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Endoscopic third ventriculostomy: can we predict success during surgery?

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Abstract

Endoscopic third ventriculostomy (ETV) is widely used as an alternative technique for hydrocephalus treatment. ETV success or failure may be influenced by numerous factors. In this study, we have analyzed preoperative and intraoperative risk factors and suggest an intraoperative scale to predict etV failure. Fifty-one patients (27 adults and 24 children) underwent an etV at Carlos Haya University Hospital, Malaga. Intraoperative video records were assessed and the following intraoperative findings were recorded: (1) abnormal ventricular anatomy, (2) intraoperative incident, (3) Liliequist membrane opening in a second endoscopic maneuver, (4) thickened or scarred membranes in the subarachnoid space, (5) absence or “weakness” of pulsation of third ventricle floor at etV completion, and (6) floppy premammillary membrane that needs edge coagulation. An intraoperative scale ranging from 0 to 6 points was performed. A significant relation was found between a higher result on the prognosis scale and etV failure (p < 0.0001). An absence or weakness of pulsation of the third ventricle floor at etV completion was significantly related to etV failure (p < 0.0001). The presence of thickened or scarred membranes in the subarachnoid space was significantly related to etV failure (p < 0.04) as well as the Liliequist membrane opening in a second endoscopic maneuver (p < 0.008). Intraoperative factors should be taken into account for prediction of etV success. More studies with larger case series are needed to determine the influence of all intraoperative factors over etV success.

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Author information

Authors and Affiliations

  1. Department of Neurosurgery, HRU Carlos Haya, Málaga, Spain

    L. Romero, B. Ros, G. Ibáñez, L. González & MA. Arráez

  2. Statistics Department, Málaga University, Málaga, Spain

    F. Ríus

Authors
  1. L. Romero
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  2. B. Ros
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  3. G. Ibáñez
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  4. F. Ríus
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  5. L. González
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  6. MA. Arráez
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Correspondence to L. Romero.

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Comments

Michelangelo Gangemi, Napoli Italy

The authors suggest a new scoring system, based on the intraoperative evaluation of peculiar anatomical aspects and correlating with the patient's age and the etiology of the hydrocephalus, whose purpose is to predict the potential failure of the endoscopic procedure of thirdventriculostomy.

Nowadays, we believe that the preoperative evaluation in the selection process of the patients who undergo the surgical procedure plays a very important role as predictive factor of etV success, especially in particular forms of communicating hydrocephalus (such as postinfective hydrocephalus, NPH, or LOVA).

Some particular anatomic variants reported by the authors in their evaluation scale are common to find (such as Monro foramen distortion, presence of arachnoidal adherences in the interpeduncolar cistern, and third ventricle floor thickening) and may require appropriate technical expedients during the endoscopic procedure. Other peculiar anatomic features may require a more frequent postoperative clinical and radiological follow-up, as reported by the authors.

Based on literature and my experience, the absence of the “flag signal” is the most important parameter to consider during the surgical procedure and I would like to stress the concept that the mesencephalic membrane or the Liliequist membrane should be opened whenever possible, especially when a weak or no flag signal is displayed.

When there is no pulsation at the level of the third ventricle floor, even though the opening of the mesencephalic membrane or the Liliequist membrane has already been performed, the possibility to convert the endoscopic procedure into a shunt implantation surgery should be considered.

Shlomi Constantini, Tel-Aviv, Israel

Neuro-endoscopy has become a cornerstone of modern neurosurgery. ETV is a magnificent operation that introduced an alternative to extra-cranial diversion procedures such as VP shunting for obstructive hydrocephalus. ETV apparently not only spares our patients inherent shunting complications, it also resolves the hydrocephalus in a physiological manner, within the skull.

When the first series describing surgical results for etV were published, considerable differences in success rates were noted. Since then, we have begun to appreciate the methodological and clinical issues involved in predicting success following this procedure. For example, when comparing results from major centers we realized that large differences exist in inclusion criteria (comparing apples and oranges), in technical nuances, and in the definition of failure.

As third ventriculostomy became more widespread, reports of surgical complications (such as basilar artery injury) and case reports on sudden death following successful procedures began to appear. There was also greater appreciation for the reality that success rates vary with regard to variables such as age, etiology of HCP, and individual anatomical variations. It is obvious that a more balanced view is required when considering the two options (VPS vs. ETV). A more methodical, scientific approach to data collection is the only way to provide the information necessary to help neurosurgeons and families in making this decision.

Because large numbers are required for statistical weight, we have started to organize international cooperative studies (under the auspices of the International Federation for Neuroendoscopy) to retrospectively collect data from several large centers. Kulkarni et al. published an “ETV Success Score” that can be derived using a formula that integrates several variables for an individual patient. We have also recently embarked on a large-scale prospective study on the role of etV vs. shunting in infants with aqueductal stenosis. The International Infant Hydrocephalus Study is not only accumulating randomized data prospectively but has also chosen neurodevelopmental scores as its primary outcome measure.

Lorena Romero Moreno and colleagues should be congratulated for making an effort to systematically study intraoperative variables noted during etV, and analyze their relevance to success. They have carefully looked at operative videos, assigning (mostly subjective) scores for relevant findings.

Their patient series is small and comprises a mixture of etiologies, history, ages, and several surgical procedures. Their findings are not surprising. They are even trivial and presently do not directly add anything to our clinical treatment paradigms.

However, by doing such a systematic analysis, they have stimulated our thinking process, providing an example of how each department should look carefully at surgical nuances, and illustrating why we should combine forces to obtain meaningful results.

References

V. Siomin, H. Weiner, J. Wisoff, G. Cinally, A. Pierre-Kahn, R. Abbott, H. Elran, L. Beni-Adani, G. Ouaknine, S. Constantini Repeat endoscopic third ventriculostomy: is it worth trying? Child's Nervous System 17(9):551–555, 2001

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A. V. Kulkarni, J. M. Drake, J. R.W. Kestle, C. L. Mallucci, S. Sgouros, J. Roth, S. Constantini for the Canadian Pediatric Neurosurgery Study Group Endoscopic third ventriculostomy in the treatment of childhood hydrocephalus. The Journal of Pediatrics 155(2):254–259, 2009

AV. Kulkarni, BC. Warf, JM. Drake, CL. Mallucci, S. Sgouros, S. Constantini, and the Canadian Pediatric Neurosurgery Study Group. Surgery for hydrocephalus in sub-Saharan Africa versus developed nations: a risk-adjusted comparison of outcome. Child's Nervous System, 26:1711–1717, 2010

AV. Kulkarni, JM. Drake, JR. Kestle, CL. Mallucci, S. Sgouros, S. Constantini for the Canadian Pediatric Neurosurgery Study Group. Endoscopic third ventriculostomy vs cerebrospinal fluid shunt in the treatment of hydrocephalus in children: a propensity score-adjusted analysis. Neurosurgery 67(3): 588–593, 2010

AV. Kulkarani, JM. Drake, JRW. Kestle, C.L. Mallucci, S. Sgouros, S. Constantini. Predicting who will benefit from endoscopic third ventriculostomy (ETV) compared to shunt in childhood hydrocephalus using the etV Success Score. Journal of Neurosurgery (Pediatrics) 6(4):310–5, 2010

S. Constantini, A. Mohanty, S. Zymberg, S. Cavalheiro, C. Mallucci, D. Hellwig, Y. Ersahin, H. Mori, C. Mascari, J. Aloysio, W. Wagner, A.V. Kulkarni, S. Sgouros, S. Oi Safety and Diagnostic Accuracy of Neuro-Endoscopic Biopsies: An International Multicenter Study. Journal of Neurosurgery-Pediatric (in press)

Jan Regelsberger and Pedram Emami, Hamburg, Germany

Predicting the success rate in etV is of major interest and this paper adds some further intraoperative aspects which may predict a successful etV. Absence or weakness of pulsation of the third ventricle floor, scarred membranes including the Liliequist membrane turned out to be “significantly” related to etV failure. In respect to the small and heterogenous group of peds and adults presented here, one may better think of “potential” factors influencing the outcome of etV and 51 patients overall do not serve for evidence. “Pulsation of the third ventricle” is the only decisive factor while “scarred membranes” is dependent to the surgeons impression and the “Liliequist membrane” remains resistant to multiple maneuvers which to be opened are associated with a certain risk.

As large series have been reporting on peds, including especially the group from Toronto which developed an etV success score on 489 pts. and reevaluated it on 322 pts. (Kulkarni et al., Naftal et al., Durnford et al.), we are pretty aware of the preoperative clinical factors for successful etV in children. In addition, radiological features, in peds and adults, have been added by others (Fukuhara et al., Kehler et al.) that give us all together a feasible tool in assessing the risk of etV failure preoperatively. Practically, in choosing one of the surgical strategies, advising the patient and predicting the clinical outcome one has to rely on preoperative factors and that is why most studies do focus on the preoperative evaluation. Once the decision has been made and one may suspect that etV will not be successful because of scarred membranes or remaining Liliequist membranes. Does it influence our treatment?

The intraoperative aspects may give us additional information predicting the success of an etV but a focused discussion on the selection criteria and the grading of the intraoperative factors leading to a successful etV would have enhanced this attempt thereby a larger patient cohort has to confirm these findings.

References

Kulkarni et al. Predicting who will benefit from endoscopic third ventriculostomy compared with shunt insertion in childhood hydrocephalus using the etV Success Score. J Neurosurg Pediatr (2010) vol. 6 (4) pp. 310–5 (Toronto)

Fukuhara et al. Risk factors for failure of endoscopic third ventriculostomy for obstructive hydrocephalus. Neurosurgery (2000) vol. 46 (5) pp. 1100–9; discussion 1109–11

Kehler et al. Outcome prediction of third ventriculostomy: a proposed hydrocephalus grading system. Minim Invasive Neurosurg (2006) vol. 49 (4) pp. 238–43

Naftel et al. Evaluating the Children's Hospital of Alabama endoscopic third ventriculostomy experience using the Endoscopic Third Ventriculostomy Success Score: an external validation study. J Neurosurg Pediatr (2011) vol. 8 (5) pp. 494–501

Durnford et al. Endoscopic third ventriculostomy in the treatment of childhood hydrocephalus: validation of a success score that predicts long-term outcome. J Neurosurg Pediatr (2011) vol. 8 (5) pp. 489–93

André Grotenhuis, Nijmegen, The Netherlands

The authors describe a series of 27 adults and 24 children treated with etV over a period of 8 years. Seven adult patients and 11 children had a shunt previously, in 7 adult patients and in 3 of the children the etV was associated with another procedure (biopsy, foraminoplasty, septostomy, and opening of fourth ventricle). In four children, the “primary” procedure for this study was a re-ETV. Etiology was very divers. There were no data on the age distribution of the children. Some of the authors have published in 2012 a series from the same neurosurgical department with 50 pediatric patients who underwent 58 etV procedures between 2003 and 2011, and they calculated an endoscopic third ventriculostomy success score based on the patient's age, hydrocephalus etiology, and presence of a previous shunt (Childs Nerv Syst. 2012 Aug;28(8):1157–62). The present study is a selection of this group where video recording was available to score the intraoperative findings.

However, all of these factors can already contribute to the failure of an etV. The authors have retrospectively looked to the video recording and have scored 6 different possible events, i.e. “(1) abnormal ventricular anatomy (destructuring of the septum, destructuring of choroid plexus, anatomic distortion of Foramen of Monro, premammillary membrane not translucent, and need for computer-assisted surgery, (2) intraoperative incident: turbid liquid or significant bleeding (that makes viewing difficult and needs irrigation-washing to continue the procedure), (3) Liliequist membrane opening in a second endoscopic maneuver, (4) thickened or scarred membranes in the subarachnoid space, (5) absence or weakness of pulsation of third ventricle floor at etV completion, (6) redundant premammillary membrane that needs edge coagulation.”

All of their six possible intraoperative events are well-known situations that are adversely associated with the success rate of the etV. However, some of them are also very subjective. Weakness of pulsation is difficult to define. When reviewing the video it is impossible to know if there was rinsing during the time when they judged the amount of pulsation of the floor or not, and how much fluid was used to rinse and clean the ventricle. Overall, this scoring system somewhat artificially combines a series of anatomical situations and intraoperative events and not taking the divers etiology in their rather small group into account as possible cause of failure. The occurrence of any of these intraoperative events will most probably not influence the decision during the procedure itself (e.g., abandon the procedure and place a shunt). However, they have rightfully concluded that those patients with a “high” score (>4, >5, or only 6?) should then be followed more intensively with imaging or that a patient with a high score should get a shunt more rapidly than those with a low score. It remains unclear what the clinical consequences of their scoring system will mean in daily practice.

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Romero, L., Ros, B., Ibáñez, G. et al. Endoscopic third ventriculostomy: can we predict success during surgery?. Neurosurg Rev 37, 89–97 (2014). https://doi.org/10.1007/s10143-013-0494-6

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