ETV in infancy and childhood below 2 years of age for treatment of hydrocephalus

Abstract

Purpose Age and etiology play a crucial role in success of endoscopic third ventriculostomy (ETV) as a treatment of obstructive hydrocephalus. Outcome is worse in infants, and controversies still exist whether ETV is superior to shunt placement. We retrospectively analyzed 70 patients below 2 years from 4 different centers treated with ETV and assessed success. Methods Children < 2 years who received an ETV within 1994-2018 were included. Patients were classified according to age and etiology; < 3, 4-12, and 13-24 months, etiologically; aqueductal stenosis, post-hemorrhagic-hydrocephalus (PHH), tumorrelated, fourth ventricle outflow obstruction, with Chiari-type II and following CSF infection. We investigated statistically the predictors for ETV success through computing Kaplan-Meier estimates using patient's follow-up time and time to ETV failure. Results We collected 70 patients. ETV success rate was 41.4%. The highest rate was in tumor-related hydrocephalus and fourth ventricle outlet obstruction (62.5%, 60%) and the lowest rate was in Chiari-type II and following infection (16.7%, 0%). The below 3 months age group showed relatively lower success rate (33.3%) in comparison to older groups which showed similar results (46.4%, 46.6%). Statistically, a previous VP shunt was a predictor for failure (p value < 0.05). Conclusion Factors suggesting a high possibility of failure were age < 3 months and etiology such as Chiari-type II or following infection. Altered CSF dynamics in patients with PHH and underdeveloped arachnoid villi may play a role in ETV failure. We do not recommend ETV as first line in children < 3 months of age or in case of Chiari II or following infection.

Endoscopic third ventriculostomy: a feasible treatment option for pediatric hydrocephalus in a high-risk cohort – a single-center report

“… 18 20 In accordance with previous studies, our findings revealed patient age as a potential risk factor for ETV and VP shunt failure. 2 5 6 9 12 Ventricular catheter obstructions are described to be the most common cause of VP shunt failure, consistent with our results, which indicated that obstruction caused a majority of all VP shunt-related complications (n=10, 27.8%). 15 Consistent with our data neonatal patients during the first year of life do have higher rates of shunt infection due to weakness in their immune response, another reason why children during early infancy are called a high-risk cohort and why foreign materials should be avoided wherever possible.…”

“…Until the age of 3 months, the ETV failure rate is supposed to be higher than that in later infancy due to immaturity of the glymphatic system and arachnoid villi. 2 19 This hypothesis is also supported by our study because the multiple logistic regression analysis revealed age as a predictor of failure in both treatment groups. Diverse findings in this field demonstrate that the mechanisms of CSF dynamics are still not well understood and indicate that the indications for both procedures, VP shunting and ETV, should be carefully considered in this particular age group.…”

“… 1–6 The reported main factors influencing the outcome of ETV are age at operation and etiology. 2–4 7 8 The success rates of ETV are low in preterm and in infants less than 1 year of age, especially in patients with posthemorrhagic and infection-related hydrocephalus. 4–6 8–10 Outcomes are more favorable in obstructive hydrocephalus, particularly idiopathic aqueductal stenosis in later childhood.…”

“… 12 Additionally, various studies described the association of etiology to shunt or ETV failure, mostly revealing a poor outcome for individuals with PHH or postinfectious hydrocephalus and higher success rates for obstructive conditions, for example, those caused by a single aqueductal stenosis. 2 7 8 17 18 …”

Long-term neurological cognitive, behavioral, functional, and quality of life outcomes after fetal myelomeningocele closure: a systematic review

“…It is suggested that neurodevelopmental impairment in shunted patients is related to shunt-related complication [ 37 ]. Endoscopic third ventriculostomy is another choice in treating hydrocephalus, but the success rate is very low if conducted in the first 48 hours after birth [ 38 ].…”