Predictors of surgery-free outcome in adult endoscopic third ventriculostomy

Endoscopic third ventriculostomy (ETV) is being used increasingly in adults as an alternative to cerebrospinal fluid (CSF) shunting. We analyze patient, radiographic, and operative factors associated with CSF diversion surgery-free outcomes after ETV.

One hundred twenty four consecutive adult patients (>18 years) treated with ETV at an academic institution were retrospectively reviewed according to demographic, clinical, operative, radiographic, and follow-up variables. After excluding patients with unclear etiologies or complex previous CSF shunting regimens, there remained 103 patients undergoing ETV for obstructive hydrocephalus, either as initial intervention or in the setting of shunt failure. The primary end point used to assess ETV failure was return to the operating room for CSF diversion. Return of radiographic findings consistent with uncompensated hydrocephalus was considered as a secondary end point. Associations with ETV failure were assessed via Cox proportionate-hazards regression analysis.

Clinical improvement was seen in 76 (74%) patients within a median of one month after surgery. Radiographic improvement was seen in 59 (57%) patients within a median of two months after surgery. Fifty-seven (55%) of the patients remained symptom and surgery-free through last follow-up, a median of 5 [2-9] years after ETV. Lasting morbidity and mortality occurred in less than 1%. Multivariate, independent associations with ETV failure included perioperative steroid use, intraoperative image guidance, and time to radiographic improvement. Patients who had image-guided surgery or perioperative steroid treatment were approximately 2.5 times less likely to experience ETV failure.

ETV is a safe and effective procedure in adult patients. Perioperative factors, intraoperative image guidance, and steroid treatment may lower ETV failure rates.