Failed Endoscopic Third Ventriculostomy in Children: Management Options

Abstract

Endoscopic third ventriculostomy (ETV) for obstructive hydrocephalus has a failure rate of 20–50% in various series. The present study analyzes ETV failures in 72 patients over a 2-year period and attempts to outline a management plan. Of the 72 patients who underwent ETV, it failed in 13. Seven of these failures occurred within 1 month, and in 5 others, ETV failed after 1–2 months. Another patient had a delayed failure 2 years after the initial surgery. Upon clinical failure, MRI scans were performed in all patients using either T2 fast spin echo or two-dimensional phase contrast MRI techniques. Of these, no flow could be demonstrated in 12 patients, whereas in 1 patient, good flow was observed. Endoscopic exploration was undertaken in the 12 patients in whom flow could not be demonstrated. Of the 12 who underwent endoscopic exploration, a patent stoma was observed in 7, necessitating insertion of a ventriculoperitoneal shunt (VPS). In the other 5, the stoma had closed by gliosis and a repeat ETV was performed. In 3 of these patients, in addition to the ETV, a VPS was also inserted in accordance with the family’s wishes. VPS insertion was carried out in the patient with suggestion of good flow through the stoma. In failed ETV, MRI with flow studies is essential to identify the possible cause of failure. Endoscopic exploration is indicated for patients with no evidence of flow. A repeat ETV is indicated in patients with a closed stoma. Patients with a patent stoma could require insertion of a cerebrospinal fluid shunt.

Third ventriculostomy vs ventriculoperitoneal shunt in pediatric obstructive hydrocephalus: results from a Swiss series and literature review

“…The management of hydrocephalus is a never-ending problem, and many studies analyzed the treatment options and outcomes [5,19,20,24,28,34,37,45]. Endoscopic procedures increased in popularity because they provide the opportunity for the patient to be shunt-free.…”

“…In literature, the rate of failure of ETV in the literature is highly variable (8-69%) [4-6, 18, 39]. The rate of failure in ventriculoperitoneal patients is highly variable as well (27-70%) [8,9,24,28,37]. The success of both procedures might vary depending on the Fig.…”

Result of Endoscopic Third Ventriculostomy for Hydrocephalus Caused by Cerebral Aqueductal Stenosis in Infant Patients

“…24 Postoperative failures usually occur early; regular clinical and radiologic follow-up must be performed, especially in the first years after the ETV. 25 According to Mohanty et al, 26 reclosure of the stoma because of gliosis and scarring has been observed in 6 to 15% of ETV failures. The high rate of reclosure in infants can be explained as follows: as CSF absorption is impeded, there is a greater tendency for the development of new arachnoid membranes in infants, and there is also growth of gliotic, ependymal, and scar tissue.…”

Outcome of endoscopic third ventriculostomy: analysis of first 23 cases

“…15,16 This may be due to reduced absorption capacity, formation of newer arachnoid membranes and development of scar around the stoma. 17 Another mechanism postulated is that, with open fontanelle, the pressure gradient across the ETV stoma is inadequate to drive the CSF into the subarachnoid space.…”