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Endoscopic third ventriculostomy for hydrocephalus after craniovertebral decompression for Chiari malformation type
Joshua Pepper1, Desiderio Rodrigues1, Pasquale Gallo2
1Department of Neurosurgery, Birmingham Women's and Children's NHS Foundation Trust, Steelhouse Lane, Birmingham, B4 6NH, UK.
Insights
Endoscopic third ventriculostomy (ETV) offers a potential treatment for hydrocephalus following craniovertebral decompression in Chiari I malformation patients. This minimally invasive approach can be effective, though technical challenges exist.
Area of Science:
- Neurosurgery
- Pediatric Neurosurgery
- Cerebrospinal Fluid Disorders
Background:
- Hydrocephalus is a recognized complication after craniovertebral decompression (CVD) for Chiari I malformation (CM-1).
- Current management includes medical therapy, lumbar punctures, external ventricular drainage (EVD), or ventriculoperitoneal shunts (VPS).
- Endoscopic third ventriculostomy (ETV) use for this specific indication is limited with controversial outcomes.
Purpose of the Study:
- To report the experience and technical nuances of using ETV to treat hydrocephalus post-CVD in CM-1 patients.
- To evaluate the efficacy and safety of ETV in this challenging patient population.
Main Methods:
- A prospectively maintained database was used to identify pediatric patients who underwent ETV for hydrocephalus after CVD for CM-1.
- Case series analysis of three pediatric patients.
Main Results:
- Two out of three pediatric patients achieved successful hydrocephalus treatment with ETV, confirmed by reduced ventricular size on imaging and no need for further CSF drainage.
- One ETV procedure was abandoned due to high-pressure cerebrospinal fluid egress and ventricle collapse, necessitating a ventriculoperitoneal shunt (VPS).
- Hydrocephalus presented an average of 8 days post-CVD.
Conclusions:
- ETV is a viable treatment option for post-CVD hydrocephalus in CM-1 patients, contingent on the hydrocephalus etiology.
- Technical and anatomical factors specific to post-CVD hydrocephalus present unique challenges compared to typical obstructive hydrocephalus ETV procedures.
- This study details the authors' experience and reviews existing literature on ETV for this condition.
Purpose:
Hydrocephalus after craniovertebral decompression (CVD) for Chiari I malformation (CM-1) is a well-recognised complication. The mainstay of management involves medical management with high-dose steroids and/or acetazolamide, repeated lumbar punctures, external ventricular drainage (EVD) or insertion of a ventriculoperitoneal shunt (VPS). Endoscopic third ventriculostomy (ETV) has only been used a handful of times to treat this type of hydrocephalus with controversial outcomes. Not much is known about this or the technical nuances of this procedure. We report our experience.
Methods:
All children who underwent ETV to treat hydrocephalus post CVD done for CM-1 were identified from a prospectively kept database.
Results:
Three children were identified (13F, 11F, 13F). The average time to presentation of hydrocephalus was 8 days after craniovertebral decompression. Two were successfully treated with ETV with brain imaging showing a reduction in the size of the ventricles post-operatively and not requiring any further cerebrospinal fluid drainage. In one patient, the procedure had to be abandoned after the peel away catheter was introduced into the right ventricle because CSF egressed under high pressure with ventricle walls collapse resulting in an obstructed view. This child ultimately required a VPS.
Conclusion:
ETV can be used to successfully treat post CVD hydrocephalus in CM-1 patients depending on the aetiology of the hydrocephalus. There are technical and anatomical commonalities between these cases which make it more challenging than an ETV performed in "typical" obstructive hydrocephalus. We describe our experience and review the cases previously reported in the literature.
