Endoscopic third ventriculostomy (ETV) toward minimize complications

Endoscopic third ventriculostomy (ETV) is a minimally invasive procedure in obstructive

hydrocephalus patients that produces good results. As is well known, hydrocephalus itself is a
dangerous condition if not immediately can cause psychosocial and mental development
disorders, craniofacial disproportion that affects cosmetics, and can cause death. There were
812 cases of congenital hydrocephalus in Bali and Nusa Tenggara in 1992-2006 with an
average of 4 cases per month. Most of the patients (80%) were categorized as obstructive
hydrocephalus (not communicating) because of blockade of CSF flow. Prompt early
treatment care with a significant reduction in morbidity and mortality and improved quality
of life for patients.

Several studies have shown that ETV is superior to ventricular shunt systems due to
complications associated with shunting such as excess or insufficient drainage, shunt
malfunction, and infection. In addition, the ETV procedure is less expensive than ventricular
shunting. This has influenced the popularity of ETV in the last two decades. ETV application
technique itself is rapidly developing in the treatment of hydrocephalus obstructive
hydrocephalus due to aqueduct stenosis, hydrocephalus with myelomeningocele,
hydrocephalus associated with Dandy-Walker malformation, communicative hydrocephalus,
normal pressure hydrocephalus, secondary hydrocephalus from intracranial hematoma,
secondary hydrocephalus such as phosphorus posterior tumors. after shunt malfunction,
hydrocephalus associated with fasciocraniosonostosis, hydrocephalus in patients with
tuberculous meningitis and combination of cauterization of the choroid plexus (CPC) with
ETV.

The endoscopic third ventriculostomy success score (ETVSS) has been validated to be a
useful preoperative tool for predicting ETV outcome. Apart from the major advantages of
being shunt-free, ETV is associated with varying success rates ranging from 50 to 90% and
can lead to the development of hydrocephalus requiring other cerebrospinal fluid (CSF)
diversion. Clinical and radiological investigations are important in influencing the success
rate of ETV. The examination will show dilation of the right and left lateral ventricles. The
sagittal incision is necessary to ensure that there is sufficient distance between the clivus and
basilar (AB) arteries from the floor of the third ventricle so that the endoscope can safely
enter the third ventricle, allowing it to move safely without risking injury to the third
ventricle. the lateral wall of the third ventricle.
Although ETV is considered the first choice in the management of obstructive
hydrocephalus, it is not without risks or complications. Overall the complication rate after
ETV is around 2% - 15%, but permanent complications are few. However, complications
such as fever, bleeding, hemiparesis, gaze palsy, memory impairment, altered consciousness,
diabetes insipidus, weight gain and precocious puberty were reported. At Sanglah General
Hospital, ETV experienced a very low complication rate (cerebrospinal fluid leakage 1.6%,
wound infection 1%, bleeding 0.5%, meningitis 0.5%).

ETV has been associated with a variety of complications, the most significant of which is
iatrogenic injury to the fornix. Wasi et. al found that the use of image guidance when
planning trajectories reduced the incidence of complications by significantly changing the
usual approach to ETV.

Forniceal injury and other nerve injuries can be avoided by proper burr hole planning,
avoiding significant side movement and by selecting the appropriate case with the Monro
foramen and a significantly enlarged third ventricle. Bleeding per surgery should be avoided
by using a water spray dissection in a thick and opaque third ventricle, avoiding significant
stretching of the structure, especially during hard floor perforation of the third ventricle.
Significant side movements should also be avoided to prevent bleeding from injury to
structures, such as the fornix and veins in the Monro foramen. Rarely, blood may drip from
the site of the burr hole into the ventricle; Proper hemostasis must be achieved before
entering the ventricles. A proper examination must be carried out before perforating the floor
of the third ventricle; fenestration of vessels should be avoided. Bradycardia due to increased
ICP can be avoided by maintaining outflow patents. Bradycardia due to stretching of the
brainstem should be avoided, especially during hard perforation of the floor of the third
ventricle.

Postoperative cerebrospinal fluid leakage can be avoided by attaching the cortical and dural
openings with gel foam, direct dural closure, especially in large ventriculomegaly in infants,
or by using artificial dural replacements and tissue sealants in patients. Postoperative
complications are known to be minimal in experienced hands.