Effect of endoscopic third ventriculostomy on subsequent shunt failure: a Hydrocephalus Clinical Research Network study.

OBJECTIVE

Endoscopic third ventriculostomy (ETV), an alternative to ventriculoperitoneal shunt (VPS) placement, is associated with a higher risk of early failure, sometimes necessitating subsequent VPS insertion. The authors evaluated the impact of ETV prior to VPS placement on the risk of VPS failure by using the Hydrocephalus Clinical Research Network (HCRN) Core Data Project.

METHODS

The authors retrospectively reviewed prospectively collected data from the HCRN Core Data Project (registry) on all children who underwent VPS surgery between April 2008 and July 2023. Children who had undergone VPS placement as initial treatment for hydrocephalus were compared with those who had undergone ETV prior to VPS insertion. The primary outcome was initial VPS survival, with failure defined as any subsequent hydrocephalus procedure. Kaplan-Meier and Cox proportional hazards analyses were performed to assess the effect of prior ETV, controlling for age at the first permanent procedure (ETV or VPS placement), hydrocephalus etiology, and complex chronic conditions (CCCs).

RESULTS

VPS placement was performed in 6206 children, of whom 642 underwent VPS placement after failed ETV. VPS insertion after ETV improved shunt survival at 1 year (74.3% vs 67.8%, p < 0.001). Unadjusted analysis showed improved VPS survival after ETV (HR 0.78, 95% CI 0.68-0.90, p = 0.001). Corrected age ≥ 30 days at the time of the first permanent procedure, choroid plexus cauterization, etiology of hydrocephalus other than intraventricular hemorrhage of prematurity, and the absence of a CCC were also associated with improved shunt survival on univariable analysis. Multivariable analysis revealed that hydrocephalus etiology, the absence of a CCC, corrected age ≥ 30 days at the time of the first permanent procedure, and ETV prior to VPS insertion (HR 0.85, 95% CI 0.74-0.98) remained associated with shunt survival (all p < 0.05).

CONCLUSIONS

This analysis demonstrates an association between ETV prior to VPS placement and improved VPS survival, even when controlling for age, comorbid conditions, and hydrocephalus etiology. Further work is needed to understand the mechanism of this effect.