Intraoperative assessment of endoscopic third ventriculostomy success

The authors' aim in this study was to determine if standardizing the evaluation of intraoperative findings during endoscopic third ventriculostomy (ETV) could predict patients with hydrocephalus in whom endoscopic treatment will fail and require ventriculoperitoneal shunt treatment. The creation of a uniform scale with predictive outcomes may reduce returns to the operating room for shunt treatment and reliance on postoperative externalized ventricular monitoring and MR imaging.

The authors evaluated the preoperative history, intraoperative findings, and postoperative monitoring and imaging findings in 109 consecutive patients undergoing 112 consecutive attempted ETVs for obstructive hydrocephalus. A 5-grade scale was developed to assess preoperative risk factors and intraoperative evaluation to unify criteria that have been suspected to influence outcome independently. A grade of 0 was assigned to patients with no negative predictors, whereas increasing scores were assigned to patients who had multiple preoperative and intraoperative risks identified. Patients' grades were compared with outcome of the procedure, utility of externalized ventricular monitoring, and results of postoperative MR imaging.

Of 112 ETVs, 77 were successful and 35 were unsuccessful. Fifty-nine patients received a grade of 0, 27 received a grade of 1, 11 received a grade of 2, and 15 received a grade of > or = 3. In all 15 patients receiving a grade > or = 3 attempted ETV procedures failed, and the patients required a ventriculoperitoneal shunt. Postoperative monitoring with externalized ventricular drains and MR images demonstrating radiographic evidence of flow was independently less reliable than intraoperative grading in predicting success. Patients with a grade of 0 almost uniformly had successful surgery, independent of MR imaging findings. Patients with a grade of 1 or 2 who had successful surgery almost always lacked negative intraoperative predictive findings.

Despite reliance in recent years on post-ETV MR images and externalized ventricular monitoring, these modalities, although often useful adjuncts, appear less reliable as predictive tests than a simple assessment at the time of endoscopic fenestration. By using a uniform grading scale, the authors have introduced a novel means through which intraoperative and postoperative decision making can be aided, with the goal of reducing unnecessary procedures and tests and preventing unnecessary returns to the operating room.