Clinical Outcome of Endoscopic Procedure in Patients with Shunt Malfunction

Abstract

Objective: The goal of this study was to analyze the clinical outcomes of endoscopic third ventriculostomy (ETV) and endoscopic septostomy when shunt malfunction occurs in a patient who has previously undergone placement of a ventriculoperitoneal shunt.

Methods: From 2001 to 2020 at Seoul National University Children's Hospital, patients who underwent ETV or endoscopic septostomy for shunt malfunction were retrospectively analyzed. Initial diagnosis (etiology of hydrocephalus), age at first shunt insertion, age at endoscopic procedure, magnetic resonance or computed tomography image, subsequent shunting data, and follow-up period were included.

Results: Thirty-six patients were included in this retrospective study. Twenty-nine patients, 18 males and 11 females, with shunt malfunction underwent ETV. At the time of shunting, the age ranged from 1 day to 15.4 years (mean, 2.4 years). The mean age at the time of ETV was 13.1 years (range, 0.7 to 29.6 years). Nineteen patients remained shunt revision free. The 5-year shunt revisionfree survival rate was 69% (95% confidence interval [CI], 0.54-0.88). Seven patients, three males and four females, with shunt malfunction underwent endoscopic septostomy. At the time of shunting, the age ranged from 0.2 to 12 years (mean, 3.9 years). The mean age at the time of endoscopic septostomy was 11.9 years (range, 0.5 to 29.5 years). Four patients remained free of shunt revision or addition. The 5-year shunt revision-free survival rate was 57% (95% CI, 0.3-1.0). There were no complications associated with the endoscopic procedures.

Conclusion: The results of our study demonstrate that ETV or endoscopic septostomy can be effective and safe in patients with shunt malfunction.

Keywords: Endoscopy; Hydrocephalus; Shunt failure; Ventriculoperitoneal shunt; Ventriculostomy.

Fig. 1.

Illustrative case of a patient who underwent endoscopic third ventriculostomy. A 23-year-old male who was diagnosed with germinoma in the pineal gland. Mid-sagittal magnetic resonance imaging shows third ventricular floor bowing. Reference line (blue) is drawn from the optic chiasm to the highest point of the midbrain. The arrow (red) indicates the distance between the reference line and the tuber cinereum.

Fig. 2.

Illustrative case of a patient who underwent endoscopic third ventriculostomy. A 15-year-old female who presented with preterm intraventricular hemorrhage. (A) Magnetic resonance imaging (MRI) shows no third ventricular floor bowing (asterisk). However, sagittal phase-contrast cine MR in diastole (B) and systole (C) show decreased aqueductal cerebrospinal fluid (CSF) flow, but patent CSF flow passes through premedullary and cerebellomedullary cistern. (D) Diminished CSF flow velocity at the aqueduct of Sylvius level is measured by phase-contrast MRI.

Fig. 3.

Kaplan-Meier curves showing overall survival. A : Patients with endoscopic third ventriculostomy for shunt malfunction. B : Patients with septostomy for isolated unilateral hydrocephalus.