Endoscopic third ventriculostomy with choroid plexus cauterization outcome: distinguishing success from failure

Abstract

E ndoscopic third ventriculostomy with choroid plexus cauterization (ETV/CPC) for the treatment of infantile hydrocephalus is being performed as an alternative to shunting. 7,11,12,16 Multiple validated success scales exist as simple tools to calculate the expected success rate of endoscopically treated hydrocephalus based on preoperative variables. 6,15 All of these predictive models depend on the manner in which the diagnosis of failure is established. The decision making in diagnosing ETV/ CPC success or failure remains subjective, ambiguous, and often opaque in current studies.Metrics of assessing infantile hydrocephalus include head circumference, ventricular size, and fontanel quality. In traditional treatment of infantile hydrocephalus, a ventriculoperitoneal shunt is inserted, and it is expected that all 3 of these metrics will begin to normalize or "improve," i.e., the fontanel will flatten and soften, accelerated head growth will cease, and ventricle size will decrease. In obJeCtive Endoscopic third ventriculostomy with choroid plexus cauterization (ETV/CPC) offers an alternative to shunt treatment for infantile hydrocephalus. Diagnosing treatment failure is dependent on infantile hydrocephalus metrics, including head circumference, fontanel quality, and ventricle size. However, it is not clear to what degree these metrics should be expected to change after ETV/CPC. Using these clinical metrics, the authors present and analyze the decision making in cases of ETV/CPC failure. MethoDs Infantile hydrocephalus metrics, including bulging fontanel, head circumference z-score, and frontal and occipital horn ratio (FOHR), were compared between ETV/CPC failures and successes. Treatment outcome predictive values of metrics individually and in combination were calculated. resUlts Forty-four patients (57% males, median age 1.2 months) underwent ETV/CPC for hydrocephalus; of these patients, 25 (57%) experienced failure at a median time of 51 days postoperatively. Patients experiencing failure were younger than those experiencing successful treatment (0.8 vs 3.9 months, p = 0.01). During outpatient follow-up, bulging anterior fontanel, progressive macrocephaly, and enlarging ventricles each demonstrated a positive predictive value (PPV) of no less than 71%, but a bulging anterior fontanel remained the most predictive indicator of ETV/CPC failure, with a PPV of 100%, negative predictive value of 73%, and sensitivity of 72%. The highest PPVs and specificities existed when the clinical metrics were present in combination, although sensitivities decreased expectedly. Only 48% of failures were diagnosed on the basis all 3 hydrocephalus metrics, while only 37% of successes were negative for all 3 metrics. In the remaining 57% of patients, a diagnosis of success or failure was made in the presence of discordant data. ConClUsions Successful ETV/CPC for infantile hydrocephalus was evaluated in relation to fontanel status, head growth, and change in ventricular size. In most patients, a designation of failure or success was m...

Global hydrocephalus epidemiology and incidence: systematic review and meta-analysis

“…While shunt insertion has represented the historical mainstay of treatment, the risk of malfunction and infection has prompted greater interest in procedures, such as endoscopic third ventriculostomy with or without choroid plexus cauterization, that might offer an alternative to shunting with fewer complications and reduced cost. 18,89,94 Whatever the optimal treatment, there is clearly an enormous worldwide volume of hydrocephalus that has been previously underrecognized. 56,61…”

The Global Rise of Endoscopic Third Ventriculostomy with Choroid Plexus Cauterization in Pediatric Hydrocephalus

“…On the surface, this distinction may seem obvious, but the fine line can be easily blurred in the face of discordant clinical data [39] . The majority of studies on ETV/CPC define failure as the need to undergo a repeat surgery for hydrocephalus or death due to hydrocephalus.…”

“…Patients with myelomeningocele and aqueductal stenosis were most likely to achieve success with ETV/CPC (83%), while those with intraventricular hemorrhage were least likely (40%). A very young (median age 1.2 months) cohort from Vanderbilt demonstrated a 43% overall success rate for ETV/ CPC in 44 patients [39] .…”

Predictors of success for combined endoscopic third ventriculostomy and choroid plexus cauterization in a North American setting: a Hydrocephalus Clinical Research Network study

“…19 This surgical technique continues to grow in popularity in both the African and the North American settings. 4 One driver for this expansion is the broadening of criteria for patients to be selected for ETV+CPC. In the original publication, 71% of infants had postinfectious or myelomeningocele etiologies for hydrocephalus.…”