Surgical management of longstanding overt ventriculomegaly in adults: evaluating the role of endoscopic third ventriculostomy

Abstract

Background

Longstanding Overt Ventriculomegaly in Adults (LOVA) and Obstructive Hydrocephalus (o-HCP) is the abnormal accumulation of cerebrospinal fluid (CSF), leading to increased intracranial pressure, and associated neurological symptoms. Endoscopic Third Ventriculostomy (ETV) is a minimally invasive surgical treatment for these conditions. ETV has demonstrated effectiveness in pediatric populations, its efficacy in adult patients remains ambigous. This systematic review and meta-analysis aims to evaluate the outcomes of ETV in adult patients with LOVA and o-HCP.

Methods

A systematic review along with meta-analysis were carried out following the PRISMA guidelines. Studies were identified through PubMed, Cochrane, Scopus, and CINAHL databases using relevant MeSH terms and BOOLEAN operators. The inclusion criteria followed the PICO model, focusing on adult patients (> 18 years) undergoing ETV. Data on postoperative complications, symptom improvement, and successful treatment outcomes were extracted. Statistical analysis, including sensitivity analyses, was performed using R Studio, with odds ratios (OR) and heterogeneity (I²) calculated. The Newcastle-Ottawa Scale was employed to assess for risk of bias.

Results

A total of 8 studies comprising 200 patients were included. The overall odds ratio for successful treatment following ETV was 4.59 (95% CI: 2.74–7.67) with moderate heterogeneity (I² = 53%). Sensitivity analysis reduced the heterogeneity to 0%, increasing the OR to 5.56 (95% CI: 3.80–8.13). Significant improvements were noted in specific symptoms, including headache (OR 9.47, 95% CI: 4.31–20.81, I² = 0%), balance (OR 10.78, 95% CI: 4.00-29.03, I² = 35%), and memory (OR 6.64, 95% CI: 1.38–31.86, I² = 61%). A low risk of bias was observed across all studies included.

Conclusions

ETV is an effective treatment for patients with LOVA and o-HCP, demonstrating significant symptom improvement and a high success rate. Low heterogenicity of outcomes with robust findings confirmed sensitivity analyses. However, patient-specific factors, such as age and duration of symptoms, should be considered for ETV.

Introduction

Longstanding Overt Ventriculomegaly in Adults (LOVA) and obstructive hydrocephalus (o-HCP) are complex neurological conditions characterized by an abnormal accumulation of cerebrospinal fluid (CSF) in the brain’s ventricles [1, 2], leading to increased intracranial pressure and a range of debilitating symptoms [3]. These conditions are particularly challenging to diagnose and treat in adults, as they can often present with nonspecific symptoms such as headaches, cognitive disturbances, and balance issues, which may be mistaken for other neurological disorders [4]. Endoscopic Third Ventriculostomy (ETV) has emerged as a promising surgical intervention, offering a minimally invasive option to restore normal CSF flow and alleviate symptoms without the need for lifelong shunt dependency [5, 6]. However, the variability in patient outcomes following ETV highlights the need for a deeper understanding of the factors influencing its success and the potential complications associated with the procedure [7].

Despite the growing body of literature on ETV and its application in the treatment of hydrocephalus, there remains a significant gap in our understanding of its efficacy in adult patients, particularly those with LOVA [8]. Most existing research has focused predominantly on pediatric populations, where the etiology, presentation, and outcomes of hydrocephalus differ markedly from those observed in adults [9]. The pathophysiology of LOVA, is often associated with a long-standing, slowly progressive course, presents unique challenges that are not fully addressed in pediatric-centric studies [9]. Furthermore, the current literature is fragmented, with studies varying widely in terms of their patient populations, surgical techniques, and outcome measures, making it difficult to draw definitive conclusions about the effectiveness of ETV. This lack of consistent data is particularly concerning given that LOVA and obstructive hydrocephalus in adults may require different management strategies compared to other forms of hydrocephalus.

The importance of this study is further underscored by the fact that LOVA, while relatively rare, can have significant impacts on the quality of life if not managed effectively [10]. Current clinical guidelines are often based on extrapolations from pediatric data, which may not adequately reflect the complexities of adult cases. Additionally, the potential for postoperative complications, such as infection, bleeding, and the need for reoperation, remains a critical concern in the surgical management of these patients [11]. There is a pressing need for more comprehensive data that specifically addresses the outcomes of ETV in adults with LOVA, or obstructive HCP. Such data could provide valuable insights into the risk factors for postoperative complications, help refine surgical techniques, and ultimately improve the long-term prognosis for these patients.

This study aims to systematically review and analyze the existing literature on the surgical outcomes of ETV in adult patients with LOVA or obstructive hydrocephalus. Specifically, this review will focus on assessing postoperative complications, clinical outcomes, and the overall effectiveness of ETV in this patient population. By addressing the current gaps in the literature, this study seeks to provide a more robust evidence base to inform surgical decision-making, optimize patient selection, and enhance the overall management of adults undergoing ETV for these complex conditions.

Method and material

This systematic review and meta-analysis were conducted by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [12], ensuring a transparent and replicable approach to reviewing the literature and synthesizing data related to the surgical outcomes of ETV in adult patients with LOVA or obstructive hydrocephalus.

Selection criteria

Inclusion criteria

The inclusion criteria were developed using the PICO (Population, Intervention, Comparator, Outcome) method to ensure a comprehensive and targeted selection of studies. The population of interest included adult patients aged 18 years and older diagnosed with LOVA, or obstructive HCP. The intervention of focus was ETV, a surgical procedure performed to alleviate the symptoms associated with these conditions. Studies that included comparisons to other surgical or non-surgical treatments, or that were single-arm studies reporting outcomes post-ETV, were considered. During the study, the primary outcomes of interest, including postoperative complications, such as infection, hemorrhage, and the need for reoperation, were recorded but were not considered as a defining outcome. The secondary outcomes included clinical improvements in symptoms like headaches, balance issues, memory, and visual obscuration. Parameters like, overall long-term survival and quality of life were not included in the outcome due to variable follow-up timings and a few patients being lost to follow up. Successful outcomes were determined both by the relief of presenting symptoms and the patency and flow through the third ventriculostomy as assessed on postoperative MR imaging.

Exclusion criteria

Studies were excluded if they involved pediatric populations or mixed-age groups without providing separate data for adults. Additionally, studies that focused on patients with secondary hydrocephalus due to conditions such as tumors or trauma, or those that did not use ETV as the primary intervention, were excluded. Articles not available in full text, non-English language publications, and studies lacking sufficient data for analysis were also excluded. Studies with a high risk of bias, determined during the quality assessment phase, were excluded to maintain the integrity of the analysis.

Literature review

A comprehensive literature review was conducted independently by two researchers across four major databases: PubMed, Cochrane Library, Scopus, and CINAHL. The search strategy included a combination of MeSH terms and free-text keywords related to LOVA, obstructive hydrocephalus, and Endoscopic Third Ventriculostomy. Specific MeSH terms used were endoscopic third ventriculostomy, ventriculomegaly, hydrocephalus, cerebrospinal fluid shunts, neurosurgical procedures, LOVA, longstanding overt ventriculomegaly, postoperative complications, symptom improvement, and treatment outcome, which were employed to create a search string using BOOLEAN operators such as AND, OR, and NOT to refine and target the search results effectively. The search was conducted without a date restrictions to ensure that all relevant studies were identified.

Data extraction

Data extraction was performed independently by two researchers using a standardized extraction form to ensure consistency and accuracy. The data extracted included study characteristics (author, year of publication, study design, sample size), patient demographics (age, gender, diagnosis), details of the intervention (surgical technique, perioperative management), comparator details, and outcomes. Specifically, the outcomes extracted included the incidence of postoperative complications, clinical improvement in symptoms, quality of life measures, and long-term survival rates. Additionally, data on the success of ETV, defined by improvement in symptomology, were collected. Any discrepancies between the two researchers during the extraction process were resolved through discussion or consultation with a third reviewer.

Outcomes

The primary outcomes of interest were the treatment success rate, defined as both the relief of presenting symptoms and the patency and flow through the third ventriculostomy as assessed on postoperative MR imaging. Secondary outcomes included improvement in specific symptoms such as headaches, balance disturbances, memory issues, and visual obscurations.

Statistical analysis

Statistical analysis was performed using the package “pcnetmeta” on R Studio, employing the inverse variance method for meta-analysis. Log odds ratios (OR) and their standard errors (SE) were calculated for dichotomous outcomes, while continuous outcomes were analyzed using mean differences or standardized mean differences, depending on the data available. The results were synthesized into forest plots to visualize the effect sizes and heterogeneity across studies. Funnel plots were constructed to assess potential publication bias. The risk of bias for each included study was assessed using the Newcastle-Ottawa Scale (NOS), with studies scoring less than six points considered to have a high risk of bias [13]. In cases of high heterogeneity, sensitivity analyses were performed to identify potential sources of variation and to evaluate the robustness of the pooled estimates [14]. Subgroup analyses were also conducted to further explore the heterogeneity and to provide insights into specific patient subgroups or study characteristics. A similar methodology has been used previously by different studies [15, 16].

Results

Article selection

The process of article selection for this systematic review and meta-analysis, conducted by the PRISMA guidelines, is detailed in Fig. 1. Initially, a total of 1,978 records were identified from database searches, with no additional records from other registers. After the removal of 629 duplicate records, 1,349 records were screened based on their titles and abstracts. Following this screening process, 1,181 records were excluded for not meeting the inclusion criteria, leaving 168 reports for full-text retrieval.

Fig. 1.

PRISMA flow diagram illustrating the selection process of studies for inclusion in the meta-analysis. A total of 1,978 records were identified, and after removing duplicates and screening for eligibility, 8 studies were included in the final analysis

One report could not be retrieved, resulting in 167 reports that were assessed for eligibility. During this full-text assessment, 159 reports were excluded for various reasons: 51 reports were excluded due to having a different primary outcome, 42 reports were excluded because they focused on a pediatric age group, 27 reports were excluded for using the wrong study design, and 21 reports were excluded for involving an obsolete intervention. Additionally, 12 reports were excluded due to incomplete or mixed data, and 6 reports were excluded because they were non-English publications.

Ultimately, 8 studies were included in the final meta-analysis [1, 8, 17–22]. These studies were thoroughly analyzed to determine the effectiveness and safety of ETV in adult patients with LOVA or obstructive HCP.

Baseline demographics

The baseline demographics across the included studies reveal a diverse patient population undergoing ETV for LOVA or obstructive hydrocephalus. The sample sizes ranged from 18 to 40 patients, with the total number of participants across all studies being 200. The gender distribution varied slightly, with most studies reporting a nearly equal number of male and female participants. For instance, one study included 24 males and 16 females, while another had 14 males and 13 females. The mean age of patients ranged from 34.25 years to 70 years, with a median age across studies around 50 years. Specifically, the mean age in individual studies was reported as 34.25 years, 43 years, 50.5 years, 52 years, 53.47 years, 57.35 years, and 70 years.

Headache was the most common symptom, reported in 11 to 22 patients per study, with a total of 110 out of 200 patients (55%) experiencing headaches. Imbalance was also prevalent, affecting between 12 and 40 patients per study, with a total of 134 out of 200 patients (67%) experiencing this symptom. Memory problems were reported in 9 to 21 patients per study, with a total of 75 out of 200 patients (37.5%) affected. Visual obscuration was present in 4 to 21 patients per study, with 68 out of 200 patients (34%) reporting this issue. Cognitive problems were less frequently reported, with 5 to 13 patients per study, totaling 36 out of 200 patients (18%). Urinary incontinence was noted in 2 to 24 patients per study, with a total of 67 out of 200 patients (33.5%) experiencing this condition.

These baseline demographics demonstrate the variability in patient characteristics and symptom profiles, which underscores the importance of considering these factors when interpreting the outcomes of ETV in adults with LOVA or obstructive hydrocephalus. The wide range in age, the variability in symptom prevalence, and the relatively balanced gender distribution contribute to the complexity of assessing the overall effectiveness of ETV in this diverse patient population (Table 1).

Table 1.

Demographics

Author year	Sample size	Male	Female	Age	Headache	Imbalance	Memory Problems	Visual Obscuration	Cognitive Problems
Al-Jumaily 2012	20	10	10	52	19	15	9	8	5
Anik 2011	29	12	17	34.25	16	12	NA	5	NA
Bianchi 2021	40	24	16	53.47	11	40	21	5	NA
Ibáñez-Botella 2017	27	14	13	50.5	17	19	14	7	9
Jenkinson 2009	24	NA	NA	43	22	15	NA	NA	NA
Oi 2000	20	14	6	39.4	14	12	11	13	NA
Palandari 2021	18	12	6	70	3	17	NA	NA	12
Tuniz 2021	22	12	10	57.35	8	16	10	NA	NA

NA: not available

Efficacy outcomes

Successful treatment

The overall analysis of successful treatment rates, as depicted in Fig. 2, indicated that the OR for successful treatment following ETV was 4.59 (95% CI: 2.74, 7.67), and a heterogeneity of (I² = 53%). This suggests a robust effect favoring ETV across all the included studies.

Fig. 2.

Forest plot displaying the odds ratio (OR) for successful treatment following Endoscopic Third Ventriculostomy (ETV). The pooled OR is 4.59 (95% CI: 2.74, 7.67), with moderate heterogeneity (I² = 53%)

Following a sensitivity analysis, as shown in Fig. 3, the heterogeneity decreased significantly, with the odds ratio adjusting to 5.56 (95% CI: 3.80, 8.13) and heterogeneity reduced to I² = 0%. This drop in heterogeneity indicates that the sensitivity analysis effectively addressed some of the variability observed in the initial analysis.

Fig. 3.

Sensitivity analysis of successful treatment following ETV. The OR increased to 5.56 (95% CI: 3.80, 8.13) after sensitivity analysis, with heterogeneity reduced to I² = 0%, demonstrating the robustness of the findings

Improvement in symptomology

Improvement in headache

The OR for improvement in headache, as shown in Fig. 4, was 9.47 (95% CI: 4.31, 20.81) with no heterogeneity (I² = 0%). This indicates a significant improvement in headache symptoms post-ETV.

Fig. 4.

Forest plot of the odds ratio for improvement in headache following ETV. The pooled OR is 9.47 (95% CI: 4.31, 20.81), with no observed heterogeneity (I² = 0%), indicating significant improvement in headache symptoms across studies

Improvement in balance

The analysis for improvement in balance, depicted in Fig. 5, demonstrated an OR of 10.78 (95% CI: 4.00, 29.03) with moderate heterogeneity (I² = 35%). This suggests significant improvement in balance across studies.

Fig. 5.

Forest plot of the odds ratio for improvement in balance following ETV. The pooled OR is 10.78 (95% CI: 4.00, 29.03), with moderate heterogeneity (I² = 35%), indicating significant improvement in balance symptoms

Improvement in memory

The OR for memory improvement, shown in Fig. 6, was 6.64 (95% CI: 1.38, 31.86) with moderate heterogeneity (I² = 61%). Following sensitivity analysis Fig. 7, the OR slightly decreased to 16.13 (95% CI: 3.89, 66.88) with no heterogeneity (I² = 0%), suggesting some variability in the results.

Fig. 6.

Forest plot of the odds ratio for improvement in memory following ETV. The pooled OR is 6.64 (95% CI: 1.38, 31.86), with moderate heterogeneity (I² = 61%), suggesting variability in memory outcomes across studies

Fig. 7.

Sensitivity analysis of improvement in memory following ETV. The OR increased to 16.13 (95% CI: 3.89, 66.88), with heterogeneity reduced to I² = 0%, confirming a robust improvement in memory after accounting for potential sources of bias

Improvement in visual obscuration

For visual obscuration, the OR as shown in Fig. 8 was 2.21 (95% CI: 0.70, 6.96) with a low heterogeneity (I² = 17%). The sensitivity analysis, as seen in Fig. 9, slightly adjusted the OR to 4.94 (95% CI: 1.09, 22.48) with no heterogeneity (I² = 0%), indicating a reduction in the effect size after addressing potential sources of bias.

Fig. 8.

Forest plot of the odds ratio for improvement in visual obscuration following ETV. The pooled OR is 2.21 (95% CI: 0.70, 6.96), with low heterogeneity (I² = 17%), indicating some improvement in visual symptoms, though not as significant as other outcomes

Fig. 9.

Sensitivity analysis of improvement in visual obscuration following ETV. The OR increased to 4.94 (95% CI: 1.09, 22.48), with heterogeneity reduced to I² = 0%, suggesting a more robust improvement in visual symptoms after accounting for variability

Risk of bias assessment

The risk of bias assessment, illustrated by the funnel plot Fig. 10, shows a symmetrical distribution of studies, suggesting that there is no significant publication bias affecting the results of this meta-analysis. This supports the reliability of the findings presented in this study. The included studies were assessed for risk of bias using the NOS, with most studies scoring between 7 and 9, indicating high methodological quality. Most studies demonstrated strong selection processes, good comparability, and reliable exposure assessment, with only minor limitations in a few areas. Overall, the risk of bias was low across the studies, supporting the robustness and reliability of the meta-analysis findings (Table 2).

Fig. 10.

Funnel plot assessing the risk of publication bias in the meta-analysis. The symmetrical distribution of studies suggests no significant publication bias, supporting the reliability of the overall findings

Table 2.

Newcastle-Ottawa scale for quality assessment

Items	Selection				Comparability	Exposure			Total scores
	Adequacy of case definition	Representativeness of the cases	Selection of controls	Definition of controls		Ascertainment of exposure	Same method of ascertainment	Non- response rate
Al-Jumaily 2012	*	-	*	*	*	*	*	-	7
Anik 2011	*	*	-	-	*	*	*	*	7
Bianchi 2021	*	*	*	*	*	*	*	*	8
Ibáñez-Botella 2017	*	-	*	*	*	*	*	-	7
Jenkinson 2009	*	-	*	*	**	-	*	*	7
Oi 2000	*	*	*	*	*	*	*	-	8
Palandari 2021	*	*	*	*	**	*	*	-	8
Tuniz 2021	*	*	*	*	**	*	*	*	9

Discussion

The findings of this study demonstrate the overall effectiveness of ETV in treating LOVA and obstructive hydrocephalus, as reflected by the high OR for successful treatment and symptom improvement. The initial analysis showed a robust effect favoring ETV, with an OR of 4.59 for successful treatment, although there was some variability among the studies, as indicated by the moderate heterogeneity (I² = 53%). This suggests that while ETV is generally effective, patient outcomes can vary depending on specific factors, such as patient demographics or surgical techniques. The subsequent sensitivity analysis, which reduced heterogeneity to 0% and slightly increased the OR to 5.56, reinforces the reliability of the treatment’s success across different studies. This reduction in variability highlights the importance of standardizing protocols and patient selection criteria in future studies to minimize heterogeneity and enhance the consistency of ETV outcomes.

Moreover, the significant improvements in specific symptoms such as headache, balance, and memory underscore the clinical benefits of ETV, although some variability in memory improvement suggests that patient-specific factors may influence this outcome more than others. The modest effect observed in visual obscuration improvement points to the need for further investigation into which patients might benefit most from ETV regarding visual symptoms. Overall, these results confirm the efficacy of ETV as a treatment option, particularly when protocols are closely followed, and patient selection is optimized.

When comparing the results of our study with previous meta-analyses conducted by Montemurro [23] and Gillespie et al. [24], several key distinctions and similarities emerge. Montemurro reported an overall postoperative clinical improvement rate of approximately 82.1% following ETV, which aligns closely with our finding of an 83.6% improvement rate. However, the odds ratio for successful treatment in our study was notably higher (OR 4.59; 95% CI: 2.74, 7.67), suggesting a more robust effect favoring ETV. This discrepancy might be attributed to the broader inclusion criteria and more recent data included in our meta-analysis, which may have captured improvements in surgical techniques and patient management practices over time. Additionally, our study’s sensitivity analysis effectively reduced heterogeneity (I² = 0%) and further strengthened the odds ratio to 5.56, a refinement that was less emphasized in the previous analyses. Gillespie et al., on the other hand, reported lower odds ratios across various symptom improvements, particularly in headache and balance, where their reported ORs were around 3.5 and 4.0, respectively. Our study found significantly higher ORs for these outcomes (OR 9.47 for headache and OR 10.78 for balance), indicating that ETV might be more effective in these domains than previously suggested. The higher efficacy observed in our study could be due to our more stringent selection criteria and the inclusion of recent high-quality studies that employed advanced imaging techniques to confirm treatment success. Moreover, Gillespie’s meta-analysis did not perform a detailed sensitivity analysis, which might explain the higher heterogeneity in their results. Overall, while our findings are consistent with the general efficacy trends reported in previous studies, our meta-analysis provides a more detailed and refined assessment, particularly by addressing heterogeneity through sensitivity analysis and including the latest data.

Several potential factors can influence the outcomes of ETV, and these factors are crucial in understanding the variability in treatment success. One significant factor is patient age [25, 26]. Younger patients tend to have better outcomes due to greater plasticity in the brain and the ability to adapt to changes in cerebrospinal fluid (CSF) dynamics [26]. In contrast, older patients may have less favorable outcomes due to pre-existing comorbidities, reduced brain plasticity, and a longer duration of symptoms before diagnosis [25]. While the inclusion of a wide age range in our study allows for generalizability, it also introduces variability, as the effectiveness of ETV might differ substantially between younger and older patients. This underscores the importance of age-stratified analysis in future research to better predict outcomes based on patient demographics. Another critical factor is the duration of symptoms before treatment [25, 27]. Patients who have had symptoms for a shorter duration may respond more favorably to ETV, as prolonged ventricular enlargement can lead to irreversible brain damage and reduced chances of symptomatic improvement post-surgery [28]. However, the timing of intervention also poses challenges; earlier interventions may prevent irreversible damage but carry the risk of overtreatment in cases where symptoms could stabilize without surgical intervention [29]. Thus, the timing of ETV must be carefully considered, balancing the potential benefits of early intervention against the risks of unnecessary surgery.

Surgical technique and experience also play a pivotal role in determining the success of ETV [30]. Surgeons with more experience in performing ETV are likely to achieve better outcomes due to refined techniques and better management of intraoperative complications [31]. Additionally, the use of advanced imaging techniques, such as intraoperative MRI, can enhance the accuracy of the procedure, reducing the likelihood of complications such as hemorrhage or inadequate fenestration [32]. However, access to such advanced technologies and highly experienced surgeons may be limited in certain settings, potentially leading to disparities in patient outcomes. This highlights the need for standardized training programs and protocols to ensure that all patients receive the highest standard of care, regardless of geographic location or institutional resources.

Finally, patient selection criteria significantly impact the effectiveness of ETV. Patients with specific anatomical features, such as aqueductal stenosis or a wide third ventricle, are more likely to benefit from ETV, while those with complex hydrocephalus or multi-compartmental CSF dynamics may have poorer outcomes [33, 34]. The rigorous application of selection criteria can enhance the success rates of ETV, but overly stringent criteria may exclude patients who could still benefit from the procedure. On the other hand, broad criteria may lead to the inclusion of patients who are less likely to respond favorably, increasing the heterogeneity of outcomes. Therefore, developing refined selection criteria that balance inclusivity with the likelihood of success is crucial for optimizing patient outcomes.

This study is particularly important because it addresses several critical gaps in the existing literature on the treatment of LOVA and obstructive hydrocephalus. By providing a more detailed analysis of the efficacy of ETV and incorporating recent advancements in surgical techniques and patient management, this study offers a contemporary perspective that can inform both current practice and future research. The inclusion of a comprehensive sensitivity analysis not only strengthens the robustness of the findings but also highlights the variability in outcomes that can arise from different patient populations and treatment settings. This study’s ability to integrate and synthesize these diverse factors makes it a valuable contribution to the field.

Looking ahead, future research should focus on further refining patient selection criteria to enhance the precision of ETV as a treatment option. Longitudinal studies that follow patients over extended periods could provide insights into the long-term efficacy and potential complications of ETV, particularly in comparison to other surgical options like ventriculoperitoneal shunting (VPS) [35, 36]. Additionally, there is a need for randomized controlled trials (RCTs) that directly compare ETV with other treatment modalities across different patient demographics and clinical settings. Such studies could help clarify the circumstances under which ETV is most beneficial, thereby optimizing treatment protocols. Finally, research into the development of advanced imaging techniques and intraoperative technologies could further improve the safety and effectiveness of ETV, ensuring that more patients can benefit from this procedure with minimal risk.

This study possesses several strengths that enhance its contribution to the field. One of the key strengths is the comprehensive nature of the analysis, which includes a robust sensitivity analysis that effectively addresses heterogeneity across studies. By doing so, this study provides a more reliable estimate of the efficacy of ETV for treating LOVA and obstructive hydrocephalus. Additionally, the inclusion of the most up-to-date studies ensures that the findings reflect current clinical practices and advancements in surgical techniques.

Limitation

One of the main limitations is the inherent variability in the patient populations and study designs across the included studies, which can introduce bias and affect the generalizability of the findings. While the sensitivity analysis mitigates some of this variability, it cannot eliminate it. Another limitation is the reliance on retrospective data from non-randomized studies, which may be subject to selection bias and confounding factors that are not fully accounted for in the analysis. Furthermore, the study’s findings, while robust, are based on a relatively small number of included studies, which limits the ability to conduct subgroup analyses that could provide more nuanced insights into the factors influencing ETV outcomes. Also, another limitation authors faced was the primary outcomes of interest, including post-operative complications such as hemorrhage, infections, and need for a re-surgery; not all studies included focused on these, and hence we had to switch focus to the information discussed in detail in all the included studies. Finally, the lack of long-term follow-up data in many of the included studies means that the secondary outcome, including the long-term survival and the quality of life post-ETV, remains areas that require further exploration. Despite these limitations, the strengths of this study provide a solid foundation for its conclusions, while also highlighting areas for future research that could address these gaps and further refine the understanding of ETV’s role in treating LOVA and obstructive hydrocephalus.

Conclusion

This study confirms the efficacy of ETV as a primary treatment for LOVA and obstructive hydrocephalus, demonstrating significant improvements in symptoms such as headaches, balance, and memory. The findings highlight the importance of patient selection and surgical expertise in optimizing outcomes, while also emphasizing the need for further research to refine treatment protocols and address long-term efficacy. Despite some limitations, including variability in study designs and the need for more long-term data, this study provides a robust analysis that can inform clinical decision-making and guide future research in this evolving field.

Author contributions

All authors made substantial contributions to the study as following: MA- corresponding authorMA, SVH and SA- Study design and conception, overseeing data collection/analysis and final approval of the version of the study submitted.MA, HS, HA, MWS and JA - data collection (screening for abstracts and full texts)MA, HK, HA, MWS and JA - data analysis, results interpretation and graph makingMA, HK, HA, HM and JA– Drafting and manuscript writingMA and JA- tables and revision of manuscript.SVH– mentor of the study submitted.SA - supervisor of the study submitted.

Funding

The authors did not receive support from any organization for the submission. The authors have no relevant financial/non-financial interest to disclose.

Data availability

No datasets were generated or analysed during the current study.

Materials availability

Data is available and will be provided on request to the corresponding author.

Declarations

Ethical approval

Ethical approval for this study was not required because no animals or patients were involved as this regards a systematic review of literature.

Consent for publication

Not applicable.

Consent to participate

Not applicable.

Competing interests

The authors declare no competing interests.