Endoscopic third ventriculostomy and choroid plexus cauterization versus Endoscopic third ventriculostomy alone in treatment of hydrocephalus in infants

Abstract

Infantile hydrocephalus is one of the variable and complex diseases in neurological surgery, hydrocephalus defined as an active distension of the ventricular system resulting from inadequate passage of cerebrospinal fluid from its point of production within the cerebral ventricles to its point of absorption into the systemic circulation. Hydrocephalus in infants which either can be congenital without obvious extrinsic cause or secondary to hemorrhage, infection or neoplasm needs intervention and treatment by one way or another. Endoscopic third ventriculostomy (ETV) is a procedure in which a CSF diversion is created through a ventriculocisternostomy directly into the subarachnoid space, besides it reduces the transmantle pulsatile stress by increasing compliance of the ventricular wall, this procedure has been debatable in infants due to high discrepancy in failure rates among different studies. Recently, the combination of Etv with Choroid plexus cauterization (CPC) in infants has been widely debatable and promising with favorable results. With the rationale being that an imbalance in CSF absorption capacity may be one of the reasons behind ETV failure. Cauterization of the choroid plexus would, in theory, decrease CSF production, compensating for the presumably hindered absorption capacity of CSF in infants and augment effect of ETV by reducing the amplitude of intraventricular pulsations, depending on hydrodynamic theory of hydrocephalus, depending on pulsatite flow theory of CSF circulation. In our review, the total number of infants in the 14 study meeting our inclusion criteria; less than 2 years of age and with no prior intervention were included with total of 968 patients, of which 541 patients (55.9%) underwent Etv alone, while 427 patients (44.1%) underwent ETV CPC. The results of our review denoted that the outcome of treatment hydrocephalus in infants with ETV and CPC together, raises success rates of ETV procedure specifically in the hydrocephalus associated with myelomeningeocele and communicating hydrocephalus. In addition to infants below 6 months, would benefit as well from the addition of CPC to the normal ETV with higher success rates. The failure of the first attempt of Etv with CPC or Etv alone, doesn’t lead to certainty of shunt insertion, as there is a probability of more than 4 out 10 infants with primary failures remain shunt free with a successful re ETV. There is no increase in neither morbidity nor mortality by adding the procedure of CPC to the normal Etv procedure.