| Background and Objective:Hydrocephalus is one of the most common neurologist diseases and the surgical outcome has been obviously improved due to shunt equipment and neuroendoscopy development in recent years. there is no recognized definitions, classifications, and complex pathophysiology of hydrocephalus currently. Dandy proposed the classical classification standard of communicating or obstructive (noncommunicating) hydrocephalus using ventricular puncture and lumbar puncture in the early decades of the twentieth century, but its neglected the status of intraventricular stenosis and extraventricular intracisternal obstruction with neuroimaging development, and some specialists proposed that all hydrocephalus was obstructive hydrocephalus. In theory, endoscopic third ventriculostomy (ETV) is an effective treatment option for obstructive hydrocephalus between posterior third ventricle and basal cisterns. Although Third ventriculostomy for intraventricular obstructive hydrocephalus is well accepted today, the outcome of treatment remains controversial and dissatisfactory in extraventricular hydrocephalus and sometimes management are fraught with problems. The goal of this study was to assess indication, effect and the risk of failure associated with factors of endoscopic third ventriculostomy in patients with intra and extraventricular hydrocephalus based on generalized obstruction.Method:The clinical date of172cases of hydrocephalus treated with ETV were analyzed retrospectively at Nan fang hospital between June2004and August2011. Follow-up10days to86months (average26.2months), the ETV outcomes were achieved in152patients. Patients were divided into subgroups based on the etiology,age, obstructive site,ETVSS, shunt history etc, and the prognostic factors was statistical analysised using Kplan-Meier and COX proportion methods.Result:1、Primary aqueductal stenosis (38.8%), tumors(32.2%), and intracranial hemorrhage (11.8%) were the most common causes of hydrocephalus.2、Follow-up10days to86months (average26.2months), the ETV outcome was analyzed in152patients who underwent155ETVs. and the overall success rate was79.6%,84.1%ith intraventricular obstructive hydrocephaus. Major complications occurred in18patients(11.8%), with the most common complications being CSF leak (4.6%),although most complications were minor. Eighty-four percent of ETV failures occur within3months after surgery and2patients has been found ETV stoma closure after ETV in the5delayed failed procedure (40%).3、155procedures were performed in152patients, including made smoothly in145cases, made difficultly in7cases because intraventricular environment and anatomical changes, and no finished in lcase because surgical equipment simultaneously.4、the complication incidence was28.1%ith infant group,7.1%ith young children group and7.7%with adult group, this result was statistically significant between different groups by R*C χ2test (χ2=10.3, P=0.006), the complication incidence of infant group is much higher than other2groups.5、In119successful ETV cases (that is, the patient shunt free and without hydrocephalus symptoms or complaints), ventricular size changed smaller in66.7%at3to6months and in89.5%at1to2years. this result was statistically significant between different groups with age(χ2=6.37, P<0.041)and history (χ2=8.14, P=0.017) by R*C χ2test. There were no statistically significant association between different groups with obstructive site, gender, ETVSS and shut history (P>0.05)6、The overall success rate in tumor group was93.9%, compared with83.1%in primary aqueductal stenosis group,50%in intraventricular hemorrhage group,50%in infection group and72.7%in other pathogeny group. By log rank test and Kaplan-Meier survival curve analysis, the overall successful rate after ETV in patients with tumor and primary aqueductal stenosis group is much higher than intraventricular hemorrhage and infection group(χ2=24.3,P<0.01).7、The overall success rate in infant group was50%, compared with88.1%in young children group and87.2%in adult group, this result was statistically significant between different groups by R*C χ2test (χ2=21.89, P<0.01). By log rank test and Kaplan-Meier survival curve analysis, The success rate at2years of follow-up was55.7%,86.8%and87.1%, the effects of infant group was much worse than other2groups and there was statistically significant(x2=22.74,P<0.01).8、The overall success rate in aqueductal stenosis group was85.5%, compared with73.7%in the fourth ventricle outlet group and50%in extraventricular obstruction group, this result was statistically significant between different groups by R*C χ2test (χ2=13.91, P=0.001). By log rank test and Kaplan-Meier survival curve analysis, the effects of aqueductal stenosis group was better than extraventricular obstruction group, and this result was statistically significant (χ2=17.18, P<0.01).9、In20patients of extrivantricular obstructive hydrocephalus, satisfying postoperative results were obtained in10patients who all showed abnormal enlargement of the fourth ventricle and outward expansion of the cerebral aqueduct outflow like a horn by MRI in12patients (83.3%), whereas the other8patients without this imageology character required shunt insertion, this result was statistically significant between different imaging features groups by fisher’s Exact test (p=0.001)10、We demonstrated that one postinfective hydrocephalic patient’s spinal subarachnoid space was extensive adhesive in12patients who all showed abnormal enlargement of the fourth ventricle and outward expansion of the cerebral aqueduct outflow like a horn by MRI using cisterongraphy CT, and called them proximal extraventricular intracisternal obstructive hydrocephalus(EXH), there was no statistically significant between intraventricular obstruction group and proximal extraventricular intracisternal obstruction group (χ2=2.95,P=0.229)11、The overall success rate in High-ETVSS group was94.8%, compared with56.7%n Moderate-ETVSS group and40%n Low-ETVSS, this result was statistically significant between different-groups by R*C χ2test (χ2=32.52, P=0.057). By log rank test and Kaplan-Meier survival curve analysis, the success rate at2years of follow-up was94.3%,62.2%and40%, the effects of Low-ETVSS was much worse than other2groups and there was statistically significant (χ2=39.4,P<0.001)12、The overall success rate in shunt group was63.2%and compared with82%in no-shunt group, there was no statistically significant by χ2test (χ2=3.62, P=0.057). In19patients with shunt group, satisfying postoperative results were obtained in12patients who all showed intraventricular and proximal intracisternal obstructive feature by MRI in15patients, whereas the other4patients without this imageology character all failed, the effects was statistically significant between the two groups by fisher’s Exact test (P=0.009).13、Factors included in the Cox model were etiology, age, complication, obstructive site of hydrocephalus, ETVSS, shunt history and etc. By multivariate analysis, the Cox model was statistically significant included age group, obstructive site and shunt history, Patients<2years of age had a6.4-fold increased risk of ETV failure than older patients (adjusted hazard ratio6.49,95%CI2.78-15.17, P<0.01)Conclusion:1、Endoscopic third ventriculostomy is a safe procedure and an effective treatment option for intraventricular and some extraventricular obstructive hydrocephalus, the age is the most important factor of outcome and the ETVSS can be used to differentiate expected survival outcomes for patients treated with ETV.2、Abnormal enlargement of the fourth ventricle and outward expansion of the cerebral aqueduct outflow like a horn by MRI is maybe one of the most important indication of ETV in patients with Extraventricular intracisternal obstructive hydrocephalus, and a mechanism of an proximal extraventricular intracisternal cerebrospinal fluid pathway obstruction could explain.3、The stoma reclosure and distal intracisternal obstruction are the most responsible factors for ETV failure in obstructive hydrocephalus. Keeping a sufficiently broad stoma and managing the adjacent membranes by electrocoagulation is effective to preventing closure of stoma. An.endoscopic inspection should done at repeated surgery in patients with failure after ventriculostomy in obstructive hydrocephalus and avoid a VP shunt.4、ETV is a safe procedure and an effective treatment option in patient with shunt malfunction. the imageology character of intraventricular and proximal extraventricular intracisternal obstruction is the main indications of ETV. 5、Intraventricular environment and anatomical changes is probably the most common cause of difficultly ETV, We should predict the difficulty index of ETV and master surgical details fully, when necessary, take advantage of endoscopic neuronavigation.Innovations of our study:We assessed the effect and the risk of failure associated with factors of endoscopic third ventriculostomy in patients with intra and extraventricular hydrocephalus based on generalized obstruction,and confirmed that ETV is a effect method for extraventricular hydrocephalus. The indication and mechanism was also proposed in our study and increased surgical outcome. |
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