Objective: In Sub-Saharan Africa, shunt dependence is a real threat for patients. For this reason, any method allowing shunt independence such as endoscopic third ventriculostomy should be promoted. The goal of this study was to show the advantages of neuroendoscopy in treating non-tumor obstructive hydrocephalus in Cameroon. Methods: We retrospectively reviewed the cases of non-tumor obstructive hydrocephalus treated with endoscopic third ventriculostomy in our hospital. Results: Twenty patients (15 males, 5 females) underwent endoscopic third ventriculostomy as first choice treatment for non-tumor obstructive hydrocephalus. Their ages ranged from six months to 41 years (mean 11.96 years, median 20.75 years). Fourteen patients (70%) were children (≤18 years old), 6 were adults, 7 were under age of two years and 3 were below one. Computed tomography scan was the radiological tool used in all cases. None did a magnetic resonance imaging scan. Etiology of hydrocephalus was aqueductal stenosis in 18 cases and stenosis of the foramina of Luschka & Magendie in two. Aqueductal stenosis was associated with myelomeningocele in one case and shunt failure in another one. Endoscopic third ventriculostomy was successful in alleviating clinical symptoms with shunt independence in 19 cases (95%), but failed in one case. ETV success was not related to patient age. Cerebrospinal fluid leak occurred in two patients as post-operative complication (10%). Overall, ETV diminished treatment cost by 600 USD. Conclusion: Even in areas with limited medical equipment like in Sub-Saharan Africa where shunt dependence is a real danger, ETV can be routinely used to successfully treat non-tumor obstructive hydrocephalus.
In Sub-Saharan Africa, because of many restrictive factors such as lack of neurosurgeons, poor transportation, and financial difficulties faced by patients’ families, shunt dependence is a real danger which threatens patients’ survival at any time. For this reason, methods allowing shunt independence like endoscopic third ventriculostomy (ETV) should be promoted and become the first choice treatment for (obstructive) hydrocephalus in these areas [
Our neuroendoscopy equipments comprised of a ventricular trocar with a 6 mm outer diameter and a working, irrigation and aspiration channels, 0˚ and 30˚ rigid fiber scopes, grasping and biopsy forceps, micro scissors, bipolar and monopolar coagulation probes, xenon cold light source, one chip standard definition digital camera (Aesculap, Tuttlingen, Germany), and an analogic screen (Sony, Tokyo, Japan).
It was a retrospective observational study on 20 cases of non-tumor obstructive hydrocephalus treated with ETV in our hospital between June 2007 and December 2014. Data was collected from patients’ files and included age, gender, clinical manifestations, imaging data, type, duration and eventual complications of surgery, post-opera- tive clinical and radiological investigations.
Inclusion criteria: patients of any age with non-tumor obstructive hydrocephalus treated with endoscopic third ventriculostomy.
Exclusion criteria: patients with tumor obstructive hydrocephalus; non-obstructive (communicant) hydrocephalus; obstructive hydrocephalus treated with shunt or external ventricular drainage.
Criteria for successful ETV: ETV was considered successful if it achieved clinical improvement, shunt independence and normal psychomotor development (for children).
All patients underwent ETV under general anesthesia with orotracheal intubation. Patients were positioned supine with the head resting on a horse shoe head holder, slightly flexed with no rotation. After sterile draping, a 2 - 3 cm linear skin incision, 2 - 3 cm from midline, was made across the coronal suture. A pre-coronal bore hole was then drilled on the right side and dura opened in cruciate fashion. The cerebral cortex was cauterized to avoid bleeding while inserting the ventricular trocar into the right frontal horn. The entry of ventricular trocar into the ventricle was evidenced by the reflux of cerebrospinal fluid (CSF). At this point, a 0˚ fiberscope was introduced into the trocar and operation was then conducted under direct visualization. After entering the right frontal horn, it was mandatory to localize the foramen of Monro by identifying the choroid plexus, septal and thalamostriate veins before ventricular navigation was continued. Upon localizing the interventricular foramen of Monro, the endoscope was then gently passed through that foramen taking care not to injure the fornix or tear the thalamostriate or septal veins. Once into the third ventricle, tuber cinereum, dorsum sellae, mammillary bodies, and in case of thin third ventricle floor, basilar artery complex were identified. A stoma was then made on the midline just anterior to mammillary bodies using the grasping forceps. The aperture was widened by opening the forceps. The forceps was slightly withdrawn to watch for pulsations of third ventricle floor due to CSF flow through the stoma. Subsequently, the endoscope was passed through the stoma in order to fenestrate any arachnoid or Liliequist membranes. Dorsum sellae dura and basilar artery complex were visualized. Sometimes, the 0˚ fiberscope was withdrawn and 30˚ scope introduced in order to visualize the posterior part of the third ventricle to see whether the cerebral aqueduct was opened or obstructed. We used ventricular irrigation only in cases of poor vision due to bleeding and not routinely. The ventriculoscope was then withdrawn and the cortical opening obstructed with gel foam. The dura was tightly sutured and the skin closed in two layers. All operations were done free hand as we did not have an endoscopic holder.
Patients were hospitalized for 2 to 3 days. The wound was inspected and dressed daily. Vital signs, neurological status, head circumference, anterior fontanel when not closed or any symptoms were monitored until discharged. Patients in whom CSF leak was noticed had repeated lumbar punctures or drainage for 2 to 3 days along with compressive dressing of the head. After discharge from the hospital, patients were seen on outpatient consultation at one week, one month, 3, 6, 12 months and then annually. Clinical symptoms, neurological status, psychomotor development were evaluated. Postoperative CT scan was prescribed to all patients at 3 months after surgery. Patients and parents were informed of possible late closure of stoma with the risk of sudden clinical deterioration.
Because of the small sample size and discrepancy in age distribution of this series, we found it not worthy to perform statistical analysis to search for statistically significant differences among age groups.
We enrolled 20 patients (15 males, 5 females) with a mean age of 11.96 years (median age, 20.75 years; range, 6 months to 41 years). At the time of ETV, 14 patients (70%) were children, 2 were 18 years old while only 4 were adults. Seven patients were under 2 years of age and 3 were less than 1 year old.
The radiological diagnosis was made by computed tomography (CT) scan in all patients. None of them did magnetic resonance imaging (MRI) because it was not available or unaffordable. CT scans showed triventricular hydrocephalus in consonance with primary aqueduct stenosis (in 18 cases). In two cases, CT-scans showed quadriventricular obstructive hydrocephalus with round shaped outlets of fourth ventricle suggesting stenosis of the foramina of Luschka and Magendie (
patients did post-operative CT scans. Therefore, we could not analyze preoperative and postoperative ventricular indices.
The procedure done was ETV alone in 19 cases and ETV combined with shunt removal in one case. The mean operation time was 34 minutes (median, 43 minutes; range, 22 - 64 minutes). During ETV procedure, we observed two minor intraventricular haemorrhages easily managed with intraventricular infusion of isotonic saline. ETV was successful in 19 cases (95%) but failed in one case (10 months old boy). ETV was successful in the shunt failure case and myelomeningocele case. Concerning post-operative complications, two patients had cerebrospinal fluid leak successfully treated with repeated lumbar puncture or drainage for three days. There was neither no death nor permanent morbidity related to this technique.
The mean hospital stay was 2.9 days (median, 4.5 days, range, and 2 - 7 days). The mean follow up duration was 4.37 years (median, 4.20 years, range, 5 months 15 days - 7 years 11 months 9 days). By the time of the last follow up visit we did not have to repeat ETV for late closure.
In Sub-Saharan Africa, financial and logistical constraints render hydrocephalus management with shunts very hazardous and shunt dependence really dangerous for patients [
In spite of its numerous advantages in treating obstructive hydrocephalus, ETV is still not widely or routinely used in Sub-Saharan African countries like Cameroon. Besides the works of Benjamin C Warf in Uganda [
Endoscopic third ventriculostomy has become the preferred treatment for obstructive or non-communicating hydrocephalus from various etiologies [
The overall success rates of ETV reported from medical literature range from 17% to 100% [
There are controversies concerning age, etiology of hydrocephalus, primary and repeated ETV as predictors of success or failure of ETV [
Although ETV is a simple and a safe procedure, many complications had been reported. Some are intraoperative like hemodynamic disturbances, intraventricular bleeding, and injury to fornix, thalamus, hypothalamus or basilar artery complex. Others are post-operative as CSF leak, meningitis or ventriculitis, diabetes insipidus, memory disturbance, epidural or subdural hematoma, delayed intraventricular hemorrhage, seizures [
Many reports had shown that psychomotor or neurocognitive outcome of infants treated with ETV alone or associated with choroid plexus cauterization is not significantly different to that of infants treated with VP shunts [
Few studies had addressed the cost of ETV in comparison to that of shunting. In Sub-Saharan Africa where income is low and most patients do not have any health insurance, cost of treatment is always a concern for patient’s management. In Brazil, Oton de Lima et al. [
Even in our clinical practice with limited equipments, we were able to perform ETV in non-tumor obstructive hydrocephalus with a very good success rate, significant cost reduction and low transient morbidity. Other authors sharing the same difficulties like us have reported similar results from other Sub-Saharan African countries. Therefore, we conclude that ETV is safe and efficient in treating obstructive hydrocephalus even in the difficult context of Sub-Saharan Africa and should be the treatment of choice.
AurélienNdoumbe,ChantalSimeu,MathieuMotah,11, (2015) Non-Tumor Obstructive Hydrocephalus Treated with Endoscopic Third Ventriculostomy in Cameroon. Open Journal of Modern Neurosurgery,05,137-143. doi: 10.4236/ojmn.2015.54022