Hydrocephalus, unless treated, is one of the terminal manifestations of intracranial metastatic disease. Single lesions causing obstructive hydrocephalus are amenable to surgical resection, but in the setting of multiple lesions and communicating hydrocephalus from leptomeningeal disease, the approach to treatment is much less defined. The use of endoscopic third ventriculostomy (ETV) and ventriculoperitoneal shunting (VPS) has been described, but data is limited. In this review, we summarize the sparse data available in literature describing the use of CSF diversion for patients with metastatic disease presenting with hydrocephalus and neurological decline

Mirza, Farhan A

Shamim, Muhammad Shahzad

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eCommons@AKUSection of Neurosurgery Department of SurgerySeptember 2018Role of palliative CSF diversion in patients withintracranial metastatic disease and symptomatichydrocephalusFarhan A. MirzaUniversity of Kentucky, UK.Muhammad Shahzad ShamimAga Khan University, shahzad.shamim@aku.eduFollow this and additional works at: https://ecommons.aku.edu/pakistan_fhs_mc_surg_neurosurgRecommended CitationMirza, F. A., Shamim, M. (2018). Role of palliative CSF diversion in patients with intracranial metastatic disease and symptomatichydrocephalus. Journal of Pakistan Medical Association, 68(9), 1412-1414.Available at: https://ecommons.aku.edu/pakistan_fhs_mc_surg_neurosurg/158AbstractHydrocephalus, unless treated, is one of the terminalmanifestations of intracranial metastatic disease. Singlelesions causing obstructive hydrocephalus are amenableto surgical resection, but in the setting of multiple lesionsand communicating hydrocephalus from leptomeningealdisease, the approach to treatment is much less defined.The use of endoscopic third ventriculostomy (ETV) andventriculoperitoneal shunting (VPS) has been described,but data is limited. In this review, we summarize thesparse data available in literature describing the use ofCSF diversion for patients with metastatic diseasepresenting with hydrocephalus and neurological decline.Keywords: Metastatic tumours, hydrocephalus,endoscopic third ventriculostomy, ventriculoperitonealshunt, CSF diversionBackgroundTreatment of cancers in the form of surgery,chemotherapy, and radiation therapy in general has beenimproving, resulting in improved survival of thesepatients. With longer survival, tumour recurrence andmetastasis are being seen more often. It is estimated that25-30% of cancer patients develop brain metastases. Inintracranial metastatic disease, especially in the presenceof multiple lesions or leptomeningeal spread, theprognosis is usually considered poor on the scale of fewweeks to months.1 In certain situations however, if there isa single lesion or a posterior fossa periventricular lesionsresulting in obstructive hydrocephalus, primary surgicalresection can be of benefit in relieving this obstructionand provide survival benefit.1The role of palliative CSF diversionary procedures for thissituation is less well defined. Limited data exists inliterature describing the use of ventriculoperitoneal shuntor endoscopic third ventriculostomy as a CSF diversionmethod for obstructive hydrocephalus.2-5 Reports are alsopresent on communicating hydrocephalus in the settingof leptomeningeal disease and high grade gliomas.4-7Lumboperitoneal shunting has also been described.8Review of EvidenceVentriculoperitoneal Shunt (VPS)In 2015, Nigim et al., published their series of 59 patientswho underwent VPS placement for hydrocephalus in thebackground of brain tumours.4 Forty patients withmetastatic lesions and 19 with primary brain neoplasmswere included. Nineteen patients had obstructive and 40patients had communicating hydrocephalus. Eighty-threepercent of patients in Nigim's series had progressivesystemic disease. Ninety-three percent patients showedimprovement in their symptoms and shunt relatedcomplications were noted in 11.9%. The authors did notcomment on outcomes with respect to the type ofhydrocephalus (obstructive vs. communicating), thus it isdifficult to generalize their results to either scenario.Overall good outcomes with good shunt patency werenoted at six months and one year.4Prior to this series, Lee et al., described their experiencewith 50 patients in 2011.5 Ten of these had parenchymallesions and the rest presented with leptomeningealdisease with or without parenchymal lesions. Thirteenpatients had obstructive and 37 had communicatinghydrocephalus. Overall 80% patients noted improvementin headache, nausea, and cognitive status and 10%complication rate was noted, including one death fromintracerebral haemorrhage. One of the interestingfindings reported was the presence of opening pressureof >30 cm H2O as an independent risk factor for pooreroutcomes. It was also reported that patients whounderwent VPS followed by therapy for their systemicdisease had better outcomes. This however wasattributed to patient selection. It is also interesting to notethat six patients in their series with primarilyleptomeningeal spread had a survival period of over oneyear after VPS placement. Their data supports theutilization of CSF diversion even in cases ofleptomeningeal disease which is usually considered as anend stage manifestation.Vol. 68, No. 9, September 20181412EVIDENCE BASED NEURO-ONCOLOGYRole of palliative CSF diversion in patients with intracranial metastatic diseaseand symptomatic hydrocephalusFarhan A. Mirza,1 Muhammad Shahzad Shamim21Department of Neurosurgery, University of Kentucky, UK, 2Department ofSurgery, Section of Neurosurgery, Aga Khan University Hospital, Karachi.Pakistan.Correspondence:Muhammad Shahzad Shamim.Email: shahzad.shamim@aku.eduEndoscopic Third Ventriculostomy (ETV)Third ventriculostomy serves as a physiologic shunt canbe performed endoscopically using anatomic landmarks,or with stereotaxis using image guidance. ETV mitigatesthe complications that may accompany shunt placementsuch as hardware malfunction, wound breakdown overshunt hardware, over-drainage, and possible seeding ofthe peritoneal cavity. It also avoids the discomfort causedby subcutaneous tunneling of the shunt. However, it maynot be applicable for all patients with hydrocephalus andthe ETV Success Score may be used to predict whichpatients are more likely to benefit from it, and which arebest treated with a VPS.9Only two reports are present in literature regarding theuse of ETV for hydrocephalus in metastatic disease.Nguyen et al., in 1999 presented their case series of sevenpatients with metastatic lesions to the thalamus orposterior fossa resulting in CSF obstruction.2 Five of thesecases showed improvement after ETV.One patientproceeded to comfort care after no improvement. Onepatient had post-operative improvement but returned ina few days with worsening hydrocephalus, and requiredJ Pak Med Assoc1413 F. A. Mirza, M. S. ShamimFigure-1 (a,b,c): MRI Brain T2 axial, Flair axial and T! coronal with contrast images showing GBM with hydrocephalus.Figure-2 (a,b,c): CT Brain axial plain showing multiple metastases from a primary lung cancer, and obstructive hydrocepahalus due to obstruction of fourth ventricle.VPS with resolution of symptoms. To further this, Chen et al., published their results of 16patients in 2011.3 All patients in their series had failedchemotherapy, had active primary disease, and had lowKPS scores. All patients had imaging findings consistentwith obstructive hydrocephalus from metastatic lesions.Symptomatic improvement was observed after palliativeETV in 11 patients (69%). Four (25%) were deceased by theend of the first month. This improvement is comparablewith that reported for the use of VP shunts.Although the data on this topic is insufficient to drawconclusions, CSF diversion appears as a reasonable choicefor certain patient subgroups with symptomatichydrocephalus and intracranial metastatic disease. Onecannot over emphadize the use of Karnofsky PerformanceScale (KPS) when approaching patients as it appears tohave direct impact on survival. Younger age, betterneurocognitive status, more limited extent of systemicdisease and responsiveness to treatment should also befactored into the equation.In choosing surgical modality,results from the ETV and VPS series are comparable, witha lower rate of complications with ETV. It would bereasonable to use ETV as the first line treatment,specifically in obstructive hydrocephalus cases, withpredictive success scores in the realm of 70-90% aspredicted by the ETV Success Score.ConclusionSurgical CSF diversion for hydrocephalus in intracranialmetastatic disease is a viable option in symptomaticpatients. It has been shown to improve symptoms andalthough the existing data is sparse, it does also supportimproved survival in select cases.References1. Laghari AA, Ahmed SI, Shamim MS. Role of surgery in brainmetastases. J Pak Med Assoc 2017; 67: 1299-300.2. Nguyen TT, Smith MV, Rodziewicz GS, Lemke SM. Hydrocephaluscaused by metastatic brain lesions: treatment by thirdventriculostomy. J Neurol Neurosurg Psychiatry.1999; 67: 552-3.3. Chen CC, Kasper E, Warnke P.Palliative stereotactic-endoscopicthird ventriculostomy for the treatment of obstructivehydrocephalus from cerebral metastasis. Surg Neurol Int. 2011; 2:76. doi: 10.4103/2152-7806.82083.4. Nigim F, Critchlow JF, Kasper EM. Role of ventriculoperitonealshunting in patients with neoplasms of the central nervoussystem: An analysis of 59 cases. Mol Clin Oncol. 2015; 3: 1381-6. 5. Lee SH, Kong DS, Seol HJ, Nam DH, Lee JI. Ventriculoperitonealshunt for hydrocephalus caused by central nervous systemmetastasis. J Neurooncol. 2011; 104: 545-51.6. Omuro AM, Lallana EC, Bilsky MH and DeAngelis LM:Ventriculoperitoneal shunt in patients with leptomeningealmetastasis. Neurology 2005; 64: 1625?7.7. Inamasu J, Nakamura Y, Saito R, Kuroshima Y, Mayanagi K, Orii M,Ichikizaki K. Postoperative communicating hydrocephalus inpatients with supratentorial malignant glioma. Clin NeurolNeurosurg. 2003; 106: 9-15.8. Yamashiro S, Hitoshi Y, Tajiri S, Uchikawa H, Ito K, Yoshida A,Kuratsu JI.Palliative lumboperitoneal shunt for leptomeningealmetastasis-related hydrocephalus: A case series. Palliat Med. 2017;31: 93-6. 9. Labidi M, Lavoie P, Lapointe G, Obaid S, Weil AG, Bojanowski MW,et al. Predicting success of endoscopic third ventriculostomy:validation of the ETV Success Score in a mixed population of adultand pediatric patients. J Neurosurg. 2015; 123: 1447-55.Vol. 68, No. 9, September 2018Role of palliative CSF diversion in patients with intracranial metastatic disease and symptomatic hydrocephalus 1414

Role of palliative CSF diversion in patients with intracranial metastatic disease and symptomatic hydrocephalus

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Role of palliative CSF diversion in patients with intracranial metastatic disease and symptomatic hydrocephalus

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