Transsphenoidal reoperations for removal of pituitary adenomas: rhinological management and timing of reoperation

Transsphenoidal reoperation of pituitary adenomas remain a difficult surgical procedure even with skilful microsurgical techniques. This paper retrospectively analysed how to overcome such difficult factors as absent normal surgical landmarks and an adhesive field. For residual or recurrent adenomas, transsphenoidal reoperations were carried out 14 times in 12 patients. Reasons for reoperations were intentionally multistaged operations in 10 cases, regrowth in three and apoplexy in one. In the first operation, we tried to preserve or restore as many anatomic landmarks as possible. Overly aggressive procedures causing cerebrospinal fluid leakage were avoided. In the three second reoperations within 3 months, a transnasal approach was used. In the other eight situations, between 4 and 119 months, transnasal approach in five, and transseptal approach in three, were used retrospectively. In two patients with fibrous adenomas, reoperations were carried out 4 and 12 months after the first. Magnetic resonance imaging (MRI) evaluation is essential to confirm the tumour descent toward or into pituitary fossa. Timing of the reoperation needs to be individualized depending on MRI findings. Trauma to the nasal mucosa and a narrower operative field became more frequent in reoperations 4 months or later. To obtain a surgical field wide enough to manipulate an ultrasonic aspirator for fibrous adenomas, removal of bony structures at the nasal cavity on the surgical corridor is useful. These rhinological preparations in the first and subsequent operations along with a selection of timing of reoperation are important to gain easier access for tumour removal and in avoidance of surgical complications.     

The effectiveness of neuroendoscopic interventions in children with brain tumours

OBJECT: The purpose of this study was to review the efficacy of neuroendoscopic interventions in children with brain tumours and tumour-related hydrocephalus. METHODS: In all, 61 consecutive neuroendoscopic operations carried out in 53 children with brain tumours over a 6-year period were reviewed. The patients ranged in age from 5 months to 18 years (median 9 years). Forty of 61 presentations were with a newly diagnosed tumour and hydrocephalus - the remainder predominantly had a known tumour and worsening hydrocephalus. CONCLUSIONS: Neuroendoscopic third ventriculostomy (NTV) successfully relieved hydrocephalus in the short term in 45 of 47 cases and in the longer term in 39 of 47 cases. Neuroendoscopic biopsy provided definitive tissue diagnosis in 10 of 16 cases and 5 tumours were resected. There was 1 postoperative death, which not directly related to the neuroendoscopy and few significant complications otherwise. Neuroendoscopic methods allow effective immediate and longer term control of hydrocephalus as well as the opportunity for CSF sampling and tumour biopsy in selected cases.     

Detection of craniospinal dissemination of intracranial germ cell tumours based on serum and cerebrospinal fluid levels of tumour markers.

Nineteen intracranial germ cell tumours treated during the past 11 years were evaluated retrospectively. The tumours were classified into three groups according to the level of alpha-fetoprotein (AFP) and beta-human chorionic gonadotropin (HCG) in serum and cerebrospinal fluid, and the optimal treatment for each group was determined. Group A consisted of patients with normal titres of AFP and HCG, group B of patients with relatively high titres (< 10 times normal), and group C comprised patients with higher titres ( 10 times normal levels). In group A, an appropriate field and dose of irradiation was necessary to prevent craniospinal dissemination. In group B, none of four patients who underwent total or subtotal resection of the tumour had craniospinal disseminatio n or tumour recurrence, whereas dissemination occurred in four further patients, including two who had received radiochemotherapy only, and two who had undergone partial resection of the tumour. While patients in group C had dissemination at the time of initial diagnosis, most patients in group B developed dissemination more than 10 months after initial treatment, suggesting that the type of treatment received as first line therapy is important in patients in this group. The prognosis of patients in group C, however, was unaffected by the priority given to either surgery, radiation or chemotherapy as first line treatment. Craniospinal dissemination can be prevented in patients with germ cell tumours who have a relative increase in levels of AFP and HCG by aggressive removal of the tumours as first line therapy, regardless of the type of adjuvant therapy given.     

Prolactin secreting pituitary carcinoma.

A man with a prolactin secreting pituitary carcinoma was treated by surgery and radiotherapy. Persistent hyperprolactinaemia partially responded to oral bromocriptine for four years. Serum prolactin then rose considerably with rapid, invasive tumour recurrence. Cytotoxic chemotherapy halted tumour progression for twelve months before fatal spread throughout the brain. Failure to normalise serum prolactin with bromocriptine may precede an aggressive course in patients with prolactinoma.     

Outcome of craniopharyngioma in children: long-term complications and quality of life

Childhood craniopharyngiomas are histologically benign tumours arising from remnants of Rathke's pouch in the hypothalamic-pituitary region. The two common treatment approaches are primary total resection or limited resection followed by radiotherapy. To study the outcome after a primary surgical approach, we followed 25 consecutive patients (10 females, 15 males) under 16 years of age who were treated in a single institution with a management policy of radical tumour excision (mean age at diagnosis 9 years 2 months, SD 4 years 3 months; range 2 years 9 months to 15 years 11 months). Mean follow-up after primary surgery was 11 years 3 months (SD 7 years 7 months). Tumour control, and neurological, endocrine, and hypothalamic complications and their impact on health-related quality of life were assessed (medical follow-up, semi-structured interview, and questionnaires). Results of tumour control were generally good, however, local failure was observed in 6 of 25 patients, and severe late-treatment complications decreased quality of life for many long-time survivors. Endocrine deficiency occurred in 24/25, visual complications in 16/24, neurological complications in 8/24, obesity in 14/23, increased daytime sleepiness in 6/21, and significant school problems in 10/20. Patients with craniopharyngioma rated their health-related quality of life as considerably lower than healthy controls; the domains of social and emotional functioning were particularly affected. Parents' ratings were considerably lower than those of the patients. Poor functional outcome was associated with large tumours infiltrating or displacing the hypothalamus, the occurrence of hydrocephalus, and young age at diagnosis, but also with multiple operations due to tumour recurrence. Alternative treatment strategies should be considered, especially in very young patients with large tumours.     

Experience in surgical management of tumours involving the cavernous sinus.

Potential injury to the neurovascular structures within the cavernous sinus often prohibits aggressive removal of tumours involving it, however, fully understanding the anatomy and selecting an appropriate surgical approach can often resolve this problem with acceptable morbidity. Moreover, a tumour may originate from different anatomical structures of the cavernous sinus which will influence the difficulty and outcome of the surgery. In general, tumours in this region can be classified as intradural, intracavernous and invasive types. The strategy of surgical treatment varies among these different anatomical types. Therefore, preoperative evaluation of tumours in the cavernous sinus is critical for the selection of an appropriate microsurgical approach. During the past 5 years, 12 tumours involving the cavernous sinus have been operated upon which included four neuromas, three meningiomas, three cavernous haemangiomas, one plasmacytoma and one chondroma. Nine of these twelve tumours were totally resected after one or two operations. There was no surgical mortality and the most common morbidity was transient cranial nerve palsy. At 2 months after surgery there was no additional postoperative cranial nerve deficit in all the patients; however, one patient developed a postoperative middle cerebral artery infarct due to accidental injury to the internal carotid artery during surgery. The respectability of the tumour mostly depends on its consistency and the involvement of the adjacent anatomy. The pathoanatomical features of the tumours and the clinicoradiological findings, as well as the selection of the microsurgical approach, are discussed.     

Cervical lipoblastomatosis producing quadriparesis: case report of surgery with chemotherapy and 10-year follow-up

Introduction Cervical lipoblastomatosis is a rare spinal tumour. Management of recurrence and long-term outcome data are not well described.Case report A 10-month-old infant presented with an upper extremity weakness. Magnetic resonance imaging (MRI) revealed an extradural cervical spinal tumour. It was debulked and histopathology revealed it to be lipoblastomatosis. The infant improved postoperatively. However, 5 months later the patient deteriorated and developed quadriparesis. The patient was managed with a more extensive resection and had chemotherapy. Ten years post-presentation the patient is well having made a full recovery and is living a normal life. Recent MRI shows minimal residual quiescent tumour.Conclusion The treatment of cervical lipoblastomatosis should involve the resection of as much tumour as possible at the first sitting as recurrence can be a problem. In cases of spinal recurrence we recommend aggressive decompression and adjuvant chemotherapy.     

High field strength magnetic resonance imaging in paediatric brain tumour surgery—its role in prevention of early repeat resections

Purpose

The purpose of this study is to compare the surgical and imaging outcome in children who underwent brain tumour surgery with intention of complete tumour resection, prior to and following the start of intra-operative MRI (ioMRI) service.

Methods

ioMRI service for brain tumour resection commenced in October 2009. A cohort of patients operated between June 2007 and September 2009 with a pre-surgical intention of complete tumour resection were selected (Group A). A similar number of consecutive cases were selected from a prospective database of patients undergoing ioMRI (Group B). The demographics, imaging, pathology and surgical outcome of both groups were compared.

Results

Thirty-six of 47 cases from Group A met the inclusion criterion and 36 cases were selected from Group B; 7 of the 36 cases in Group A had unequivocal evidence of residual tumour on the post-operative scan; 5 (14 %) of them underwent repeat resection within 6 months post-surgery. In Group B, ioMRI revealed unequivocal evidence of residual tumour in 11 of the 36 cases following initial resection. In 10 of these 11 cases, repeat resections were performed during the same surgical episode and none of these 11 cases required repeat surgery in the following 6 months. Early repeat resection rate was significantly different between both groups (p?=?0.003).

Conclusion

Following the advent of ioMRI at our institution, the need for repeat resection within 6 months has been prevented in cases where ioMRI revealed unequivocal evidence of residual tumour.     

脑立体定向术治疗冲动攻击行为精神病疗效观察

本文报告脑立体定向术治疗冲动攻击行为精神病20例。经半年至2年观察,冲动攻击行为完全消失者占65％,总有效率85％。用BPRS量表及Kawiecka病情量表检测,术前术后计分对比有显著差异。论述丘脑背内侧核的解剖生理基础,提出准确的脑室穿刺,良好的脑室造影,多靶点毁损,术后一定量的药物维持,对提高手术疗效有重要作用。     

Natural history of elderly patients with asymptomatic meningiomas

OBJECTIVE: For the treatment of elderly patients with asymptomatic meningiomas, it is important to determine their natural history. Based on results of follow up examinations, the natural history of such patients was clarified and prognostic factors concerning the potential of tumour growth in the aged were identified. METHODS: The clinical records and imaging studies of 40 elderly (over 70 years) patients with asymptomatic meningiomas were analysed. The patients were followed up with repeated imaging studies, and changes in tumour size, clinical signs, and outcomes were evaluated. RESULTS: There were 32 women and eight men with a mean age of 76.1 years. The mean follow up period was 38.4 months, ranging from 6 to 97 months. Six patients died during the follow up period from disorders other than the tumours, and one patient died as a result of the tumour. Twenty six patients (mean follow up period 41.8 months, range 10-97 months) showed no tumour growth. Fourteen patients showed tumour growth (mean follow up period 32.1 months, range 6-88 months). Five (four men and one woman) of these patients became symptomatic. Based on imaging analysis (1) calcification of the tumour was associated with no tumour growth (p=0.036), and (2) the tumour size at the initial diagnosis was related to subsequent tumour growth (p=0.016). Other possible factors related to tumour growth included sex and hyperintensity on MRI T2 weighted images. CONCLUSION: In elderly patients with asymptomatic meningiomas, careful clinical follow up with imaging studies is important. The imaging features mentioned may contribute to prediction of tumour growth.     

Brain metastases from unknown primary tumour

The best management of patients with brain metastases from an unknown primary tumour is still unclear, as data are scarce and studies are retrospective. We report 33 patients with biopsy-proven brain metastases from a primary tumour not found at the first investigations, who were treated by surgery and/or radiotherapy and followed with serial CT until death. Median survival time for all patients was 10 months and survival rates at 6 months, 1 year and 2 years were 76 %, 42 % and 15 % respectively. Patients with single brain metastasis treated by gross total resection and whole-brain radiotherapy (WBRT) had a median survival of 13 months with 76 % alive at 6 months, 57 % at 1 year and 19 % at 2 years. Patients with multiple brain metastases who underwent either WBRT alone or WBRT preceded by gross total resection of the symptomatic lesions had a poorer prognosis: median survival of 6–8 months with 50–100 % alive at 6 months, 17–20 % at 1 year and none alive at 2 years. In 85 % of patients with a single brain metastasis a significant improvement in neurological functions was observed after surgical resection; among patients with multiple brain metastases a neurological improvement was observed in all patients who had a resection of symptomatic lesions and only in a half of patients who had WBRT alone. During the follow-up the primary tumour was found in 27/33 patients (82 %) and was located in the lung in 78 %. Between 1987 and 1991 (with limited screening for the primary tumour in the follow-up) the unknown tumours were 6/15 (40 %); in the more recent period (1992–1996) (CT-based screening for the primary tumour in the follow-up) no primary tumour remained unknown but overall survival has not significantly improved. The number of brain metastases was the only significant factor affecting survival after both univariate and multivariate analysis. This study suggests that, in patients with both single and multiple brain metastases from an undetected primary site when first studied, surgery and/or WBRT enable the control of the brain disease, partly because the systemic disease may be silent for a prolonged time. Only a few asymptomatic patients may benefit from an early detection and treatment of the primary tumour during the follow-up. Received: 1 May 2000 / Received in revised form: 13 October 2000 / Accepted: 10 December 2000     

Surgical treatment of intramedullary tumors: preliminary results

Since 1995 in the Department of Neurosurgery, Mining Hospital in Sosnowiec a surgical technique has been used of total or gross total removal of tumour. It includes the use of CO2 laser for myelotomy and tumour vaporisation as well as ultrasonic aspirator, microsurgical techniques and intraoperative monitoring of SSEP. Ten patients 11-61 years of age were operated on. Four tumours were located in the cervical part of the spinal cord, three in the cervico-thoracic area while the remaining three in the thoracic part. The condition of four patients before the operation was assessed as I-II degree on the McCormick scale, of one patient as--III degree--and of the other five patients as IV-V degree. Only in two cases the removed tumour was ependymoma; in six cases these were benign astrocytomas and in two other--anaplastic tumours. After the treatment, the clinical condition of almost all patients improved. Pain and trouble some paraesthesias subsided. Five patients are completely self-dependent and three other walk with the aid of handrails. The treatment proved unsuccessful in one patient with an anaplastic tumour in whom paralysis of lower limbs occurred before the operation. Six months after the operation the patient died of tumour metastasis. The observation period ranged from 6 months to 3 years. On the basis of our own observations it is suggested that total safe removal of even infiltrating intramedullary tumours is possible when proper surgical techniques are used. Best results are obtained in patients in good clinical condition irrespective of tumour extent.     

A case of glioblastoma multiforme with long term survival: can we predict the outcome?

Glioblastoma Multiforme (GBM) presents a major challenge for a neurosurgeon as the most common primary malignant tumour of the central nervous system. The median life span after the diagnosis still remains between 6 months to 1 year even after gross total excision of the tumour. However, few patients survive long and develop recurrence after a substantial time interval. The exact reason behind the long term survival in GBM cases remains obscure. However, few predictors have been identified of late. Young age, p53 positivity, O6-methylguanine methyltransferase (MGMT) methylation, aggressive surgical resection and a good pre-operative Karnofsky Performance Score (KPS) have been identified with good survival rates in these select cases. Immunohistochemistry forms an integral part of a glioblastoma work up and it must be done in each and every case as it may provide crucial insights regarding prognosis. We report a rare case of glioblastoma multiforme with a long term survival of 20 years. This patient developed a frontal cystic tumour bilaterally in these 20 years and is still leading an active life. The clinical summary, imaging, histopathology, immunohistochemistry along with relevant literature have been discussed.     

Prognosis of medulloblastoma in infants

The prognosis of medulloblastoma in children less than 3 years old is usually considered to be rather poor. However, recent experiences with this type of tumour seem to indicate that survival in this specific subgroup of patients can be longer than expected. Nineteen infants with posterior fossa tumours treated by the authors in the period 1983–1994, all of them with symptoms presenting during the 1st year of life and all operated on before the end of the 2nd year of life, have been retrospectively analysed. Total tumour removal was achieved in 14 cases, subtotal in 1 and partial in 3. One subject underwent only a biopsy of the tumour. In 14 patients a CSF shunt was inserted. Chemotherapy was administered to 18 out of the 19 patients in the series. At the time of the study, 11 children had died (57.9%) and 8 were alive (42.1%; mean survival 86.5 months). One patient died of complications secondary to the surgical treatment. Three patients died because of local recurrence of the tumour after apparent total excision, death supervening 5, 12 and 18 months after the surgical treatment. A further 2 patients in whom total tumour removal had been performed died 3 and 17 months after surgery of local recurrence of the disease associated with regional metastases. Progression of the residual tumour, accompanied by metastatic dissemination in 3 cases, accounted for death in the other 5 patients who did not survive. Brain stem infiltration appeared to be the most significant adverse prognostic factor. All 8 long-term survivors had their tumour totally excised. Five of them underwent radiotherapy when at least 2 years old. On the basis of the results, the authors conclude that the current prognosis of infants with medulloblastoma is not necessarily any worse than that of older children with the same disease and that chemotherapy can be particularly useful in this subgroup of patients, as shown by 3 long-term survivals obtained in children treated with this type of therapy only. Received: 12 December 1996     

Evaluation of the effect of treatment on movement disorders in astrocytomas of the basal ganglia and the thalamus.

Twenty patients with movement disorders associated with astrocytomas (grade I-IV according to the WHO tumour classification) of the basal ganglia and the thalamus were evaluated for the effects of treatment. Five patients had more than one movement disorder when the histological diagnosis was verified by stereotactic biopsy. Twelve had tremors, eight hemidystonia, three hemichorea, and one hemichorea/ballismus, and myoclonus respectively. Ten patients died during the follow up period, and for the surviving patients follow up periods ranged from 6-21 years. The movement disorders changed over long periods of time related to therapeutic interventions. CSF shunt operations and percutaneous radiotherapy had no definite effect on the movement disorders. There was a moderate response to medical treatment in a few patients. Stereotactic aspiration of tumour cysts had a marked influence on the movement disorder in two patients, and functional stereotactic surgery abolished tumour induced tremor in one. Interstitial radiotherapy was performed in fifteen patients for treatment of the underlying neoplasm and resulted in different and variable alterations of the movement disorders. These differences may be explained by complex interactions involving structures affected primarily by the tumour, as well as by secondary functional lesions of adjacent structures.     

The treatment of skull base meningiomas – combining surgery and radiosurgery

While the operative results for treating skull base meningiomas have improved due to modern microsurgical techniques, surgery is still accompanied by a high morbidity rate. Over the last 6 years, we operated on 50 patients with intracranial meningiomas, 23 of which were skull-based lesions. Among these patients with skull base meningiomas, seven (30%) were treated with both surgery and radiosurgery.All patients received standard operative procedures. Five patients received subtotal resections and two patients received partial resections. No mortalities occurred in our series. Following the operations, the clinical status improved in six patients, while only one patient (with a tuberculum sellae meningioma) experienced deterioration of a preexisting visual disturbance. Radiosurgery was performed at a mean of 4.3 months after the operations. One patient was treated by a two-staged radiosurgery regimen in light of the patient's large tumour volume (57.5 cm(3)). The treatment volume of the series ranged from 0.3 to 29.6 cm(3)(mean 11.6 cm(3)), and the minimum dose for the tumours was from 8 Gy to 12 Gy (mean, 11.6 Gy). Tumour regression was observed in three patients (43%) during the follow up period for radiosurgery (mean: 28 months). No patients revealed tumour growth in the follow up period or suffered symptomatic radiation injury. The clinical status remained unchanged in each of the seven patients after radiosurgery. Although we treated only seven patients with skull base meningiomas using surgery combined with radiosurgery, and the follow up period has been short, we believe that such combination treatment may be a very useful option in selected patients.     

Factors influencing visual and clinical outcome in Nigerian patients with cranial meningioma.

We retrospectively analysed the impact of selected clinicopathological factors on visual and clinical outcome in patients with histologically verified cranial meningioma. The 60 patients analysed for tumour characteristics consisted of 32 females and 28 males (sex ratio 1.1:1) aged 9-77 years (mean 40 years) seen between 1977 and 1999 at the University College Hospital, Ibadan, Nigeria. The patients for whom sufficient clinical data was available (n=35) presented within 2-60 months (mean 18 months) of symptom onset with large tumours (mean size 52 mm), and perifocal oedema (26/35), poor vision, focal neurological deficits, seizures and clinical evidence of intracranial hypertension. The most common tumour site was the convexity. There was loss of vision in 30/35 (85.7%) patients. Loss of vision was significantly related to tumour site and tumour size as well as perifocal oedema, (P<0.05). The case-mortality rate was 11.4% at 1 month and 20% at 6 months post-operation and was significantly correlated with intracranial hypertension. Neither age nor sex affected the outcome (P>0.05).     

Working through conflict with self-destructive preschool children.

This case history charts the treatment of a preschooler who first presented at the age of three years and ten months with aggressive and self-destructive behaviors. During the initial months of treatment, the therapist focused upon establishing a therapeutic alliance with the child in order to evoke a transference reaction. Compelling evidence of the transference in this case occurred in the ninth month of treatment when the therapist told the child that she would be going on vacation. The child, whose own mother had abandoned him several times, responded with uncharacteristic physical and verbal abuse. Although the child engaged in aggressive and self-destructive play enactments almost from the onset of treatment, these behaviors intensified from the fifth month of treatment onwards, as it became evident that he had entered the working-through phase. Aggressive impulses were shown in his manipulation of toys and other objects, and self-destructive episodes emerged in the child's incessant efforts to jump from chairs and tables, as well as in repeated threats to "shoot" himself with a toy gun. The therapist was sensitive to the child's need to continually repeat and gradually modify these behaviors. She permitted their display without exhibiting shock or alarm, but at the same time, expressed concern for the child's safety and reinforced this concern by setting limits on his unacceptable behavior. Gradually, the child's self-destructive and aggressive tendencies abated. Further evidence that the conflict had been worked through was also seen in the child's ability to express a more realistic assessment of his home environment, one which reconciled the conflict between "good" and "bad" impulses. This advancement in perception was demonstrated by the child's verbal recognition that while his mother was capable of doing "bad" things, she was still his mother and he loved her. Prior to the termination of treatment, both the child's grandmother and teachers reported significant improvement in the child's behavior and linguistic abilities.     

Socio-demographic factors and their impact on the number of resections for patients with recurrent glioblastoma

Glioblastoma multiforme (GBM) is the most aggressive malignant brain tumour. Having a second or subsequent operation at recurrence may be a positive prognostic factor for survival. Recent studies suggest that socio-demographic variables may influence survival, raising the question whether surgical care differs based on these variables. We examined the relationship between selected socio-demographic variables and the number of repeat operations undergone by patients with recurrent GBM. Data from all patients diagnosed with GBM between 2001 and 2011 was obtained from a clinical database maintained across two institutions (one public, one private). The clinical and socio-demographic factors for patients who received one operation were compared to those who had two or more operations, using chi-squared analyses to determine statistical differences between groups. Socioeconomic status was measured using the Index of Relative Socioeconomic Advantage and Disadvantage scores. Of 553 patients, 449 (81%) had one operation and 104 (19%) had ?2 operations. Patients who had ?2 operations were significantly younger (median 55 years versus 64 years, p < 0.001), less likely to have multifocal (p = 0.043) or bilateral (p = 0.037) disease and more likely to have initial macroscopic resection (p = 0.006), than those who had only one operation. Socioeconomic status did not significantly differ between the groups (p = 0.31). Similarly, there was no significant difference between the number of operations in patients from regional versus city residence and public versus private hospital. This is reassuring as it suggests similar surgical management options are available for patients regardless of socio-demographic background.     

Repeat endoscopic third ventriculostomy: is it worth trying?

OBJECT: The goal of this study was to evaluate the safety, efficacy, and indications for repeat endoscopic third ventriculostomies (ETV). METHODS AND RESULTS: We reviewed the records of 20 patients who had undergone repeat ETV from 1987 to 1999. Their ages ranged from 8 months to 53 years (mean 17 years). The primary etiologies of hydrocephalus were: primary aqueductal stenosis (9 cases), tumor (5), Chiari malformation (2), prior infection (2), prior intraventricular hemorrhage (1), and blocked foramen of Monro (1 patient). The interval between the first and second ETVs ranged from 8 days to almost 6 years (mean 12.8 months). The intraoperative findings at repeat surgery were: occlusion of the primary orifice by scar (10 cases), virginal floor of the third ventricle (5 cases), pinhole ventriculostomy (3 cases), incompletely penetrated membrane (1 case), and blood clot occluding the orifice (1 case). The follow-up period ranged from 3 to 47 months (median 20 months). Repeat ETV was successful in 13 patients (65%). These patients did not require further shunting or other procedures during follow-up. Seven patients (35%) required placement of a shunt after repeat ETV. Several complications were observed in 1 patient (5%), including seizures, elevated ICP, bilateral pulmonary edema, and cardiac arrhythmia. This patient ultimately recovered fully; the ETV was successful, and the patient did not require a shunt. CONCLUSIONS: Based on the experience of this group of patients, repeat ETV is as effective and as safe as a primary ETV procedure, and should be attempted in selected patients.