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PURPOSE: Myelomeningocele (MMC) is a prevalent neural tube closure defect often associated with hydrocephalus, necessitating surgical intervention in a significant proportion of cases. While ventriculoperitoneal shunting (VPS) has been a standard treatment approach, endoscopic third ventriculostomy (ETV) has emerged as a promising alternative. However, factors influencing the success of ETV in MMC patients remain uncertain. This retrospective observational study aimed to identify clinical and radiological factors correlating with a higher success rate of ETV in MMC patients. METHODS: Medical records of MMC patients who underwent ETV at a tertiary care center between 2015 and 2021 were reviewed. Demographic, clinical, and radiological data were analyzed. ETV success was defined as the absence of further hydrocephalus treatment during follow-up. RESULTS: Of 131 MMC patients, 21 met inclusion criteria and underwent ETV. The overall success rate of ETV was 57.1%, with a six-month success rate of 61.9%. Age ≤ 6 months was significantly associated with lower ETV success (25%) compared to older patients (76.9%) (OR: 0.1; 95% CI 0.005-2.006; p = 0.019). Radiological factors, including posterior fossa dimensions and linear indices, did not exhibit statistically significant associations with ETV success. CONCLUSION: Age emerged as a significant factor affecting ETV success in MMC patients, with younger patients exhibiting lower success rates. Radiological variables did not significantly influence ETV outcomes in this study. Identifying predictors of ETV success in MMC patients is crucial for optimizing treatment strategies and improving patient outcomes.
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Introduction Hydrocephalus is a condition characterized by the abnormal accumulation of cerebrospinal fluid within the brain's ventricular system. It can stem from obstructive and nonobstructive causes. Pregnancy introduces physiopathological changes that may heighten the risk of developing or worsening symptomatic hydrocephalus. Nevertheless, comprehensive reports on this aspect, especially regarding surgical interventions, remain scarce. Case Report A young woman with a history of recurrent headaches experienced a worsening of her symptoms at the onset of her pregnancy. A magnetic resonance imaging (MRI) in the first trimester revealed increased ventricular dilation, indicating an obstructive cause due to aqueduct stenosis. During a neurosurgical board meeting, treatment options were discussed, considering the identifiable obstruction, the heightened intra-abdominal pressure associated with pregnancy, and the risk of ventricular shunt dysfunction. The patient underwent an endoscopic third ventriculostomy (ETV) without complications, leading to both symptom relief and a successful conclusion to the pregnancy. Discussion Neurosurgical procedures in pregnant women are uncommon due to the increased risks to both the mother and the fetus. However, when performed by a qualified multidisciplinary team, they can lead to positive outcomes. In cases of hydrocephalus during pregnancy, ETV appears to be a viable alternative for surgical intervention, particularly when hydrocephalus becomes symptomatic and an obstructive cause is identified, whether in patients with existing shunts or those with newly developed hydrocephalus.
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Introducción. Las neoplasias de fosa posterior son los tumores de sistema nervioso central más frecuentes en la población pediátrica y una causa frecuente de hidrocefalia. El objetivo del presente trabajo es analizar los factores de riesgo asociados a hidrocefalia luego de las cirugías de resección de tumores de fosa posterior en una población pediátrica. Material y métodos. Se realizó un estudio observacional retrospectivo de pacientes pediátricos operados de tumores de fosa posterior en un único hospital. Se analizaron potenciales factores de riesgo pre y post quirúrgicos. Se consideró como variable respuesta la necesidad de derivación definitiva para tratar la hidrocefalia a los 6 meses de la resección tumoral. Resultados. En el análisis univariado se detectaron múltiples factores de riesgo significativos. Sin embargo, solamente 3 se mantuvieron en el modelo multivariado: grado de resección (Subtotal: OR 7.86; Parcial: OR 20.42), infección postoperatoria (OR 17.31) y ausencia de flujo de salida postoperatorio en IV ventrículo (OR 4.29). Éste modelo presentó una buena capacidad predictiva (AUC: 0.80, Sensibilidad 80.5%, Especificidad 76.3%). Conclusión. La realización de tercer ventriculostomía endoscópica preoperatoria no redujo la incidencia de hidrocefalia postoperatoria. El grado de resección tumoral, la presencia de infección postoperatoria y la obstrucción de salida del IV ventrículo fueron los factores de riesgo más importantes para el requerimiento de sistema derivativo definitivo luego de la resección de un tumor de fosa posterior. Ésto podría influir en la toma de decisiones respecto al tratamiento en este grupo de pacientes pediátricos
Background. Posterior fossa tumors are the most frequent central nervous system neoplasms in the pediatric population and a frequent cause of hydrocephalus. The objective of this study is to analyze the risk factors associated with hydrocephalus after posterior fossa tumors resection in a pediatric population. Methods. A retrospective observational study was conducted on pediatric patients who underwent posterior fossa tumor resection in a single hospital. Potential pre- and post-operative risk factors were analyzed. The need for definitive shunt placement to treat hydrocephalus at 6 months after tumor resection was considered as the outcome variable. Results. Univariate analysis identified multiple significant risk factors. However, only 3 factors remained in the multivariate model: extent of resection (subtotal: OR 7.86; partial: OR 20.42), postoperative infection (OR 17.31), and absence of postoperative outflow of the fourth ventricle (OR 4.29). This model showed good predictive capacity (AUC: 0.80, Sensitivity 80.5%, Specificity 76.3%). Conclusion. Preoperative endoscopic third ventriculostomy did not reduce the incidence of postoperative hydrocephalus. The extent of tumor resection, presence of postoperative infection, and obstruction of fourth ventricle outflow were the most important risk factors for the requirement of a definitive shunt system after posterior fossa tumor resection. This could influence treatment decisions in this group of pediatric patients
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PediatriaRESUMO
Introduction: Treatment options for hydrocephalus related to posterior fossa tumors have been extensively studied in the pediatric population, but the value of endoscopic third ventriculostomy in hydrocephalus secondary to vestibular schwannoma in adults, is controversial. A systematic search of the medical literature was carried out in Pubmed/Medline and SciElo for the identification and inclusion of articles, in addition to the preprint servers bioRxiv and medRxiv. The following descriptors were used: hydrocephalus and vestibular schwannomas or acoustic neuromas or acoustic neurinomas and endoscopic third ventriculostomy. The initial search found 195 articles. After selection, 5 articles were chosen for the study. Objective: To specify the role of the endoscopic third ventriculostomy in hydrocephalus secondary to vestibular schwannomas. Development: The articles included a total of 82 patients, in which an improvement of the symptoms was achieved in 86.6 percent of the cases. The decrease in ventricular diameter was reported in 82.9 percent of the cases and was only found explicit in 3 articles. Although the failure criteria used were varied, 2 of them predominated: the persistence of progressive symptomatic hydrocephalus and/or the need for shunt placement. Endoscopic third ventriculostomy failure only represented 14.6 percent. Conclusions: Third ventriculostomy is an acceptable technique with relative success for the treatment of symptomatic obstructive hydrocephalus secondary to vestibular schwannomas(AU)
Introducción: Las opciones de tratamiento para la hidrocefalia relacionada con tumores de fosa posterior han sido ampliamente estudiadas en la población pediátrica, pero es controvertido el valor de la tercer ventriculostomía endoscópica, en la hidrocefalia secundaria a schwanoma vestibular en adultos, previo a la resección del tumor. Se realizó una búsqueda sistemática de la literatura médica en Pubmed/Medline y SciElo para la identificación e inclusión de artículos, además de los servidores de preprint bioRxiv y medRxiv. Se utilizaron los siguientes descriptores: hydrocephalus y vestibular schwannomas o acoustic neuromas o acoustic neurinomas y endoscopic third ventriculostomy. La búsqueda inicial encontró 195 artículos. Después de la selección, se eligieron 5 artículos para el estudio. Objetivo: Especificar el papel de la tercer ventriculostomía endoscópica en la hidrocefalia secundaria a schwanomas vestibulares. Desarrollo: Los artículos incluyeron un total de 82 pacientes, en los que se logró una mejoría de los síntomas en el 86,6 por ciento de los casos. La disminución del diámetro ventricular se reportó en el 82,9 por ciento de los casos y solo se encontró explícita en 3 artículos. Aunque los criterios de fracaso utilizados fueron variados, predominaron dos de ellos: la persistencia de hidrocefalia sintomática progresiva o la necesidad de colocación de derivación. La falla de la tercer ventriculostomía endoscópica solo representó el 14,6 por ciento. Conclusiones: La tercera ventriculostomía endoscópica es una técnica aceptable y con relativo éxito para el tratamiento de la hidrocefalia obstructiva sintomática secundaria a schwanomas vestibulares(AU)
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Humanos , Ventriculostomia/métodos , Neuroma Acústico , Hidrocefalia/tratamento farmacológicoRESUMO
Endoscopic third ventriculostomy (ETV) and ventriculoperitoneal shunt (VPS) are surgical methods for treating obstructive hydrocephalus. However, there is still disagreement regarding the most effective technique, in terms of both operative success and postoperative complications. Therefore, we performed a systematic review and meta-analysis to compare the efficacy and safety of these two methods in patients with obstructive hydrocephalus. We performed a systematic search of the PubMed, Scopus, and Cochrane Library databases. Randomized clinical trials (RCTs) comparing ETV and VPS in pediatric or adult patients with obstructive hydrocephalus were included. The outcomes included were operative success, postoperative cerebrospinal fluid leak, postoperative infection, postoperative or intraoperative bleeding, blockage rate, and mortality. The risk ratio (RR) was calculated with a 95% confidence interval (CI). Heterogeneity was evaluated with I 2 statistics. We used a fixed-effects model for outcomes with I 2 < 25% and DerSimonian and Laird random-effects model for other conditions. The Cochrane collaboration tool for assessing the risk of bias in randomized trials was used for risk-of-bias assessment. R, version 4.2.1, was used for statistical analyses. Of the 2,353 identified studies, 5 RCTs were included, involving 310 patients with obstructive hydrocephalus, of which 163 underwent ETV. There was a significant difference in favor of ETV for postoperative infection (risk ratio [RR]: 0.11; 95% confidence interval [CI]: 0.04-0.33; p < 0.0001; I 2 = 0%) and blockage rate (RR: 0.15; 95% CI: 0.03-0.75; p = 0.02; I 2 = 53%). Meanwhile, there was no significant difference between groups for the postoperative or intraoperative bleeding (RR: 0.44; 95% CI: 0.17-1.15; p = 0.09; I 2 = 0%), postoperative cerebrospinal fluid leak (RR: 0.65; 95% CI: 0.22-1.92; p = 0.44; I 2 = 18%), operative success (RR: 1.18; 95% CI: 0.77-1.82; p = 0.44; I 2 = 84%), and mortality (RR: 0.19; 95% CI: 0.03-1.09; p = 0.06; I 2 = 0%). Three RCTs had some concerns about the risk of bias and one RCT had a high risk of bias due to the process of randomization and selection of reported results. Thus, this meta-analysis of RCTs evaluating ETV compared with VPS demonstrated that although there is no superiority of ETV in terms of operative success, the incidence of complications was significantly higher in patients who underwent VPS. Our results suggest that the use of ETV provides greater benefits for the treatment of obstructive hydrocephalus. However, more RCTs are needed to corroborate the superiority of ETV.
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BACKGROUND: The main treatments for hydrocephalus due to posterior fossa tumors are tumor resection with or without an external ventricular drain, ventriculoperitoneal shunt (VPS), and endoscopic third ventriculostomy. Although preoperative cerebrospinal fluid diversion by any of these techniques improves clinical outcomes, evidence comparing the efficacy of these techniques is scarce. Therefore, we aimed to retrospectively evaluate each treatment modality. METHODS: This single-center study analyzed 55 patients. Treatments were classified as successful (hydrocephalus resolution with a single surgical event) or failed and compared with a χ2 test. Kaplan-Meier curves and log-rank tests were employed. A Cox proportional hazard model was used to determine relevant covariates predicting outcomes. RESULTS: Mean patient age was 36.3 years, 43.4% of patients were men, and 50.9% of patients presented with uncompensated intracranial hypertension. Mean tumor volume was 33.4 cm3, and extent of resection was 90.85%. Tumor resection with or without an external ventricular drain was successful in 58.82% of cases, VPS was successful in 100%, and endoscopic third ventriculostomy was successful in 76.19% (P = 0.014). Mean follow-up time was 15.12 months. Log-rank test found statistically significant differences between survival curves of treatments (P = 0.016) favoring the VPS group. Postoperative surgical site hematoma was a significant covariate in the Cox model (hazard ratio = 17; 95% confidence ratio, 2.301-81.872; P = 0.004). CONCLUSIONS: This study favored VPS as the most reliable treatment of hydrocephalus due to posterior fossa tumors in adult patient; however, several factors influence clinical outcomes. We proposed an algorithm based on our findings and other authors' findings to facilitate the decision-making process.
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Neoplasias Encefálicas , Hidrocefalia , Neoplasias Infratentoriais , Terceiro Ventrículo , Masculino , Humanos , Adulto , Feminino , Estudos Retrospectivos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/cirurgia , Neoplasias Encefálicas/cirurgia , Neoplasias Infratentoriais/complicações , Neoplasias Infratentoriais/diagnóstico por imagem , Neoplasias Infratentoriais/cirurgia , Hidrocefalia/etiologia , Hidrocefalia/cirurgia , Ventriculostomia/métodos , Derivação Ventriculoperitoneal/métodos , Terceiro Ventrículo/diagnóstico por imagem , Terceiro Ventrículo/cirurgia , Resultado do TratamentoRESUMO
Background: Endoscopic third ventriculostomy (ETV) is currently used as a treatment for different types of hydrocephalus. However, the anatomical endoscopic variants of the third ventricle floor (3VF), as well as their surgical implications, have been underrated. The anatomic variations of the 3VF can influence the technique and the success rate of the ETV. The purpose of this article is to describe the anatomical variations of 3VF, assess their incidence, and discuss the implications for ETV. Methods: Intraoperative videos of 216 patients who underwent ETV between January 2012 and February 2020 at Hospital Infantil Universitario de San José, Bogotá, Colombia were reviewed. One hundred and eighty patients who met the criteria to demonstrate the type of 3VF were selected. Results: 3VF types were classified as follows: (1) Thinned, (2) thickened, (3) partially erased, (4) globular or herniated, and (5) narrowed. Conclusion: Knowledge of anatomical variations of the 3VF is paramount for ETV and it influences the success rate of the procedure.
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Agenesis of the internal carotid artery (aICA) is a rare congenital vascular condition that can affect one or both sides of the patient. Most patients remain asymptomatic, but ischemic/hemorrhagic stroke, intracranial aneurysm, and other neurologic findings can occur. CT scan can demonstrate the absence of the bony carotid canal and helps to differentiate a complete aICA from aplasia or hypoplasia. The association of aICA and aqueductal stenosis (AS) has never been reported in the literature. We report the case of a 9-year-old with agenesis of the right ICA associated with AS and hydrocephalus, which was treated successfully with an endoscopic third ventriculostomy (ETV). We review the literature looking for the association of the clinical findings and the evolution of the patient.
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Hidrocefalia , Neuroendoscopia , Terceiro Ventrículo , Artéria Carótida Interna/anormalidades , Artéria Carótida Interna/diagnóstico por imagem , Artéria Carótida Interna/cirurgia , Aqueduto do Mesencéfalo/anormalidades , Aqueduto do Mesencéfalo/diagnóstico por imagem , Aqueduto do Mesencéfalo/cirurgia , Criança , Doenças Genéticas Ligadas ao Cromossomo X , Humanos , Hidrocefalia/diagnóstico por imagem , Hidrocefalia/etiologia , Hidrocefalia/cirurgia , Neuroendoscopia/efeitos adversos , Terceiro Ventrículo/diagnóstico por imagem , Terceiro Ventrículo/cirurgia , Resultado do Tratamento , Ventriculostomia/efeitos adversosRESUMO
Introdução: A mielomeningocele (MMC) é o defeito do tubo neural compatível com a vida mais comum, e uma de suas complicações mais frequentes é a ocorrência de hidrocefalia, principalmente em pacientes cuja correção do defeito se deu no período pós-natal. O tratamento padrão para esta população ainda é a inserção de uma derivação ventrículo-peritoneal (DVP), associada a complicações e maior morbimortalidade. Alternativamente à DVP, destaca-se a terceiro ventriculostomia endoscópica (TVE), procedimento sem a necessidade de dispositivo implantável, mas que apresenta uma taxa de sucesso muito variável na literatura médica. Objetivos: Avaliar a taxa de sucesso da TVE no tratamento da hidrocefalia associada à MMC, identificar possíveis fatores clínicos e/ou radiológicos relacionados ao sucesso do procedimento e identificar se o sucesso estimado pelo Endoscopic Third Ventriculostomy Success Score (ETVSS) foi comparável à real taxa de sucesso. Método: Vinte e um pacientes com o diagnóstico de MMC, nascidos entre 2015 e 2021 e submetidos a TVE para o tratamento da hidrocefalia foram incluídos nesse estudo. Pacientes com correção fetal da MMC foram excluídos. Dados clínicos como o perímetro cefálico ao nascimento e no pré-operatório prematuridade, presença de DVP, número de revisões e presença de infecção prévias, idade no momento da TVE, além de fatores radiológicos como o índice de Evans, ângulo clivo-occipital, volume estimado da fossa posterior e volume estimado do compartimento supratentorial foram analisados. Resultados: A taxa de sucesso em seis meses foi de 61,9%, a taxa geral de sucesso foi de 57,1% e o ETVSS médio calculado foi de 46,7%. O único fator com aparente relevância para o sucesso da TVE foi a idade, pacientes com mais de 6 meses completos apresentaram uma taxa de sucesso de 76,9% enquanto os mais novos apresentaram uma taxa de sucesso de 25% (OR: 0,03; IC 95% 0,01-0,35; p = 0,013). Não foi identificado nenhum fator radiológico associado ao sucesso do procedimento. Conclusões: O único fator de relevância estatística com o sucesso da TVE foi a idade, sendo que pacientes com idade inferior a 6 meses completos apresentaram uma probabilidade maior de falha. Já o ETVSS subestimou a taxa de sucesso do procedimento em 6 meses o que demonstra a necessidade de modificações para seu aprimoramento em pacientes mais jovens.
Introduction: Myelomeningocele (MMC) is the most common neural tube defect compatible with life, and one of its most frequent complications is the occurrence of hydrocephalus (HCF), especially in patients whose defect correction took place in the postnatal period. The standard treatment for this population is still the insertion of a ventriculoperitoneal shunt (VPS), but it is associated with complications and higher morbidity and mortality. As an alternative to DVP, endoscopic third ventriculostomy (ETV) stands out, it is a procedure without the need for an implantable device, but its success rate is inconsistent in the medical literature. Objectives: To evaluate the success rate of EVT in the treatment of hydrocephalus associated with MMC and to identify possible clinical and/or radiological features associated with ETV success. Methods: Twenty-one patients with myelomeningocele, born between 2015 and 2021, that underwent EVT for hydrocephalus were included in this study. Patients with fetal MMC correction were excluded. Clinical data such as head circumference at birth and preoperatively, prematurity, presence of previous VPS, number of previous revisions, presence of a previous infection, age at the time of ETV, in addition to radiological factors such as the Evans index, clivo-occipital angle, the estimated volume of the posterior fossa and estimated volume of the supratentorial compartment were analyzed. Results: The six-month success rate was 61.9%, the overall success rate was 57.1%, and the mean calculated ETVSS was 46.7%. The only factor with apparent relevance to the success of ETV was age: the patients older than six full months had a success rate of 76.9%, while the younger ones had a success rate of 25% (OR: 0.03; 95% CI 0.01-0.35; p = 0.013). No radiological features were identified as associated with the procedure's success. Conclusions: The only factor of statistical relevance with the success of TVE was age, with patients younger than six full months of age having a higher probability of failure. The ETVSS, on the other hand, underestimated the procedure's success rate at six months, which shows a need for modifications to improve its results when applied in younger patients.
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Ventriculostomia , Meningomielocele , Hidrocefalia , Neurocirurgia , Pediatria , Humanos , Dissertação AcadêmicaRESUMO
BACKGROUND: Endoscopic third ventriculostomy (ETV) has been shown to be a sufficient alternative to shunts in surgical treatment of obstructive hydrocephalus. Long-term failure, age limitations, and outcome by cause are some of the issues debated in literature. The objective of this article is to analyze the clinical success and failure of ETV and its main complications. METHODS: A total of 209 patients with hydrocephalus were submitted to ETV, including a mixed population of children and adults (from 0 to 59 years). Patients were divided into five groups: A - tumors, B - aqueductal stenosis, C - myelomeningocele, D - infection and hemorrhage, and E - arachnoid cyst. Variables were analyzed: age, ETV success rate, cerebrospinal fluid (CSF) fistula, mortality, and complications. RESULTS: The two main causes of hydrocephalus were tumors (44.9%) and aqueductal stenosis (25.3%). The overall success rate was of 82.8%, and patients in Group E had the highest rate 90.9%. Group A had a success rate of 89.3%, and Group B had a rate of 88.6%. The ETV success rate was significantly higher in patients older than 1 year (P < 0.001); the former also had a lower risk of CSF fistula (P < 0.0001). The overall mortality rate was 2.8%. CONCLUSION: Better results were observed in the groups of patients with tumors, aqueductal stenosis, and arachnoid cysts, while those whose primary causes of hydrocephalus were myelomeningocele, infections, or bleeding had higher rates of failure after the procedure. This study demonstrated that age under 1 year and hydrocephalus caused by myelomeningocele, bleeding, and infection were considered independent risk factors of poor prognosis in ETV.
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BACKGROUND: Pineal tumors are very rarely encountered, with an incidence of <1% of intracranial lesions in adults. Life-threatening hydrocephalus due to obstruction of the third ventricle can result from the location of these tumours. Endoscopic third ventriculostomy (ETV) and tumor biopsy is a safe and feasible strategy, particularly if the tumor appears benign. This mitigates the high risks of uncontrollable venous bleeding from open and stereotactic biopsies. While typically performed using either ipsilateral single or dual bur holes, the location of the tumor may require modifications to the standard endoscopic techniques. CASE DESCRIPTION: A 55-year-old male presented with signs of intracranial hypertension and was found to have obstructive hydrocephalus due to a pineal tumour. The tumour displayed a right-sided dominance when the pre-operative imaging was assessed, which would risk forniceal injury if biopsied via a right-sided burr hole. Craniometric measurements revealed a superior trajectory to the tumour via the left foramen of Monro. A biforaminal approach was performed, with a traditional ETV using a right coronal bur hole and biopsy via a left frontal bur hole. This minimized forniceal stretching and allowed a safe biopsy. CONCLUSION: The bi-foraminal approach has not been widely described in the literature but can potentially avoid morbidity with biopsy in patients with right-sided pineal tumours. We believe this technique should be considered, particularly in low-resource settings where neuroendoscopy is not commonly done, and where the use of ipsilateral single or dual-bur holes may lead to forniceal injury.
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OBJECTIVE: Untreated hydrocephalus poses a significant health risk to children in the developing world. In response to this risk, global neurosurgical efforts have increasingly focused on endoscopic third ventriculostomy with choroid plexus cauterization (ETV/CPC) in the management of infantile hydrocephalus in low- and middle-income countries (LMICs). Here, the authors report their experience with ETV/CPC at the Hospital Bernard-Mevs/Project Medishare (HBMPM) in Port-au-Prince, Haiti. METHODS: The authors conducted a retrospective review of a series of consecutive children who had undergone ETV/CPC for hydrocephalus over a 1-year period at HBMPM. The primary outcome of interest was time to ETV/CPC failure. Univariate and multivariate analyses using a Cox proportional hazards regression were performed to identify preoperative factors that were associated with outcomes. RESULTS: Of the 82 children who underwent ETV/CPC, 52.2% remained shunt free at the last follow-up (mean 6.4 months). On univariate analysis, the ETV success score (ETVSS; p = 0.002), success of the attempted ETV (p = 0.018), and bilateral CPC (p = 0.045) were associated with shunt freedom. In the multivariate models, a lower ETVSS was independently associated with a poor outcome (HR 0.072, 95% CI 0.016-0.32, p < 0.001). Two children (2.4%) died of postoperative seizures. CONCLUSIONS: As in other LMICs, ETV/CPC is an effective treatment for hydrocephalus in children in Haiti, with a low but significant risk profile. Larger multinational prospective databases may further elucidate the ideal candidate for ETV/CPC in resource-poor settings.
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OBJECTIVE: Previous models have been utilized in other low- and middle-income countries (LMICs) to explore and assess the cost, sustainability, and effectiveness of infant hydrocephalus treatment. However, similar models have not been implemented in Haiti due to a paucity of data, epidemiology, and outcomes for hydrocephalus. Therefore, the authors utilized previously described economic modeling to estimate the annual cost and benefit of treating hydrocephalus in infants at a neurosurgery referral center, Hospital Bernard Mevs (HBM), in Port-au-Prince, Haiti. METHODS: The authors conducted a retrospective review of data obtained in all children treated for hydrocephalus at the HBM from 2008 to 2015. The raw data were pooled with previously described surgical outcomes for hydrocephalus in other LMICs. Modeling was performed to determine outcomes, neurosurgical costs, disability-adjusted life years (DALYs), and economic benefits of Haitian hydrocephalus treatment during this time frame. Standard account methodology was employed to calculate cost per procedure. Using these formulas, the net economic benefit and cost/DALY were determined for hydrocephalus treatment at HBM from 2008 to 2015. RESULTS: Of the 401 patients treated during the study period, 158 (39.4%) met criteria for postinfectious hydrocephalus, 54 (13.5%) had congenital hydrocephalus, 38 (9.5%) had myelomeningocele, 19 (4.7%) had aqueductal stenosis, and 132 (33%) were not placed into a category. Overall, 317 individuals underwent surgical treatment of their hydrocephalus, averting 3077 DALYs. The total cost of the procedures was $754,000, and the cost per DALY ranged between $86 and $245. The resulting net economic benefit for neurosurgical intervention ranged from $2.5 to $5.5 million. CONCLUSIONS: This work demonstrates the substantial economic benefit of neurosurgical intervention for the treatment of pediatric hydrocephalus at a single hospital in Haiti. Based on DALYs averted, the need for additional centers offering basic neurosurgical services is apparent. A single center offering these services for several days each month was able to generate between $2.5 to $5.5 million in economic benefits, suggesting the need to develop neurosurgical capacity building in Haiti. Ultimately, prevention, screening, and early surgical treatment of these infants represent a public health and socioeconomic requisite for Haiti.
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OBJECTIVEHydrocephalus is recognized as a common disabling pediatric disease afflicting infants and children disproportionately in the developing world, where access to neurosurgical care is limited and risk of perinatal infection is high. This surgical case series describes the Project Medishare Hydrocephalus Specialty Surgery (PMHSS) program experience treating hydrocephalus in Haiti between 2008 and 2015.METHODSThe authors conducted a retrospective review of all cases involving children treated for hydrocephalus within the PMHSS program in Port-au-Prince, Haiti, from 2008 through 2015. All relevant epidemiological information of children treated were prospectively collected including relevant demographics, birth history, hydrocephalus etiology, head circumference, and operative notes. All appropriate associations and statistical tests were performed using univariate and multivariate logistic regression analyses.RESULTSAmong the 401 children treated within PMHSS, postinfectious hydrocephalus (PIH) accounted for 39.4% (n = 158) of cases based on clinical, radiographic, and endoscopic findings. The majority of children with hydrocephalus in Haiti were male (54.8%, n = 197), born in the rainy season (59.7%, n = 233), and born in a coastal/inland location (43.3%, n = 61). The most common surgical intervention was endoscopic third ventriculostomy with choroid plexus cauterization (ETV/CPC) (45.7%, n = 175). Multivariate logistic regression analysis yielded coastal birth location (OR 3.76, 95% CI 1.16-12.18) as a statistically significant predictor of PIH. Increasing head circumference (adjusted OR 1.06, 95% CI 0.99-1.13) demonstrated a slight trend toward significance with the incidence of PIH.CONCLUSIONSThis information will provide the foundation for future clinical and public health studies to better understand hydrocephalus in Haiti. The 39.4% prevalence of PIH falls within observed rates in Africa as does the apparently higher prevalence for those born during the rainy season. Although PIH was the most frequent etiology seen in almost all birth locations, the potential relationship with geography noted in this series will be the focus of further research in an effort to understand the link between climate and PIH in Haiti. The ultimate goal will be to develop an appropriate public health strategy to reduce the burden of PIH on the children of Haiti.
RESUMO
A Terceiro Ventriculostomia Endoscópica (TVE) é operação intracerebral que trata a hidrocefalia. Para sua realização é necessário conhecimento da anatomia cirúrgica da membrana aracnoidea de Liliequist, que deve ser aberta durante o procedimento. Porém, a anatomia do ponto de vista neuroendoscópico é pouco conhecida, já que os ângulos de abordagem são diferentes da anatomia descritiva clássica e mesmo da anatomia cirúrgica microscópica. Há discrepância na literatura quanto a eficácia da TVE, sobretudo em crianças, em que pode ocorrer a não abertura completa da membrana de Liliequist (ML). Para compreensão do comportamento da ML, a sua associação com o Tuber Cinereo (TC) e o assoalho do III Ventrículo (IIIVT) e outras peculiaridades, foi realizada, prospectivamente, a observação sistemática destas características durante 57 operações. Os dados foram registrados após o procedimento e posteriormente estudados. Os objetivos eram sistematizar as características anatômicas destas estruturas do ponto de vista neuroendoscópico, avaliar se as alterações seguiam algum padrão e se interferiam no procedimento técnico, correlacionando com a evolução. Pela análise dos dados percebeu-se que as características da ML são variáveis e dificultam, em uma percentagem considerável de vezes, a sua interpretação e seu manejo pelo neurocirurgião. Também, que o TC alterado e separado da ML são fatores associados à maior dificuldade de realização da TVE. Que as TVE realizadas nas hidrocefalias por malformações congênitas, processos inflamatórios e pós sangramento (prevalentes na infância) estão associadas a maior dificuldade de manejar a ML e podem explicar o índice de insucesso maior observado na literatura em crianças abaixo de 2 anos.
Endoscopic Third Endoscopic (ETV) is a neurosurgical procedure to treat hydrocephalus. To be fully performed it is necessary opening an arachnoid structure, the Liliequist Membrane (LM). However the LM surgical anatomy from the neuroendoscopic point of view is not yet completely studied, since approach angles are different from classics descriptive and microsurgical anatomies. There is a literature discrepancy regarding the ETV efficacy, especially in children over 2 years old, which may be due to LM incomplete opening. In order to understand the LM anatomical behavior, the relationship with tuber cinereo (TC), the floor of the III Ventricle and other peculiarities, a systematic prospective observation of these characteristics was performed during the 57 surgeries. Data were recorded after the procedure and studied. Objectives were to systematize LM anatomical characteristics from neuroendoscopic perspective, understand if anatomical changes follows a pattern interfering on the procedure, and if there is correlation with patients evolution. The data analysis shows that LM characteristics are variable, making difficult the neurosurgeon management. Whenever TC anatomy modifies, or when TC and ML are separated, difficulty to perform ETV increases. When hydrocephalies are due to congenital malformations, inflammatory processes and post bleeding (prevalent in childhood), LM management is much harder, witch may explain the higher failure rate in children under 2 years of age observed in literature.
Assuntos
Ventriculostomia , Terceiro Ventrículo , Neuroendoscopia , Hidrocefalia , Dissertação AcadêmicaRESUMO
This study aims to review historical aspects and rebirth of the endoscopic choroid plexus coagulation (CPC) for pediatric hydrocephalus. The first CPC procedure goes back to early 1930s. After the development of other treatment methods and the understanding of CSF dynamics, the application of CPC dramatically decreased by 1970s. In 2000s, there was a rebirth of CPC in combination with endoscopic third ventriculostomy (ETV), and remains one of the options for the treatment of pediatric hydrocephalus in selected cases. CPC might provide a temporary reduction in CSF production to allow the further development of CSF absorption in infant, and adding to ETV for infants with communicating hydrocephalus may increase the shunt independent rate thus avoiding the consequence of late complication related to the shunt device. This is important for patients who are difficult to be followed up, due to geographical and/or socioeconomic difficulties. And also adding CPC to ETV for obstructive hydrocephalus in infants younger than 1 year of age may also increase the successful rate. Furthermore, CPC may be an option for cases with high chance of shunt complication such as multiloculated hydrocephalus, extreme hydrocephalus and hydranencephaly. In comparison with the traditional treatment of CSF shunting, the role of CPC needs to be further evaluated in particular concerning the neurocognitive development.
Assuntos
Humanos , Lactente , Eletrocoagulação , Hidrocefalia/cirurgia , Neuroendoscopia/métodos , Plexo Corióideo/cirurgia , Coagulação Sanguínea , Cauterização , Terceiro Ventrículo/cirurgia , Ventriculostomia/métodosRESUMO
OBJECTIVES: The purpose of this work is to elucidate the efficacy of endoscopic basal cisterns exploration, biopsy, and third ventriculostomy (ETV) in patients with basal cistern meningitis and arachnoiditis. MATERIALS AND METHODS: The cases and videos of all patients in whom flexible neuroendoscopy was performed during the period of January 2005-June 2012 at the University Hospital 'Dr. Ignacio Morones Prieto' in San Luis Potosí, México. A group of 47 patients with radiological diagnosis of basal meningitis, arachnoiditis, and negative cerebrospinal fluid analysis were included. RESULTS: From the 28 (60%) patients with histological diagnosis, 22 (47%) were made from biopsy from the arachnoid membranes of the basal cisterns only, 4 (9%) only from the cerebral cortex, and 2 (4%) from both sites. There were no complications related to the endoscopic procedure. In 23 patients from the 42 with hydrocephalus, ETV was successful. The grade of diagnostic accuracy of both biopsies in detect etiology was 68% (28 of 47 patients), the diagnostic accuracy of arachnoid biopsy was 60%, and diagnostic accuracy of convexity brain biopsy was 21% with 24 and 6 patients, respectively. DISCUSSION: Endoscopic transventricular biopsy of the basal cisterns seems to be a safe and a relatively accurate procedure. As longs as frozen subarachnoid space was not seen, the possibilities of performing ETV in hydrocephalus condition are elevated depending on the causal micro-organism.
Assuntos
Endoscopia/métodos , Hidrocefalia/cirurgia , Meningite/cirurgia , Terceiro Ventrículo/cirurgia , Ventriculostomia/métodos , Adolescente , Adulto , Idoso , Biópsia , Córtex Cerebral/diagnóstico por imagem , Córtex Cerebral/patologia , Criança , Pré-Escolar , Erradicação de Doenças , Feminino , Seguimentos , Humanos , Lactente , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Espaço Subaracnóideo/patologia , Espaço Subaracnóideo/cirurgia , Terceiro Ventrículo/diagnóstico por imagem , Adulto JovemRESUMO
Neuroendoscopic surgery in children has particular features and is associated with different success rates (SR). The aim of this study was to identify putative factors that could influence the outcome in pediatric patients. Clinical data of 177 patients under 18 years of age submitted to 200 consecutive neuroendoscopic procedures from January 2000 to January 2010 were reviewed.