Related Experiment Video
Updated: Jun 8, 2026
Neuronavigation and Laparoscopy Guided Ventriculoperitoneal Shunt Insertion for the Treatment of Hydrocephalus
Published on: October 14, 2022
Predicting who will benefit from endoscopic third ventriculostomy compared with shunt insertion in childhood
Abhaya V Kulkarni1, James M Drake, John R W Kestle
1Hospital for Sick Children, Toronto, Canada. abhaya.kulkarni@sickkids.ca
Insights
The ETV Success Score (ETVSS) helps predict endoscopic third ventriculostomy (ETV) success in pediatric hydrocephalus. Higher scores indicate better ETV outcomes compared to shunts, especially early on.
Area of Science:
- Neurosurgery
- Pediatric Neurosurgery
- Hydrocephalus Management
Background:
- Endoscopic third ventriculostomy (ETV) is a surgical option for pediatric hydrocephalus.
- The ETV Success Score (ETVSS) was developed to predict ETV success based on age, etiology, and prior shunt status.
- Clinical utility of the ETVSS in comparing long-term outcomes of ETV versus shunt insertion needs assessment.
Purpose of the Study:
- To evaluate the clinical utility of the ETV Success Score (ETVSS).
- To determine if long-term survival outcomes differ between ETV and shunt insertion within ETVSS strata.
- To assess the predictive value of ETVSS for ETV success compared to shunts.
Main Methods:
- Analysis of a multicenter, international cohort of pediatric patients (≤19 years) with newly diagnosed hydrocephalus.
- Comparison of outcomes between ETV (489 patients) and shunt insertion (720 patients).
- Calculation of ETVSS for all patients and performance of survival analyses with time-dependent hazard ratios.
Main Results:
- In the High-ETVSS group, ETV showed a lower risk of failure from the outset compared to shunts.
- In the Moderate-ETVSS group, ETV had a higher initial failure rate but became favorable after 3 months.
- In the Low-ETVSS group, ETV's early failure risk was higher, with outcomes becoming favorable after 6 months.
Conclusions:
- The ETVSS effectively stratifies patients for ETV versus shunt outcomes.
- For high-ETVSS candidates, ETV offers early and sustained lower failure risk than shunts.
- For lower-ETVSS candidates, ETV failure risk is initially higher but becomes lower than shunts after 3-6 months, warranting further prospective studies.
Object:
The authors recently developed and internally validated the ETV Success Score (ETVSS)--a simplified means of predicting the 6-month success rate of endoscopic third ventriculostomy (ETV) for a child with hydrocephalus, based on age, etiology of hydrocephalus, and presence of a previous shunt. A high ETVSS predicts a high chance of early ETV success. In this paper, they assess the clinical utility of the ETVSS by determining whether long-term survival outcomes for ETV versus shunt insertion are different within strata of ETVSS (low, moderate, and high scores).
Methods:
A multicenter, international cohort of children (≤ 19 years old) with newly diagnosed hydrocephalus treated with either ETV (489 patients) or shunt insertion (720 patients) was analyzed. The ETVSS was calculated for all patients. Survival analyses with time-dependent modeling of the hazard ratios were performed.
Results:
For the High-ETVSS Group (255 ETV-treated patients, 117 shunt-treated patients), ETV appeared to have a lower risk of failure right from the early postoperative phase and became more favorable with time. For the Moderate-ETVSS Group (172 ETV-treated patients, 245 shunt-treated patients), ETV appeared to have a higher initial failure rate, but after about 3 months the instantaneous risk of ETV failure became slightly lower than shunt failure (that is, the hazard ratio became < 1). For the Low-ETVSS Group (62 ETV-treated patients, 358 shunt-treated patients), the early risk of ETV failure was much higher than the risk of shunt failure, but the instantaneous risk of ETV failure became lower than the risk of shunt failure at about 6 months following surgery (the hazard ratio became < 1).
Conclusions:
Across all ETVSS strata, the risk of ETV failure becomes progressively lower compared with the risk of shunt failure with increasing time from the surgery. In the best ETV candidates (ETVSS ≥ 80), however, the risk of ETV failure is lower than the risk of shunt failure very soon after surgery, while for less-than-ideal ETV candidates (ETVSS ≤ 70), the risk of ETV failure is initially higher than the risk of shunt failure and only becomes lower after 3-6 months from surgery. These results need to be confirmed by larger, prospective, and preferably randomized studies.
