Third ventriculostomy versus cerebrospinal fluid shunt as a first procedure in pediatric hydrocephalus

BACKGROUND: Third ventriculostomy (TV) has been reported to be efficacious for diverse causes of obstructive hydrocephalus in pediatric patients, and preferable to a first CSF shunt (CS) in those eligible. We reviewed the respective failure rates in a prospective cohort of patients at our institution. METHOD: All patients having either TV or CS (i.e ventriculoperitoneal shunt) over the period 1987 to 1997 were prospectively entered into a database. To compare homogeneous patients, only diagnoses of either aqueductal stenosis or tumor were considered. Failure was defined as any subsequent surgical procedure for CSF diversion. Kaplan-Meier curves were constructed to determine survivorship. A multivariable Cox model using time-dependent covariates was constructed. RESULTS: There were 32 TV and 210 CS patients: 14 (44%) and 95 (45%) failed, respectively. TV patients were older (median age = 8.1 vs. 3.6 years) and had a higher incidence of aqueductal stenosis (53 vs. 25%). There was no statistically significant difference between the two procedures based on bivariate analysis (p = 0.87) and on multivariable analysis using the Cox model after adjusting for the potential confounders (p = 0.66, hazard ratio = 1.19, 95% confidence interval = 0.55-2.56). CONCLUSION: Failure from TV is not unlike that of CS when analyzed by survival methods. Larger prospective series are needed to look at specific subgroups who may benefit from TV. Quality of life and clinical outcome measures are also required to analyze the difference between these two procedures.