Endoscopic Third Ventriculostomy for Non-communicating, Obstructive Hydrocephalus

An endoscopic third ventriculostomy (ETV) can be a sufficient alternative to a cerebral shunt in the treatment of noncommunicating forms of hydrocephalus. Hydrocephalus can present with numerous signs and symptoms, including headache, vomiting, neck pain, macrocephaly, and vision impairment. Surgical procedure includes entrance of the lateral ventricles through a bur hole, and blunt/cautery fenestration of the third ventricular floor, which lies between the mamillary bodies and tuber cinereum. Choroid plexus cautery has been noted in the literature as being a viable addition to the procedure, in which a reduction in CSF production is achieved. Though, exact surgical procedure is left to the discretion of the surgeon.

The patient presented is a 30-month-old boy with non-communicating obstructive hydrocephalus secondary to congenital aqueductal stenosis. The patient has a history of progressive developmental delays, balance issues, and increased seizure frequency from a known seizure disorder. Therefore, an endoscopic third ventriculostomy via right frontal approach was elected.

Authors: William Fuell, Marcus Stephens M.D., Eylem Ocal M.D.
Institutions: Arkansas Children’s Hospital, University of Arkansas for Medical Sciences

Endoscopic third ventriculostomy via right frontal approach
(1) Delayed-onset/congenital aqueductal stenosis. (2) Obstructive hydrocephalus particularly due to posterior fossa tumors (3) As an alternative to shunt replacement in selected patients with obstructive hydrocephalus and Shunt malfunction Pre-operative MRI for this patient confirmed narrowing/stenosis of the cerebral aqueduct and moderately severe ventriculomegaly. In general, surgical intervention should primarily be reserved for cases of non-communicating obstructive hydrocephalus.
Patients presenting with communicating hydrocephalus
After induction of general anesthesia, the patient was placed supine with head slightly flexed on a neutral horseshoe headrest.
History and physical examination, brain MRI confirming narrowing of cerebral aqueduct and ventriculomegaly.
The incision was marked in a curvilinear fashion, 2 cm lateral to the midline, and just above the coronal suture on the right frontal bone, known as Kocher’s point. This approach is used to avoid damage to the primary motor cortex. The endoscope was navigated through the foramina of Monro. The mammillary bodies, infundibular recess, and tuber cinereum were identified. Fenestration of the pulsating floor of the third ventricle was made with a Bugbee wire, making sure not to damage the basilar artery.
An ETV can provide patients with effective treatment of hydrocephalus, and avoiding life-long cerebral shunting. There is a notable decrease in post-operative infection due to the absence of a foreign body, as seen with a shunt. ETV failure can be due to total occlusion of the fenestration, development of subarachnoid webbing in the pontine cisterns, thus requiring a second ETV or cerebral shunting.
Damage to the basilar artery during fenestration resulting in subarachnoid/intracerebral hemorrhaging, infection, damage to neighboring important structures, CSF leaks postoperatively, and hematoma. Improper closure of the stoma after ventriculostomy can result in subgaleal CSF leaks and CSF fistula. Using thermal energy cauterization to aid in the initial perforation of the ventricular floor poses some risk of hypothalamic damage and basilar artery injury, though special precaution is taken to ensure the amount of thermal energy used, less than 5 Watts, offers minimal risk of injury[5].
[1] Vulcu, S., Eickele, L., Cinalli, G., Wagner, W., & Oertel, J. (2015). Long-term results of endoscopic third ventriculostomy: an outcome analysis. Journal of neurosurgery, 123(6), 1456-1462. [2] Sgouros, S., Kulkharni, A. V., & Constantini, S. (2006). The international infant hydrocephalus study: concept and rational. Child's Nervous System, 22(4), 338-345. [3] Kahle, K. T., Kulkarni, A. V., Limbrick, D. D., & Warf, B. C. (2016). Hydrocephalus in children. The Lancet, 387(10020), 788-799. [4] Bouras, T., & Sgouros, S. (2013). Complications of endoscopic third ventriculostomy. World neurosurgery, 79(2), S22-e9. [5] Yadav, Y. R., Parihar, V., Ratre, S., & Kher, Y. (2015). Complication avoidance in endoscopic third ventriculostomy and its managements. J Neurol Surg A Cent Eur Neurosurg. [6] ÇATALTEPE, O. (2002). Endoscopic third ventriculostomy: indications, surgical technique, and potential problems. Turkish Neurosurgery, 12(3-4).

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