Is Endoscopic Third Ventriculostomy a Feasible Option or Ventriculoperitoneal Shunt a Safer Bet for the Treatment of Posttraumatic Hydrocephalus? A Gap Time Model-based Algorithm.

Background: Posttraumatic hydrocephalus (PTH) adds to the morbidity and mortality of traumatic brain injury (TBI) and there are insufficient clinical data to suggest usefulness of ventriculoperitoneal shunt (VPS) over endoscopic third ventriculostomy (ETV) in PTH or vice versa.

Objective: To evaluate the usefulness of VPS and ETV in the treatment of PTH and to establish the indications for their usage.

Materials And Methods: This was an ambispective study of 141 patients who developed PTH out of 2500 cases of TBI treated during the study duration (2012-2016). These patients were segregated into two groups depending on the primary procedure for PTH-ETV group and VPS group. The two groups were compared to analyze the differences in radiological and clinical outcome.

Results: 141 patients were included in the study and 175 procedures were performed in these patients. ETV group had 30 procedures and VPS had 145 procedures. In the ETV group, 37% of cases showed improvement v/s 73% cases in the VPS group. A statistically significant number of patients had improvement in presenting symptoms in the VPS group, as compared with the ETV group (P = 0.001). There was no significant difference in Glasgow coma scale (GCS) at discharge (P = 0.15) and Glasgow outcome score at 6 months of follow-up (P = 0.22) between the two groups. Poor GCS, previous cerebrospinal fluid infection, and postoperative meningitis were found to have significant effect on the failure-free period of the procedure. On comparing the probabilities of failure-free period of ETV v/s VPS, the chances of VPS failure are 61% lesser than ETV.

Conclusions: VPS is an effective modality for the management of PTH and has a much lower failure rate as compared to ETV. However, ETV can be considered as a salvage procedure in difficult situations of recurrent shunt malfunction or infection.