Management of Pediatrics Hydrocephalus: A Systematic review and metanalysis; on Endoscopic third Ventriculostomy (ETV), vs. ventriculoperitoneal shunt (VPS), Treatments and Postoperative Outcomes

INTRODUCTION

Hydrocephalus is defined as a failure in cerebrospinal fluid (CSF) homeostasis and the progressive active distension of the ventricles and the cerebral ventricular system resulting from inadequate passage of CSF through the points of production, such as the choroid plexus, absorption, and drainage into the dural venous sinus. Therefore, infants with hydrocephalus tend to have an increased head circumference and may present with signs and symptoms of intracranial pressure. [1]. A canine experiment conducted by Walter Dandy in the mid-19th and early 20th centuries on obstructive hydrocephalus using phenolsulfonphthalein led to a more up-to-date understanding of communicating and non-communicating hydrocephalus. Although Hippocrates reported the term "water" in macrocephalic children, hydrocephalus itself was first described in the writings of Celsus, between 25 BC and 50 AD. [2]. Epidemiologically, approximately 400,000 new cases of pediatric hydrocephalus develop worldwide each year, with over 80% of these cases occurring in low- to middle-income countries [3]. Hydrocephalus is caused by neural tube defects, and up to 85% of children may be born with myelomeningocele and/or spina bifida-like myelomeningocele [4]. Endoscopic third ventriculostomy (ETV) involves fenestrating the floor of the third ventricle and diverting cerebrospinal fluid to the basal cisterns. When combined with choroid plexus cauterization (CPC-ETV), it is indicated in children under 2 years of age, where ETV alone carries a poor prognosis [5]. Figure 1 shows a) ETV for pediatric patients with hydrocephalus and fenestration of the third ventricle. b) VP-shunt: detailed components by structure and function for hydrocephalus drainage and external program, (ICP) measure of a Codman-Hakim shunt device. The aim of this systematic review is to analyze ETV vs. ventriculoperitoneal shunt (VPS) treatments and postoperative outcomes

Materials and Methods

Results

In our systematic review, we found a total of N=3,119 pediatric patients with hydrocephalus, which we distributed in Supplementary Table 1 [7,8,9,10,11,12,13,14,15,16,17,18]. N=1728 patients, (55%), with endoscopic procedure N=948, (30%). VP-shunt N=765. (24%). While in Supplementary Table 2 [19,20,21,22,23,24,25,26,27,28,29,30], N=1391 patients (44%). ETV/VP shunt; N=474, (15%). ETV/CPC; N=766 (24%). Heterogeneity was assessed as follows: Chi² = 17.96, df = 11, P < 0.08 vs. I² = 39%, test for overall effect: Z = 1.24, P = 0.21; Tau² = 0.01; Chi² = 20.13, df = 11, P < 0.04; I² = 45%, confidence interval test for overall effect: Z = 0.91, P = 0.72, P < 0.36. Tau2; 0.00; Chi² = 20.00, df = 11, P = 0.05; vs. I² = 45%, test for overall effect: Z = 1.09, P = 0.27. In a randomized controlled trial of 70 preterm infants aged 24 to 34 weeks with progressive enlargement of the cerebral ventricles, only 34 infants were assigned to irrigation and fibrinolytic therapy following intraventricular hemorrhage to remove blood and cytokines. Two shunts failed, requiring 13 revision surgeries (44%). Only 36 were evaluated with standard therapy, resulting in only 5 shunt failures. Only 14 infants underwent revision surgery (50%), while 12 infants underwent revision surgery (25%), a difference that was not statistically significant. Only 3 patients (8%) experienced secondary intraventricular hemorrhage, increasing the risk of subsequent shunt surgery and the need for more blood transfusions. Therefore, there was no reduction in the number of surgeries or mortality associated with shunt surgery. [6]. Figure 3 shows graphic representation of pediatric patients with hydrocephalus and surgical treatment, while figure 4 shows graphics of hydrocephalus studies and surgical interventions

Discussion

Patients with large CSF volumes typically undergo a procedure with VPS. Patients with subdural collections often present with cognitive problems and smaller brain volumes, but mortality does not vary. Although some studies suggest that subdural collections are due to brain atrophy with a thin cortical mantle, CSF volume was not related to age and sex preoperatively; on the contrary, it was related to higher rates of subdural collection volumes. [11,12]. A recent randomized, prospective, comprehensive controlled study conducted on 158 five-year-old children, assessed using the Mark 2 health index (HUI-2), questioned the results compared through covariance with adjustment of baseline variables between age at surgery and initial developmental status of hydrocephalus (HOQ), as a measure of quality of life. Initially, of 78 patients, 19 were treated with shunting and 61 with endovascular anastomosis (EVA), at a mean age of 62.1 months (SD 6.3). The mean 5-year HUI-2 score was 0.90 (SD 0.19) for EVA and 0.94 (SD 0.10) for shunting (p = 0.21). The mean 5-year HOQ score was 0.81 (SD 0.15) for EVA and 0.85 (SD 0.12) for shunting (p = 0.42). Therefore, they believe that overall health status is high, with no significant difference in quality of life observed between the two surgical types in infants treated for aqueductal stenosis. [11,12]. The gross brain volume indicates that smaller brain volumes are normalized between 12-24 months without reflecting the absolute loss of volume. [13]. Arynchyna-Smith et al. proposed a revision study of (ETV) after the failure of (ETV+CPC) in children. The revision ETV showed a success rate of 29% of patients, a lower rate than the initial ETV+CPC. None of the patients presented with neurological deficits, infected wounds, or diabetes during the revision ETV. However, there was a significant difference between the two groups by age: older patients in the ETV group had a different success rate than those in the ETV+CPC group, as shown by a difference in ventricular size as measured by focal heart rate monitoring. [17]. Surgical Techniques for Subgaleal Ventricular Insertion Before placing the patient in the supine position, we must observe the coronal sutures and try to locate the Kocher point for insertion of the ventricular catheter. It is also extremely important not to restrain the thin skin of premature infants throughout the procedure. First, we must place the ventricular catheter in the frontal horn. Next, this ventricular catheter will be connected to a reservoir, using a right-angle connector, on a short, closed-end tube with slots, establishing unidirectional flow from both the ventricle and the subgaleal pouch. [50]. If the reservoir is not used, the tube will be fixed to the periosteum with a suture to prevent the catheter from migrating into the lateral ventricle; to prevent this, the reservoir must be used. Then, a subgaleal pouch will be created by blunt dissection with the fingers or with blunt-tipped Metz scissors with curved ends. [51]. Once dissected, care must be taken to avoid dissecting the subgaleal space too superficially or too deeply. Since larger subgaleal pouches tend to prolong the subgaleal ventricle shunt, the dissection should always be lateral, towards the ear, then over the occiput (but not the forehead), carefully approaching the midline to avoid skin perforation. The subgaleal catheter will be placed to drain into the pouch, and the wounds will be closed in two layers. The effectiveness of the subgaleal ventricle shunt will be assessed by the reduction in head circumference, the softening of the anterior fontanelle, and the reduction in ventricular size, observed with cranial ultrasound and other imaging studies. If the subgaleal pouch is tense anteriorly in a soft, fluctuant manner, with subgaleal fluid, cranial imaging studies are recommended to confirm ventricular enlargement. [52]. When a shunt fails, endoscopic third ventriculostomy (ETV) is recommended. When shunt dysfunction and recurring infection occur, ETV is recommended as an adjuvant treatment. [54,55,53]. This method works well, although it is not as good as ventriculoperitoneal shunting in situations of fourth ventricle obstruction and endoscopic transforaminal transventricular foraminoplasty with flexibility of the foramina of Magendie and Luschka in an open suboccipital craniotomy. [57,58,56]. Additionally, ETV is often helpful in situations of fourth ventricle neurocysticercosis. [60,59]. A combination rigid-flexible endoscope will be helpful for the endoscopic transluminal endoscopy (ETV) and biopsy, which will be carried out via a single burr hole. [62,61]. ETV will be recommended in cases of hydrocephalus with posterior fossa lesions, such as cerebellar infarction with a cerebellopontine angle tumor and no severe brainstem compression. (63). The diagnosis of basal meningitis will also be aided by a biopsy of the basal cisterns. (64). (TVE); is helpful in removing brain clots from intraventricular hemorrhages. [66,65]. Additionally, full-term newborns with normal birth weight and patients with Chiari type 1 deformities, whether or not they have syringomyelia, benefit greatly from it. [68,67]. Limitations and Future Directions Cerebrospinal fluid (CSF) occlusion in the aqueduct is regarded as a high-risk procedure for harm to tissues including the midbrain, and endoscopic third ventriculostomy (VTE) accounts for about 50% of cases. These kinds of pathology are also linked to neurological impairments such oculomotor or trochlear nerve palsy, as well as Parinaud's syndrome and periaqueductal syndrome. Overdrainage, proximal and distal shunt blockage, catheter breakage or migration, and when to use third ventricle endoscopy are all limits to take into account. Revisions are also required, but deciding whether to fix the shunt or just replace it with a new ventricular system is crucial. Any component that is positioned incorrectly may result in drainage failure, necessitating either third ventricle endoscopy or revision of the pulmonary venous shunt. Although the usage of new shunt systems is increasing, the surgeon's experience must still be taken into account to prevent damaging vascular or anatomical structures. Although some research is still continuing, hydrocephalus has previously been treated with new stem cell procedures. Neuronavigation has shown promise in the assessment and treatment of burr holes and in cases of tumor-induced obstructive hydrocephalus.

Conclusion

Endoscopic third ventriculostomy (ETV) and choroid plexus cauterization (CPC) are combined operations used to treat hydrocephalus in children. These treatments range from straightforward Kocher point stenting to intricate shunt systems. Cerebrospinal fluid (CSF) flow is managed with a single choice, which permits some control over normal head circumference. Ventriculoperitoneal shunting and various treatments to remove extra CSF result from overdrainage. This review illustrates the path from the implantation of a ventriculoperitoneal shunt to the choice to carry out a third ventriculoscopy in order to manage excess CSF and avoid childhood hydrocephalus symptoms. Management is usually simple and short-lived, but when postoperative failure happens, it becomes complicated, necessitating adjustments to retract or reposition the shunt and, eventually, the choice to undergo a third ventriculoscopy. This study shows that every part of the shunt needs to be exact in order to prevent failure, which will result in excess fluid and, ultimately, chronic hydrocephalus. Intraventricular bleeding and consequences, such as midbrain lesions and lesions of other anatomical structures, might result from the enlargement of the lateral ventricles with cranial growth. This study demonstrates that while there are variations in the infants' age and sex, there are no variations in the complications, and surgery is nearly always the only treatment for hydrocephalus symptoms.