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Endoscopic third ventriculostomy in the treatment of idiopathic normal pressure hydrocephalus: a review study

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Abstract

Idiopathic normal pressure hydrocephalus is a hydrodynamic disorder whose etiology remains unclear. The diagnosis is mainly clinical and the traditional treatment is cerebrospinal fluid shunt diversion. With the introduction of modern management strategies, endoscopic third ventriculostomy has become a viable alternative to shunting and constitutes a well-established method of treatment for obstructive hydrocephalus. The new hydrodynamic concept of hydrocephalus suggests that endoscopic third ventriculostomy (ETV) may be an effective treatment for communicative hydrocephalus. In our current review, the authors focus on the up-to-date knowledge regarding the consideration of endoscopic third ventriculostomy as a safe surgical option in the management of idiopathic normal pressure hydrocephalus.

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Author contributions

Author contributions to the study and manuscript preparation include the following. Tasiou contributed to the conception and design. Tasiou and Brotis contributed to the acquisition of data. Tasiou and Brotis helped for the analysis and interpretation of the data. All authors drafted and critically revised the article, reviewed the final version of the manuscript, and approved it for submission. Paterakis supervised the study.

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Authors and Affiliations

  1. Department of Neurosurgery, University Hospital of Larissa, Larissa, Greece

    Anastasia Tasiou & Alexandros G. Brotis

  2. Division of Neurosurgery, Department of Neurological Sciences, Universita degli Studi di Napoli Federico II, Napoli, Italy

    Felice Esposito

  3. Medical School of Thessaly, Larissa, Greece

    Konstantinos N. Paterakis

  4. Mavrogenous 65, Livadaki, Larissa, Greece

    Alexandros G. Brotis

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  1. Anastasia Tasiou
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  2. Alexandros G. Brotis
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Correspondence to Alexandros G. Brotis.

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Comments

Paolo Cappabianca, Naples, Italy

Endoscopic third ventriculostomy (ETV) is considered as a treatment of choice for obstructive hydrocephalus, being indicated in hydrocephalus secondary to aqueductal stenosis, posterior third ventricle tumor, multiloculated, posterior fossa tumor, and a variety of other etiologies. It is considered safe and effective in properly selected cases.

Nevertheless, its success rate and long-term outcome in obstructive hydrocephalus is better than in communicating hydrocephalus, such as the normal pressure hydrocephalus (NPH). The role of ETV in NPH is controversial; it was found to be safe and effective by various authors, who report that such technique is not an internal shunt alone but it may improve hydrodynamic in these cases, since the intraoperative finding of mobility of the third ventricle floor after the ventriculostomy suggest that the ETV helps in the restoration of pulsatility of the ventricular walls (brain compliance), with a major complication rate lower than ventriculo-peritoneal shunt.

The article by Tasiou et al. tries to make the point on the effectiveness of ETV in NPH with a review article on the effectiveness and safety of endoscopic third ventriculostomy (ETV) for the surgical management of idiopathic normal pressure hydrocephalus (iNPH). The authors performed a systematic literature review in MEDLINE on ETV and iNPH, which constitute the first review of such type on this topic. Their review showed that ETV has a relatively high success rate in patients with iNPH, especially in carefully selected cases, with a low rate of complications and with a low revision rate. The overall take-at-home message from the study is that ETV is a safe, minimally invasive, and effective procedure, offering an alternative option in the treatment patients suffering from iNPH.

It is interesting to note that they found only 12 studies meeting the criteria they used for the literature search, and none of such studies were class 1 or 2, but rather of class 3 or 4, highlighting the fact that further studies on larger cohorts of patients are needed. Furthermore, they did not find uniform inclusion criteria, length of the follow-up, and definition of effectiveness criteria in the studies they analyzed. Such fact confirms that it is still unknown what is the best surgical management of this disease.

Hartmut Collmann, Reichenberg, Germany

It is generally accepted meanwhile that obstructive hydrocephalus should preferably be treated by endoscopic third ventriculostomy (ETV) because of low long-term morbidity compared with extracranial shunting. Conversely, communicating hydrocephalus has generally been considered as contraindication for ETV. As an intriguing fact, in recent years, several reports on successful application of ETV in idiopathic normal pressure hydrocephalus have been published. Do they provide facts or fiction? Mrs. Tasiou and her coworkers are to be acknowledged for having looked at these reports more closely. In their review, they analyze 12 papers found in a medical database. Not surprisingly, the authors detect several methodical limitations preventing definite conclusions: variable inclusion criteria of study cohorts, different lengths of follow-up, different definitions of treatment “success,” and small sample size in most studies. They also mention a noticeable rate of intraoperative complications and a highly variable failure rate. Finally, the authors argue that most of the reviewed studies provide only evidence level 3 or 4, while the single randomized trial [2] lacks sufficient sample size among other limitations. As recently outlined by Ghobrial and Lang [1], the statistical analysis of different treatment modalities of “idiopathic” normal pressure hydrocephalus is seriously hampered by the complex problems associated with definition, pathogenesis, diagnostic evaluation of this disorder as well as proper definition of treatment “success.” Therefore, ETV should still be looked at with due reservation until a carefully designed randomized controlled study in a cohort of sufficient number provides more certainty. Surprisingly, the authors are finally optimistic when they recommend this method in selected cases.

References

(1) Ghobrial GM, Lang MJ (2013) Journal club: role of endoscopic third ventriculostomy and ventriculoperitoneal shunt in idiopathic normal pressure hydrocephalus: preliminary results of a randomized clinical trial. Neurosurgery-online 73(5):508-10.

(2) Pinto FC, Saad F, Oliveira MF, Pereira RM, Miranda FL, Tornai JB, Lopes MI, Ribas ES, Valinetti EA, Teixeira MJ (2013) Role of endoscopic third ventriculostomy and ventriculoperitoneal shunt in idiopathic normal pressure hydrocephalus: preliminary results of a randomized clinical trial. Neurosurgery 72(5):845-853.

Waleed A. Azab, Kuwait city, Kuwait

Ever since its initial description, Idiopathic normal pressure hydrocephalus has always been an area of controversy. Such an enigma encompassed the pathophysiological mechanisms underlying the disorder as well as its treatment modalities.

In their work, Tasiou et al. carry out a review of the literature on the utility of endoscopic third ventriculostomy (ETV) in patients with idiopathic normal pressure hydrocephalus. Their work is of importance because it realistically demonstrates how far we are from reaching a definitive understanding of the disease process or how may it be altered by an ETV. Needless to say, excluding a shunt from the treatment paradigm would be a great achievement; however, for solid conclusions to be drawn as to whether ETV is as effective as VP shunting, multicenter randomized studies with large numbers of patients included based on unified criteria are warranted.

Johannes Lemcke and Ullrich Meier, Berlin, Germany

For the neurosurgeon, endoscopic third ventriculostomy (ETV) is the beautiful sister of shunt surgery and everybody who has the chance would prefer to date her. As we know from our own biography, this fact results in a situation where every young and enthusiastic generation is trying to fathom the depth of the indications for ETV.

Nevertheless, it remains occult why ETV sometimes works for communicating hydrocephalus at all. Even if we assume that the pathophysiology of NPH is based on dynamic pressure and not on static pressure, there is no explanatory model for sporadic effectiveness of ETV in NPH patients [1].

In our own patients, we thought to have found a selection criteria by performing a lumbar infusion test and ventricular infusion test. Patients who showed a mismatch in terms of a pathological ventricular infusion test and a physiological lumbar infusion test were assumed to have a functional aqueductal stenosis and were qualified for ETV [2]. We published these results in one of the papers reviewed by Tasiou et al. in 2015. But, in the meantime, almost one third of these patients underwent shunt surgery due to insufficient clinical effectiveness of the ETV over the long term. The reason for “ETV failure” in these patients has not been secondary occlusion of the stoma, since we performed re-endoscopy in some patients or at least a functional MRI.

In conclusion, we became very reserved about normal pressure hydrocephalus and ETV over the years.

Reference

[1] Greitz D (2004) Radiological assessment of hydrocephalus: new theories and implications for therapy. Neurosurgical Review 27(3): 145-65

[2] Meier U, Zeilinger FS, Schonher B (2000) Endoscopic ventriculostomy versus shunt operation in normal pressure hydrocephalus: diagnosis and indication. Minim Invasive Neurosurg 43(2):87-90

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Tasiou, A., Brotis, A.G., Esposito, F. et al. Endoscopic third ventriculostomy in the treatment of idiopathic normal pressure hydrocephalus: a review study. Neurosurg Rev 39, 557–563 (2016). https://doi.org/10.1007/s10143-015-0685-4

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