ENDOSCOPIC THIRD VENTRICULOSTOMY

ENDOSCOPIC THIRD VENTRICULOSTOMY Introduction: a procedure in which perforation is made in the floor of the third ventricle, thus allowing movement of cerebrospinal fluid out of the blocked ventricle and into the inter-penduncular cistern. Objective- procedure is to reduce pressure in the ventricle without using a shunt. Third ventriculostomy is usually a onetime procedure while numerous revisions are required in shunt.

Endoscopic third ventriculostomy

Materials and Methods: Prospective study of 176 ETV in our institute. A detailed history and physical examination. CT scan in all the patients. MRI in some patients only.

Endoscopic third ventriculostomy

Materials and Methods:

Inclusion criterion: all cases of obstructive hydrocephalus. Stoma of 5 mm or more. Floor was punctured with blunt instruments, opening enlarged using grasping forceps. Fogarty catheter was used in initial 35 patients.

Endoscopic third ventriculostomy

Materials and Methods: Post operative complications like infections, CSF leak and failure of procedure were evaluated. Post operative CT scan [n=56] and MRI [n=23] were done in 79 patients who did not improve, deteriorated or had evidence of failure of ETV such as a bulging fontanelle or CSF leak from the operative site. ETV was considered clinically successful when anterior fontanelle was depressed or flush to the adjoining scalp and the patient improved clinically. Follow up ranged from 9 to 48 months.

Endoscopic third ventriculostomy

The primary requirement for ventriculostomy:

Non communication hydrocephalus ventricular width of 7 mm or more No previous radiation treatment

Endoscopic third ventriculostomy

Procedure

Endoscopic third ventriculostomy Skin incision

Endoscopic third ventriculostomy

Steps of surgery

Burr Hole site

Endoscopic third ventriculostomy

Identification of foramen of Monro

Endoscopic third ventriculostomy

No significant movement

Endoscopic third ventriculostomy

Endoscopic third ventriculostomy procedure: Hole in the floor of 3rd ventricle was made between Mammllary bodies and Infundibular recess

Endoscopic third ventriculostomy

Third Ventricle Mammllary Bodies

Infundibular recess
Interpeduncular cistern

ViDeO

Endoscopic third ventriculostomy

Translucent Area
Mammllary Bodies

Endoscopic third ventriculostomy

Infundibular recess

ETV Hole

Mammllary bodies

Endoscopic third ventriculostomy Lilliquest membrane should be ruptured

Basilar Artery

Brain stem perforators

Posterior Cerebral Artery

Endoscopic third ventriculostomy

Successful ETV is defined by improvement in clinical features, decrease or arrest of abnormal increase in head circumference, depressed or flushed fontanelle and by MRI or CT appearance. It is important to note that in some cases, ventricles may remain large despite signs of clinical normalization.

Pre-op

Post-op

Incision size

Next day of surgery

Endoscopic third ventriculostomy

Out of total 176 patients, 143 congenital hydrocephalus with aqueductal stenosis, 15 TBM, 14 post fossa tumor & 2 each of post hemorrhagic & post pyogenic meningitis. Out of 176 ETV, There were 87 infants,44 childrens more than one year and 45 adults.

Endoscopic third ventriculostomy - Male and Female ratio

Female 49% Male 51%

Male Female

Results of ETV in infants

13 (15%)

Successful ETV Failed ETV

74 (85%)

Endoscopic third ventriculostomy in various age group

90 80 70 60 50 40 30 20 10 0 Age group

Various Age group

<1yr 1-4yr 5-9yr 10-14yr 15-24 25-34yr 35-44yr 55-64yr 65+yr

No. of patients

Endoscopic third ventriculostomy in infants

7 (8%)

Pre mature low birth weight Full term normal birth weight

80 (92%)

Endoscopic third ventriculostomy in infants

Fishers exact test, P =0.03).

60%

Failure rate ETV

50% 40% 30% 20% 10% 0% Pre mature/ Full term

11.3% 57%

Pre mature low birth weight Full term normal birth weight

Age wise success rate of ETV

100 90 80 70 60 50 40 30 20 10 0
Age wise success P >0.05

<1yr 1-4yr 5-9yr 10-14yr 15-24yr 25-34yr 45-54yr 55-64yr 65+yr Age group

Success rate

ETV Success rate in relation to pathology

100 90 80 70 60 50 40 30 20 10 0 tumor Stenosis TBM IVH Menin. Faliure Success

Complications in ETV
10

10 9 8 7 6 5 4 3 2 1 0

8
6 5 14 11 9 7 4 18

Infection CSF leak Minor Bleed Stoma block Complex hydrocephalus

Percentage

Complications

Incidence of ETV & VP Shunt failure in relation to time

100 80 60 40 20 0 0 month

Percentage

ETV 2yrs

ETV VP Shunt

Time after surgery

Re ETV
88.8%
8 7 6 5 4 3 2 1 0 Results Re ETV Successful Re ETV Failed Re ETV

No of patients

8 11.2% 1

Our Policy after Failed ETV

Blocked stoma after ETV.. Re ETV Patent stoma after ETV.. LP shunt

Endoscopic third ventriculostomy in infants

Conclusion: ETV is fairly safe and effective in full term

normal birth weight infants while the results in low birth weight pre mature infants are poor. Age or type of pathology (TBM or Congenital) did not have any impact on the success rate ( P >0.05). Complex hydrocephalus could be cause of ETV failure. So called obstructive hydrocephalus may have defective absorption & or defective permeation of CSF in SAS. So the efforts should be made to diagnose such cases pre operatively to avoid unnecessary second surgery. Re ETV is quite successful in stoma closure cases.

Endoscopic third ventriculostomy

Caution: Very little margin of error

Intra-operative bleeding Proper instruments (specially angled) are not available Steep learning curve Although ETV can produce the much-desired result of treating hydrocephalus without a shunt, the skill and experience of the surgeon is an important factor. Attempts to perforate the ventricular floor can cause bleeding, damage to the ventricular walls or perforation of the basilar artery. Good communication between patient and physician is a must, specially about potential complications

Endoscopic third ventriculostomy