Endoscopic management of intraventricular shunt-related cystic compartment in paediatric patients

Abstract

Background. Intraventricular uniloculated compartments are relatively seen frequently in children previously treated with ventriculoperitoneal shunts for hydrocephalus. These compartments may present before shunt insertion and even as an end result to the shunt gliosis. Although the availability of different surgical modalities for the management of such loculations but till now there is no consensus about a single therapeutic approach for its management. Objective. The aim of this study is to assess the role of neuroendoscopy in management of uniloculated compartments, in pediatric cases who underwent shunting for hydrocephalus, to avoid multiple shunt insertion and even to eliminate the need for the preexisting shunt system. Patients and Methods. We retrospectively studied 44 consecutive previously shunted patients with isolated intraventricular compartment who underwent 58 endoscopic procedures by a single surgeon during the period between February 2015 and February 2018. These procedures included endoscopic cyst fenestration, intraventricular septum pellucidotomy, foraminoplasty and additionally third ventriculostomy in some cases was added to the previous procedures. Multiloculated hydrocephalus and cysts related to the tumours were excluded. Clinical, radiological and surgical data were assessed. Results. The most common cause of a single loculation in those patients was neuroepithelial cyst (20 cases) followed by post shunt isolated compartment (12 cases), meningitis (8 cases) and four cases of intraventricular haemorrhage. The patient's age varied from two months up to seven years (mean = 3.2 years). The follow-up period was ranged from (2-49 months) with the mean of 12.3 months. The overall success of restoration of communication between the uniloculated compartment and the ventricular system was achieved in 36 patients (81.8%), with 28 (63.6%) patient needed only one shunt and eight (18.2%) patients became independent of their previous shunts. Fourteen repeated endoscopic procedures were considered necessary in ten patients for either reopening of a closed stoma and/or shunt revision and finally, eight patient (18%) required additional shunt insertion during follow up period. The complications encountered were minor and reversible (CSF leak in two cases, infection in two cases, subdural fluid collection in four cases) with no mortality. Conclusion. Minimal invasive endoscopic technique is a useful operative alternative to control uniloculated compartments in patients with previous ventriculoperitoneal shunts. It does not only simplify the existing shunt system by restoration of the communication between the loculated compartment and the draining shunt but it may eliminate the need for external shunt in some cases as well.

Keywords

• loculated hydrocephalus
• endoscopy
• fenestration