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  IN THIS Article
 ::  Abstract
 ::  Introduction
 ::  Case Report
 ::  Discussion
 ::  Conclusion
 ::  References
 ::  Article Figures

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  Table of Contents     
CASE REPORT
Year : 2011  |  Volume : 57  |  Issue : 2  |  Page : 123-125

Utility of ventricular access in an acute deterioration after endoscopic third ventriculostomy


Department of Neurosurgery, Bombay Hospital Institute of Medical Sciences, Mumbai, India

Date of Submission14-Sep-2010
Date of Decision15-Dec-2010
Date of Acceptance11-Feb-2011
Date of Web Publication4-Jun-2011

Correspondence Address:
A Kumar
Department of Neurosurgery, Bombay Hospital Institute of Medical Sciences, Mumbai
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0022-3859.81869

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 :: Abstract 

Endoscopic third ventriculostomy (ETV) has now been accepted widely as a safe procedure for treatment of non-communicating hydrocephalus. Despite its learning curve, most of the neurosurgeons have understood its technical details, benefits, and risks and have started to practice it to perfection. The benefit of shunt independence with minimal risks offers a remarkable advantage which has made this procedure widely popular. However, late closure of stoma leading to morbidity and even death has been reported off late. We report a case of a 7-year-old girl with hydrocephalus due to tectal glioma who deteriorated after 7 months following a successful procedure. She developed a cardio-respiratory arrest and was resuscitated with aspiration of cerebrospinal fluid from the ommaya reservoir kept during the primary surgery. Keeping all the patients under strict surveillance for stoma patency is mandatory and in addition, ommaya reservoir in certain high-risk patients may be a useful option for achieving quick ventricular access by medical and nonmedical personnel in case of deterioration. This case is the first reported case of acute deterioration after ETV from India. Previously, 14 such cases have been reported worldwide and only 2 of them have survived.


Keywords: Acute deterioration, death, hydrocephalus, ventriculostomy


How to cite this article:
Kumar A, Deopujari C E, Biyani N. Utility of ventricular access in an acute deterioration after endoscopic third ventriculostomy. J Postgrad Med 2011;57:123-5

How to cite this URL:
Kumar A, Deopujari C E, Biyani N. Utility of ventricular access in an acute deterioration after endoscopic third ventriculostomy. J Postgrad Med [serial online] 2011 [cited 2019 Nov 17];57:123-5. Available from: http://www.jpgmonline.com/text.asp?2011/57/2/123/81869



 :: Introduction Top


Endoscopic third ventriculostomy (ETV) has been a safe and viable treatment option for all ages of patients with non-communicating hydrocephalus. The primary causes are aqueductal stenosis and tectal gliomas, although secondary reasons like meningitis, hemorrhage are also common. If performed in well-indicated patients with tri-ventricular hydrocephalus, it has been successful in up to 80 to 90% of cases. However, a word of caution must also be mentioned along with its advantages. Minor complications like hemorrhage, cerebrospinal fluid (CSF) leak, infection, and major complications like vascular injuries and damage to the deeper neural structures can occur early in the learning curve. Late failure of ETV is a rare complication and only 14 cases have been reported in the past. We did not find any case report in the recent literature where an immediate ventricular access has actually saved a patient, although recommendations regarding the use of a reservoir have been made in the past. We report a case of late deterioration following a successful ETV in a 7-year-old child who could be resuscitated in time by immediate CSF aspiration from an ommaya reservoir placed during the primary surgery.


 :: Case Report Top


A 7-year-old girl presented to us with history of occasional headaches and minimal walking difficulty. She was operated at 1 year of age for a myelomeningocele at some other institution. On examination, she had no neurological deficits apart from bilateral papilledema. The magnetic resonance imaging (MRI) revealed a tectal region lesion with aqueductal obstruction and tri-ventricular hydrocephalus [Figure 1]. She underwent an ETV. Right-sided pre-coronal burr hole was made and 0 degree endoscope was used to access the lateral ventricle. Third ventricle was entered and stoma was made with a Fogarty catheter and was dilated with the same. The procedure was uneventful. There was no obvious "second" membrane and the basilar artery was visualized well along with flapping of the third ventricular floor. An ommaya reservoir was kept with the catheter tip inside the lateral ventricle. Although the biopsy was also done at the same time, its histopathology was inconclusive. The patient had complete resolution of symptoms and was discharged later. At 3 months follow-up, the papilledema had resolved completely and the MRI showed resolution of sub-ependymal ooze, although ventriculomegaly was still present [Figure 2]. CSF flow studies demonstrated doubtful flow across the stoma. As the child was asymptomatic, it was decided to observe her and she was kept under close surveillance after a thorough discussion with the parents. After 4 months, she started to develop headaches again. She was asked to come for a follow-up and possible repeat third ventriculostomy suspecting stenosis. The day she came for a follow-up, she was seen at the outpatient clinic for severe headaches. She had papilledema bilaterally with stable vitals and was advised admission for surgery the next day. After 45 minutes, she was found unresponsive in the wards with bilateral dilatation of pupils (3 mm; non-reacting to light) and tonic extensor posturing. She was pulseless (confirmed on electrocardiogram) and blood pressure could not be recorded. Immediately, 35 cc CSF was aspirated from the reservoir and the cardiopulmonary resuscitation was started at the bed side. She was resuscitated and was kept on ventilatory support in an intensive care unit. An external ventricular drainage was set up from the same reservoir. Computed tomography scan showed a right frontal extra-dural hematoma with decompressed ipsilateral lateral ventricle [Figure 3]. After she was stabilized, she was taken up for repeat procedure the next day. Intraoperatively, the stoma was seen to be obliterated [Figure 4] and a new stoma was made. Postoperatively, she had good recovery. The immediate postoperative MRI showed patent stoma which was confirmed by CSF flow studies [Figure 5]. The child is still under close follow-up and is doing well in academics and outdoor activities.
Figure 1: MRI showing ballooning of third ventricle due to tectal glioma with normal fourth ventricle

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Figure 2: MRI after first surgery with ventriculomegaly without subependymal ooze

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Figure 3: Right frontal EDH due to rapid tapping of CSF from the reservoir leading to ipsilateral ventricular decompression

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Figure 4: Stenosed stoma seen as a punctum in the third ventricular floor during second surgery

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Figure 5: MRI after second surgery showing good CSF flow in third ventricle

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 :: Discussion Top


Late deterioration after ETV is a known but rare phenomenon whose exact etiology still remains obscure. Across the globe, 12 deaths have been reported. Various cited reasons include non-penetration of second membrane, [1] infection with high CSF proteins, [1] bleeding in the region of stoma, and even a case was reported where a medulloblastoma seedling had occluded the stoma. [2] Re-stenosis of the stoma was found in 10 of the 14 reported cases of acute deterioration till date. Our patient also had a re-stenosis (confirmed by re-endoscopy), and low threshold for raised intracranial pressure may have caused the deterioration in her. Although she had none of the above cited reasons for an ETV failure, the exact etiology behind the re-stenosis remains obscure. This only suggests that there are probably many more factors involved in the process which need to be evaluated in detail. Late failure is more commonly observed in patients who have been shunted previously. Ventricular non-compliance is responsible for the low threshold in these patients who are poor in tolerating subtle increases in the intracranial pressure. Maybe previous ETV results in a lower than normal ventricular compliance (as in shunted patients). Hader et al. first reported three deaths due to this phenomenon. [3] In a study involving various neurosurgical hospitals in different countries, Drake et al. reported 13 deaths due to late failure of ETV. [4] Due to the only mortality in their experience, Mobbs et al. proposed for the first time, keeping a subcutaneous reservoir in order to have a quick access to the ventricle. [5] They followed this practice in 21 of their patients without any complications. Although chances of infection may increase with a foreign body, the importance of a reservoir and ventricular access cannot be better understood in our patient who had an arrest, and ventricular access could be achieved in no time which helped reducing the raised intracranial pressure. Some overzealous aspiration led to a frontal extradural hematoma, but it proved immensely useful. Although no recommendation exists, we would suggest gradual aspiration of 20 cc CSF in cases of acute deterioration to avoid such complication. Although many authors have proposed a prophylactic reservoir insertion, [4],[5] there has not been a single case in the literature where instant tapping has actually helped a moribund patient to spring back into life. The ommaya reservoir can be inserted in no time after an ETV. It does not add too much to the overall expenditure. Moreover, it can be used to assess the patency of the stoma by injecting a water-soluble dye from the reservoir in doubtful cases. If well explained, even parents or a non-medical person can tap the ventricle at bedside in case of a sudden deterioration. This gives time to transfer the patient to higher center and also does not mandate the presence of a neurosurgeon to tap the ventricle (as may be the case with a burrhole without a reservoir). The chief disadvantage of placing a reservoir is the risk of CSF leak and meningitis. Long-term follow-up studies at our center have shown no extra-risks to these patients with a reservoir and no patient has undergone its removal owing to impending infection or meningitis.


 :: Conclusion Top


Vigilant follow-up after ETV is hence recommended, especially in patients with previous shunt history and in children who may sink rapidly without many symptoms. The reservoir gives an immediate ventricular access and can be life saving for patients in far flung areas, although its use on a routine basis may not be warranted at all the times. We cannot recommend its use in each and every ETV, but this case report may contribute to the literature as evidence in support. Maybe it can be worthwhile using reservoirs in select high-risk cases, mainly children with certain predisposing factors. Rarely, postoperative ventriculography may be done for confirming the adequate functioning of stoma in doubtful cases where CSF flow studies are unequivocal. Randomized studies with long-term follow-up involving larger number of patients may be required before arriving at a conclusion.

 
 :: References Top

1.Buxton N, Macarthur D, Mallucci C, Punt J, Vloeberghs M. Neuroendoscopic third ventriculostomy in patients less than 1 year old. Paediatr Neurosurg 1998;29:73-6.  Back to cited text no. 1
    
2.Nigri F, Telles C, Acioly MA. Late obstruction of an endoscopic third ventriculostomy stoma by metastatic seedling of a recurrent medulloblastoma. J Neurosurg Pediatr 2010;5:641-4.  Back to cited text no. 2
[PUBMED]  [FULLTEXT]  
3.Hader WJ, Drake J, Cochrane D, Sparrow O, Johnson ES, Kestle J. Death after late failure of third ventriculostomy in children: Report of three cases. J Neurosurg 2002;97:211-5.  Back to cited text no. 3
[PUBMED]  [FULLTEXT]  
4.Drake J, Chumas P, Kestle J, Pierre-Kahn A, Vinchon M, Brown J, et al. Late rapid deterioration after endoscopic third ventriculostomy: Additional cases and review of the literature. J Neurosurg 2006;105:118-26.  Back to cited text no. 4
[PUBMED]  [FULLTEXT]  
5.Mobbs RJ, Vonau M, Davies M. Death after late failure of endoscopic third ventriculostomy: A potential solution. Neurosurgery 2003;53:384-6.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]

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