Is there an indication for ETV in young infants in aetiologies other than isolated aqueduct stenosis?

OBJECTIVES: The objective was to determine whether endoscopic third ventriculostomy (ETV) has a role in the management of obstructive hydrocephalus in aetiologies other than idiopathic aqueduct stenosis (AS) in infants. MATERIALS AND METHODS: In addition to reviewing the literature, we performed a retrospective analysis of our endoscopy database, which was established in 1998, and analysed the outcome results of all cases of ETV in those under 1 year of age which were performed between 1998 and 2003. We included cases of idiopathic AS in the outcome analysis as a benchmark of successful outcome. Successful outcome was assessed by resolution of the presenting clinical features and shunt freedom. RESULTS: Aetiologies that were identified included, in addition to idiopathic AS, suprasellar arachnoid cysts, AS in association with post-haemorrhagic hydrocephalus (PHH), post-infectious hydrocephalus (PIH), tumour-related hydrocephalus and a heterogenous group including Dandy-Walker malformation and other developmental anomalies. Suprasellar arachnoid cysts had a 100% outcome success. Idiopathic AS had a 50% outcome success and the successful outcome of PHH cases was poor at 18%. A statistical analysis revealed no effect of age at the time of ETV on the outcome in the aetiological groups. CONCLUSIONS: The definitive initial neurosurgical management of suprasellar arachnoid cysts causing significant hydrocephalus is ETV, whereas that for PHH and PIH is probably that of a ventriculo-peritoneal shunt placement. We speculate that there may be a sub-group of AS cases, termed pure or idiopathic AS, which have a higher rate of successful outcome that may be durable from a younger age. The role of repeat ETV is controversial.

Leksell gamma knife radiosurgery for cerebral arteriovenous malformations in pediatric patients.

OBJECTS: The authors report their experience of gamma knife radiosurgery (GKR) in a large series of pediatric cerebral arteriovenous malformations (cAVMs). The advantages, risks and failures of this approach are presented and discussed. METHODS: Gamma knife radiosurgery was performed on 63 children aged < or =16 years. Haemorrhage was the clinical onset in 50 out of 63 cases. The mean pre-GK cAVM volume was 3.8 cm(3). Fifty-eight out of 63 cAVMs were Spetzler-Martin grades I-III. Most lesions (47 out of 63) were in eloquent or deep-seated brain regions. CONCLUSION: Gamma knife radiosurgery-related complications occurred in 2 out of 47 cases with an available follow-up (1 had transient and 1 permanent morbidity). No bleeding occurred during the latency period. In 39 children with >36-month follow-up, complete cAVM occlusion was angiographically documented in 31, with a 3- and 4-year actuarial obliteration rate of 72 and 77% respectively. High rates of complete obliteration and very low frequency of permanent morbidity with no bleeding during the latency period encourage widespread application of GKR in the treatment of pediatric cAVMs.