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Traffic light alarming signs are indispensable prerequisites for fruitful endoscopic third ventriculostomy
Egyptian Journal of Neurosurgery volume 38, Article number: 43 (2023)
Abstract
Background
Endoscopic third ventriculostomy (ETV) is a satisfying neuro-endoscopic journey in candidates with preoperatively predicted higher success rates. Alarming cases require extra care to avoid serious complications, predict/identify failure and offer reasonable intra-/postoperative decisions.
Purpose
To create easily interpretable traffic light alarming signs to increase the awareness level for neurosurgeons regarding ETV difficulty/failure.
Methods
A 3-year-retrospective study of postoperative ETV infants of both sexes with obstructive hydrocephalus and preoperative ETV success score ≤ 70, age ≤ 12 months, and follow-up for ≥ 6 months with a postoperative radiological evaluation of the ETV patency and cerebrospinal fluid dynamics. The ETV difficulty scale (ETV-DS) was designed as an intraoperative monitor for surgical/anatomical difficulties. And the ETV failure threshold (ETV-FT) was offered for postoperative evaluation to identify cases that are mistakenly interpreted as failure.
Results
Among our 159 case series, 54 infants were involved. Patients’ demographics, age: ≤ 28 days, > 28 days to 6 months, and >6 to 12 months, were 5.5%, 70.3%, and 24.2%, respectively. Postoperatively, the outcome based on ETV-FT color scale was dark green (ETV-FT=0), light green (ETV-FT=1), yellow (ETV-FT=2), orange (ETV-FT=3), red (ETV-FT=4) in 29%, 14%, 20%, 10.3%, and 26.7%, respectively. Actual failure is identified as ETV-FT=4 based on clinical/radiological data. The failure rate was significantly attributed to inadequate communication with the basal cistern due to difficult/unsafe perforation of the thick/dense Liliequist membrane (87%) (P = 0.001).
Conclusion
The traffic light alarming signs (ETV-DS and ETV-FT) can warn neurosurgeons to recognize critical cases that necessitate ultra-precautions to navigate safely through landmines for worthy outcomes.
Introduction
In good candidates [1,2,3], and based on our triade [2] of proper candidate selection, surgical pearls to ensure rich communication between the third ventricle and basal cisterns, and appropriate postoperative management, endoscopic third ventriculostomy (ETV) will be an satisfying journey. The other side of the coin is the intraoperative unveiled events including, unique anatomical variables (>1/3 of cases) that increase the risk of intraoperative complications and associated with a 50% chance of early postoperative ETV failure [2,3,4,5,6,7,8]. Ensuring sufficient communication between the third ventricle (III-VT) and subarachnoid space and/or basal cisterns (SAS/BC) [2, 3], inevitability of additional procedures, cerebrospinal fluid (CSF) dynamics [2, 3, 9,10,11,12,13,14,15,16,17,18], and CSF pathway re-closure [19] can affect the outcome. Further, the well-known phenomenon of persistent/recurring increased intracranial pressure (↑ICP) in the initial postoperative adaptation period [20] is likely to be observed as a failure and misguidedly taken as a sign for shunt insertion [21,22,23,24,25,26,27,28,29]. Moreover, lack of preoperative tests predict the compliance and buffering capacity of the SAS/BC (which might account for an additional 25 to 40% failure rate) [30,31,32,33] and different thresholds for considering ETV failure [2, 3, 34,35,36,37,38,39,40,41,42,43,44,45] still limitations.
Herein, first, we designed a traffic light ETV difficulty scale (ETV-DS) as an intraoperative monitor to help neurosurgeons to be well prepared for challenging surgical/anatomical difficulties. Second, we proposed a postoperative traffic light ETV failure threshold (ETV-FT) that could be used to identify and manage cases that are mistakenly interpreted as failure.
Materials and methods
Study design, subject selection, duration, and intervention
The idea, design, administrative, technical, and material support by the corresponding author (AN). In compliance with ethical standards, the University’s research ethics committee approval and consent, from all patients’ parents/guardians who participated in this study, were obtained.
Availability of data and materials
The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.
This is a single-institution 3-year retrospective study done between July 2019 and September 2022.
Inclusion criteria
Inclusion criteria were as follows: postoperative ETV infants of both sexes with obstructive hydrocephalus due to aqueduct stenosis/tumor, post-hemorrhagic or post-infection with/without a history of previous shunt failure/complication, preoperative ETV success score [1] (ETV-SS) ≤ 70, age ≤12 months and follow-up for ≥ 6 months with postoperative phase-contrast magnetic resonance images (PC-MRI) cerebrospinal fluid (CSF) flowmetry to evaluate the ETV patency and ETV-CSF dynamics. All cases were operated with LOTTA® ventriculoscopes using the 4K-HD camera. Fogarty arterial embolectomy catheters (FAEC) (code 12A0805F/120805F) size 5F (inflated balloon diameter of 11 mm) were used to enlarge the ETV stoma. Tailored choroid plexus coagulation (CPC) was done only in selected infants with post-hemorrhagic hydrocephalus due to choroid plexus aneurysm-like structure (AnLS) to eliminate potential feeders (not as an augmenting procedure). ETV was an alternative when infants’ parents/guardians refused shunt.
Exclusion criteria
Undoable ETV (inability to fenestrate the tuber cinerium), infants with other etiologies (including congenital anomalies) [44], active infection, compartmental (multicystic) hydrocephalus, age >12 months, received augmenting procedures (CPC)/postoperative lumber puncture, done with another ventriculoscopes/cameras/surgeon/institution, without postoperative CSF flowmetry, missed during the follow-up, refused ETV or unfit for surgery were excluded from this study.
The radiological protocol for postoperative evaluation of ETV patients was determined by two investigators, including an experienced independent radiologist, who was blinded to the patient’s clinical data and the aim of the index study. Furthermore, the data of overall flow and stroke volumes across the stoma are measured by the machine's own software. Based on these two points, the influence of bias on research results can be excluded. Cine phase contrast (PC)-magnetic resonance image (MRI) CSF flowmetry was used for qualitative and quantitative assessment of ETV-CSF flow dynamics [6,7,8,9,10,11,12]. The traffic lights were assigned to the overall flow amplitude (OFA) [2, 6,7,8,9,10,11,12] to predict/interpret the response to surgery.
Statistical analysis
The collected data were tabulated, and SPSS 26.0 was employed for statistical analysis along with Microsoft Excel 2016 and MedCalC program software version 19.1. A value of P < 0.05 was considered significant.
Traffic light alarming signs (ETV-DS and ETV-FT) (Figs. 1, 2)
ETV-DS (Fig. 1) focused on six parameters
-
1.
Third ventricular (III-VT) anomaly that hinders the freedom for ETV stoma maneuverability (such as hypothalamic adhesions (Fig. 3)), ventricular wall deposits, presence of AnLS (Figs. 3, 4, 5).
-
2.
Tuber cinerium (TC) types (Fig. 3).
-
3.
stoma size
- 4.
-
5.
Visual confirmation of specific neurovascular structures in SAS/BC (naked basilar artery (BA)/presence of dolicoectatic BA (DEBA) (Fig. 6)/ brainstem and cranial nerve identification) (Figs. 3,4, 5, 6).
-
6.
CSF appearance (Fig. 5).
ETV-FT (Fig. 2)
It is proposed to overcome the different thresholds for considering ETV failure [1, 20,21,22]. ETV-FT focused on two parameters: I) evaluation of ETV stoma with CSF flowmetry and II) clinical picture.
Surgical technique and illustrative cases
Surgical nuances
Our step-by-step technique can be reviewed elsewhere [2]. We always consider the “curved reservoir skin incision with subgaleal pocket technique” in all cases [2, 4].
III-VT floor Tumor biopsy/resection
We ensure reasonable CSF flow by debulking of the posterior part of the tumor that covers the Aq.Slv.
Dealing with phantom III ventricle (Figs. 6, 7) “NO Man’s Land SAS/BC”
In infants with post-infection hydrocephalus, the regular anatomy is unclear and the landmarks are totally lost (we defined it as phantom III ventricle). Besides, the SAS/BC for these infants were considered as “No Man’s Land” (undoable ETV). We always scout around for clivus/dorsum sellae (DS) as the only reliable buried turning point. In those cases the DS as a bony structure can be traced and palpated.
Results
Patients’ demographics (Table 1)
Among our 159 case series, 54 patients were included in this study. Our included candidates showed slight male predominance (61.4%). Age ≤ 28 days (neonates), > 28 days to 6 months (babies), and >6 to 12 months (young infants) were 5.5%, 70.3%, and 24.2%, respectively. Obstructive hydrocephalus due to aqueductal stenosis, aqueductal tumor, post-hemorrhagic, post-infection or others was 81.6%, 5.5%, 3.7%, 3.7%, and 5.5%, respectively. All neonates were presented with post-hemorrhagic hydrocephalus, whereas aqueductal stenosis was common among babies young infants. ETV with the opening of LM and visual confirmation of the basal cisterns were achieved in all cases. Tumor biopsy was done in all tumor cases (5.5%). The histopathology of biopsied cases revealed, subependymoma or astrocytoma, in 66.6% and 33.4%, respectively.
Pertinent anatomy
In the index study, we realized three types of TC (Fig. 3) thin/transparent (green sign), congested (green sign) and thick/opaque (yellow sign) in 57%, 4% and 39%, respectively. Besides, three types of LM (Fig. 3,4,5,6) were observed: thick/dense (33.3%), thin/transparent (63%), and fenestrated (3.7%). The failure rate was significantly attributed to inadequate communication with the basal cistern due to difficult/unsafe perforation of the thick/dense LM (87%) (P = 0.001), particularly in infants ≤6 months, stoma closure with scar formation (3.7%), delayed post-meningetic sequences (5.6%) or other (3.7%).
ETV-DS and ETV-FT
Intraoperatively, the traffic light ETV-DS with its color scale was green (ETV-DS= ≤1), Yellow (ETV-DS=2-4), orange/red (ETV-DS=5-8), and black (ETV-DS=≥9), in 3.7%, 59.3%, 33.3%, and 3.7%, respectively.
Postoperatively, the traffic light ETV-FT was green, yellow, and red in 43%, 20%, and 37%, respectively, while the ETV outcome based on ETV-FT color scale (Fig. 7) was dark green (ETV-FT=0), light green (ETV-FT=1), yellow (ETV-FT=2), orange (ETV-FT=3), red (ETV-FT=4) in 29%, 14%, 20%, 10.3% and 26.7%, respectively. Favorable outcome was documented in 63% (dark green, light green, and yellow), while unfavorable outcome was unveiled in 37% (orange and red) (Table 1).
Interpretation of ETV-DS (Fig. 1) and ETV-FT (Fig. 2)
ETV-DS (traffic light and scoring system): Difficultly is directly proportional to the ETV-DS and color grading scale. The green, yellow, and red traffic lights are assigned for straightforward communication with SAS/BC, difficult-but-achievable, and complex cases that require advanced skills, respectively. Black color is assigned for the most ever challenging anatomy that we called “phantom III-VT.”
ETV-FT (traffic light and scoring system)
The failure threshold is defined as two red signs = score “4.” Failure is directly proportional to the ETV-FT score and color grading scale. The green, yellow, and red traffic lights are assigned for patent stoma with adequate flow & complete resolution of symptoms, patent stoma with gradual resolution of symptoms during the adaptation-period [20,21,22,23,24,25,26,27] and obstructed stoma with failure, respectively.
We defined ETV success as the resolution of symptoms with a patent stoma on the postoperative CSF flowmetry and uneventful 6-month follow-up. While ETV true failure was defined as persistent symptoms (including progressive head enlargement) that are resistant to postoperative CSF release (adaptation failure) with an obstructed stoma on the postoperative CSF flowmetry during 6-month follow-up. Our actual failed ETV cases received another intervention (redo-ETV or shunt) for CSF diversion.
Complications (Table 1)
Entirely intraoperative negatives were referred to unintentional damages around the FM including unilateral minor injury “red spots” to the column of the fornix (2%) which was attributed to the torque effect of the rigid endoscope around the FM during tumor biopsy or ETV via an extremely narrow FM [2, 4]. Controllable bleeding due to minor injury to venous structures (3.7%). Besides, we had a baby with intraoperative subdural hematoma (0.5%) following the dry filed technique for hemostasis that mandated immediate endoscopic evacuation. Additionally, another baby developed significant postoperative subdural hygroma (0.5%) and required subdural-peritoneal shunt to resolve his symptoms. Those cases had an uneventful postoperative course.
Neither tension pneumocephalus nor serious major neurovascular injuries (intact vertebrobasilar arteries, perforators, major veins, cranial nerves, brainstem, mammillary bodies, optic apparatus, infundibulum, (hypo)thalamus and basal ganglia).
Subgaleal (SG)-CSF collection/leak (Table 1)
Tense SG collection (type II/red sign) was seen in 7.4% of cases, mostly in age ≤6 months. Among them, 5.6% showed at least on attack of CSF leak during the early adaptation-period which was controlled with conservative measures. Two of CSF leak babies developed post-meningitic sequelae (3.7%) with delayed ETV failure and required another intervention. Yet, soft SG collections (type I/yellow sign) in 22% were resolved spontaneously. In those cases (except 3.7% post-meningitic sequelae), follow-up CSF flowmetry revealed good flow across the stoma.
Discussion
Anatomy, surgical nuances, and concerns to be valued while producing the ETV-DS
Interestingly, ventricular wall inspection for deposits and CSF nature can give additional vital information. In neonates, post-hemorrhagic ventricular wall pigmentations were linked to ruptured AnLS (Fig. 3,4) in 3.7%, and post-infection debris was linked to phantom III-VT in 3.7% (Fig. 7,8). We realized that ventricular wall deposits are often associated with difficult communication between the III-VT and SAS/BC due to thick dense LM in 33.3%. Moreover, congested and thick/opaque types of TC [24, 26, 43] can influence the stoma creation in 43% which became more challenging in the presence of inter-(hypo)thalamic adhesions.
Radiological facts that we consider while designing ETV-FT
-
1-
PC-MRI CSF flowmetry is considered more accurate/reliable for evaluating the patency of ETV [7, 8] and assessing ETV-CSF dynamics [6,7,8,9,10,11,12].
-
2-
Ventricular size reduction is often slow with minimal/no changes [13].
-
3-
The BA pulsation produces a flow void in the pre-pontine cistern that may interfere with the interpretation flow void that seen on T2-MRI at ETV stoma. Therefore, the absence of this void does not necessarily indicate impaired ETV function [6,7,8,9,10,11,12].
-
4-
Early postoperative turbulent flow at the ETV stoma in the first CSF-flowmetry does not inevitably postulate failure. Such finding progressively returns to normal [15].
-
5-
Greater stroke volumes (adequate flow=Grade III) [26] at the ETV stoma are a positive judge of favorable clinical outcome. Consequently, in patients with low/impaired flow (Grade II/I) [26] it might predict unfavorable clinical outcomes and further careful observation is vital as they may progress to occlusion [16].
-
6-
If a patent ETV stoma is detected without sufficient CSF flow, this might be attributed to the existence of an alternative CSF diversion pathway (ex: internal drainage due to reopening of the aqueduct following removal of tumor) [17, 18].
Postoperative clinical facts during the adaptation-period
CSF dynamics/absorption, ICP, and rule of curved reservoir skin incision with subgaleal pocket technique:
-
1.
The ICP does not decrease quickly in definite cases as it takes several months for CSF absorptive capacity/dynamics through the SAS/BC to show further improvement [22].
-
2.
During the ETV initial postoperative adaptation period, a voluminous quantity of CSF directly streams into the blocked SAS/BC leading to a recurrent ↑ICP which is liable to be viewed as a failure [23,24,25,26,27].
-
3.
Although a sequence of LPs should always be performed in patients who remain symptomatic/↑ICP, before ETV is assumed to have failed [23,24,25], in our delicate patients’ population we could apply LP in selected cases. Instead, we took the advantage of our curved reservoir skin incision with subgaleal pocket technique to accommodate released CSF during the early adaptation period [2]. This idea allows the CSF to egress via a reverse brilliant manner (to be absorbed in the subgaleal pocket) to escape questionable acute obstruction. It allows the natural intermittent controlled CSF release/absorption according to the infant’s own needs [2].
-
4.
CSF release recovers the compliance and buffering capacity of the SAS/BC [6,7,8,9,10,11,12].
Limitations and ideas to overcome them
The retrospective nature of this single-institution study along with the relatively small number of the included infants might be considered a limitation. Besides, a surgeon’s learning curve can affect the degree of maneuverability in such challenging cases and the overall outcome. To overcome these limitations, it is reasonable to have a multicenter engaged in a prospective trial to further validate and/or modify this unique traffic light concept for both adult and pediatric populations.
Conclusions
Traffic light ETV-DS and ETV-FT are easily interpretable/memorable alarming signs for robust decision-making. They can warn neurosurgeons to distinguish challenging patients that require ultra-precautions to navigate safely through landmines for worthy outcomes. It can be validated in delicate patient populations including neonates, babies, and young infants >1 year.
Availability of data and materials
All data used are available from the corresponding author on request.
Abbreviations
- ↑ICP:
-
Increased intracranial pressure
- AnLS:
-
Aneurysm-like structure
- Aq.Slv:
-
Aqueduct of Sylvius
- BA:
-
Basilar artery
- CPC:
-
Choroid plexus coagulation
- CSF:
-
Cerebrospinal fluid
- DEBA:
-
Dolicoectatic BA
- DS:
-
Dorsum sellae
- ETV:
-
Endoscopic third ventriculostomy
- ETV-DS:
-
ETV difficulty scale
- ETV-FT:
-
ETV failure threshold
- FAEC:
-
Fogarty arterial embolectomy catheters
- FM:
-
Foramen of Monro
- HC:
-
Head circumference
- III-VT:
-
Third ventricle
- LM:
-
Liliequist membrane
- LP:
-
Lumbar puncture
- MB:
-
Mammillary bodies
- PC-MRI:
-
Cine phase contrast-magnetic resonance image
- SAS/BC:
-
Subarachnoid space and/or basal cisterns
- SG:
-
Subgaleal
- SSAJ:
-
Scissors with single action jaw
- TC:
-
Tuber cinerium
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Nagm, A. Traffic light alarming signs are indispensable prerequisites for fruitful endoscopic third ventriculostomy. Egypt J Neurosurg 38, 43 (2023). https://doi.org/10.1186/s41984-023-00225-w
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DOI: https://doi.org/10.1186/s41984-023-00225-w