Comparison of endoscopic third ventriculostomy with stereotactic prepontine stenting in patients with aqueductal stenosis.

Objective: The standard treatment for noncommunicating hydrocephalus is endoscopic third ventriculostomy (ETV). An alternative procedure is the stereotactic implantation of a shunt catheter through the ventricles into the prepontine cistern, which serves as a stent (STS). This procedure may reduce the risk of stoma occlusion. The aim of this study was to compare the surgical and clinical results of both procedures.

Methods: Patients with aqueductal stenosis treated by either ETV or STS from January 2013 to July 2024 were included in this single-center retrospective study. Patient records were searched for indication, procedural data, complications, and clinical outcomes. In addition, available MR images were analyzed for the Evans index, basilar artery to clivus distance, and ventricular width. The parameters were compared between ETV and STS groups.

Results: STS was performed in 50 patients with a mean age of 46 years and ETV in 97 patients with a mean age of 36 years. STS was carried out more frequently in patients with secondary aqueductal stenosis due to a tumor (66% vs 21%), while ETV was conducted more frequently in patients with primary aqueductal stenosis (76% vs 26%). The distance between the basilar tip and clivus was significantly smaller in the STS group (2.8 vs 3.7 mm, p = 0.0007). The most common symptoms before surgery in both groups were headaches (48%), cognitive impairment (46%), and gait disorder (48%). Both procedures resulted in significant improvement of symptoms. There was no significant difference in the number of revision surgical procedures due to infection or bleeding (STS 8% vs ETV 4%) or insufficiency of the hydrocephalus treatment (STS 4% vs ETV 13%, p = 0.09). Subgroup analyses that excluded newborns and stratified results by etiology of aqueductal stenosis had no effect on the results.

Conclusions: The safety and efficacy of both surgical procedures are comparable. The selection of the surgical approach must be made on an individual basis.