Endoscopic treatment of complex multiloculated hydrocephalus in children, steps that may help to decrease revision rate

Abstract

Background: Multiloculated hydrocephalus (MLH) is associated with increased intracranial pressure, with intraventricular septations, loculations, and isolation of parts of the ventricular system. Search continues for ideal surgical remedy capable of addressing the dimensions of the problem. We aimed to evaluate endoscopic septal fenestration and pellucidotomy combined with proximal shunt tube refashioning and further advancement into isolated loculations of the ventricular system containing choroid plexus.

Methods: This retrospective study was conducted on 55 patients with symptomatic complex MLH who underwent endoscopic surgery. The collected data included patients' age, gender, presenting manifestations, operative details, rate of remission of preoperative clinical and imaging signs, postoperative complications, redo surgery, or extra shunt hardware insertion. Patients were divided into Group A (underwent the standard technique of endoscopic multiseptal wide fenestration and final ventriculoperitoneal shunt insertion) and Group B (modified technique by adding extra side ports along the proximal shunt hardware).

Results: Groups A and B included 25 and 30 patients, respectively. The percentage of patients showing improvement of almost all manifestations was higher in Group B compared to Group A, with no significant difference (P > 0.05). Group B had lower rate of complications (20% vs. 36%, P = 0.231), insertion of two shunts (16.7% vs. 20%, P = 1.000), and redo surgery (20% vs. 44%, P = 0.097).

Conclusion: The modified technique was associated with better outcomes in terms of the use of single shunt and redo surgery. Launching randomized clinical trials to compare the two techniques are recommended to ascertain the efficacy of the modified technique.

Keywords: Multiloculated hydrocephalus; Neuroendoscopy; Reoperation; Ventriculostomy.

Figure 1:

(a) Axial T1-weighted MRI showing multiloculated hydrocephalus with asymmetric ventriculomegaly and a midline shift to the left side. (b) An illustration showing shunt tube refashioning by adding extra ports in all around manner to mimic the factory fashion. (c) An illustration showing the intended pathway and advancement of the proximal catheter into the ventricular system. (d) A screenshot from the navigation platform with four quadrants, the left upper corner is an endoscopic linked live closer view of the septum pellucidum being fenestrated by monopolar probe (white arrowhead). The rest of the quadrants are axial, sagittal, and coronal images showing the path of endoscope sheath used as navigation tool after registration on the system. (e) Insertion of the refashioned antibiotic impregnated proximal catheter (white arrowhead). (f) An axial T2-weighted MRI 3 months following surgery showing the proximal catheter tip on the contralateral ventricle as targeted (white arrowhead).

Figure 2:

(a) Axial CT brain showing multiloculated hydrocephalus with distention of the right lateral ventricle toward left side proximal shunt catheter (white arrowhead). (b) An intraoperative endoscopic right side view showing the left side proximal catheter behind the septum pellucidum (white arrowhead). (c) The wall of the septum pellucidum is fenestrated using bipolar probe. (d) The fenesetram is widely dilated to show the second leaflet of the septum pellucidum needs fenestration. (e and f) Fenestration and wide dilatation are further progressed down across ependymal adhesions isolating the dilated third and fourth ventricles (white arrowhead). (g) Insertion of the refashioned antibiotic impregnated proximal catheter throughout fourth, third, and lateral ventricles (white arrowhead). (h-j) Postoperative images showing the path of the catheter through the ventricular system with a resolution of midline shift.

Figure 3:

Algorithm for the management of complex multiloculated hydrocephalus.