Mangat, Manvinder Singh
(2017)
A shunt dependency outcome of endoscopic third ventriculostomy in the management of obstructive hydrocephalus.
Masters thesis, Universiti Sains Malaysia.
Abstract
Background: Endoscopic third ventriculostomy (ETV) is an accepted alternative to cerebro-spinal fluid(CSF) shunting in cases of obstructive hydrocephalus. The aim of this study is to evaluate the shunt dependency following ETV in obstructive hydrocephalus patients and factors influencing it.
Methods: This was a cross-sectional study of which a total of 206 patients presenting with obstructive hydrocephalus that underwent ETV from 3 major centres ;. Kuala Lumpur General Hospital, Hospital Universiti Sains Malaysia and Sarawak General Hospital were studied. Successful ETV is taken as clinically no symptoms of raised intracranial pressure and imaging evidence of resolution of hydrocephalus(1).
Results: Mean age of patients was 21.1 ± 22.6 years with 98 (47.6%) being paediatrics (<12 years) and 108 (52.4%) adults (≥12 years). 63 (30.6%) were of congenital causes, 90 (43.7%) tumoral related, 40 (19.4%) due to hemorrhage and 13 (6.3%) post-infective. Shunt free outcome at one month was 179 (86.9%) and 177 (85.9%) at six months. Chi-square test showed no statistical significance in outcome with age groups (p value = 0.629) or outcome with diagnosis (p value = 0.057). Univariate analysis via logistic regression showed significance of Liliequist membrane with odds ratio 4.375 ; 95% CI (1.188 - 16.115), p value 0.027 ; of which patients with Liliequist membrane present are 4-fold risk of failure and ending up with a shunt after 1month following ETV. Also noted the nature of fenestration with the outcome where at one month odds ratio 17.969 ; 95% CI (2.077 - 5.957), p value 0.009 and at six months odds ratio 19.154 ; 95% CI (2.11,173.868), p value 0.009 signifies a large fenestra with well flapping floor of the third ventricle has a 17-fold chance of being shunt free at one month and 19-fold chance at six months. Multivariatelogistic regression analysis showed significance of nature of fenestration with the outcome where at one month adjusted ratio 0.231 ; 95% CI (0.091-0.518), p value 0.005 and at six months adjusted ratio 0.241 ; 95% CI (0.092 - 0.535), p value 0.006 signifies a large fenestra with well flapping floor of the third ventricle has a 0.2-fold chance of being shunt free at one month and six months respectively. Also noted was 6 months outcome based on age group with adjusted ratio 0.202 ; 95% CI (0.109 - 0.206), p value 0.006 ; of which adult patients have 0.2-fold chance of being shunt free at six month following endoscopic third ventriculostomy.
Survival analysis using Cox regression to generate Hazard ratio showed ETV failure at any point of time in this study for tumoral causes are 0.322 times less likely to fail compared to congenital causes ( HR 0.322 ; 95% CI 0.122 - 0.847 ; p value 0.022).
Conclusion: ETV is a safe and effective procedure in patients with obstructive hydrocephalus. Patients with presence of Liliequist membrane has a higher chance of ETV failure and nature of the fenestra plays a vital role in outcome of ETV. Paediatric age group has a slightly higher chance of ETV failure. Patients with tumors predominantly pineal and posterior fossa tumors has a higher chance of success compared to congenital cases.
Keywords: endoscopic third ventriculostomy, hydrocephalus, shunt dependency, Liliequist membrane
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