Inferior short-term safety profile of endoscopic third ventriculostomy compared with ventriculoperitoneal shunt placement for idiopathic normal-pressure hydrocephalus: A population-based study

BACKGROUND: In small series, endoscopic third ventriculostomy (ETV) has been shown to potentially have efficacy similar to that of ventriculoperitoneal shunting (VPS) for idiopathic normal-pressure hydrocephalus (iNPH). Therefore, some clinicians have advocated for ETV to avoid the potential long-term complications associated with VPS. Complication rates for these procedures vary widely based on limited small series data. OBJECTIVE: We used a nationwide database that provides a comprehensive investigation of the perioperative safety of ETV for iNPH compared with VPS. METHODS: We identified discharges with the primary diagnosis of iNPH (International Classification of Diseases, Ninth Revision code 331.5 [ICD-9]) with ICD-9 primary procedure codes for VPS (02.34) and ETV (02.2) from 2007 to 2010. We analyzed short-term safety outcomes using univariate and hierarchical logistic regression analyses. RESULTS: There were a total of 652 discharges for ETV for iNPH and 12 845 discharges for VPS for iNPH over the study period. ETV was associated with a significantly higher mortality (3.2% vs 0.5%) and short-term complication (17.9% vs 11.8%) rates than VPS despite similar mean modified comorbidity scores. On multivariate analysis, ETV alone predicted increased mortality and increased length of stay when adjusted for other patient and hospital factors. CONCLUSION: This is the first study that robustly assesses the perioperative complications and safety outcomes of ETV for iNPH. Compared with VPS, ETV is associated with higher perioperative mortality and complication rates. This consideration is important to weigh against the potential benefit of ETV: avoiding long-term shunt dependence. Prospective, randomized studies are needed.