydrocephalus. For occasion, a research by Sacko et al. confirmed that the most typical trigger of hydrocephalus between the yr 1999 and 2007 was tumors, adopted by aqueductal stenosis [13].

In our research, the success of outcomes was considerably decrease in sufferers lower than a yr outdated in comparison with ≥one-year-old sufferers (p < 0.0001), which is in keeping with latest research [11,12,14]. Madsen et al. reported that ETV was much less profitable in high-risk causes of hydrocephalus and sufferers who had been youthful [14]. Younger affected person age and high-risk etiologies had been correlated with surgical failure. In distinction, Gangemi et al. revealed that the long-term outcomes of ETV weren’t affected by the age of the affected person in addition to the trigger of the hydrocephalus [15]. In one other research by Brockmeyer et al., the speed of profitable ETV different broadly by trigger of hydrocephalus and the age of a person. Patients with aqueductal stenosis and myelomeningocele had the best success charges. [16]. In our research, postoperative problems included an infection, postoperative bleeding, and seizure. The fee of postoperative infections in our establishment was alarmingly excessive which is a regarding matter for the establishment. Several others have been reported by Brockmeyer et al. comparable to transient herniation syndrome, basilar artery perforation, ventriculitis, transient lower in the extent of consciousness, and transient hemiparesis [16]. Strict measures ought to be taken to keep away from postoperative problems in sufferers who endure ETV.

In this research, about one-third of sufferers underwent CPC and ETV, which is the traditional remedy for hydrocephalus amongst youngsters significantly in underdevelopment nations [17,18]. In most situations, not solely will the long-term hazards of shunt reliance be prevented however there additionally could be quite a few benefits. Biluts et al. discovered that the postoperative an infection and surgical causes of demise for shunt insertion surgical procedures had been increased in their establishment than for the mixed ETV and CPC surgical procedure [19]. A radical meta-analysis was performed to match the protection and effectivity of ETV and VPS in sufferers with hydrocephalus [20]. A complete of 546 research had been assessed together with 4 randomized managed trials. Lu et al. revealed that ETV was related to a decrease prevalence fee of postoperative an infection (p = 0.0002), postoperative hematoma (p = 0.03), and blockage fee (p = 0.001) in contrast with VPS. ETV had no specific affect on demise charges (p = 0.06) and prevalence of CSF leakage (p = 0.47) after the surgical procedure in comparability with VPS. However, there have been no circumstances reported of demise amongst sufferers handled with ETV [20].

On the premise of the present literature and the findings of the research, we advocate that ETV with or with out CPC ought to be carried out for pediatric sufferers with obstructive hydrocephalus as most advantages might be obtained using ETV. However, extra research are wanted to establish the advantages of ETV in sufferers with speaking hydrocephalus.

In our research, there have been sure limitations as a result of retrospective nature of the research. For instance, we couldn’t preserve an intensive follow-up of greater than six months and had been unable to evaluate the long-term outcomes. Complication administration charges in our research couldn’t be assessed as a result of readmission information weren’t retrievable. Moreover, the one-year mortality fee was not documented as this was a retrospective research, and in our set-up, the information weren’t maintained correctly in many circumstances.

Conclusions

In much less developed international locations, ETV might be undertaken for chosen sufferers with passable outcomes, as reported in our research. However, vigilance should be undertaken, particularly in sufferers who’re younger as sufferers aged lower than a yr had been extra vulnerable to poorer surgical outcomes in comparison with older sufferers. The fee of postoperative infections in our establishment was alarmingly excessive which is a regarding matter for the establishment.



https://www.cureus.com/articles/93872-outcomes-of-endoscopic-third-ventriculostomy-in-pediatric-patients-with-hydrocephalus

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