Ventriculoperitoneal Shunt Versus. Endoscopic Third Ventriculostomy: A Qualitative Survey Assessing Current Provider Attitudes

Introduction: Treatment of hydrocephalus is the most common procedure done by pediatric neurosurgeons, with approximately 1/770 babies born developing hydrocephalus. The mainstays of treatment are placement of a ventriculoperitoneal shunt (VPS) and endoscopic third ventriculostomy (ETV)+/- choroid plexus cauterization. Individual surgeon attitudes, incorporating professional experience and regional standards, influence the decision for both upfront management and management after initial treatment failure. This study aims to assess national differences in provider attitudes towards hydrocephalus procedures

Methods: A qualitative survey was emailed to board-certified pediatric neurosurgeons throughout North America. There were twenty questions regarding background, typical annual case volumes, practice patterns, when to choose VPS versus ETV, and how to assess failure. Additionally, four clinical scenarios were presented.

Results: Sixty-three surgeons returned completed questionnaires. The majority of respondents perform more VPS procedures than ETVs annually. Post-hemorrhagic hydrocephalus and post-infectious hydrocephalus were the most common contraindications to performing an ETV, with approximately 1/3 of respondents not performing an ETV in each of those scenarios. 75% of respondents routinely use a fast sequence T2 MRI to assess ETV function. Presented with a well appearing child s/p ETV, 62% said they would consider increase in ventricular size an indication for reoperation; while 35% said there is no absolute radiographic criteria for reoperation. 89% of respondents said they would consider a repeat ETV after a late ETV failure; however, when

given a clinical scenario of a 16-year-old with a failed ETV 10 years out, only 5% of respondents said they would perform a repeat ETV.

Conclusion : This study aims to better understand varying surgical decision-making for VPS versus ETV and attitudes around what constitutes an ETV failure. Interestingly, responses varied when presented with a theoretical question versus a clinical scenario. As practice varies, this project serves to provide better understanding of consensus approaches to hydrocephalus management.