Is endoscopic third ventriculostomy superior to shunts in patients with non-communicating hydrocephalus? A systematic review and meta-analysis of the evidence.

BACKGROUND: Endoscopic third ventriculostomy (ETV) and shunts are both utilized in the treatment of non-communicating hydrocephalus. The objective of this study was to review the evidence comparing the effectiveness of these two techniques.

METHODS: The Cochrane Central Register of Controlled Trials (CENTRAL) and Medline databases were searched between 1990 and August 2012. We included all studies comparing the failure rate of patients with non-communicating hydrocephalus treated with ETV and shunts. Two authors (HJM and FTR) appraised quality and extracted data independently.

RESULTS: Of 313 articles identified, 12 were selected for further review. Of these, 6 were included for qualitative analysis, and 5 for quantitative analysis (n = 504). ETV was associated with a non-statistically significant reduction in failure using the random-effects model (OR 0.58, 95 % CI 0.29-1.13).

CONCLUSIONS: Both ETV and shunts are associated with a relatively high failure rate. At present there is insufficient proof to unequivocally recommend one mode of treatment above the other. However, there is some evidence that ETV may confer long-term survival advantage over shunts in the treatment of non-communicating hydrocephalus, particularly in patients with certain aetiologies such as aqueductal stenosis. Prospective randomized controlled trials are currently underway and may provide more robust evidence to answer this important question and better guide future management.