Abstract
Post-tubercular meningitic hydrocephalus (TBMH) and post-traumatic hydrocephalus (PTH) is often considered a contraindication for endoscopic third ventriculostomy (ETV), as it is mostly of communicating type in these cases. The aim of the present study was to define the role of ETV in patients with communicating hydrocephalus. Ten consecutive patients of TBMH, PTH and postneurocysticercus (NCC) hydrocephalus were formed the study group. Diagnosis of communicating hydrocephalus was made using magnetic resonance ventriculography (MRV). If contrast was seen coming out from the ventricular system into the basal cisterns, it was considered as communicating hydrocephalus. Patients with clinical and imaging evidence of raised intracranial pressure and failed medical treatment were taken up for ETV. All patients were studied by preoperative and postoperative MRV. Success of the procedure was assessed by the improvement in clinical and imaging parameters on postprocedure follow-up in all these cases. Technically successful ETV was performed in all 10 patients. Overall success rate of ETV in communicating hydrocephalus was 70% (n = 7). The shunt surgery was performed in the remaining three patients with ETV failure. One patient developed complication following postoperative MRV and was managed conservatively. We conclude that ETV is effective in post-TBM, post-traumatic communicating and post-NCC communicating hydrocephalus and should be considered as initial surgical option for cerebrospinal fluid diversion in these patients. MRV is a relatively safe technique to ascertain the patency of subarachnoid space as well as ETV stoma.
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Nikolai Hopf, Stuttgart, Germany
The authors describe 10 patients with communicating hydrocephalus treated by endoscopic third ventriculostomy (ETV). Communicating hydrocephalus was caused by trauma, tubercular meningitis or neurocysticercosis.
All patients had MR ventriculography before and after ETV. Seven patients were treated successfully, based on clinical findings and MRI. The others show nicely the usefulness of MR-ventriculography for indication and outcome of ETV, even though their technique of performing it under general anesthesia and repetitive puncturing of the ventricle via the same burr hole seams associated with an additional risk of infection and not applicable to a large patient population. But it is certainly a very valuable investigation in patients with not accepted indication for ETV or nonconclusive MRI findings.
My concern with this paper is the definition of communicating hydrocephalus. The others define it by MR ventriculography when the contrast medium exits the fourth ventricle but stays in the cisterns of the posterior fossa. Patients with further spread of the contrast were excluded (two patients).
In all treated patients (10 patients), CSF did obviously not reach the region of CSF reabsorption. Therefore this type of hydrocephalus should be categorized as noncommunicating. It is well-known that ETV is successful whenever a formerly nonexisting access to the convexity can be created and reabsorption is not impaired. However the paper most importantly demonstrates that patients with posttraumatic, postmeningitic, and hydrocephalus from neurocysticercosis may profit from ETV, if an obstruction of the CSF pathway is present. This can nicely be demonstrated by MR ventriculography. But it is certainly not correct, based on this paper, to conclude that communicating hydrocephalus can be treated successfully by ETV.
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Singh, I., Haris, M., Husain, M. et al. Role of endoscopic third ventriculostomy in patients with communicating hydrocephalus: an evaluation by MR ventriculography. Neurosurg Rev 31, 319–325 (2008). https://doi.org/10.1007/s10143-008-0137-5
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DOI: https://doi.org/10.1007/s10143-008-0137-5