Endoscopic third ventriculostomy as adjunctive therapy in the treatment of low-pressure hydrocephalus in adults

Abstract

Background: Treatment of low-pressure hydrocephalus (LPH) may require prolonged external ventricular drainage (EVD) at sub-zero pressures to reverse ventriculomegaly. Endoscopic third ventriculostomy (ETV) has been used in the treatment of noncommunicating hydrocephalus; however, indications for ETV are expanding.

Methods: Patients with the diagnosis of LPH as defined by the Pang and Altschuler criteria who underwent sub-zero drainage treatment over an 8-year period were included. Patients were divided into two cohorts based on whether or not ETV was employed during their treatment. Time from EVD placement to internalization of shunt was recorded for both groups; time from ETV to placement of shunt was recorded for the patients undergoing ETV.

Results: Sixteen adult patients with LPH were managed with sub-zero drainage method. Ten (62.5%) patients did not undergo ETV and the average time from first ventriculostomy to shunting was 73 days (range 14-257 days). Six (37.5%) patients underwent ETV during the course of their treatment; average time from initial ventriculostomy to shunt was 114 days (range 0-236 days) (P = 0.16). Time from development of LPH to ETV ranged from 28 days to 6.5 months. In the ETV group, of the 4 patients who underwent shunting, the average time to shunting following ETV was 15.25 days.

Conclusions: ETV can be used successfully in the management of refractory LPH to decrease the duration of EVD.

Keywords: Adult hydrocephalus; endoscopic third ventriculostomy; intracranial pressure; low-pressure hydrocephalus; shunt; subarachnoid space.

Figure 1

Axial computed tomography image showing ventriculomegaly of the fourth ventricle (a) and lateral ventricles (b) obtained 3 h prior to endoscopic third ventriculostomy/choroid plexus cauterization, with external ventricular drain positioned at 5 cmH2O below midbrain. Computed tomography image obtained immediately following endoscopic third ventriculostomy/choroid plexus cauterization of the fourth ventricle (c) and lateral ventricles (d). Computed tomography image obtained 3 h prior to placement of ventriculopleural shunt, with external ventricular drain at 5 cmH2O above midbrain, showing fourth (e) and lateral ventricles (f). Computed tomography imaging obtained on postoperative day 2 from shunting (g and h) and at 3 months neurosurgical follow-up (i and j)