Endoscopic third ventriculostomy with or without choroid plexus cauterization for preventing shunt dependence in pediatric hydrocephalus: preliminary results of a prospective clinical case series in a lower-middle-income country (Egypt).

Purpose: Pediatric hydrocephalus imposes a significant clinical and financial burden in developing countries. Traditional treatment by ventricular shunting in this setting suffers a high rate of shunt infection and malfunction. This study aims at assessing the efficacy and safety of endoscopic third ventriculostomy (ETV), either alone or combined with choroid plexus cauterization (CPC), for preventing shunt dependence in pediatric hydrocephalus within a healthcare setting of a tertiary hospital in Egypt.

Methods: A prospective clinical case series included patients aged 16 years or younger with clinical manifestations of hydrocephalus requiring CSF diversion. Cases with active infection or brain imaging showing prohibitive anatomical distortion or multiloculated hydrocephalus were excluded. Failed ETV + / - CPC cases were categorized into early (< 3 months) and late (> 3 months) failure groups, each with specific management strategies.

Results: A total of 40 patients were admitted to Ain Shams University Hospital between March 2022 and August 2023 and underwent ETV/CPC (n = 32) for those younger than 2 years and ETV alone (n = 8) for patients > 2 years old, using a flexible neuroendoscope. Aqueductal stenosis was the most common etiology, observed in 13 patients (32.5%), followed by Chiari type 2 in 11 patients (27.5%), and post-infectious causes in 6 patients (15%). The median age of the patients was 5.05 months (mean 22 months; range 0.23-169.27 months). The median preoperative ETV success score (ETVSS) was 50. Overall, 25 patients (62.5%) achieved successful outcomes following either ETV alone or ETV/CPC procedures, with no procedure-related morbidity or mortality. Fifteen patients (37.5%) experienced ETV failure, of whom 6 underwent ETV redo procedures. Across the entire cohort, 28 patients (70%) remained shunt-free, with a mean follow-up of 12 months.

Conclusion: The addition of CPC to ETV (for patients < 2 years) using the flexible scope demonstrates effectiveness in decreasing the necessity for shunt placement in younger patients with a likelihood of ETV failure. Moreover, being a safe procedure, it supports a sustainable and cost-effective approach to hydrocephalus treatment.