Neurology India Medknow Publications on behalf of the Neurological Society of India ISSN: 0028-3886 EISSN: 1998-4022 Vol. 54, Num. 2, 2006, pp. 161-163

Neurology India, Vol. 54, No. 2, April-June, 2006, pp. 161-163

Original Article

Endoscopic third ventriculostomy in infants

Yadav YR, Jaiswal Sumeet, Adam Nelson, Basoor Abhijeet, Jain Gaurav

Neurosurgery Unit, NSCB Medical College, Jabalpur, MP
Correspondence Address:Neurosurgery Unit, NSCB Medical College, Jabalpur, MP, yadavyr@yahoo.co.in

Code Number: ni06047

Abstract

Keywords: Endoscopic third ventriculostomy, infants, hydrocephalus.

Introduction

Materials and Methods

This is a prospective study of 54 infants who underwent ETV in our institution during the period July 2003 to June 2005. A detailed history and physical examination was done in all the cases. CT scan was also done in all the infants. MRI could be done in 21 patients only. ETV was done in all cases of obstructive hydrocephalus. Out of a total of 54 patients, majority of patients (n=48) had congenital hydrocephalus with aqueductal stenosis and 6 had tuberculous meningitis [TBM].

Stoma of 5 mm or more was made in all the cases. In majority of the cases the floor was punctured with blunt instruments and the opening was enlarged using grasping forceps. Fogarty catheter was used in 15 patients to enlarge the opening.

All post operative complications like infections, CSF leak and failure of procedure were evaluated. Post operative CT scan [n=8] and MRI [n=5] were done in 13 patients who did not improve, deteriorated or had evidence of failure of ETV such as a bulging fontanelle or CSF leak from the operative site. ETV was considered clinically successful when anterior fontanelle was depressed or flush to the adjoining scalp and the patient improved clinically. Follow up ranged from 9 to 32 months with an average of 18 months.

Results

A total of 54 infants were studied, out of these 33 were male and 21 female. There were 10 infants of one month or less than one month of age. Out of these 5 were born prematurely and had a low birth weight while 5, 7, 14 and 18 infants were of more than one month to < 2 months, 2 months to 3 months, 3 months to 6 months and 6 months to one year respectively. Forty five patients (83.7%) showed overall clinical improvement. The clinical improvement in infants of one month of age, > one month to 2 months, 2 months to 3 months, 3 months to 6 months and 6 months to one year was 6 (60%), 4 (80%), 6 (85.7%), 13 (92.8%) and 16 (88.8%) patients respectively. Only 2 (40%) pre mature low birth weight infants out of 5 cases in the age group of less than one month improved while 4 (80%) out of 5 cases in one month age group full term normal birth weight infants showed clinical improvement. Age did not have any impact on the success rate. The mean age of the cases with success was observed 5.24 (± 3.18) months while the mean age of those in whom ETV failed was 4.5 (± 3.73) months ( P >0.05). There was no difference in the success rates ( P >0.05) when the patients were considered as two groups based on age (one neonates and another infants).

Eight patients developed CSF leak from the burr hole. Leak stopped in 5 days in 4 patients but 4 infants had a persistent CSF leak. MRI without flow study was suggestive of stoma closure in these cases. All these patients had evidence of infection also. Four patients had bleeding during surgery, which stopped after continuous irrigation. Procedure had to be abandoned in 1 patient due to poor visualization of floor of the third ventricle. The stoma was found to be closed in 8 cases. Out of these, 4 had concomitant infection and 2 had bleeding during surgery while the other two did not have infection or per operative bleeding. In 7 cases stoma closer occurred within 6 weeks time while in the remaining case this complication was seen within 3 months. When we analyzed stoma closure cases, we found that 3 out of 8 stoma closures were in low birth weight pre mature infants. Failure rate in low birth weight pre mature infants (n=5) was 60% compared to 12.3% in full term normal birth weight infants (Fishers exact test, P =0.03).

One of our patients developed transient diabetes insipidus (DI), which resolved on its own. Successful re-endoscopic surgery was done in 4 patients who had stoma closure, while four patients with associated infection were treated with ventriculo-peritoneal shunt after management of infection.

Four out of 6 [66.6%] cases of TBM had clinical success while it was 41 out of 48 [85.4%] cases in congenital hydrocephalus with aqueductal stenosis. This difference was not statistically significant (Fisher′s exact test P =0.3)

Discussion

Failure of ETV was 16.7% in our study, including one procedure which was abandoned (2%) due to poor visualization of the floor of the third ventricle. This was a case of TBM hydrocephalus in which we could not see the mamillary bodies and the infundibular recess. Most of the stoma blockage (6 out of a total of 8) occurred following infection (4) and bleeding during surgery (2). Failure rate of ETV in low birth weight pre mature infants (n=5) was higher (60%) as compared to full term normal birth weight infants (12.3%). Ventriculitis developed in 4 patients (8%). Infection was also a common complication in other studies. 11%infants developed infection in Gorayeb[9] series while 10%[6] and 15%[10] of patients developed infection in other series.

CSF leak occurred in 8 (16%) patients which stopped in 4 cases spontaneously. The cause of persistent leak in 4 patients (8%) was closure of stoma. Causes of temporary CSF leak could be due to failure of closure of dura, thinned out scalp and thin cortical mantle in patients with gross hydrocephalus. We therefore started closing dura in patients with gross hydrocephalus with thin cortical mantle, in the later part of our study. We opened dura in linear fashion which could be easily closed in these patients rather than using a cruciate dural opening. Incidence of CSF leak after ETV have varied between 2%[11] to 7%.[12]

Bleeding occurred in 4 patients (8%) during surgery which stopped after persistent irrigation. Two out of these 4 patients developed closure of stoma resulting in failure of ETV. Bleeding was also seen in about 5%[7] and 3%[8] of cases in other series. Aspiration of clots and thorough irrigation of ventricular cavity should be done after bleeding stops; this measure can reduce chances of stoma closure.

Clinical success in TBM was 66.6% while it was 84.5% in congenital hydrocephalus with aqueductal stenosis. Similar results of 77% success was reported by Singh et al[13] while Jonathan et al[14] reported long term successful results with ETV in both their caseswith hydrocephalus secondary to TBM.

Eight patients (11%) had blockage of stoma, of these 4 had associated infection. Four of these patients who had stoma blockage underwent successful re-endoscopic surgery while 4 patients with infection were treated by ventriculo-peritoneal shunt after management of infection. Transient Diabetes insipidus (DI) was observed in 1 patient (2%), which resolved on its own by 7th postoperative day. Possible cause of this could be hypothalamic pituitary axis injury. Diabetes insipidus was also reported by Choi et al[8] in 3% cases. Our complication rate is comparable to the above study.

The strength of our study is the large number of patients and prospective nature of the study. Limitation of this study is that the follow up is short with only 75% patients having follow up of more than 1 year. However all the complications in this study occurred within 3 months including those patients with follow up of 2 years and more. But delayed complications including failure can occur and a longer follow up is desirable.

Acknowledgement

References

Copyright 2006 - Neurology India