Labidi Moujahed, Lavoie Pascale, Lapointe Geneviève, Obaid Sami, Weil Alexander G, Bojanowski Michel W, Turmel André
Neurological Sciences Department, Division of Neurosurgery, CHU de Québec-Hôpital de l'Enfant-Jésus, Québec City; and.
Surgery Department, Division of Neurosurgery, CHUM-Hôpital Notre-Dame, Montréal, Québec, Canada.
J Neurosurg. 2015 Dec;123(6):1447-55. doi: 10.3171/2014.12.JNS141240. Epub 2015 Jul 24.
Endoscopic third ventriculostomy (ETV) has become the first line of treatment in obstructive hydrocephalus. The Toronto group (Kulkarni et al.) developed the ETV Success Score (ETVSS) to predict the clinical response following ETV based on age, previous shunt, and cause of hydrocephalus in a pediatric population. However, the use of the ETVSS has not been validated for a population comprising adults. The objective of this study was to validate the ETVSS in a "closed-skull" population, including patients 2 years of age and older.
In this retrospective observational study, medical charts of all consecutive cases of ETV performed in two university hospitals were reviewed. The primary outcome, the success of ETV, was defined as the absence of reoperation or death attributable to hydrocephalus at 6 months. The ETVSS was calculated for all patients. Discriminative properties along with calibration of the ETVSS were established for the study population. The secondary outcome is the reoperation-free survival.
This study included 168 primary ETVs. The mean age was 40 years (range 3-85 years). ETV was successful at 6 months in 126 patients (75%) compared with a mean ETVSS of 82.4%. The area under the receiver operating characteristic curve was 0.61, revealing insufficient discrimination from the ETVSS in this population. In contrast, calibration of the ETVSS was excellent (calibration slope = 1.01), although the expected low numbers were obtained for scores < 70. Decision curve analyses demonstrate that ETVSS is marginally beneficial in clinical decision-making, a reduction of 4 and 2 avoidable ETVs per 100 cases if the threshold used on the ETVSS is set at 70 and 60, respectively. However, the use of the ETVSS showed inferior net benefit when compared with the strategy of not recommending ETV at all as a surgical option for thresholds set at 80 and 90. In this cohort, neither age nor previous shunt were significantly associated with unsuccessful ETV. However, better outcomes were achieved in patients with aqueductal stenosis, tectal compressions, and other tumor-associated hydrocephalus than in cases secondary to myelomeningocele, infection, or hemorrhage (p = 0.03).
The ETVSS did not show adequate discrimination but demonstrated excellent calibration in this population of patients 2 years and older. According to decision-curve analyses, the ETVSS is marginally useful in clinical scenarios in which 60% or 70% success rates are the thresholds for preferring ETV to CSF shunt. Previous history of CSF shunt and age were not associated with worse outcomes, whereas posthemorrhagic and postinfectious causes of the hydrocephalus were significantly associated with reduced success rates following ETV.
内镜下第三脑室造瘘术（ETV）已成为梗阻性脑积水的一线治疗方法。多伦多研究小组（库尔卡尼等人）制定了ETV成功评分（ETVSS），以根据儿科人群的年龄、既往分流情况和脑积水病因预测ETV后的临床反应。然而，ETVSS在成人人群中的应用尚未得到验证。本研究的目的是在包括2岁及以上患者的“闭合颅骨”人群中验证ETVSS。
在这项回顾性观察研究中，对两所大学医院连续进行的所有ETV病例的病历进行了审查。主要结局，即ETV的成功，定义为6个月时无因脑积水导致的再次手术或死亡。计算所有患者的ETVSS。为研究人群建立了ETVSS的判别特性以及校准。次要结局是无再次手术生存率。
本研究包括168例原发性ETV。平均年龄为40岁（范围3 - 85岁）。126例患者（75%）在6个月时ETV成功，而平均ETVSS为82.4%。受试者工作特征曲线下面积为0.61，表明该人群中ETVSS的判别能力不足。相比之下，ETVSS的校准效果极佳（校准斜率 = 1.01），尽管得分<70时获得的预期数量较少。决策曲线分析表明，ETVSS在临床决策中略有益处，如果将ETVSS的阈值分别设定为70和60，每100例病例可减少4例和2例可避免的ETV。然而，与根本不推荐ETV作为手术选择的策略相比，当阈值设定为80和90时，ETVSS的净效益较低。在该队列中，年龄和既往分流情况均与ETV不成功无显著相关性。然而，导水管狭窄、顶盖受压和其他肿瘤相关性脑积水患者的结局优于脊髓脊膜膨出、感染或出血继发的病例（p = 0.03）。
ETVSS在该2岁及以上患者人群中未显示出足够的判别能力，但校准效果极佳。根据决策曲线分析，在以60%或70%成功率作为优先选择ETV而非脑脊液分流术阈值的临床场景中，ETVSS略有帮助。既往脑脊液分流病史和年龄与较差结局无关，而出血后和感染后导致的脑积水与ETV后成功率降低显著相关。
