title: Predicting success of endoscopic third ventriculostomy: validation of the ETV Success Score in a mixed population of adult and pediatric patients.
abstract: OBJECTIVE
  Endoscopic third ventriculostomy (ETV) has become the first line of treatment in obstructive hydrocephalus. The Toronto group (Kulkarni et al.) developed the ETV Success Score (ETVSS) to predict the clinical response following ETV based on age, previous shunt, and cause of hydrocephalus in a pediatric population. However, the use of the ETVSS has not been validated for a population comprising adults. The objective of this study was to validate the ETVSS in a "closed-skull" population, including patients 2 years of age and older.
  
  
  METHODS
  In this retrospective observational study, medical charts of all consecutive cases of ETV performed in two university hospitals were reviewed. The primary outcome, the success of ETV, was defined as the absence of reoperation or death attributable to hydrocephalus at 6 months. The ETVSS was calculated for all patients. Discriminative properties along with calibration of the ETVSS were established for the study population. The secondary outcome is the reoperation-free survival.
  
  
  RESULTS
  This study included 168 primary ETVs. The mean age was 40 years (range 3-85 years). ETV was successful at 6 months in 126 patients (75%) compared with a mean ETVSS of 82.4%. The area under the receiver operating characteristic curve was 0.61, revealing insufficient discrimination from the ETVSS in this population. In contrast, calibration of the ETVSS was excellent (calibration slope = 1.01), although the expected low numbers were obtained for scores < 70. Decision curve analyses demonstrate that ETVSS is marginally beneficial in clinical decision-making, a reduction of 4 and 2 avoidable ETVs per 100 cases if the threshold used on the ETVSS is set at 70 and 60, respectively. However, the use of the ETVSS showed inferior net benefit when compared with the strategy of not recommending ETV at all as a surgical option for thresholds set at 80 and 90. In this cohort, neither age nor previous shunt were significantly associated with unsuccessful ETV. However, better outcomes were achieved in patients with aqueductal stenosis, tectal compressions, and other tumor-associated hydrocephalus than in cases secondary to myelomeningocele, infection, or hemorrhage (p = 0.03).
  
  
  CONCLUSIONS
  The ETVSS did not show adequate discrimination but demonstrated excellent calibration in this population of patients 2 years and older. According to decision-curve analyses, the ETVSS is marginally useful in clinical scenarios in which 60% or 70% success rates are the thresholds for preferring ETV to CSF shunt. Previous history of CSF shunt and age were not associated with worse outcomes, whereas posthemorrhagic and postinfectious causes of the hydrocephalus were significantly associated with reduced success rates following ETV.
authors.affiliation: Neurological Sciences Department, Division of Neurosurgery, CHU de Québec-Hôpital de l'Enfant-Jésus, Québec City; and.
authors.forename: Moujahed
authors.initials: M
authors.lastname: Labidi
authors.affiliation: Neurological Sciences Department, Division of Neurosurgery, CHU de Québec-Hôpital de l'Enfant-Jésus, Québec City; and.
authors.forename: Pascale
authors.initials: P
authors.lastname: Lavoie
authors.affiliation: Neurological Sciences Department, Division of Neurosurgery, CHU de Québec-Hôpital de l'Enfant-Jésus, Québec City; and.
authors.forename: Geneviève
authors.initials: G
authors.lastname: Lapointe
authors.affiliation: Surgery Department, Division of Neurosurgery, CHUM-Hôpital Notre-Dame, Montréal, Québec, Canada.
authors.forename: Sami
authors.initials: S
authors.lastname: Obaid
authors.affiliation: Surgery Department, Division of Neurosurgery, CHUM-Hôpital Notre-Dame, Montréal, Québec, Canada.
authors.forename: Alexander G
authors.initials: AG
authors.lastname: Weil
authors.affiliation: Surgery Department, Division of Neurosurgery, CHUM-Hôpital Notre-Dame, Montréal, Québec, Canada.
authors.forename: Michel W
authors.initials: MW
authors.lastname: Bojanowski
authors.affiliation: Neurological Sciences Department, Division of Neurosurgery, CHU de Québec-Hôpital de l'Enfant-Jésus, Québec City; and.
authors.forename: André
authors.initials: A
authors.lastname: Turmel
mesh_terms: D000293:Adolescent; D000328:Adult; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D002648:Child; D002675:Child, Preschool; D005260:Female; D006801:Humans; D006849:Hydrocephalus / Q000209:etiology / Q000401:mortality / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D044583:Neuroendoscopy; D011237:Predictive Value of Tests; D012086:Reoperation; D012189:Retrospective Studies; D012307:Risk Factors; D020542:Third Ventricle / Q000601:surgery*; D016896:Treatment Outcome; D014696:Ventriculostomy; D055815:Young Adult
keywords: ETV = endoscopic third ventriculostomy; ETVSS = ETV Success Score; EVD = external ventricular drain; ROC = receiver operating characteristic; hydrocephalus; minimally invasive neurosurgery; neuroendoscopy; third ventriculostomy