Prognostic Factors for Endoscopic Third Ventriculostomy Success in Hydrocephalus with Myelomeningocele

Prognostic Factors for Endoscopic Third Ventriculostomy Success in Hydrocephalus with Myelomeningocele | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Prognostic Factors for Endoscopic Third Ventriculostomy Success in Hydrocephalus with Myelomeningocele Fernando Augusto Medeiros Carrera Macedo, Alexandre Varella Giannetti, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4619271/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 20 Jul, 2024 Read the published version in Child's Nervous System → Version 1 posted 9 You are reading this latest preprint version Abstract Purpose Myelomeningocele (MMC) is a prevalent neural tube closure defect often associated with hydrocephalus, necessitating surgical intervention in a significant proportion of cases. While ventriculoperitoneal shunting (VPS) has been a standard treatment approach, endoscopic third ventriculostomy (ETV) has emerged as a promising alternative. However, factors influencing the success of ETV in MMC patients remain uncertain. This retrospective observational study aimed to identify clinical and radiological factors correlating with a higher success rate of ETV in MMC patients. Methods Medical records of MMC patients who underwent ETV at a tertiary care center between 2015 and 2021 were reviewed. Demographic, clinical, and radiological data were analyzed. ETV success was defined as the absence of further hydrocephalus treatment during follow-up. Results Of 131 MMC patients, 21 met inclusion criteria and underwent ETV. The overall success rate of ETV was 57.1%, with a six-month success rate of 61.9%. Age ≤ 6 months was significantly associated with lower ETV success (25%) compared to older patients (76.9%) (OR: 0.1; 95% CI 0.005–2.006; p = 0.019). Radiological factors, including posterior fossa dimensions and linear indices, did not exhibit statistically significant associations with ETV success. Conclusion Age emerged as a significant factor affecting ETV success in MMC patients, with younger patients exhibiting lower success rates. Radiological variables did not significantly influence ETV outcomes in this study. Identifying predictors of ETV success in MMC patients is crucial for optimizing treatment strategies and improving patient outcomes. Myelomeningocele Hydrocephalus Endoscopic Third Ventriculostomy Neural Tube Defects Figures Figure 1 Introduction Myelomeningocele (MMC) is a prevalent neural tube closure defect, with an estimated incidence of approximately one in 1,000 live births [ 1 , 2 ]. MMC is associated with a broad spectrum of complications, and hydrocephalus is one of the most common, often necessitating surgical intervention in about 80% of patients who have undergone postnatal defect correction [ 3 , 4 ]. Among those undergoing ventriculoperitoneal shunting (VPS), 40% experience complications related to the procedure within the first year [ 5 ]. The burden of morbidity and mortality from VPS complications is higher in MMC patients compared to those with hydrocephalus from other etiologies. Even among MMC patients, those who are shunt-independent have a higher survival rate and a better quality of life than those who require VPS [ 1 , 5 , 6 ]. Efforts have been focused on exploring alternative approaches for managing hydrocephalus in this population. Endoscopic third ventriculostomy (ETV) has emerged as a promising option despite its success rates varying widely, ranging from 29–92% in the literature [ 7 ]. The present study aims to identify clinical and radiological factors correlating with a higher success rate of ETV in MMC patients. Methods This retrospective, observational study utilized the medical records of patients treated at the Hospital das Clínicas of the Federal University of Minas Gerais (HC/UFMG) between 2015 and 2021. It was approved by the Research Ethics Committee and adhered to by the Brazilian Health Council for human research resolutions. Inclusion criteria encompassed myelomeningocele patients born from 01/01/2015 to 31/12/2021 who underwent ETV at HC/UFMG with a follow-up period of at least six months after the procedure. Exclusions included patients undergoing simultaneous complementary surgical techniques, incomplete medical records, multiple congenital malformations, genetic syndromes, or fetal correction of MMC. A detailed analysis of eligible patients' medical and radiological records included information on patient identification, birth, gender, age, VPS history, pre-ETV central nervous system (CNS) infections, and ETV-related data. ETV success was defined as cases not requiring further hydrocephalus treatment during follow-up. Patients with persistent symptoms underwent re-treatment, either with a new VPS or a new endoscopic procedure. All procedures were consistently performed by the same neurosurgeon (A.V.G.) using a rigid endoscope. Radiological data analysis ensured standardization, considering only DICOM format-exportable exams from HC/UFMG archives. CT scans used a Toshiba Aquilon 64 scanner, and MRI exams utilized a 1.5 tesla GE Signa HDxT machine. Image analysis was performed using Radiant Dicom Viewer software, with measurements obtained within 30 days before ETV. The variables analyzed and the way they are obtained are described in Table 1 and Fig. 1 . Statistical analysis, conducted with Prisma 8 software, employed Fisher's and chi-squared tests, with a 5% significance level. Table 1 Radiologic variables analysed Measurement Description Evans’ Index (EI) Ratio of the maximum width of the frontal horns of the lateral ventricles to the maximum width of the biparietal diameter Fronto-occipital horn ratio (FOHR) Ratio of the sum of the maximum width of the frontal horns and the maximum width of the occipital horns to twice the maximum biparietal diameter N – Ts The distance between the Naseun (N) and the tuberculum sellae (Ts) Clivo-occipital angle (COA) This is a measure of the angle between the clivus and the occipital plane. It is used to assess the size of the posterior fossa. Twining’s line (Tw) The distance between the tuberculum sellae (Ts) and the internal occipital protuberance (IOP) Twining’s line to vertex (Tw-vertex i) Twining's line is divided into four parts. At a distance of 1/4 from Ts a perpendicular line is raised to vertex. This distance represents the maximun heigh of the supratentorial space. Supratentorial heigh (H) At a distance of 1/4 from the IOP a perpendicular line is raised to indicate de secondary height (H) above twining's line in that region. Infratentorial heigh (h) At a distance of 1/4 from the IOP a line is drawn dowwards to the bottom of the posterior fossa to indicate the heigh (h) below Twining's line in that region Posterior fossa area \(\frac{3}{4}\times \left(Tw \times h\right)\) Supratentorial area \(\left(\frac{3}{4}\times \left(N-Ts\right)+Tw\right)\times \left(Tw-Vertex i\right)\) Results Between January 1, 2015, and December 31, 2021, 131 patients underwent postnatal myelomeningocele repair at HC/UFMG. Seven patients had restricted therapeutic interventions due to adverse clinical circumstances. Of the remaining 124 patients, 83.4% exhibited hydrocephalus, requiring cerebrospinal fluid shunting within the study's observation timeframe. All patients underwent hydrocephalus surgical intervention within the first 12 months of life, with an average age of 24.9 ± 36.8 days. VPS was the primary treatment for 97.1% of these patients, with a 44.5% overall success rate for the first VPS procedure. Twenty-one patients met the inclusion criteria and underwent ETV. Two patients (9.5%) had ETV as their primary surgical intervention, while 90.5% underwent ETV due to a dysfunctional VPS. The mean age at ETV procedure was 357.8 ± 331.3 days, with a success rate of 61.9% at six months and an overall rate of 57.1%. The mean success rate in 6 months projected to the same group using the ETVSS [ 8 ] was 46.7 ± 11.7%. Notably, age significantly influenced ETV success, with patients over six months exhibiting a higher success rate (76.9%) compared to those under six months (25%) (OR: 0.1; 95% CI 0.005–2.006; p = 0.019). This age-related impact persisted in subsets, such as secondary ETV (RR: 0.03; 95% CI 0.01–0.35; p = 0.013) and patients under 24 months at the time of secondary ETV (RR: 0.05; 95% CI 0.01–0.5; p = 0.04). Moreover, no statistically significant associations with ETV success were found when analyzing the percentile of the head circumference (HC) at the time of ETV (p = 0.35), the presence of a prior VPS (p = 1), the age at which the first VPS was implanted (p = 0.07), the number of prior revisions (p = 0.63), the interval of time between the VPS and ETV (p = 0.30), the occurrence of a CNS infection prior to ETV (p = 0.68), the occurrence of an infection within 90 days of ETV (p = 0.47), the variability between the percentile of the HC at the time of the first shunt implant and the percentile of the HC at the time of ETV (p = 0.18), prematurity (p = 0.12), and birth weight (p = 0.30). Table 2 presents an overview of the clinical data. Radiological data analysis included 16 out of the 21 initial patients, with computed tomography of the skull being the primary imaging modality (88%), followed by magnetic resonance imaging (12%). Table 2 General view of patients clinical features Variables ETV ETV success ETV failure n = 21 n = 12 n = 9 Male 11(52.3%) 6 (50%) 5 (55,6%) p = 1 HC at birth 35 ± 4.4 cm 34.7 ± 3.6 cm 35.5 ± 5.2 cm p = 0.19 HC at VPS 37.6 ± 2.9 cm 36.5 ± 2.4 cm 38.9 ± 2.9 cm HC at ETV 45.6 ± 3 cm 46.3 ± 2.4 cm 45.3 ± 3.7 cm p = 0.34 Prematurity 5 (23.8%) 1 (8.3%) 4 (44.4%) p = 0.12 Birth Weight 2879 ± 530 g 2877 ± 482 g 2881 ± 589 g p = 0.30 Mean age at ETV 357.8 ± 331.3 387 ± 261.2 309 ± 363.8 p = 0.61 Primary ETV 2 2 0 p = 1 Secondary ETV 19 10 9 p = 1 Δ Birth-VPS 20.4 ± 16.9 d 22.1 ± 13.5 d 18.4 ± 12.3 d p = 0.07 Δ First VPS-ETV 349 ± 342.8 d 401 ± 316.3 d 291 ± 361.5 d p = 1 Δ Last VPS-ETV 334 ± 353 d 399 ± 317 d 262 ± 375.8 d p = 0.30 VPS dysfunction p = 0.63 1 15 8 6 2 2 1 1 ≥ 3 2 0 2 CNS infection 8 5 3 p = 0.68 Δ Last infection-ETV 128 ± 119.7 days 148 ± 28.5 days 136 ± 27 days p = 0.58 ETVSS 46.7 ± 11.7% 51.7 ± 9% 40 ± 11.5% p = 0,59 HC = head circumference. BW = birth weight. Δ = Interval between Infratentorial analysis focused on the analysis of the posterior fossa volume. Measurements derived from planimetric data did not demonstrate a significant posterior fossa volume difference between the success and failure groups. Similarly, the clivus-occipital angle, serving as an indirect assessment of posterior fossa volume, did not exhibit statistical significance between the success group (68.9º±11.2º) and the failure group (76.6º±6.1º) (RR 2.5; 95% CI 0.3–29.8; p = 0.36). The supratentorial analysis focused on the ventricular size and volume. Linear indices, including Evans' Index and FOHR, showed similarities between the success and failure groups without statistical significance. Planimetric measurements and associated ratios, such as third ventricle measurements and biparietal distance, did not reveal significant differences between the two groups. Table 3 presents a comprehensive summary of the radiological outcomes. Table 3 Radiologic features analysed Parameters ETV Success ETV failure Linear indexes FOHR 0.52 0.54 p = 0.53 Evans 0.42 0.41 p = 0.29 Planimetry data in the median sagittal plane according to Kroeges et al. h/H 0.20 0.20 p = 0.61 h/Tw 0.25 0.25 p = 1 PFa 8.94 9.27 p = 1 STa 104.23 100.74 p = 1 PFa/STa 8.75 9.14 p = 1 Clivus-supraocciput angle CSA 68.9° 76.6° p = 0.33 Linear data in the axial plane 3VT 1.38 1.28 p = 1 BPD 11.11 10.86 p = 1 BPD/3VT 10.40 10.27 p = 1 3VT/BPD 12.23 12.23 p = 0.59 PFa = Posterio fossa area, STa = Supratentorial area. BPD = Biparietal distance. 3VT = Third ventricle Discussion Patients diagnosed with hydrocephalus related to myelomeningocele face a higher risk of procedure failure, whether with VPS or ETV, compared to patients with hydrocephalus due to other etiologies [ 5 , 9 ]. In this study, the incidence of MMC-associated hydrocephalus (83.4%) was similar to that reported in the general literature (80%) [ 3 , 4 ]. The overall ETV success rate was 57.1%, with a six-month success rate of 61.9%. The influence of demographic, radiological, and clinical factors on ETV outcomes in myelomeningocele (MMC) patients remains uncertain [ 10 ]. Our study highlighted age as a critical clinical determinant of ETV success. Infants ≤ 6 months old had lower success rates (25%) compared to older patients (76.9%) [RR: 0.1; 95% CI 0.01–0.78; p = 0.0318]. These findings are consistent with prior research. Zaben et al. [ 11 ] found lower success rates in infants under six months (44.4%) compared to older infants (66.7%, p = 0.0007). Similarly, Teo and Jones [ 12 ] reported a success rate of 12.5% in infants under six months, contrasting with 80% success in older infants. The prevalent view suggests that in younger patients, the immaturity of arachnoid villi leads to reduced cerebrospinal fluid (CSF) absorption. This results in a non-communicating state, potentially reducing the effectiveness of ETV. However, recent research indicates that arachnoid villi are less critical in CSF dynamics among younger patients. As such, it is imperative to explore alternative explanations for the observed correlation between younger age and decreased ETV success rates [ 13 , 14 ]. A contributing factor could be the cranial volume expansibility in infants due to incomplete skull ossification. In younger patients, a CSF volume increase would be accommodated by an increase in head diameter, maintaining intracranial pressure. However, it could lead to an increased venous pressure gradient, inhibiting CSF absorption, especially in patients with MMC due to the significantly smaller posterior fossa volume. Epstein and Hochwal (1975) advocated compressive cranial bandages to limit cranial growth in infants with hydrocephalus, promoting CSF absorption and avoiding shunting [ 25 ]. In our study, with an average patient age of 234 days, the applicability of the Monroe-Kellie doctrine may be questioned due to potential ventricular volume increase and subsequent head circumference change. However, our analysis of head circumference, an indirect measure of CSF compartment volume, showed no significant difference between successful and failed ETV groups, indicating no apparent impact. Linear indices, offering more accurate ventricular volume estimation than head circumference [ 15 ], were similar in both successful and failed ETV groups, aligning with Börcek et al.'s findings [ 16 ] that preoperative lateral ventricle measurements did not correlate with ETV success. Another plausible explanation for the high failure rates in younger patients may be a greater predisposition towards stoma closure produced during ETV [ 17 ]. In a study involving eleven infants under one year who underwent ETV revision following previous procedure failure, stoma occlusion was evident, ranging from partial closure to complete occlusion or blockage [ 18 ]. The increased stoma occlusion rates in infants might stem from a higher tendency for the formation of new arachnoid membranes, gliotic tissue, and ependymal tissue. This stoma obstruction likely contributed more significantly to ETV failure than the prevalence of disabsorptive components [ 17 , 18 ]. The absence of a pressure gradient between the III ventricle and the subarachnoid space could also exacerbate stoma occlusion. Börcek et al. [ 16 ] identified changes in the morphology of the third ventricle as having the strongest correlation with the success or failure of ETV [ 16 , 19 ]. A meta-analysis showed an 85% success rate in patients exhibiting third ventricle bulging, suggesting an increased success rate associated with this finding [ 20 ]. Consequently, the bulging of the third ventricle's floor may indirectly indicate a pressure gradient between the ventricular system and the pre-pontine cistern, potentially tripling the chance of ETV success [ 16 , 21 ]. However, our study lacks sufficient postoperative MRI images to demonstrate these associations conclusively with ETV failures. The average success rate, as determined by the ETV Success Score (ETVSS), is closely aligned with the actual success rate when considering the margin of error (46.7 ± 11.7% and 61.9%, respectively). Although ETVSS is commonly used in contemporary practice, its limitations should be acknowledged, particularly in patients with myelomeningocele. For populations under two, ETVSS tends to underestimate the success rate [ 22 ]. This discrepancy can be attributed to the ETVSS's foundation in multivariate regression models of multicentric variables, which disproportionately associate age with ETV failure [ 23 ]. Further caution should be exercised due to the ETVSS's underrepresentation of MMC patients in its development studies [ 23 ]. From a radiological perspective, particular attention was given to the posterior fossa due to its disproportionate size-to-content relationship inherent to myelomeningocele's (MMC) pathophysiology [ 4 ]. The posterior fossa volume was indirectly assessed via the clivus-occipital angle and directly through planimetric measurements proposed by Krogness et al. [ 24 ]. A h/H ratio less than 0.2 was associated with a lower success rate of ETV, albeit not statistically significant (RR 0.38; 95% CI 0.04–3.11, p = 0.61). Similarly, an angle less than 76º corresponded to a 2.5 times higher ETV success rate, yet also not statistically significant (p = 0.36). Other measurements did not reveal associations with ETV success. The h/H measurement, indicative of infratentorial to supratentorial disproportion, does not necessarily imply a small posterior fossa. If there is significant supratentorial disproportion, the value can be altered despite a normal-sized posterior fossa. This criticism extends to the posterior fossa ratio. Although Krogness's (1978) measurements are easy to apply, cranial compartment volume can be more effectively calculated using specific software despite requiring additional training [ 25 ]. This study linked a smaller posterior fossa dimension to ETV success. An angle less than 76º corresponded to a 2.5 times higher ETV success rate, yet not statistically significant (p = 0.3575). This could be seen as paradoxical, as a restricted fossa would intuitively cause increased venous congestion and hinder cerebrospinal fluid absorption. Therefore, we might hypothesize that in cases with severely restricted posterior fossa volumes, the disproportion between the recipient compartment and its content could cause significant anatomic distortions and obstructions to fluid flow, outweighing the effects of venous congestion. In assessing cases where ETV failed, two patient groups emerged. In the first group, ETV failed around 15 days post-procedure, while in the second group, failure was only recorded 100 days after ETV. Preliminary analysis revealed normal h/H, h/Tw, and posterior fossa ratios (0.31, 0.32, and 14.4%) in patients with early failure. Conversely, those who experienced late failure showed values typical of a narrow posterior fossa (0.17, 0.23, and 7.8%), supporting the structural modification theory leading to hydrocephalus. However, no statistical relationship could be evaluated due to limited available imaging data. This study acknowledges several limitations, including challenges in assembling a large sample group due to its retrospective nature and incomplete historical medical records. Restricting the evaluation to DICOM-available imaging studies limited the availability of images, primarily from after 2015, and the low prevalence of pre-ETV MRIs hindered comprehensive radiological factor analysis. Identifying patients who are more likely to achieve ETV success is crucial for reducing valve dependency among MMC patients, emphasizing the need to establish preoperative factors predictive of ETV outcomes tailored to MMC patients' unique characteristics. Future research should prioritize prospective, multicenter studies assessing correlations between clinical and radiological factors and short- and long-term ETV outcomes. Nevertheless, developing a new classification system or score to evaluate ETV success in MMC patients requires extensive development, sensitivity testing, reliability assessment, and validation. Conclusion In this retrospective study, the overall success rate of ETV was 57.1%, with a six-month success rate of 61.9%. Age emerged as a significant factor affecting ETV success, with patients under six months of age having a higher likelihood of procedure failure. Radiological variables, such as posterior fossa dimensions and linear indices, did not exhibit statistically significant associations with ETV success in this study. However, limited imaging data hindered a comprehensive analysis of the relationship between radiological factors and ETV efficacy. Declarations Author Contribution Macedo was the main researcher of the projectGiannetti guided and revised the projectVandi helped with the hard work of collecting data and analysis The authors have no competing interests to declare relevant to this article's content. References Copp AJ, Adzick NS, Chitty LS, et al (2015) Spina bifida. Nat Rev Dis Prim 1:15007. https://doi.org/10.1038/nrdp.2015.7 Nascimento LFC (2008) Prevalência de defeitos de fechamento de tubo neural no Vale do Paraíba, São Paulo. 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Cite Share Download PDF Status: Published Journal Publication published 20 Jul, 2024 Read the published version in Child's Nervous System → Version 1 posted Editorial decision: Accepted 09 Jul, 2024 Reviews received at journal 09 Jul, 2024 Reviews received at journal 08 Jul, 2024 Reviewers agreed at journal 30 Jun, 2024 Reviewers agreed at journal 28 Jun, 2024 Reviewers invited by journal 28 Jun, 2024 Editor assigned by journal 24 Jun, 2024 Submission checks completed at journal 24 Jun, 2024 First submitted to journal 21 Jun, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4619271","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":324830679,"identity":"1ea8eb23-ad73-4e1d-8cea-3119a8d79529","order_by":0,"name":"Fernando Augusto Medeiros Carrera Macedo","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABDElEQVRIiWNgGAWjYHACA4YEZC4/iEgoIEWLZANIiwEBLajcA1gEkYFue/PGBw/32NgzsB9+9rmi4p688fnViR8eGDDI84sdwKrF7MyxYoOEZ2mJDTxpxjPPnCk23Hbj7WYJoMMMZ85OwK7lRo6ZRMKBwwkMEgzGjI1tCYzbbpzdANKSYHAbh5b7b8x/ALXYM0iwf2Zs/Jdgv3nG2c0/8Gq5wWPGANTC2CDBA7SlISFxA3/vNvy2nEkrBjosLbGNJ6eYseFYQvKMG7zbLBIMJHD75fjhjR9/HLCx52c/vpmxoSbBtr//7OabPyps5PmlsWuBAzY4SwKsUgK/clTAf4AU1aNgFIyCUTACAADdAmFGr2wwaAAAAABJRU5ErkJggg==","orcid":"","institution":"Federal University of Minas Gerais – Belo Horizonte","correspondingAuthor":true,"prefix":"","firstName":"Fernando","middleName":"Augusto Medeiros Carrera","lastName":"Macedo","suffix":""},{"id":324830680,"identity":"0ade821e-c902-4829-906b-a69ecfbb5a7b","order_by":1,"name":"Alexandre Varella Giannetti","email":"","orcid":"","institution":"Federal University of Minas Gerais – Belo Horizonte","correspondingAuthor":false,"prefix":"","firstName":"Alexandre","middleName":"Varella","lastName":"Giannetti","suffix":""},{"id":324830681,"identity":"2f945688-e1c1-4935-aa0f-b0d5b5cf33c9","order_by":2,"name":"Hudson Henrique Santos Vandi","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Hudson","middleName":"Henrique Santos","lastName":"Vandi","suffix":""}],"badges":[],"createdAt":"2024-06-21 20:54:04","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4619271/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4619271/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00381-024-06542-1","type":"published","date":"2024-07-20T16:13:13+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":60618411,"identity":"bf848960-91a6-4fb2-aaaf-b6f1688c20cf","added_by":"auto","created_at":"2024-07-18 20:36:32","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":302723,"visible":true,"origin":"","legend":"\u003cp\u003eSchematic indicating how to make measurements in this study.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4619271/v1/12e0f51167fb00985921e6ab.jpeg"},{"id":61595139,"identity":"b773f47b-f4e4-4f4a-8337-f54ca32330cd","added_by":"auto","created_at":"2024-08-01 17:20:34","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":716679,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4619271/v1/4b785fba-c12c-40aa-b8f3-526f35b13083.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003ePrognostic Factors for Endoscopic Third Ventriculostomy Success in Hydrocephalus with Myelomeningocele\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMyelomeningocele (MMC) is a prevalent neural tube closure defect, with an estimated incidence of approximately one in 1,000 live births [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. MMC is associated with a broad spectrum of complications, and hydrocephalus is one of the most common, often necessitating surgical intervention in about 80% of patients who have undergone postnatal defect correction [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAmong those undergoing ventriculoperitoneal shunting (VPS), 40% experience complications related to the procedure within the first year [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The burden of morbidity and mortality from VPS complications is higher in MMC patients compared to those with hydrocephalus from other etiologies. Even among MMC patients, those who are shunt-independent have a higher survival rate and a better quality of life than those who require VPS [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEfforts have been focused on exploring alternative approaches for managing hydrocephalus in this population. Endoscopic third ventriculostomy (ETV) has emerged as a promising option despite its success rates varying widely, ranging from 29\u0026ndash;92% in the literature [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe present study aims to identify clinical and radiological factors correlating with a higher success rate of ETV in MMC patients.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis retrospective, observational study utilized the medical records of patients treated at the Hospital das Cl\u0026iacute;nicas of the Federal University of Minas Gerais (HC/UFMG) between 2015 and 2021. It was approved by the Research Ethics Committee and adhered to by the Brazilian Health Council for human research resolutions.\u003c/p\u003e \u003cp\u003eInclusion criteria encompassed myelomeningocele patients born from 01/01/2015 to 31/12/2021 who underwent ETV at HC/UFMG with a follow-up period of at least six months after the procedure. Exclusions included patients undergoing simultaneous complementary surgical techniques, incomplete medical records, multiple congenital malformations, genetic syndromes, or fetal correction of MMC.\u003c/p\u003e \u003cp\u003eA detailed analysis of eligible patients' medical and radiological records included information on patient identification, birth, gender, age, VPS history, pre-ETV central nervous system (CNS) infections, and ETV-related data.\u003c/p\u003e \u003cp\u003eETV success was defined as cases not requiring further hydrocephalus treatment during follow-up. Patients with persistent symptoms underwent re-treatment, either with a new VPS or a new endoscopic procedure. All procedures were consistently performed by the same neurosurgeon (A.V.G.) using a rigid endoscope.\u003c/p\u003e \u003cp\u003eRadiological data analysis ensured standardization, considering only DICOM format-exportable exams from HC/UFMG archives. CT scans used a Toshiba Aquilon 64 scanner, and MRI exams utilized a 1.5 tesla GE Signa HDxT machine. Image analysis was performed using Radiant Dicom Viewer software, with measurements obtained within 30 days before ETV. The variables analyzed and the way they are obtained are described in Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eStatistical analysis, conducted with Prisma 8 software, employed Fisher's and chi-squared tests, with a 5% significance level.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRadiologic variables analysed\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMeasurement\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDescription\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEvans\u0026rsquo; Index (EI)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRatio of the maximum width of the frontal horns of the lateral ventricles to the maximum width of the biparietal diameter\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFronto-occipital horn ratio (FOHR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRatio of the sum of the maximum width of the frontal horns and the maximum width of the occipital horns to twice the maximum biparietal diameter\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN \u0026ndash; Ts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe distance between the Naseun (N) and the tuberculum sellae (Ts)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClivo-occipital angle (COA)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThis is a measure of the angle between the clivus and the occipital plane. It is used to assess the size of the posterior fossa.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTwining\u0026rsquo;s line (Tw)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe distance between the tuberculum sellae (Ts) and the internal occipital protuberance (IOP)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTwining\u0026rsquo;s line to vertex (Tw-vertex i)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTwining's line is divided into four parts. At a distance of 1/4 from Ts a perpendicular line is raised to vertex. This distance represents the maximun heigh of the supratentorial space.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSupratentorial heigh (H)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAt a distance of 1/4 from the IOP a perpendicular line is raised to indicate de secondary height (H) above twining's line in that region.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInfratentorial heigh (h)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAt a distance of 1/4 from the IOP a line is drawn dowwards to the bottom of the posterior fossa to indicate the heigh (h) below Twining's line in that region\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePosterior fossa area\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\frac{3}{4}\\times \\left(Tw \\times h\\right)\\)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSupratentorial area\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\left(\\frac{3}{4}\\times \\left(N-Ts\\right)+Tw\\right)\\times \\left(Tw-Vertex i\\right)\\)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eBetween January 1, 2015, and December 31, 2021, 131 patients underwent postnatal myelomeningocele repair at HC/UFMG. Seven patients had restricted therapeutic interventions due to adverse clinical circumstances. Of the remaining 124 patients, 83.4% exhibited hydrocephalus, requiring cerebrospinal fluid shunting within the study's observation timeframe.\u003c/p\u003e \u003cp\u003eAll patients underwent hydrocephalus surgical intervention within the first 12 months of life, with an average age of 24.9\u0026thinsp;\u0026plusmn;\u0026thinsp;36.8 days. VPS was the primary treatment for 97.1% of these patients, with a 44.5% overall success rate for the first VPS procedure.\u003c/p\u003e \u003cp\u003eTwenty-one patients met the inclusion criteria and underwent ETV. Two patients (9.5%) had ETV as their primary surgical intervention, while 90.5% underwent ETV due to a dysfunctional VPS. The mean age at ETV procedure was 357.8\u0026thinsp;\u0026plusmn;\u0026thinsp;331.3 days, with a success rate of 61.9% at six months and an overall rate of 57.1%. The mean success rate in 6 months projected to the same group using the ETVSS [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] was 46.7\u0026thinsp;\u0026plusmn;\u0026thinsp;11.7%.\u003c/p\u003e \u003cp\u003eNotably, age significantly influenced ETV success, with patients over six months exhibiting a higher success rate (76.9%) compared to those under six months (25%) (OR: 0.1; 95% CI 0.005\u0026ndash;2.006; p\u0026thinsp;=\u0026thinsp;0.019). This age-related impact persisted in subsets, such as secondary ETV (RR: 0.03; 95% CI 0.01\u0026ndash;0.35; p\u0026thinsp;=\u0026thinsp;0.013) and patients under 24 months at the time of secondary ETV (RR: 0.05; 95% CI 0.01\u0026ndash;0.5; p\u0026thinsp;=\u0026thinsp;0.04).\u003c/p\u003e \u003cp\u003eMoreover, no statistically significant associations with ETV success were found when analyzing the percentile of the head circumference (HC) at the time of ETV (p\u0026thinsp;=\u0026thinsp;0.35), the presence of a prior VPS (p\u0026thinsp;=\u0026thinsp;1), the age at which the first VPS was implanted (p\u0026thinsp;=\u0026thinsp;0.07), the number of prior revisions (p\u0026thinsp;=\u0026thinsp;0.63), the interval of time between the VPS and ETV (p\u0026thinsp;=\u0026thinsp;0.30), the occurrence of a CNS infection prior to ETV (p\u0026thinsp;=\u0026thinsp;0.68), the occurrence of an infection within 90 days of ETV (p\u0026thinsp;=\u0026thinsp;0.47), the variability between the percentile of the HC at the time of the first shunt implant and the percentile of the HC at the time of ETV (p\u0026thinsp;=\u0026thinsp;0.18), prematurity (p\u0026thinsp;=\u0026thinsp;0.12), and birth weight (p\u0026thinsp;=\u0026thinsp;0.30). Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e presents an overview of the clinical data.\u003c/p\u003e \u003cp\u003eRadiological data analysis included 16 out of the 21 initial patients, with computed tomography of the skull being the primary imaging modality (88%), followed by magnetic resonance imaging (12%).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eGeneral view of patients clinical features\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eETV\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eETV success\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eETV failure\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11(52.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (50%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5 (55,6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHC at birth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35\u0026thinsp;\u0026plusmn;\u0026thinsp;4.4 cm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e34.7\u0026thinsp;\u0026plusmn;\u0026thinsp;3.6 cm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e35.5\u0026thinsp;\u0026plusmn;\u0026thinsp;5.2 cm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.19\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHC at VPS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37.6\u0026thinsp;\u0026plusmn;\u0026thinsp;2.9 cm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36.5\u0026thinsp;\u0026plusmn;\u0026thinsp;2.4 cm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e38.9\u0026thinsp;\u0026plusmn;\u0026thinsp;2.9 cm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHC at ETV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45.6\u0026thinsp;\u0026plusmn;\u0026thinsp;3 cm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e46.3\u0026thinsp;\u0026plusmn;\u0026thinsp;2.4 cm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e45.3\u0026thinsp;\u0026plusmn;\u0026thinsp;3.7 cm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.34\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrematurity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (23.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (8.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4 (44.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBirth Weight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2879\u0026thinsp;\u0026plusmn;\u0026thinsp;530 g\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2877\u0026thinsp;\u0026plusmn;\u0026thinsp;482 g\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2881\u0026thinsp;\u0026plusmn;\u0026thinsp;589 g\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.30\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eMean age at ETV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e357.8\u0026thinsp;\u0026plusmn;\u0026thinsp;331.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e387\u0026thinsp;\u0026plusmn;\u0026thinsp;261.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e309\u0026thinsp;\u0026plusmn;\u0026thinsp;363.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.61\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary ETV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eSecondary ETV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eΔ Birth-VPS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20.4\u0026thinsp;\u0026plusmn;\u0026thinsp;16.9 d\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22.1\u0026thinsp;\u0026plusmn;\u0026thinsp;13.5 d\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e18.4\u0026thinsp;\u0026plusmn;\u0026thinsp;12.3 d\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.07\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eΔ First VPS-ETV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e349\u0026thinsp;\u0026plusmn;\u0026thinsp;342.8 d\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e401\u0026thinsp;\u0026plusmn;\u0026thinsp;316.3 d\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e291\u0026thinsp;\u0026plusmn;\u0026thinsp;361.5 d\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eΔ Last VPS-ETV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e334\u0026thinsp;\u0026plusmn;\u0026thinsp;353 d\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e399\u0026thinsp;\u0026plusmn;\u0026thinsp;317 d\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e262\u0026thinsp;\u0026plusmn;\u0026thinsp;375.8 d\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.30\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eVPS dysfunction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.63\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eCNS infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.68\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eΔ Last infection-ETV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e128\u0026thinsp;\u0026plusmn;\u0026thinsp;119.7 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e148\u0026thinsp;\u0026plusmn;\u0026thinsp;28.5 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e136\u0026thinsp;\u0026plusmn;\u0026thinsp;27 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.58\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eETVSS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46.7\u0026thinsp;\u0026plusmn;\u0026thinsp;11.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e51.7\u0026thinsp;\u0026plusmn;\u0026thinsp;9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e40\u0026thinsp;\u0026plusmn;\u0026thinsp;11.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0,59\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003eHC\u0026thinsp;=\u0026thinsp;head circumference. BW\u0026thinsp;=\u0026thinsp;birth weight. Δ\u0026thinsp;=\u0026thinsp;Interval between\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eInfratentorial analysis focused on the analysis of the posterior fossa volume. Measurements derived from planimetric data did not demonstrate a significant posterior fossa volume difference between the success and failure groups. Similarly, the clivus-occipital angle, serving as an indirect assessment of posterior fossa volume, did not exhibit statistical significance between the success group (68.9\u0026ordm;\u0026plusmn;11.2\u0026ordm;) and the failure group (76.6\u0026ordm;\u0026plusmn;6.1\u0026ordm;) (RR 2.5; 95% CI 0.3\u0026ndash;29.8; p\u0026thinsp;=\u0026thinsp;0.36).\u003c/p\u003e \u003cp\u003eThe supratentorial analysis focused on the ventricular size and volume. Linear indices, including Evans' Index and FOHR, showed similarities between the success and failure groups without statistical significance. Planimetric measurements and associated ratios, such as third ventricle measurements and biparietal distance, did not reveal significant differences between the two groups. Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e presents a comprehensive summary of the radiological outcomes.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRadiologic features analysed\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eParameters\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eETV Success\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eETV failure\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003eLinear indexes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFOHR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.53\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEvans\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.29\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003ePlanimetry data in the median sagittal plane according to Kroeges et al.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eh/H\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.61\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eh/Tw\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePFa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSTa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e104.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e100.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePFa/STa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003eClivus-supraocciput angle\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e68.9\u0026deg;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e76.6\u0026deg;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.33\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003eLinear data in the axial plane\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3VT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBPD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBPD/3VT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3VT/BPD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.59\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003ePFa\u0026thinsp;=\u0026thinsp;Posterio fossa area, STa\u0026thinsp;=\u0026thinsp;Supratentorial area. BPD\u0026thinsp;=\u0026thinsp;Biparietal distance. 3VT\u0026thinsp;=\u0026thinsp;Third ventricle\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003ePatients diagnosed with hydrocephalus related to myelomeningocele face a higher risk of procedure failure, whether with VPS or ETV, compared to patients with hydrocephalus due to other etiologies [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In this study, the incidence of MMC-associated hydrocephalus (83.4%) was similar to that reported in the general literature (80%) [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The overall ETV success rate was 57.1%, with a six-month success rate of 61.9%.\u003c/p\u003e \u003cp\u003eThe influence of demographic, radiological, and clinical factors on ETV outcomes in myelomeningocele (MMC) patients remains uncertain [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Our study highlighted age as a critical clinical determinant of ETV success. Infants\u0026thinsp;\u0026le;\u0026thinsp;6 months old had lower success rates (25%) compared to older patients (76.9%) [RR: 0.1; 95% CI 0.01\u0026ndash;0.78; p\u0026thinsp;=\u0026thinsp;0.0318]. These findings are consistent with prior research. Zaben et al. [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] found lower success rates in infants under six months (44.4%) compared to older infants (66.7%, p\u0026thinsp;=\u0026thinsp;0.0007). Similarly, Teo and Jones [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] reported a success rate of 12.5% in infants under six months, contrasting with 80% success in older infants.\u003c/p\u003e \u003cp\u003eThe prevalent view suggests that in younger patients, the immaturity of arachnoid villi leads to reduced cerebrospinal fluid (CSF) absorption. This results in a non-communicating state, potentially reducing the effectiveness of ETV. However, recent research indicates that arachnoid villi are less critical in CSF dynamics among younger patients. As such, it is imperative to explore alternative explanations for the observed correlation between younger age and decreased ETV success rates [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA contributing factor could be the cranial volume expansibility in infants due to incomplete skull ossification. In younger patients, a CSF volume increase would be accommodated by an increase in head diameter, maintaining intracranial pressure. However, it could lead to an increased venous pressure gradient, inhibiting CSF absorption, especially in patients with MMC due to the significantly smaller posterior fossa volume. Epstein and Hochwal (1975) advocated compressive cranial bandages to limit cranial growth in infants with hydrocephalus, promoting CSF absorption and avoiding shunting [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn our study, with an average patient age of 234 days, the applicability of the Monroe-Kellie doctrine may be questioned due to potential ventricular volume increase and subsequent head circumference change. However, our analysis of head circumference, an indirect measure of CSF compartment volume, showed no significant difference between successful and failed ETV groups, indicating no apparent impact.\u003c/p\u003e \u003cp\u003eLinear indices, offering more accurate ventricular volume estimation than head circumference [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], were similar in both successful and failed ETV groups, aligning with B\u0026ouml;rcek et al.'s findings [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] that preoperative lateral ventricle measurements did not correlate with ETV success.\u003c/p\u003e \u003cp\u003eAnother plausible explanation for the high failure rates in younger patients may be a greater predisposition towards stoma closure produced during ETV [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. In a study involving eleven infants under one year who underwent ETV revision following previous procedure failure, stoma occlusion was evident, ranging from partial closure to complete occlusion or blockage [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The increased stoma occlusion rates in infants might stem from a higher tendency for the formation of new arachnoid membranes, gliotic tissue, and ependymal tissue. This stoma obstruction likely contributed more significantly to ETV failure than the prevalence of disabsorptive components [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe absence of a pressure gradient between the III ventricle and the subarachnoid space could also exacerbate stoma occlusion. B\u0026ouml;rcek et al. [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] identified changes in the morphology of the third ventricle as having the strongest correlation with the success or failure of ETV [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. A meta-analysis showed an 85% success rate in patients exhibiting third ventricle bulging, suggesting an increased success rate associated with this finding [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Consequently, the bulging of the third ventricle's floor may indirectly indicate a pressure gradient between the ventricular system and the pre-pontine cistern, potentially tripling the chance of ETV success [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. However, our study lacks sufficient postoperative MRI images to demonstrate these associations conclusively with ETV failures.\u003c/p\u003e \u003cp\u003eThe average success rate, as determined by the ETV Success Score (ETVSS), is closely aligned with the actual success rate when considering the margin of error (46.7\u0026thinsp;\u0026plusmn;\u0026thinsp;11.7% and 61.9%, respectively). Although ETVSS is commonly used in contemporary practice, its limitations should be acknowledged, particularly in patients with myelomeningocele. For populations under two, ETVSS tends to underestimate the success rate [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. This discrepancy can be attributed to the ETVSS's foundation in multivariate regression models of multicentric variables, which disproportionately associate age with ETV failure [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Further caution should be exercised due to the ETVSS's underrepresentation of MMC patients in its development studies [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFrom a radiological perspective, particular attention was given to the posterior fossa due to its disproportionate size-to-content relationship inherent to myelomeningocele's (MMC) pathophysiology [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The posterior fossa volume was indirectly assessed via the clivus-occipital angle and directly through planimetric measurements proposed by Krogness et al. [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA h/H ratio less than 0.2 was associated with a lower success rate of ETV, albeit not statistically significant (RR 0.38; 95% CI 0.04\u0026ndash;3.11, p\u0026thinsp;=\u0026thinsp;0.61). Similarly, an angle less than 76\u0026ordm; corresponded to a 2.5 times higher ETV success rate, yet also not statistically significant (p\u0026thinsp;=\u0026thinsp;0.36). Other measurements did not reveal associations with ETV success.\u003c/p\u003e \u003cp\u003eThe h/H measurement, indicative of infratentorial to supratentorial disproportion, does not necessarily imply a small posterior fossa. If there is significant supratentorial disproportion, the value can be altered despite a normal-sized posterior fossa. This criticism extends to the posterior fossa ratio. Although Krogness's (1978) measurements are easy to apply, cranial compartment volume can be more effectively calculated using specific software despite requiring additional training [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis study linked a smaller posterior fossa dimension to ETV success. An angle less than 76\u0026ordm; corresponded to a 2.5 times higher ETV success rate, yet not statistically significant (p\u0026thinsp;=\u0026thinsp;0.3575). This could be seen as paradoxical, as a restricted fossa would intuitively cause increased venous congestion and hinder cerebrospinal fluid absorption. Therefore, we might hypothesize that in cases with severely restricted posterior fossa volumes, the disproportion between the recipient compartment and its content could cause significant anatomic distortions and obstructions to fluid flow, outweighing the effects of venous congestion.\u003c/p\u003e \u003cp\u003eIn assessing cases where ETV failed, two patient groups emerged. In the first group, ETV failed around 15 days post-procedure, while in the second group, failure was only recorded 100 days after ETV. Preliminary analysis revealed normal h/H, h/Tw, and posterior fossa ratios (0.31, 0.32, and 14.4%) in patients with early failure. Conversely, those who experienced late failure showed values typical of a narrow posterior fossa (0.17, 0.23, and 7.8%), supporting the structural modification theory leading to hydrocephalus. However, no statistical relationship could be evaluated due to limited available imaging data.\u003c/p\u003e \u003cp\u003eThis study acknowledges several limitations, including challenges in assembling a large sample group due to its retrospective nature and incomplete historical medical records. Restricting the evaluation to DICOM-available imaging studies limited the availability of images, primarily from after 2015, and the low prevalence of pre-ETV MRIs hindered comprehensive radiological factor analysis. Identifying patients who are more likely to achieve ETV success is crucial for reducing valve dependency among MMC patients, emphasizing the need to establish preoperative factors predictive of ETV outcomes tailored to MMC patients' unique characteristics. Future research should prioritize prospective, multicenter studies assessing correlations between clinical and radiological factors and short- and long-term ETV outcomes. Nevertheless, developing a new classification system or score to evaluate ETV success in MMC patients requires extensive development, sensitivity testing, reliability assessment, and validation.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn this retrospective study, the overall success rate of ETV was 57.1%, with a six-month success rate of 61.9%.\u003c/p\u003e \u003cp\u003eAge emerged as a significant factor affecting ETV success, with patients under six months of age having a higher likelihood of procedure failure. Radiological variables, such as posterior fossa dimensions and linear indices, did not exhibit statistically significant associations with ETV success in this study. However, limited imaging data hindered a comprehensive analysis of the relationship between radiological factors and ETV efficacy.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eMacedo was the main researcher of the projectGiannetti guided and revised the projectVandi helped with the hard work of collecting data and analysis\u003c/p\u003e\u003cp\u003eThe authors have no competing interests to declare relevant to this article\u0026apos;s content.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eCopp AJ, Adzick NS, Chitty LS, et al (2015) Spina bifida. Nat Rev Dis Prim 1:15007. https://doi.org/10.1038/nrdp.2015.7\u003c/li\u003e\n\u003cli\u003eNascimento LFC (2008) Preval\u0026ecirc;ncia de defeitos de fechamento de tubo neural no Vale do Para\u0026iacute;ba, S\u0026atilde;o Paulo. Rev Paul Pediatr 26:372\u0026ndash;377. https://doi.org/10.1590/s0103-05822008000400011\u003c/li\u003e\n\u003cli\u003eBizzi JWJ, Machado A (2012) Meningomielocele: basic concepts and recent advances. Revis\u0026atilde;o J Bras Neurocir 23:138\u0026ndash;151\u003c/li\u003e\n\u003cli\u003eTamburrini G, Frassanito P, Iakovaki K, et al (2013) Myelomeningocele: the management of the associated hydrocephalus. Child\u0026rsquo;s Nerv Syst 29:1569\u0026ndash;1579. https://doi.org/10.1007/s00381-013-2179-4\u003c/li\u003e\n\u003cli\u003eProtzenko T, Bellas A, Pousa MS, et al (2019) Reviewing the prognostic factors in myelomeningocele. Neurosurg Focus 47:. https://doi.org/10.3171/2019.7.FOCUS19462\u003c/li\u003e\n\u003cli\u003eCavalheiro S, da Costa MDS, Moron AF, Leonard J (2017) Comparison of Prenatal and Postnatal Management of Patients with Myelomeningocele. Neurosurg. Clin. N. Am. 28:439\u0026ndash;448\u003c/li\u003e\n\u003cli\u003eMcCarthy DJ, Sheinberg DL, Luther E, McCrea HJ (2019) Myelomeningocele-associated hydrocephalus: nationwide analysis and systematic review. Neurosurg Focus 47:E5. https://doi.org/10.3171/2019.7.FOCUS19469\u003c/li\u003e\n\u003cli\u003eKulkarni A V., Drake JM, Kestle JRW, et al (2010) Predicting who will benefit from endoscopic third ventriculostomy compared with shunt insertion in childhood hydrocephalus using the ETV success score: Clinical article. J Neurosurg Pediatr 6:310\u0026ndash;315. https://doi.org/10.3171/2010.8.PEDS103\u003c/li\u003e\n\u003cli\u003eJernigan SC, Berry JG, Graham DA, Goumnerova L (2014) The comparative effectiveness of ventricular shunt placement versus endoscopic third ventriculostomy for initial treatment of hydrocephalus in infants: Clinical article. J Neurosurg Pediatr 13:295\u0026ndash;300. https://doi.org/10.3171/2013.11.PEDS13138\u003c/li\u003e\n\u003cli\u003eRei J, Pereira J, Reis C, et al (2017) Endoscopic Third Ventriculostomy for the Treatment of Hydrocephalus in a Pediatric Population with Myelomeningocele. World Neurosurg 105:163\u0026ndash;169. https://doi.org/10.1016/j.wneu.2017.05.107\u003c/li\u003e\n\u003cli\u003eZaben M, Manivannan S, Sharouf F, et al (2020) The efficacy of endoscopic third ventriculostomy in children 1 year of age or younger: A systematic review and meta-analysis. Eur. J. Paediatr. Neurol. 26:7\u0026ndash;14\u003c/li\u003e\n\u003cli\u003eTeo C, Jones R (1996) Management of Hydrocephalus by Endoscopic Third Ventriculostomy in Patients with Myelomeningocele. Pediatr Neurosurg 25:57\u0026ndash;63. https://doi.org/10.1159/000121098\u003c/li\u003e\n\u003cli\u003eJohanson CE, Duncan JA, Klinge PM, et al (2008) Multiplicity of cerebrospinal fluid functions: New challenges in health and disease. Cerebrospinal Fluid Res 5:1\u0026ndash;32. https://doi.org/10.1186/1743-8454-5-10\u003c/li\u003e\n\u003cli\u003eNigel P, Shizuo O (2013) Theories of cerebrospinal fluid dynamics and hydrocephalus: historical trend. J Neurosurg Pediatr 11:170\u0026ndash;177\u003c/li\u003e\n\u003cli\u003eRagan DK, Cerqua J, Nash T, et al (2015) The accuracy of linear indices of ventricular volume in pediatric hydrocephalus: Technical note. J Neurosurg Pediatr 15:547\u0026ndash;551. https://doi.org/10.3171/2014.10.PEDS14209\u003c/li\u003e\n\u003cli\u003eB\u0026ouml;rcek A\u0026Ouml;, U\u0026ccedil;ar M, Karaaslan B (2017) Simplest radiological measurement related to clinical success in endoscopic third ventriculostomy. Clin Neurol Neurosurg 152:16\u0026ndash;22. https://doi.org/10.1016/j.clineuro.2016.11.006\u003c/li\u003e\n\u003cli\u003eEl Damaty A, Aly K, El Refaee E, Zohdi AM (2013) Success rate of endoscopic third ventriculostomy in infants below six months of age with congenital obstructive hydrocephalus (a preliminary study of eight cases). Asian J Neurosurg 8:147. https://doi.org/10.4103/1793-5482.121686\u003c/li\u003e\n\u003cli\u003eWagner W, Koch D (2005) Mechanisms of failure after endoscopic third ventriculostomy in young infants. J Neurosurg Pediatr 103:43\u0026ndash;49. https://doi.org/10.3171/ped.2005.103.1.0043\u003c/li\u003e\n\u003cli\u003eWang Q, Cheng J, Si Z, et al (2020) Third ventricle floor bowing: a useful measurement to predict endoscopic third ventriculostomy success in infantile hydrocephalus. Acta Neurochir (Wien) 162:31\u0026ndash;37. https://doi.org/10.1007/s00701-019-04133-7\u003c/li\u003e\n\u003cli\u003eHilman S, Aristiady EB, Santiana L, et al (2022) Third Ventricular Floor Bowing Indicates Surgical Success in Patients Undergoing Endoscopic Third Ventriculostomy\u0026mdash;Systematic Review and Meta-Analysis. World Neurosurg 157:e88\u0026ndash;e93. https://doi.org/10.1016/j.wneu.2021.09.092\u003c/li\u003e\n\u003cli\u003eDlouhy BJ, Capuano AW, Madhavan K, et al (2012) Preoperative third ventricular bowing as a predictor of endoscopic third ventriculostomy success: Clinical article. J Neurosurg Pediatr 9:182\u0026ndash;190. https://doi.org/10.3171/2011.11.PEDS11495\u003c/li\u003e\n\u003cli\u003eGorayeb RP, Cavalheiro S, Zymberg ST (2004) Endoscopic third ventriculostomy in children younger than 1 year of age. J Neurosurg Pediatr 100:427\u0026ndash;429. https://doi.org/10.3171/ped.2004.100.5.0427\u003c/li\u003e\n\u003cli\u003eKulkarni A V., Drake JM, Mallucci CL, et al (2009) Endoscopic Third Ventriculostomy in the Treatment of Childhood Hydrocephalus. J Pediatr 155:. https://doi.org/10.1016/j.jpeds.2009.02.048\u003c/li\u003e\n\u003cli\u003eKrogness KG, Nyland H (1978) Posterior fossa measurements II. Size of the posterior fossa in myelomeningocele. Pediatr Radiol 6:198\u0026ndash;202. https://doi.org/10.1007/BF00975536\u003c/li\u003e\n\u003cli\u003eKrogness KG, Nyland H (1978) Early infantile hydrocephalus assessed by the posterior fossa ratio method. Acta Neurochir (Wien) 45:115\u0026ndash;121. https://doi.org/10.1007/BF01774386\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"childs-nervous-system","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"cnsy","sideBox":"Learn more about [Child's Nervous System](http://link.springer.com/journal/381)","snPcode":"381","submissionUrl":"https://submission.nature.com/new-submission/381/3","title":"Child's Nervous System","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Myelomeningocele, Hydrocephalus, Endoscopic Third Ventriculostomy, Neural Tube Defects","lastPublishedDoi":"10.21203/rs.3.rs-4619271/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4619271/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003ePurpose\u003c/b\u003e\u003c/p\u003e \u003cp\u003eMyelomeningocele (MMC) is a prevalent neural tube closure defect often associated with hydrocephalus, necessitating surgical intervention in a significant proportion of cases. While ventriculoperitoneal shunting (VPS) has been a standard treatment approach, endoscopic third ventriculostomy (ETV) has emerged as a promising alternative. However, factors influencing the success of ETV in MMC patients remain uncertain. This retrospective observational study aimed to identify clinical and radiological factors correlating with a higher success rate of ETV in MMC patients.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003eMedical records of MMC patients who underwent ETV at a tertiary care center between 2015 and 2021 were reviewed. Demographic, clinical, and radiological data were analyzed. ETV success was defined as the absence of further hydrocephalus treatment during follow-up.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eOf 131 MMC patients, 21 met inclusion criteria and underwent ETV. The overall success rate of ETV was 57.1%, with a six-month success rate of 61.9%. Age\u0026thinsp;\u0026le;\u0026thinsp;6 months was significantly associated with lower ETV success (25%) compared to older patients (76.9%) (OR: 0.1; 95% CI 0.005\u0026ndash;2.006; p\u0026thinsp;=\u0026thinsp;0.019). Radiological factors, including posterior fossa dimensions and linear indices, did not exhibit statistically significant associations with ETV success.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e \u003cp\u003eAge emerged as a significant factor affecting ETV success in MMC patients, with younger patients exhibiting lower success rates. Radiological variables did not significantly influence ETV outcomes in this study. Identifying predictors of ETV success in MMC patients is crucial for optimizing treatment strategies and improving patient outcomes.\u003c/p\u003e","manuscriptTitle":"Prognostic Factors for Endoscopic Third Ventriculostomy Success in Hydrocephalus with Myelomeningocele","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-18 20:36:27","doi":"10.21203/rs.3.rs-4619271/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Accepted","date":"2024-07-09T16:41:43+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-07-09T12:18:17+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-07-09T01:15:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"325066219902930811714633504280358187","date":"2024-06-30T18:18:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"59917518738091217034072365663520682495","date":"2024-06-29T00:37:22+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-06-28T17:44:04+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-06-24T05:49:10+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-06-24T05:47:40+00:00","index":"","fulltext":""},{"type":"submitted","content":"Child's Nervous System","date":"2024-06-21T20:52:44+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"childs-nervous-system","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"cnsy","sideBox":"Learn more about [Child's Nervous System](http://link.springer.com/journal/381)","snPcode":"381","submissionUrl":"https://submission.nature.com/new-submission/381/3","title":"Child's Nervous System","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"9dea68ab-c80f-4d81-a168-8ada2d23d0f8","owner":[],"postedDate":"July 18th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-08-01T16:19:35+00:00","versionOfRecord":{"articleIdentity":"rs-4619271","link":"https://doi.org/10.1007/s00381-024-06542-1","journal":{"identity":"childs-nervous-system","isVorOnly":false,"title":"Child's Nervous System"},"publishedOn":"2024-07-20 16:13:13","publishedOnDateReadable":"July 20th, 2024"},"versionCreatedAt":"2024-07-18 20:36:27","video":"","vorDoi":"10.1007/s00381-024-06542-1","vorDoiUrl":"https://doi.org/10.1007/s00381-024-06542-1","workflowStages":[]},"version":"v1","identity":"rs-4619271","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4619271","identity":"rs-4619271","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}