title: Lower rates of symptom recurrence and surgical revision after primary compared with secondary endoscopic third ventriculostomy for obstructive hydrocephalus secondary to aqueductal stenosis in adults.
abstract: OBJECT Endoscopic third ventriculostomy (ETV) is the treatment of choice for obstructive hydrocephalus; however, the success of ETV in patients who have previously undergone shunt placement remains unclear. The present study analyzed 103 adult patients with aqueductal stenosis who underwent ETV for obstructive hydrocephalus and evaluated the effect of previous shunt placement on post-ETV outcomes. METHODS This study was a retrospective review of 151 consecutive patients who were treated between 2007 and 2013 with ETV for hydrocephalus. One hundred three (68.2%) patients with aqueductal stenosis causing obstructive hydrocephalus were included in the analysis. Postoperative ETV patency and aqueductal and cisternal flow were assessed by high-resolution, gradient-echo MRI. Post-ETV Mini-Mental State Examination, Timed Up and Go, and Tinetti scores were compared with preoperative values. Univariate and multivariate analyses were performed comparing the post-ETV outcomes in patients who underwent a primary (no previous shunt) ETV (n = 64) versus secondary (previous shunt) ETV (n = 39). RESULTS The majority of patients showed significant improvement in symptoms after ETV; however, no significant differences were seen in any of the quantitative tests performed during follow-up. Symptom recurrence occurred in 29 (28.2%) patients after ETV, after a median of 3.0 (interquartile range 0.8-8.0) months post-ETV failure. Twenty-seven (26.2%) patients required surgical revision after their initial ETV. Patients who received a secondary ETV had higher rates of symptom recurrence (p = 0.003) and surgical revision (p = 0.003), particularly in regard to additional shunt placement/revision post-ETV (p = 0.005). These differences remained significant after multivariate analysis for both symptom recurrence (p = 0.030) and surgical revision (p = 0.043). CONCLUSIONS Patients with obstructive hydrocephalus due to aqueductal stenosis exhibit symptomatic improvement after ETV, with a relatively low failure rate. Patients with a primary history of shunt placement who undergo ETV as a secondary intervention are at increased risk of symptom recurrence and need for surgical revision post-ETV.
authors.affiliation: Departments of 1 Neurosurgery and.
authors.forename: Eric W
authors.initials: EW
authors.lastname: Sankey
authors.affiliation: Departments of 1 Neurosurgery and.
authors.forename: C Rory
authors.initials: CR
authors.lastname: Goodwin
authors.affiliation: Departments of 1 Neurosurgery and.
authors.forename: Ignacio
authors.initials: I
authors.lastname: Jusué-Torres
authors.affiliation: Departments of 1 Neurosurgery and.
authors.forename: Benjamin D
authors.initials: BD
authors.lastname: Elder
authors.affiliation: Departments of 1 Neurosurgery and.
authors.forename: Jamie
authors.initials: J
authors.lastname: Hoffberger
authors.affiliation: Departments of 1 Neurosurgery and.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Lu
authors.affiliation: Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: Ari M
authors.initials: AM
authors.lastname: Blitz
authors.affiliation: Departments of 1 Neurosurgery and.
authors.forename: Daniele
authors.initials: D
authors.lastname: Rigamonti
mesh_terms: D000328:Adult; D000368:Aged; D002557:Cerebrospinal Fluid Shunts; D004724:Endoscopy / Q000379:methods*; D005260:Female; D006801:Humans; D006849:Hydrocephalus / Q000175:diagnosis* / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000517:prevention & control* / Q000601:surgery*; D012008:Recurrence; D012086:Reoperation; D012189:Retrospective Studies; D000067251:Symptom Flare Up; D020542:Third Ventricle / Q000601:surgery*; D014696:Ventriculostomy / Q000379:methods*
keywords: CISS = constructive interference in steady state; DVT = deep venous thrombosis; ETV = endoscopic third ventriculostomy; IQR = interquartile range; MMSE = Mini-Mental State Examination; NPH = normal pressure hydrocephalus; PE = pulmonary embolism; TUG = Timed Up and Go; aqueductal stenosis; endoscopic third ventriculostomy; obstructive hydrocephalus; revision; shunt; symptom recurrence