Pediatric Obstructive Hydrocephalus: Comparative Outcomes of Endoscopic Third Ventriculostomy Alone Versus Single-Stage Endoscopic Third Ventriculostomy with Ventriculoperitoneal Shunt Placement
DOI:
https://doi.org/10.58600/eurjther2951Keywords:
cerebrospinal fluid diversion, endoscopic third ventriculostomy, obstructive hydrocephalus, pediatric hydrocephalus, ventriculoperitoneal shuntAbstract
Objective: To compare the clinical outcomes of endoscopic third ventriculostomy (ETV) alone versus single-stage ETV combined with ventriculoperitoneal (VP) shunt placement in pediatric obstructive hydrocephalus, and to determine whether the combined approach reduces early failure in high-risk etiologies without increasing complication rates.
Methods: A retrospective cohort of 59 children treated for obstructive hydrocephalus between 2010 and 2024 was analyzed. Patients underwent either ETV alone (n=26) or single-stage ETV with VP shunt placement (n=33). Etiology, demographic characteristics, intraoperative findings, postoperative complications, revision surgeries, and radiological outcomes were systematically recorded. Treatment success was defined as the absence of additional cerebrospinal fluid diversion procedures and sustained clinical-radiological stability during follow-up. Early and late complications, infection rates, and mortality were also evaluated. Statistical analyses included the Student t-test or Mann-Whitney U test for continuous variables and Fisher exact test for categorical variables, with significance set at p<0.05.
Results: Aqueductal stenosis was the most common etiology (64.4%), followed by posthemorrhagic obstruction (16.9%), fourth ventricular outlet obstruction (11.9%), and tumor-related obstruction (6.8%). Treatment success was significantly higher in the combined ETV+VP shunt group compared with the ETV-alone group (87.9% vs. 65.4%, p=0.038). Revision surgery was required in 9 ETV patients (34.6%) and 4 combined-procedure patients (12.1%, p=0.038). Early infection rates were identical between groups (2 cases each, p=1.000), and late infection rates did not differ significantly. Overall infection rates (p=0.744) and mortality (4 vs. 3 patients, p=0.696) were comparable between the two approaches.
Conclusion: In this cohort, single-stage ETV with VP shunt placement was associated with a higher treatment success rate compared with ETV alone, particularly in infants and children with posthemorrhagic ventricular obstruction. These findings suggest that the combined strategy may help address early physiological limitations of ETV and could be considered a safe and promising option in appropriately selected pediatric patients with obstructive hydrocephalus.
References
[1] Kahle KT, Kulkarni AV, Limbrick DD Jr, Warf BC (2016) Hydrocephalus in children. Lancet. 387(10020):788–799. https://doi.org/10.1016/S0140-6736(15)60694-8
[2] Wright Z, Larrew TW, Eskandari R (2016) Pediatric hydrocephalus: current state of diagnosis and treatment. Pediatr Rev. 37(11):478–490. https://doi.org/10.1542/pir.2015-0134
[3] Välimaa J, Huuskonen TJ, Tervonen J, Leinonen V, Rantala S (2025) Rate and risk factors for shunt revision in pediatric patients with hydrocephalus during a 17-year study period: a retrospective, population-based study. Childs Nerv Syst. 41(1):316. https://doi.org/10.1007/s00381-025-06992-1
[4] Kestle JR, Garton HJL, Whitehead WE, Drake JM, Kulkarni AV, Cochrane DD, Muszynski C, Walker ML (2006) Management of shunt infections: a multicenter pilot study. J Neurosurg. 105(3 Suppl):177–181. https://doi.org/10.3171/ped.2006.105.3.177
[5] Tully HM, Dobyns WB (2014) Infantile hydrocephalus: a review of epidemiology, classification and causes. Eur J Med Genet. 57(8):359–368. https://doi.org/10.1016/j.ejmg.2014.06.002
[6] García-Milán V, Moreno-Madueño G, Urreta Juárez G, Rivero-Garvía M, Márquez-Rivas J (2024) Long-term success of endoscopic third ventriculostomy in the pediatric population with aqueductal stenosis. World Neurosurg 189:e364–e369. https://doi.org/10.1016/j.wneu.2024.06.056
[7] Al-Hakim S, Schaumann A, Tietze A, Schulz M, Thomale UW (2019) Endoscopic third ventriculostomy in children with third ventricular pressure gradient and open ventricular outlets on MRI. Childs Nerv Syst. 35(12):2319–2326. https://doi.org/10.1007/s00381-019-04383-x
[8] Geyik M, Geyik S, Dogan A (2022) Comparison of different endoscopic techniques for the treatment of hydrocephalus in children. Turk Neurosurg. 32(2):271–276. https://doi.org/10.5137/1019-5149.JTN.35124-21.1
[9] Simon TD, Riva-Cambrin J, Srivastava R, Bratton SL, Dean JM, Kestle JRW (2008) Hospital care for children with hydrocephalus in the United States. Pediatrics. 121(1):e1–e10. https://doi.org/10.3171/PED/2008/1/2/131
[10] Patwardhan RV, Nanda A (2005) Implanted ventricular shunts in the United States: the billion-dollar-a-year cost of hydrocephalus treatment. Neurosurgery. 56(1):139–144. https://doi.org/10.1227/01.neu.0000146206.40375.41
[11] Kulkarni AV, Drake JM, Kestle JR, Mallucci CL, Sgouros S, Constantini S (2010) Predicting who will benefit from endoscopic third ventriculostomy compared with shunt insertion in childhood hydrocephalus using the ETV Success Score. J Neurosurg Pediatr. 6(4):310–315. https://doi.org/10.3171/2010.8.PEDS103
[12] Naftel RP, Reed GT, Kulkarni AV, Wellons JC (2011) Evaluating the Children’s Hospital of Alabama endoscopic third ventriculostomy experience using the Endoscopic Third Ventriculostomy Success Score: an external validation study. J Neurosurg Pediatr. 8(5):494–501. https://doi.org/10.3171/2011.8.PEDS1145
[13] Kadrian D, van Gelder J, Florida D, Jones R, Vonau M, Teo C, Stening W, Kwok B (2005) Long-term reliability of endoscopic third ventriculostomy. Neurosurgery. 56(6):1271–1278. https://doi.org/10.1227/01.neu.0000159712.48093.ad
[14] Vulcu S, Eickele L, Cinalli G, Wagner W, Oertel J (2015) Long-term results of endoscopic third ventriculostomy: an outcome analysis. J Neurosurg. 123(6):1456–1462. https://doi.org/10.3171/2014.11.JNS14414
[15] Minta KJ, Zielińska M, Roszkowski M, Błaszczyk M, Czernicki Z (2024) Outcomes of endoscopic third ventriculostomy (ETV) and ventriculoperitoneal shunt (VPS) in the treatment of paediatric hydrocephalus: systematic review and meta-analysis. Childs Nerv Syst. 40(4):1045–1052. https://doi.org/10.1007/s00381-023-06225-3
[16] Schulz M, Bührer C, Pohl-Schickinger A, Haberl H, Thomale UW (2014) Neuroendoscopic lavage for the treatment of intraventricular hemorrhage and hydrocephalus in neonates. J Neurosurg Pediatr. 13(6):626–635. https://doi.org/10.3171/2014.2.PEDS13397
[17] Marano PJ, Stone SS, Mugamba J, Ssenyonga P, Warf EB, Warf BC (2015) Reopening of an obstructed third ventriculostomy: long-term success and factors affecting outcome in 215 infants. J Neurosurg Pediatr. 15(4):399–405. https://doi.org/10.3171/2014.10.PEDS14250
[18] Shim KW, Kim DS, Choi JU (2008) Simultaneous endoscopic third ventriculostomy and ventriculoperitoneal shunt for infantile hydrocephalus. Childs Nerv Syst. 24(4):443–451. https://doi.org/10.1007/s00381-007-0526-z
[19] Texakalidis P, Tora MS, Wetzel JS, Chern JJ (2019) Endoscopic third ventriculostomy versus shunt for pediatric hydrocephalus: a systematic literature review and meta-analysis. Childs Nerv Syst. 35(8):1283–1293. https://doi.org/10.1007/s00381-019-04203-2
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