J Korean Neurosurg Soc.  2023 Mar;66(2):162-171. 10.3340/jkns.2022.0089.

Clinical Outcome of Endoscopic Procedure in Patients with Shunt Malfunction

• Kim KH
• Shim Y
• Lee JY
• Phi JH
• Koh EJ
• Kim SK

• KMID: 2539877
• DOI: http://doi.org/10.3340/jkns.2022.0089

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.

Keyword

Hydrocephalus; Ventriculoperitoneal shunt; Shunt failure; Endoscopy; Ventriculostomy

Figure

• 

  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.

Reference

References

1. Albanese V, Tomasello F, Sampaolo S. Multiloculated hydrocephalus in infants. Neurosurgery. 8:641–646. 1981.

2. Aldana PR, Kestle JR, Brockmeyer DL, Walker ML. Results of endoscopic septal fenestration in the treatment of isolated ventricular hydrocephalus. Pediatr Neurosurg. 38:286–294. 2003.

3. Baldauf J, Fritsch MJ, Oertel J, Gaab MR, Schröder H. Value of endoscopic third ventriculostomy instead of shunt revision. Minim Invasive Neurosurg. 53:159–163. 2010.

4. Baskin JJ, Manwaring KH, Rekate HL. Ventricular shunt removal: the ultimate treatment of the slit ventricle syndrome. J Neurosurg. 88:478–484. 1998.

5. Bilginer B, Oguz KK, Akalan N. Endoscopic third ventriculostomy for malfunction in previously shunted infants. Childs Nerv Syst. 25:683–688. 2009.

6. Boschert J, Hellwig D, Krauss JK. Endoscopic third ventriculostomy for shunt dysfunction in occlusive hydrocephalus: long-term follow up and review. J Neurosurg. 98:1032–1039. 2003.

7. Brockmeyer D, Abtin K, Carey L, Walker ML. Endoscopic third ventriculostomy: an outcome analysis. Pediatr Neurosurg. 28:236–240. 1998.

8. Buxton N, Macarthur D, Robertson I, Punt J. Neuroendoscopic third ventriculostomy for failed shunts. Surg Neurol. 60:201–203. discussion 203-204. 2003.

9. Chan DYC, Tsang ACO, Ho WWS, Cheng KKF, Li LF, Tsang FCP, et al. Emergency endoscopic third ventriculostomy for blocked shunts? Univariate and multivariate analysis of independent predictors for failure. J Neurosurg. 131:1–7. 2018.

10. Cinalli G, Salazar C, Mallucci C, Yada JZ, Zerah M, Sainte-Rose C. The role of endoscopic third ventriculostomy in the management of shunt malfunction. Neurosurgery. 43:1323–1327. discussion 1327-1329. 1998.

11. Deopujari CE, Karmarkar VS, Shaikh ST. Endoscopic third ventriculostomy: success and failure. J Korean Neurosurg Soc. 60:306–314. 2017.

12. Dlouhy BJ, Capuano AW, Madhavan K, Torner JC, Greenlee JD. Preoperative third ventricular bowing as a predictor of endoscopic third ventriculostomy success. J Neurosurg Pediatr. 9:182–190. 2012.

13. Duru S, Peiro JL, Oria M, Aydin E, Subasi C, Tuncer C, et al. Successful endoscopic third ventriculostomy in children depends on age and etiology of hydrocephalus: outcome analysis in 51 pediatric patients. Childs Nerv Syst. 34:1521–1528. 2018.

14. Eller TW, Pasternak JF. Isolated ventricles following intraventricular hemorrhage. J Neurosurg. 62:357–362. 1985.

15. Hader WJ, Walker RL, Myles ST, Hamilton M. Complications of endoscopic third ventriculostomy in previously shunted patients. Neurosurgery. 63(1 Suppl 1):ONS168–ONS174. discussion ONS174-ONS175. 2008.

16. Hamada H, Hayashi N, Kurimoto M, Umemura K, Hirashima Y, Endo S. Neuroendoscopic septostomy for isolated lateral ventricle. Neurol Med Chir (Tokyo). 43:582–587. discussion 588. 2003.

17. Hopf NJ, Grunert P, Fries G, Resch KD, Perneczky A. Endoscopic third ventriculostomy: outcome analysis of 100 consecutive procedures. Neurosurgery. 44:795–804. discussion 804-806. 1999.

18. Jamjoom AB, Mohammed AA, al-Boukai A, Jamjoom ZA, Rahman N, Jamjoom HT. Multiloculated hydrocephalus related to cerebrospinal fluid shunt infection. Acta Neurochir (Wien). 138:714–719. 1996.

19. Jenkinson MD, Hayhurst C, Al-Jumaily M, Kandasamy J, Clark S, Mallucci CL. The role of endoscopic third ventriculostomy in adult patients with hydrocephalus. J Neurosurg. 110:861–866. 2009.

20. Kalsbeck JE, DeSousa AL, Kleiman MB, Goodman JM, Franken EA. Compartmentalization of the cerebral ventricles as a sequela of neonatal meningitis. J Neurosurg. 52:547–552. 1980.

21. Kim SK, Cho BK, Chung YN, Kim HS, Wang KC. Shunt dependency in shunted arachnoid cyst: a reason to avoid shunting. Pediatr Neurosurg. 37:178–185. 2002.

22. Kulkarni AV, Drake JM, Mallucci CL, Sgouros S, Roth J, Constantini S, et al. Endoscopic third ventriculostomy in the treatment of childhood hydrocephalus. J Pediatr. 155:254–259.e1. 2009.

23. Lazareff JA, Peacock W, Holly L, Ver Halen J, Wong A, Olmstead C. Multiple shunt failures: an analysis of relevant factors. Childs Nerv Syst. 14:271–275. 1998.

24. Lee SH, Kong DS, Seol HJ, Shin HJ. Endoscopic third ventriculostomy in patients with shunt malfunction. J Korean Neurosurg Soc. 49:217–221. 2011.

25. Marton E, Feletti A, Basaldella L, Longatti P. Endoscopic third ventriculostomy in previously shunted children: a retrospective study. Childs Nerv Syst. 26:937–943. 2010.

26. Melikian A, Korshunov A. Endoscopic third ventriculostomy in patients with malfunctioning CSF-shunt. World Neurosurg. 74:532–537. 2010.

27. Neils DM, Wang H, Lin J. Endoscopic third ventriculostomy for shunt malfunction: what to do with the shunt? Surg Neurol Int. 4:3. 2013.

28. Nida TY, Haines SJ. Multiloculated hydrocephalus: craniotomy and fenestration of intraventricular septations. J Neurosurg. 78:70–76. 1993.

29. O'Brien DF, Javadpour M, Collins DR, Spennato P, Mallucci CL. Endoscopic third ventriculostomy: an outcome analysis of primary cases and procedures performed after ventriculoperitoneal shunt malfunction. J Neurosurg. 103(5 Suppl):393–400. 2005.

30. Oertel JM, Schroeder HW, Gaab MR. Endoscopic stomy of the septum pellucidum: indications, technique, and results. Neurosurgery. 64:482–491. discussion 491-493. 2009.

31. Oi S, Hidaka M, Honda Y, Togo K, Shinoda M, Shimoda M, et al. Neuroendoscopic surgery for specific forms of hydrocephalus. Childs Nerv Syst. 15:56–68. 1999.

32. Sainte-Rose C, Piatt JH, Renier D, Pierre-Kahn A, Hirsch JF, Hoffman HJ, et al. Mechanical complications in shunts. Pediatr Neurosurg. 17:2–9. 1991.

33. Salmon JH. Isolated unilateral hydrocephalus following ventriculoatrial shunt. J Neurosurg. 32:219–226. 1970.

34. Shaikh S, Deopujari CE, Karmarkar V, Muley K, Mohanty C. Role of secondary endoscopic third ventriculostomy in children: review of an institutional experience. Pediatr Neurosurg. 54:188–195. 2019.

35. Siomin V, Cinalli G, Grotenhuis A, Golash A, Oi S, Kothbauer K, et al. Endoscopic third ventriculostomy in patients with cerebrospinal fluid infection and/or hemorrhage. J Neurosurg. 97:519–524. 2002.

36. Siomin V, Weiner H, Wisoff J, Cinalli G, Pierre-Kahn A, Saint-Rose C, et al. Repeat endoscopic third ventriculostomy: is it worth trying? Childs Nerv Syst. 17:551–555. 2001.

37. Spennato P, O'Brien DF, Fraher JP, Mallucci CL. Bilateral abducent and facial nerve palsies following fourth ventricle shunting: two case reports. Childs Nerv Syst. 21:309–316. 2005.

38. Teo C, Jones R. Management of hydrocephalus by endoscopic third ventriculostomy in patients with myelomeningocele. Pediatr Neurosurg. 25:57–63. discussion 63. 1996.

39. Waqar M, Ellenbogen JR, Mallucci C. Endoscopic third ventriculostomy for shunt malfunction in children: a review. J Clin Neurosci. 51:6–11. 2018.

40. Zhao R, Shi W, Yang H, Li H. Endoscopic third ventriculostomy instead of shunt revision in children younger than 3 years of age. World Neurosurg. 88:92–96. 2016.