Predicting who will benefit from endoscopic third ventriculostomy compared with shunt insertion in childhood hydrocephalus using the ETV Success Score

Abstract

<jats:sec> <jats:title>Object</jats:title> <jats:p>The authors recently developed and internally validated the ETV Success Score (ETVSS)—a simplified means of predicting the 6-month success rate of endoscopic third ventriculostomy (ETV) for a child with hydrocephalus, based on age, etiology of hydrocephalus, and presence of a previous shunt. A high ETVSS predicts a high chance of early ETV success. In this paper, they assess the clinical utility of the ETVSS by determining whether long-term survival outcomes for ETV versus shunt insertion are different within strata of ETVSS (low, moderate, and high scores).</jats:p></jats:sec> <jats:sec> <jats:title>Methods</jats:title> <jats:p>A multicenter, international cohort of children (≤ 19 years old) with newly diagnosed hydrocephalus treated with either ETV (489 patients) or shunt insertion (720 patients) was analyzed. The ETVSS was calculated for all patients. Survival analyses with time-dependent modeling of the hazard ratios were performed.</jats:p></jats:sec> <jats:sec> <jats:title>Results</jats:title> <jats:p>For the High-ETVSS Group (255 ETV-treated patients, 117 shunt-treated patients), ETV appeared to have a lower risk of failure right from the early postoperative phase and became more favorable with time. For the Moderate-ETVSS Group (172 ETV-treated patients, 245 shunt-treated patients), ETV appeared to have a higher initial failure rate, but after about 3 months the instantaneous risk of ETV failure became slightly lower than shunt failure (that is, the hazard ratio became &lt; 1). For the Low-ETVSS Group (62 ETV-treated patients, 358 shunt-treated patients), the early risk of ETV failure was much higher than the risk of shunt failure, but the instantaneous risk of ETV failure became lower than the risk of shunt failure at about 6 months following surgery (the hazard ratio became &lt; 1).</jats:p></jats:sec> <jats:sec> <jats:title>Conclusions</jats:title> <jats:p>Across all ETVSS strata, the risk of ETV failure becomes progressively lower compared with the risk of shunt failure with increasing time from the surgery. In the best ETV candidates (ETVSS ≥ 80), however, the risk of ETV failure is lower than the risk of shunt failure very soon after surgery, while for less-than-ideal ETV candidates (ETVSS ≤ 70), the risk of ETV failure is initially higher than the risk of shunt failure and only becomes lower after 3–6 months from surgery. These results need to be confirmed by larger, prospective, and preferably randomized studies.</jats:p></jats:sec>

Comparison of Intracranial Neuroendoscopic Procedures in Children versus Adults

“…Various classification systems are emerging not only to help predict outcome after endoscopic procedures for hydrocephalus, but also to aid in the selection of appropriate patients to maximize positive outcomes. 25,[42][43][44][45] The most common indication for ETV is aqueductal stenosis, either from congenital narrowing of the aqueduct or obstructive tumors such as tectal gliomas 46 and obstructive cysts. 47,48 Other indications include the fenestration of loculated compartments, 49,50 ventriculoperitoneal shunt malfunction, 26,27 and preresectional ETV for posterior fossa tumors.…”

Ventricular endoscopy in the pediatric population: review of indications

“…They concluded that a high ETV success score correlated with a greater reliability of ETV compared to CSF shunts immediately after surgery, whereas this benefit was not attained among lower ETV success scorers until 3 to 6 months after surgery [30]. In determining the ETV success score, patient age was implicated as the strongest predictor of success; older children (>6 months) typically experienced superior outcomes versus their younger counterparts [31].…”

Editorial

“…A shunt cohort contained patients collected from 2 separate groups, The Shunt Design Trial (recruited 1993-1995) and the Endoscopic Shunt Insertion Trial (recruited 1996-1999). 14 Kulkarni and colleagues found that for patients with a high ETVSS, ETV had a lower risk of failure than CSF shunting beginning immediately after surgery and that it remained durable over time. For patients with a moderate ETVSS, ETV had a higher initial failure rate that became more favorable with time.…”

“…In the accompanying thoughtful article, 14 Kulkarni and colleagues have attempted to shed some light on this problem, using a quantitative scale they developed, the ETV Success Score (ETVSS), to evaluate the outcome of ETV compared to CSF shunt placement. The ETVSS was initially created to predict the effectiveness of ETV using only 3 parameters: age of the patient, etiology of the hydrocephalus, and the presence of a previous shunt, with a high score predictive of a good outcome.…”