Commentary: Converting Pediatric Patients and Young Adults From a Shunt to a Third Ventriculostomy: A Multicenter Evaluation.
Commentary: Converting Pediatric Patients and Young Adults From a Shunt to a Third Ventriculostomy: A Multicenter Evaluation.
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评论：将儿科患者和年轻人从分流术转为第三脑室造口术：多中心评估。
DOI：
10.1093/neuros/nyz535
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发表时间：
2020
期刊：
影响因子：
4.8
通讯作者：
Grant,Gerald
中科院分区：
文献类型：
--
作者：
Kumar,KevinK;Grant,Gerald
考虑到分流失败和感染的临床负担，使患者转为分流独立的可能性非常有价值。对于分流失败或接受分流翻修的患者，其中一种策略是考虑进行内镜下第三脑室造口术（ETV）。在Hersh等3及其同事发表的文章中，作者评价了10年期间现有脑室分流患者从分流转为ETV的成功率。在他们的80例患者队列中，64%的患者在中位随访2.0年时实现了分流独立性。4例患者需要重复ETV手术。作者发现，年龄是ETV失败的唯一显著预测因素，老年患者的诊断更有利。已发表的研究提供了有价值的证据，表明需要进行分流翻修的患者可能是ETV的优秀候选人。作者认为，通过磁共振或计算机断层扫描进行仔细的影像学检查，以确定脑脊液（CSF）阻塞的区域，而不是主要关注脑积水的病因，这是评估ETV候选人资格的一条有价值的信息。最常见的阻塞部位涉及大脑导水管和第四脑室。这种对确定CSF流动阻塞部位的关注甚至适用于既往有脑室内出血或肿瘤切除术的患者。在这些情况下，影响CSF动力学的碎片或瘢痕可能会随着时间的推移而成熟，这可能会影响手术候选人。本研究补充了已发表的研究，例如Kulkarni等人2016年的前瞻性研究，其中包括既往接受过分流术的患者子集。1 ETV成功评分（ETVSS）是成功的定义，用于估计6个月时手术成功的机会。ETVSS基于3个因素计算评分：患者年龄、脑积水原因和是否存在既往分流。虽然对儿科患者群体非常有价值，但本研究的发现对成人神经外科医生评估分流失败或感染的患者也具有重大影响。通常，在获得必要的成像并进行分流后，患者被带到手术室进行分流询问和翻修。这为神经外科医生提供了一个机会，以考虑ETV是否有助于缓解CSF流动阻塞并实现分流独立性。虽然一部分患者肯定会失败ETV，作者认识到，放置Ommaya水库后ETV作为最终ETV失败的情况下，可以作为安全措施。虽然数据是在至少6个月的随访时提供的，但确定ETV治疗分流失败患者的受益持久性将具有重要意义。此外，虽然对3个中心的大型患者队列进行了回顾性分析，但目前尚不清楚ETV在更广泛病因的现有分流患者中的成功程度，以及这些结果是否可在其他中心推广。ETV具有已知的并发症，包括CSF泄漏、出血和感染。2因此，神经外科界将受益于一项多中心前瞻性随机对照试验，研究现有分流患者的ETV。
Given the clinical burden of shunt failure and infection over a lifetime, the potential to convert patients to shunt independence is highly valuable. One such strategy for patients when in shunt failure or undergoing shunt revision is to consider performing an endoscopic third ventriculostomy (ETV). In the published article by Hersh et al 3 and colleagues, the authors evaluated the success of converting from shunt to ETV in patients with existing ventricular shunts over a 10-yr period. In their cohort of 80 patients, 64% of patients achieved shunt-independence at a median follow-up of 2.0 yr. Four patients required a repeat ETV procedure. The authors identified that age was the only factor significantly predictive of ETV failure with older patients having a more favorable diagnosis. The published study provides valuable evidence that patients requiring a shunt revision may be excellent candidates for ETV. Rather than primarily focus on the etiology of the hydrocephalus, the authors recognize that careful radiographic review by magnetic resonance or computed tomography to identify the area of cerebrospinal fluid (CSF) obstruction serves as a valuable piece of information in assessing candidacy for ETV. The most common site of blockage involved the cerebral aqueduct and fourth ventricle. This focus on identifying the site of CSF flow obstruction is applicable even in patients with prior intraventricular hemorrhage or tumor resection. In these cases, debris or scarring impacting CSF dynamics may mature with time, which may impact surgical candidacy. This study complements published studies, such as prospective studies by Kulkarni et al 2016, which included a subset of patients that had previous shunt. 1 The ETV Success Score (ETVSS) is a definition of success that was estimating the chance of success of the procedure at 6 mo. The ETVSS calculates a score based on 3 factors: patient age, cause of hydrocephalus, and the presence or absence of a previous shunt. While highly valuable in the pediatric patient population, the findings of this study also have substantial implications for adult neurosurgeons evaluating patients in shunt failure or with an infection. Generally, after obtaining necessary imaging and performing a shunt tap, patients are taken to the operating room for shunt interrogation and revision. This presents an opportunity for neurosurgeons to consider if ETV would be helpful to relieve CSF flow obstruction and achieve shunt independence. Although a proportion of patients will certainly fail ETV, the authors recognize that placement of an Ommaya reservoir following ETV as may serve as safety measure in the event of ultimate ETV failure. While the data was provided at a minimum follow up of 6 mo, it will be of significant interest to determine the durability of benefit for patients in shunt failure treated with an ETV. In addition, while a large cohort of patients analyzed retrospectively across 3 centers, it is unclear to what degree ETV in patients with an existing shunt could be successful across a broader range of etiologies and whether these results are generalizable across other centers. ETV has known complications including CSF leak, hemorrhage, and infection. 2 Thus, the neurosurgical community would benefit from a multicenter prospective randomized control trial investigating ETV in patients with an existing shunt.