Evidence that prior endoscopic third ventriculostomy with choroid plexus cauterization protects against subsequent shunt failure among infants treated for hydrocephalus.

Abstract

Objective: It is unclear whether shunt survival differs for infants in whom prior endoscopic third ventriculostomy with choroid plexus cauterization (ETV/CPC) failed compared with those treated initially by shunt placement. Results among four previous studies spanning a range of age groups have suggested either no effect or a protective effect of prior endoscopic treatment on shunt survival. The aim of this study was to determine whether prior ETV/CPC positively impacts shunt survival among infants with hydrocephalus regardless of etiology.

Methods: The authors conducted a historical cohort review of all patients under 12 months corrected age who underwent ventriculoperitoneal shunt (VPS) placement either with or without prior ETV/CPC at their institution between December 2008 and December 2023. Statistical analyses included Cox regression modeling, Kaplan-Meier survival curves, and log-rank testing to evaluate the time to shunt failure.

Results: The study included 122 infants with and 46 infants without prior ETV/CPC who underwent VPS placement. There were no statistically significant differences between groups regarding sex, race, gestational age at birth, or corrected age at initial treatment for hydrocephalus. The distribution of etiologies and initial frontal-occipital horn ratios (FOHRs) were similar. The median pre-shunt FOHR was greater in the ETV/CPC group. The patients in the primary shunt placement group were all candidates for ETV/CPC based on retrospective review. Seventy-one infants (58%) with prior ETV/CPC remained free of shunt revision compared with 17 infants (37%) with primary shunt placement (OR 2.4, 95% CI 1.1-5.1; p = 0.01). The estimated 2-year shunt survival probability was 75% with and 50% without prior ETV/CPC (log-rank p = 0.001). The estimated 5-year survival was 60% with and 45% without prior ETV/CPC (p = 0.045).

Conclusions: Infants who underwent ETV/CPC prior to VPS placement had better shunt survival than those who did not. ETV/CPC might reduce the risk of subsequent shunt failure, indicating the potential benefit of the procedure even when it fails.