Endoscopic third ventriculostomy for obstructive hydrocephalus

The indications for neuroendoscopy are not only constantly increasing, but even the currently accepted indications are constantly being adjusted and tailored. This is also true for one of the most frequently used neuroendoscopic procedures, the endoscopic 3rd ventriculostomy (ETV) for obstructive hydrocephalus. ETV has gained popularity and widespread acceptance during the past few years, but little attention has been paid to the techniques of the procedure. After a short introduction describing the history of ETV, an overview is given of all the different techniques that have been and still are employed to open the floor of the 3rd ventricle. The spectrum of indications for ETV has been widely enlarged over the last years. Initially, the use of this procedure was restricted to patients older than 2 years, to patients with an obvious triventricular hydrocephalus, and to those with a bulging, translucent floor of the 3rd ventricle. Nowadays, indications include all kinds of obstructive hydrocephalus but also communicating forms of hydrocephalus. The results of endoscopic procedures in treating these pathologies are given under special consideration of shunt technologies. In summary, from the review of the publications since the first ETV performed by Mixter in 1923, this technique is the treatment of choice for obstructive hydrocephalus caused by different etiologies and is an alternative to cerebrospinal fluid shunt application.Commentaries on this paper are available at and     

Endoscopic third ventriculostomy in obstructive hydrocephalus due to giant basilar artery aneurysm

OBSTRUCTIVE: hydrocephalus due to giant basilar artery (BA) aneurysm is a rare finding, and endoscopic treatment has not been reported. Here the authors present their experience with endoscopic third ventriculostomy (ETV) in obstructive hydrocephalus due to giant BA aneurysm. Between December 2000 and March 2007, 3 patients (2 men and 1 woman; age range 32-80 years) underwent an ETV for the treatment of obstructive hydrocephalus caused by a giant BA aneurysm. All 3 patients presented with cephalgia, nausea, vomiting, and a variable decrease in consciousness. An obstructive hydrocephalus caused by a giant BA aneurysm was found in each case as the underlying pathological entity. Intraoperatively, a narrowing of the third ventricle by upward displacement of the tegmentum was found in all 3 patients. A standard ETV was performed and included an inspection of the prepontine cisterns. The endoscopic treatment was successful in all patients with respect to clinical signs and radiological ventricular enlargement. No complications were observed. In all, the endoscopic ventriculostomy was proven to be a successful treatment option in obstructive hydrocephalus even if it is caused by untreated giant BA aneurysm.     

Endoscopic third ventriculostomy for hydrocephalus.

The authors report on 125 patients who underwent endoscopic third ventriculostomy for obstructive hydrocephalus in three Italian Neurosurgical Centers. The series includes 77 cases of primary aqueductal stenosis, 33 with triventricular hydrocephalus due to external tumor compression, and 15 with tetraventricular hydrocephalus. The operations were carried out mainly under general anesthesia, using a flexible endoscope. Decrease of size of the third ventricle and the presence of a signal void at the level of the fenestration are the main postoperative MRI findings. Signs of intracranial hypertension, increased head circumference and Parinaud syndrome respond more frequently to the endoscopic treatment. The overall rate of good results (shunt-independent patients) in this series is 86.4%; primary aqueductal stenosis (93.5%) and triventricular hydrocephalus due to external compression (84.8%) are associated to the higher rate of good postoperative results than tetraventricular hydrocephalus (53.3%). Because of the very low invasivity of this technique, the absence of postoperative mortality and the scarce and usually transient postoperative complications, the authors advise to enlarge the indications for endoscopic third ventriculostomy to all patients with obstructive hydrocephalus when the third ventricle is large enough and there are no alterations of the CSF resorption.     

Endoscopic third ventriculostomy for management of obstructive hydrocephalus secondary to supratentorial intraventricular hematoma. Case report

We report two cases of intraventricular hematoma with obstructive hydrocephalus. We perform endoscopic treatment of the hydrocephalus: aspiration of the hematoma associated with a third ventriculostomy. Both patients respectively aged 59 and 74 years had an obstructive hydrocephalus due to intraventricular hemorrage. The patient neurological status worsen at day 6 for patient No. 1 and at day 4 for patient No. 2. Endoscopic ventriculoscopy was performed respectively at day 6 and at day 5. Operatively, immediate vision was poor but was progressively improved by repetitive irrigation with Ringer-lactate (RL). Obstruction of the right Monro foramen by clot was observed. Introduction of the neuroendoscope into the third ventricle was possible after suction of the hematoma. Perforation of the floor of the third ventricle was performed after identification of the mammillary bodies and the infundibulum. Neurological status recovered within 10 days after surgery and the patients were referred to a medical unit. The patients were independent at home. The one-year MRI follow-up study showed a functional acqueduc in case 1 and a non-functional acqueduc in case 2 indicating in this case that the ventriculocisternotomy was useful. Intraventricular hematoma is not a contraindication for endoscopic third ventriculostomy. If possible, waiting for 6 or 5 days to allow the structuring of the blood clot and using large irrigation RL may facilitate the endoscopic procedure. This indication for endoscopic third ventriculostomy constitutes an alternative to external ventricular drainage which is significatively associated with complication (infection and obstruction). We cannot affirm that the removal of the clots and ventriculocisternostomy versus temporary external drainage avoids secondary hydrocephalus.     

Endoscopic third ventriculostomy: towards more indications for the treatment of non-communicating hydrocephalus.

OBJECTIVE: Since its reintroduction during the last 2 decades, third ventriculostomy has shown promising results. However, with more experience and better selection of cases, the indications and contraindications are likely to change. METHODS: During the period from November 1994 to December 1996, we have treated 27 patients with non-communicating hydrocephalus by endoscopic third ventriculostomy at the King Khalid University Hospital. Their ages ranged from 35 weeks preterm to 26 years of age. Sixteen (59%) patients were one year old or younger. Their follow-up ranged from 9 months to 2.5 years. According to the etiology of the non-communicating hydrocephalus, patients were divided into 4 subgroups. These were as follows: 11 aqueduct stenosis, 6 post ventriculitis, 6 cysts, and 4 posterior fossa tumours. The outcome was graded into 3 grades: Grade III were patients who improved after the procedure. Grade II were patients who improved after adding a VP-shunt to the procedure. Grade I were failure patients. RESULTS: An overall outcome of Grade III was achieved in 22 patients (81%). This was broken down according to subgroups as follows: 8/11 (73%) patients of subgroup 1, 5/6 in each of the patients of subgroup 2 and 3, and all of the patients with posterior fossa tumours. DISCUSSION: The overall results were very encouraging and so for the subgroups as compared with the reported cases in the literature. CONCLUSION: Better selection of the cases and increased experience with the procedure is expected to improve the outcome.     

Endoscopic third ventriculostomy in the management of obstructive hydrocephalus: an outcome analysis

OBJECT: The purpose of this paper is to elucidate the safety and efficacy of, and indications and outcome prognosis for endoscopic third ventriculostomy (ETV) in 58 patients with obstructive hydrocephalus. METHODS: Between September 1999 and April 2003, 58 ETVs were performed in 58 patients with obstructive hydrocephalus (36 male and 22 female patients) at the authors' institution. The ages of the patients ranged from 5 to 67 years (mean age 35 years) and the follow-up period ranged from 3 to 41 months (mean duration of follow up 24 months). Patients were divided into four subgroups based on the cause of the obstructive hydrocephalus: 21 with intracranial tumors; 11 with intracranial cysts; 18 with aqueductal stenosis: and eight with intracranial hemorrhage or infection. Both univariate and multivariate statistical analyses were performed to assess the prognostic relevance of the cause of the obstructive hydrocephalus, early postoperative clinical appearance, and neuroimaging findings in predicting the result of the ETV. The survival rate was 87% at the end of the 1st year and 84% at the end of the 2nd year post-ETV. One month after ETV an overall clinical improvement was observed in 45 (77.6%) of 58 patients. If we also consider the successful revision of ETV in two patients, a success rate of 78.3% (47 of 60 patients) was reached. The ETV was successful in 17 (81%) of 21 patients with intracranial tumors, nine (82%) of 11 with cystic lesions, 16 (88.9%) of 18 with aqueductal stenosis, and three (38%) of eight with intracranial hemorrhage or infection. A Kaplan-Meier analysis illustrates that the percentage of functioning ETVs stabilizes between 75 and 80% 1 year after the operation. In a comparison of results 1 year after ETV, the authors found that the aqueductal stenosis subgroup had the highest proportion of functioning ETV (89%). The proportions of the tumor and cyst subgroups were 84 and 82%, respectively, whereas the proportion was only 50% in the ventriculitis/intracranial hemorrhage subgroup (strata log-rank test: chi2 = 7.93, p = 0.0475). In the present study, ETV failed in eight patients (13.8%) and the time to failure after the procedure was a mean of 3.4 months (median 2 months, range 0-8 months). The logistic regression analysis confirmed an early postoperative improvement (within 2 weeks after ETV, significance [Sig] of log likelihood ratio [LLR] < 0.0001) and a patent stoma on cine phase-contrast magnetic resonance (MR) images (Sig of LLR = 0.0002) were significant prognostic factors for a successful ETV. The results demonstrated the multivariate model (B = -53.7309, standard error = 325.1732, Wald = 0.0273, Sig = 0.8688) could predict a correct result in terms of success or failure from ETV surgery in 89.66% of observed cases. The Pearson chi-square test demonstrated that little reliance could be placed on the finding of a reduced size of the lateral ventricle (chi2 = 5.305, p = 0.07) on neuroimaging studies within 2 weeks after ETV, but it became a significant predictive factor at 3 months (chi2 = 8.992, p = 0.011) and 6 months (chi2 = 10.586, p = 0.005) post-ETV. Major complications occurred in seven patients (12.1%), including intraoperative venous bleeding in three, arterial bleeding in one, and occlusion of the stoma in three patients. The overall mortality rate was 10.3% (six patients). One of these patients died of pulmonary infection and another of ventriculitis. Four additional patients died of progression of malignant tumor during the follow-up period. CONCLUSIONS: The results indicate that ETV is a most effective treatment in cases of obstructive hydrocephalus that is caused by aqueductal stenosis and space-occupying lesions. For patients with infections or intraventricular bleeding, ETV has considerable effects in selected cases with confirmed CSF dynamic studies. Early clinical and cine phase-contrast MR imaging findings after the operation play an important role in predicting patient outcomes after ETV. The predictive value of an alteration in ventricle size, especially during the early stage following ETV, is unsatisfactory. Seventy-five percent of ETV failures occur within 6 months after surgery. A repeated ventriculostomy should be considered to be a sufficient treatment option in cases in which stoma dysfunction is suspected.     

Endoscopic third ventriculostomy for chronic hydrocephalus after tuberculous meningitis

BACKGROUND: Cerebrospinal fluid diversion procedures are indicated in patients with hydrocephalus after tuberculous meningitis (TBM). We present 2 patients with hydrocephalus after TBM who were successfully treated with endoscopic third ventriculostomy (ETV). METHODS: Two patients had been diagnosed with hydrocephalus after TBM and had undergone ventriculoperitoneal shunt surgery for the same. They presented with multiple episodes of shunt dysfunction. Endoscopic third ventriculostomy was performed (twice for one patient), and the patients were evaluated clinically and radiologically after the procedure. RESULTS: On long-term clinical follow-up (3 and 2 years, respectively), both patients were asymptomatic after the ETV. The first patient was radiologically evaluated 7 months after the procedure and the second patient 2 years after the procedure. The first patient showed a decrease in ventricular size. The second patient did not show any significant change in the ventricular size. CONCLUSION: Endoscopic third ventriculostomy can be considered as a safe and long-lasting solution for hydrocephalus after chronic TBM.     

神经内镜下第三脑室底造瘘术治疗脑积水11例分析

目的探讨神经内镜下第三脑室底造瘘术（ETV）治疗脑积水的手术技巧、疗效及并发症的预防。方法回顾性分析2008年7月至2010年8月接受ETV的11例脑积水患者的临床资料,其中梗阻性脑积水8例,交通性脑积水3例。复习相关文献资料进行分析。结果 9例患者临床症状明显好转,1例临床症状未见明显变化,1例术后出现造瘘口闭合,行脑室-腹腔分流术后临床症状好转。结论 ETV治疗脑积水符合生理结构,安全有效,并发症少,应大力推广此手术方式。     

Long-term outcome of endoscopic third ventriculostomy in obstructive hydrocephalus.

This multicentric study reports on 140 patients who underwent endoscopic third ventriculostomy for obstructive hydrocephalus in four Italian neurosurgical centers between 1994 and 1999. Its aim is to define the long-term outcome of these patients many years (6-12) after the initial procedure. The study includes both children and adults; the etiology of the hydrocephalus was malformative aqueductal stenosis in 88 cases (62.8%), compression by tumors of the mesencephalic and pineal regions and posterior fossa in 45 (32.2%) and post-infection aqueductal stenosis in 7 (5%). The ETV was performed by using the standard technique. The overall rate of good results (shunt-independent patients with clinical remission or improvement) was 87.1%. Eighteen patients (12.9%) required a shunt because of ETV failure. The long-term outcome of ETV in this study was not influenced by the patient's age and the etiology of the hydrocephalus (although cases secondary to cisternal hemorrhage and infections are not included). Other series including cases with long follow-up are analyzed. In conclusion, ETV results in a high rate of good long-term outcome in patients with obstructive hydrocephalus. Because postoperative failures occur early, clinical and radiological control studies must be performed particularly in the first years after the neuroendoscopic procedure.     

The role of third ventriculostomy in the management of obstructive hydrocephalus.

OBJECTIVE: Endoscopic third ventriculostomy (ETV) is an effective treatment for occlusive hydrocephalus caused by an obstruction of the CSF flow in the aqueduct or the posterior fossa. We evaluated the factors age, pathology and surgical technique on the results of the ETV. METHODS: Between November 1992 and October 2000 171 ETV have been performed in 159 patients. The follow-up was evaluated in 150 patients. The age ranged from 10 days to 77 years (mean age 35 years). The hydrocephalus was caused by benign aqueductal stenosis in 77 patients, space-occupying lesions in 59, by intraventricular hemorrhages in 11, and by other causes in 3 patients. The trajectory was planned in 31 patients by frame-based and in 4 patients by frameless stereotaxy. RESULTS: The overall success rate of a single ETV was 71.3 % and including successful re-ETV 76.7 %. Best results were observed in adults and children older than 1 year. Infants demonstrated significantly worser outcomes. Patients with benign aqueductal stenosis and tumor compressing the aqueduct had the greatest profit from the ETV. The stereotactic guidance had no influence on the outcome and the number of severe complications. Complications were one arterial bleeding, three venous bleedings, and one ICB, all without permanent deficit, except one permanent hemiparesis. No mortality was observed.     

Unsuccessful third ventriculostomy for occlusive hydrocephalus.

For non-communicating hydrocephalus, neuroendoscopic third ventriculostomy has become a major choice. But sometimes, the procedure results in failure. Typically, impairment of a distal CSF absorption, a preexisting arachnoid membrane just below the fenestrated site and a glial scarring of fenestrated site were pointed out as a factors of failure. On the other side, the intraventricular pressure dynamics of a functioning third ventriculostomy is in the process of study. Recently some reports have noticed the importance of the flow of CSF into the prepontine cistern, mimicking the flow through the aqueduct of Sylvius. We report an unsuccessful trial of third ventriculostomy in a case with huge posterior fossa tumor.     

Endoscopic third ventriculostomy in post-tubercular meningitic hydrocephalus: a preliminary report.

Hydrocephalus is a common sequel of tubercular meningitis. Endoscopic third ventriculostomy (ETV) was performed in thirty-five patients. According to the duration of illness, six patients were in the early (less than 6 weeks), nineteen were in the intermediate (6 weeks to 6 months) and ten patients were in the late phase (more than 6 months) of tubercular meningitis (TBM). Six patients were in stage I, seven patients in stage II and twenty-two patients were in stage III. The overall success rate of ETV in TBM was 77 %. Sixty percent had early and seventeen percent had delayed recovery. Obstructive hydrocephalus was present in 54.3 % and 45.7 % had communicating hydrocephalus. The radiological recovery rate was 55.6 %. The outcome with a thin to transparent floor of the third ventricle was 87 %.     

第三脑室底造瘘治疗脑积水的手术并发症

目的 探讨第三脑室底造瘘治疗脑积水产生手术并发症的原因及预防措施。方法 对13例（15例次）行第三脑室底造瘘术治疗脑积水出现并发症的情况进行回顾性分析。结果 本组患者出现脑室内感染2例、膜膜下积液1例、造瘘口再堵塞1例、术中出血后的血凝块堵塞第三脑室形成脑疝1例。并发症的主要原因为手术设备的不良和先期经验的不足。结论 采用良好的手术设备,提高对各种并发症发生原因的不足,可减少手术并发症的发生。     

Management of hydrocephalus in pediatric patients with posterior fossa tumors: the role of endoscopic third ventriculostomy.

OBJECT: The authors undertook a study to evaluate the effectiveness of endoscopic third ventriculostomy in the management of hydrocephalus before and after surgical intervention for posterior fossa tumors in children. METHODS: Between October 1, 1993, and December 31, 1997, a total of 206 consecutive children with posterior fossa tumors underwent surgery at H?pital Necker-Enfants Malades in Paris. Excluded were 10 patients in whom shunts had been placed at the referring hospital. The medical records and neuroimaging studies of the remaining 196 patients were reviewed and categorized into three groups: Group A, 67 patients with hydrocephalus present on admission in whom endoscopic third ventriculostomy was performed prior to tumor removal; Group B, 82 patients with hydrocephalus who did not undergo preliminary third ventriculostomy but instead received conventional treatment; and Group C, 47 patients in whom no ventricular dilation was present on admission. There were no significant differences between patients in Group A or B with respect to the following variables: age at presentation, evidence of metastatic disease, extent of tumor resection, or follow-up duration. In patients in Group A, however, more severe hydrocephalus was demonstrated (p < 0.01): the patients in Group C were in this respect different from those in the other two groups. Ultimately, there were only four patients (6%) in Group A compared with 22 patients (26.8%) in Group B (p = 0.001) in whom progressive hydrocephalus required treatment following removal of the posterior fossa tumor. Sixteen patients (20%) in Group B underwent insertion of a ventriculoperitoneal shunt, which is similar to the incidence reported in the literature and significantly different from that demonstrated in Group A (p < 0.016). The other six patients (7.3%) were treated by endoscopic third ventriculostomy after tumor resection. In Group C, two patients (4.3%) with postoperative hydrocephalus underwent endoscopic third ventriculostomy. In three patients who required placement of CSF shunts several episodes of shunt malfunction occurred that were ultimately managed by endoscopic third ventriculostomy and definitive removal of the shunt. There were no deaths; however, there were four cases of transient morbidity associated with third ventriculostomy. CONCLUSIONS: Third ventriculostomy is feasible even in the presence of posterior fossa tumors (including brainstem tumors). When performed prior to posterior fossa surgery, it significantly reduces the incidence of postoperative hydrocephalus. The procedure provides a valid alternative to placement of a permanent shunt in cases in which hydrocephalus develops following posterior fossa surgery, and it may negate the need for the shunt in cases in which the shunt malfunctions. Furthermore, in patients in whom CSF has caused spread of the tumor at presentation, third ventriculostomy allows chemotherapy to be undertaken prior to tumor excision by controlling hydrocephalus. Although the authors acknowledge that the routine application of third ventriculostomy in selected patients results in a proportion of patients undergoing an "unnecessary" procedure, they believe that because patients' postoperative courses are less complicated and because the incidence of morbidity is low and the success rate is high in those patients with severe hydrocephalus that further investigation of this protocol is warranted.     

Endoscopic third ventriculostomy in the treatment of idiopathic normal pressure hydrocephalus: a review study

Idiopathic normal pressure hydrocephalus is a hydrodynamic disorder whose etiology remains unclear. The diagnosis is mainly clinical and the traditional treatment is cerebrospinal fluid shunt diversion. With the introduction of modern management strategies, endoscopic third ventriculostomy has become a viable alternative to shunting and constitutes a well-established method of treatment for obstructive hydrocephalus. The new hydrodynamic concept of hydrocephalus suggests that endoscopic third ventriculostomy (ETV) may be an effective treatment for communicative hydrocephalus. In our current review, the authors focus on the up-to-date knowledge regarding the consideration of endoscopic third ventriculostomy as a safe surgical option in the management of idiopathic normal pressure hydrocephalus.     

Endoscopic third ventriculostomy for hydrocephalus: early and late efficacy in relation to aetiology

Summary.  Objectives: The aim of the study was to analyse the effectiveness and usefulness of treatment of hydrocephalus by Endoscopic Third Ventriculostomy (ETV). We sought to relate rates of failure to the cause of hydrocephalus, distinguishing between early and late outcome.  Patients and methods: Between September 1999 and April 2001, 30 patients underwent ETV. In 23 patients hydrocephalus was caused by an expansive mass (tumour). Three groups of patients were distinguished, according to the different aims of ETV. Thus in group T – ETV was carried out to eliminate hydrocephalus prior to the main surgery (53%), in C – ETV was the definite treatment of choice (30%), and in group P – ETV was a palliative treatment (17%). The results were assessed in the early postoperative period and in long term follow-up using clinical relief of symptoms, and radiological criteria (pre- and postoperative computed tomography and/or magnetic resonance scans).  Results: In the early postoperative period ETV was rated to be effective by clinical criteria in 29 patients, and by radiological criteria in 27. According to late assessment the method was successful in 25 patients using clinical criteria, and in 21 using radiological criteria. There was no peri-operative mortality. A transient complication (wound CSF leak) occurred in two patients.  Conclusions: ETV is effective in well chosen patients in relieving symptoms of hydrocephalus. It is valuable before a definitive major operation to remove the cause of hydrocephalus, as a palliative treatment, and in itself as a method of definitive management when indications are correct. Published online March 3, 2003 Acknowledgments  The authors wish to thank professor B. L. Bauer from the Department of Neurosurgery in Hannover for his help in the training and also the team from the Department of Paediatric Neurosurgery in Warsaw led by professor Marcin Roszkowski for their help in the practical use of the neuroendoscopic method at our department.  Correspondence: Stanisław J. Kwiek MD, Ph.D., Department of Neurosurgery, Medical University of Silesia, ul. Medyków 14, 40-752 Katowice, Poland.