Woodworth Graeme, McGirt Matthew J, Thomas George, Williams Michael A, Rigamonti Daniele
The Johns Hopkins School of Medicine, Baltimore, MD 21287, USA.
Neurol Res. 2007 Jan;29(1):27-31. doi: 10.1179/016164106X119914.
Endoscopic third ventriculostomy (ETV) is accepted as an effective treatment for obstructive hydrocephalus (OHC); however, its benefit in patients previously treated with cerebrospinal fluid (CSF) shunting remains unclear. The value of concurrent ETV and ventriculoperitoneal (VP) shunting in patients with frequent shunt failure remains unstudied.
Outcomes were compared between OHC patients receiving ETV as initial CSF diversion treatment (n= 19) versus OHC patients receiving ETV for shunt failure (n= 11) by log-rank analysis and Kaplan-Meier plots of recurrence-free periods. To determine if the performance of ETV with concurrent shunt revision decreased the incidence of catastrophic treatment failure in patients experiencing frequent and emergent shunt failures (n = 8), the time to treatment failure after ETV and shunt revision was compared with the mean duration of their previous CSF shunts.
ETV after shunt failure was 2.5-fold more likely to fail [risk ratio (RR): 2.48, p<0.05] versus ETV as initial CSF diversion treatment for OHC. Following ETV as initial CSF diversion treatment, 17 patients (89%) experienced immediate improvement and 65% remained recurrence-free at year 2. Following ETV after shunt failure, 16 patients (71%) experienced immediate improvement, but only 25% remained recurrence-free at year 2. In patients with a history of multiple shunt revisions and complications, concurrent use of ETV and VP shunt did not significantly decrease treatment failure. However, the incidence of catastrophic shunt failure requiring acute intervention decreased (43% versus 17%).
In our experience with ETV for OHC, prior CSF shunting in patients with obstructive hydrocephalus was associated with the decreased time to treatment failure following conversion to ETV. ETV may be less effective for the treatment of OHC in previously shunted patients. ETV combined with concurrent CSF shunting may be an important strategy to prevent catastrophic treatment failure in OHC patients with a history of multiple shunt revisions and complications.
内镜下第三脑室造瘘术（ETV）被认为是治疗梗阻性脑积水（OHC）的有效方法；然而，其对先前接受过脑脊液（CSF）分流治疗的患者的益处仍不明确。对于频繁出现分流失败的患者，同期进行ETV和脑室腹腔（VP）分流的价值尚未得到研究。
通过对数秩分析和无复发生存期的Kaplan-Meier曲线，比较接受ETV作为初始CSF分流治疗的OHC患者（n = 19）与因分流失败接受ETV治疗的OHC患者（n = 11）的结局。为了确定同期进行ETV和分流修复是否能降低频繁出现紧急分流失败的患者（n = 8）发生灾难性治疗失败的发生率，将ETV和分流修复后的治疗失败时间与其先前CSF分流的平均持续时间进行比较。
与将ETV作为OHC的初始CSF分流治疗相比，分流失败后进行ETV的失败可能性高2.5倍[风险比（RR）：2.48，p<0.05]。在将ETV作为初始CSF分流治疗后，17例患者（89%）立即得到改善，2年后65%无复发。分流失败后进行ETV治疗后，16例患者（71%）立即得到改善，但2年后只有25%无复发。在有多次分流修复和并发症病史的患者中，同期使用ETV和VP分流并不能显著降低治疗失败率。然而，需要急性干预的灾难性分流失败的发生率有所下降（43%对17%）。
根据我们使用ETV治疗OHC的经验，梗阻性脑积水患者先前的CSF分流与转为ETV后治疗失败时间缩短有关。ETV对先前接受过分流治疗的OHC患者的治疗效果可能较差。ETV联合同期CSF分流可能是预防有多次分流修复和并发症病史的OHC患者发生灾难性治疗失败的重要策略。
