Review Factors affecting surgical outcome of endoscopic third ventriculostomy in congenital hydrocephalus Ajay Bisht, Ashish Suri ⇑ , Sumit Bansal, P. Sarat Chandra, Rajinder Kumar, Manmohan Singh, Bhawani Shankar Sharma Department of Neurosurgery, Neurosciences Center, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India article info Article history: Received 6 June 2013 Accepted 14 December 2013 Available online xxxx Keywords: Aqueductal stenosis Congenital Endoscopic third ventriculostomy Hydrocephalus abstract Endoscopic third ventriculostomy (ETV) is an accepted modality of treatment for obstructive hydrocepha- lus, with good results in adult patients. However in the pediatric age group results vary from poor to similar to the adult population. This study evaluates the outcome of ETV in congenital hydrocephalus of both early and delayed presentation, and investigates factors that determine the outcome. Patients with congenital hydrocephalus who underwent ETV between January 2006 and December 2011 were retrospectively ana- lyzed. Any conditions potentially influencing the need for redo surgery (persistent cerebrospinal fluid [CSF] leak not responding to local measures, tense fontanelle, increased ventricular size, recurrence of symptoms or radiological evidence of failure) were analyzed. A total of 102 patients with a mean age of 7.45 years were included. Presenting features were increasing head circumference and delayed milestones. Ninety-eight patients had triventricular hydrocephalus due to aqueductal stenosis. Procedures performed were ETV only (n = 74), ETV with aqueductoplasty (n = 22), ETV with cystoventriculostomy (n = 2) and aqueductoplasty only (n = 2). Failure of ETV occurred in 11 patients and all were managed with a ventriculoperitoneal shunt. CSF leak in the perioperative period was the only factor that was significantly associated with failure of ETV. ETV is a safe procedure with a good success rate and can be offered to children with aqueductal stenosis. There is a higher chance of failure if there is a CSF leak in the early or late postoperative period. Ó 2014 Elsevier Ltd. All rights reserved. 1. Introduction Congenital hydrocephalus is a common neurosurgical problem and delay or failure of treatment can have a potentially devastating effect on the developing brain. Early surgical treatments included choroid plexectomy, with the subsequent introduction of third ventriculostomy [1]. The procedure was later carried out endo- scopically and endoscopic third ventriculostomy (ETV) became the only available surgical method with a reasonable chance of success [1]. The development of ventriculoperitoneal (VP) shunts offered a reliable and effective treatment modality and they became the predominant method used to treat these patients [2,3]. However, long-term results with shunts have shown a high incidence of malfunction and infection (60% revision rate by 2 years) [4] which can create a potentially life-threatening situa- tion. In countries with poor access to specialized healthcare, this can have devastating effects. ETV has long been available for the treatment of hydrocephalus, but has been used predominantly in adults, as children were thought to have a poorly developed subarachnoid space [5]. This was later demonstrated to be untrue [6,7] and ETV has been used in the treatment of congenital obstructive hydrocephalus. The ini- tial results were encouraging in older children, but they were not as promising in younger children [8,9], though some studies showed no difference in outcomes in the younger population [10–12]. ETV has even been carried out in fetuses for prenatal treatment of hydrocephalus [13]. The principal advantages of ETV over VP shunt are that firstly, no external hardware (with its inherent problems) is introduced into the body; secondly, most studies have shown that the majority of ETV failures occur early [10,14] and patients who have a functional ETV at 6 months are very unlikely to have a failure (late failure with fatal outcome has been reported, though it is rare) [15]. The literature on ETV shows a success rate varying between 60–80% [10,16] including pediatric patients. This compares favor- ably against VP shunt, which has a failure rate of 60% at 2 years [4]. Patients with successful ETV avoid the lifetime risks of having a shunt. Variables previously associated with poor outcome include age [8,9], diagnosis [11,17] and thickness of ventricular floor [18]. The studies in the literature are mostly single http://dx.doi.org/10.1016/j.jocn.2013.12.033 0967-5868/Ó 2014 Elsevier Ltd. All rights reserved. ⇑ Corresponding author. Tel.: +91 11 2659 3538; fax: +91 11 2658 8559. E-mail address: surineuro@gmail.com (A. Suri). Journal of Clinical Neuroscience xxx (2014) xxx–xxx Contents lists available at ScienceDirect Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn Please cite this article in press as: Bisht A et al. Factors affecting surgical outcome of endoscopic third ventriculostomy in congenital hydrocephalus. J Clin Neurosci (2014), http://dx.doi.org/10.1016/j.jocn.2013.12.033