Childs Nerv Syst (2006) 22: 506–513

DOI 10.1007/s00381-005-0031-1 ORIGINA L PA PER

Ramon Navarro
Raul Gil-Parra
Endoscopic third ventriculostomy in children:
Aaron J. Reitman
Greg Olavarria
early and late complications
John A. Grant and their avoidance
Tadanori Tomita

Received: 1 April 2005

Revised: 12 July 2005
Published online: 11 January 2006
# Springer-Verlag 2006
R. Gil-Parra . A. J. Reitman .
T. Tomita (*)
Division of Pediatric Neurosurgery,
Falk Brain Tumor Center, Children’s
Memorial Hospital, Northwestern
University Feinberg School of Medicine,
Chicago, IL, USA
e-mail: ttomita@childrensmemorial.org
Tel.: +1-773-8804373
Fax: +1-773-8804311
R. Navarro
Department of Pediatric Neurosurgery,
Hospital Sant Joan de Deu,
Universitat de Barcelona,
Barcelona, Spain
G. Olavarria
Division of Pediatric Neurosurgery,
Miami Children’s Hospital,
University of Miami,
Miami, FL, USA
J. A. Grant
Department of Neurosurgery,
Kansas Unversity Medical School,
Kansas, KS, USA
Abstract Introduction: Endoscopic
third ventriculostomy (ETV) is con-
sidered by many authors the initial
surgical procedure of choice for the
treatment of non-communicant hy-
drocephalus. However, this procedure
has early and late complications that
neurosurgeons must be aware of when
performing it. Materials and
results: A retrospective study of in-
fants and children treated with ETV at
Children’s Memorial Hospital (Chi-
cago, IL) between 1993 and 2004 is
presented. A total of 136 ETVs in 122
patients were performed with 8.8%
early complication rate (hemorrhage,
CSF leak, infection, diabetes insipi-
dus, and seizures). There were no
fatalities but one patient had severe
neurological disturbances due to in-
tracranial hemorrhage at the second
ETV. We identified several significant
factors that influence the late ETV
failure rate: age under 12 months
(p=0.012), cases performed early in
our experience (p=0.009), patients
with hydrocephalus without expan-
sive lesions (p=0.026), patients that
had an external ventricular drain
(EVD) after ETV (p<0.005), and
patients who developed early com-
plications (p=0.035). Conclusion: A
careful patient selection and preoper-
ative planning lead to better results of
ETV. A higher early and late compli-
cation rate in children younger than 1-
year-old were noted in our series.
There is definitely a learning curve for
this technique, and several technical
considerations are helpful to avoid
adverse events. Most of the early
complications are transient, while
potential devastating injuries can
occur. Long-term follow-up is needed
to identify delayed closure of the
fenestration. Ventricular access devise
is helpful for diagnostic and thera-
peutic purposes during the follow-up.
Keywords Third ventriculostomy .
Neuroendoscopy . Surgical outcome .
Complications . Hydrocephalus .
Children . Ommaya reservoir

Introduction Despite possible potential complications, the ETV can

Endoscopic third ventriculoscopy (ETV) is considered
by many authors the initial surgical procedure of choice
for the treatment of non-communicant hydrocephalus [1–
4]. Some may contend that ETV may be useful for
patients with hydrocephalus secondary to meningitis,
intraventricular hemorrhage (IVH), and myelomeningo-
cele (MM) [5–8]. Like other surgical procedures, this
procedure can have various degrees of complications.
reduce the use of ventricular–peritoneal shunts (VPS) in
a significant number of children, and many patients with
ETV have fewer complications than patients with VPS
have in the long run. Currently, there are reports in the
literature with an ETV surgical morbidity between 0 and
20% and mortality of 0–1% [2, 3, 5, 9–14]. We present
our experience with hydrocephalic patients who under-
went ETV, focusing on early and late complications and
their avoidance.

Material and methods
This is a retrospective study of patients who underwent an
endoscopic third ventriculostomy at Children’s Memorial
Hospital from January 1993 to July 2004. The study has
been approved by our Internal Review Board. Patients more
than 18 years old were excluded. We reviewed the medical
records, operative reports, and radiological studies [mag-
netic resonance imagimg (MRI) and computed tomography
(CT) scans] in all of the 129 patients in whom ETV was
attempted. Of these, seven procedures could not be
completed. The remaining 122 patients who had successful
ETV were entered into this study. A subsequent need of
CSF diversion procedure was considered ‘failure’ of the
ETV.
Patients were divided by age, etiology of hydrocephalus,
period when the ETV was performed, outcome, presence of
complications, and whether or not an external ventricular
drain (EVD) or Ommaya reservoir was inserted. Five main
groups were classified depending on the etiology:
1. Stenosis at the level of the aqueduct (congenital
aqueductal stenosis, tectal gliomas, and pineal tumors)
2. Stenosis at the posterior fossa (cerebellar and brain-
stem tumors)
3. Congenital (congenital hydrocephalus, Dandy–Walker
malformation, and Chiari type I malformation)
4. Secondary to IVH/meningitis
5. Patients with myelomeningocele
Statistical analyses (descriptive analysis, Pearson chi-
square test, and Kaplan–Meier survival analysis) were
conducted using a statistical software (SPSS, Chicago, IL).
Surgical technique
A right frontal burr hole is placed over the coronal suture and
slightly medial to the mid-pupillary line. Two methods were
used for ventriculostomy: one with a peel-away sheath for
channel neuroendoscope (outer diameter 3.5 mm), and an-
other with either an inner vision catheter or slotted catheter
using NeuroPEN neuroendoscope (Medtronics, Minneapo-
lis). An endoscope is advanced into the lateral ventricle
aiming the foramen of Monro, and the anatomy is identified.
Endoscopic ventriculostomy is performed between the mam-
millary bodies and the infundibulum using either a French #3
Fogarty catheter or the tip of the NeuroPEN scope. The
stoma was enlarged by inflating the Fogarty balloon or pas-
sing the catheter over the endoscope. No or little ventricular
bleeding is expected and it is easily controlled by gentle
irrigation with normal saline solution at body temperature.
Significant arachnoid membranes in the subarachnoid space
are perforated until structures of the interpeduncular and
prepontine cistern are visualized. In earlier patients, an EVD
was left for the postoperative purpose for a few days, and
removed at bedside. The most recent 32 patients with cath-
507
eter perforation technique had the catheter left in the lateral
ventricle, which was connected to the subgaleal Ommaya
reservoir.
Results
Although all 129 patients were intended to complete the
ETV, the procedure was aborted in seven (6.9%) due to
endoscopic findings such as presence of tumor, arachnoid-
itis, or poor anatomy which precluded the performance of
ventriculostomy in a safe manner. These seven patients
were excluded from the analysis. Fourteen patients under-
went more than one ETV procedure; therefore, a total of
136 ETV were performed in 122 patients between January
1993 and July 2004. Thirty-eight patients (29.5%) were
children under 1 year of age. Mean follow-up time was
3.3 years.
Early complications
There were 12 patients (9.8%) who developed complica-
tions following a third ventriculostomy (Table 1). The age
of these patients ranged from 1 month to 12 years (mean
age 3.7 years). There were eight male and four female
patients. Hydrocephalus was caused by stenosis at the level
of the aqueduct in ten patients and posterior fossa tumor in
one patient while one patient was with hydrocephalus
secondary to intraventricluar hemorrhage. Seventy-five
percent of the patients that had a complication underwent
ETV before 1998.
We performed a total of 136 ETVs, with a total of 12
complications (8.8%). Four of these 12 complications
occurred after the second EVT. Repeated ETV had a
statistically significant higher risk of early complications
(p=0.009). Case 9 had an intra-operative complication at
the second ETV: while the floor of the third ventricle was
being perforated with the blunt head of an endoscope, the
patient developed severe intracranial hemorrhage (intra-
ventricular and posterior fossa subdural hematoma) due to
vascular injury to the interpeduncular cistern structures.
Although this infant survived, he was severely disabled.
This complication occurred in the earliest period of this
series. In the remaining 11 patients, the complication was
identified in the immediate postoperative period: three CSF
leaks without infection, two CSF leaks with subsequent
meningitis, one meningitis and one ventriculitis without
CSF leak, one intraventricular hemorrhage, acute subdural
hematomas and seizure, another with seizure, and two with
transient diabetes insipidus. The latter patients showed
clinical symptoms of diabetes insipidus in the immediate
postoperative period, which was resolved within 10 days
after transient use of DDAVP. A significant number of
patients (8 of 12) that developed a complication also had a
third ventriculostomy failure with a statistically significant
508

Table 1 Surgical complications in third ventriculostomy

Case Sex Age Diagnosis Follow-up (months) Final outcome Complication

1b F 9 months Aqueductal stenosis 2 VP Seizure, SDH, IVH

2a,b M 11 years Posterior fossa tumor 72 – CSF leak
3a,b F 10 years Tectal tumor 5 VP CSF leak, meningitis
4 M 12 years Tectal tumor 2 VP CSF leak
5a M 8 months Pineal tumor 11 VP CSF leak
6 M 10 months Aqueductal stenosis 61 – Seizure
7b M 9 months Aqueductal stenosis 56 – TDI
8b M 4 months IVH 1 VP Meningitis
9b F 3 months Aqueductal stenosis 108 VP IVH, SDH (severe)
10b M 1 month Tectal tumor 68 – TDI
11b M 7 years Pineal tumor 60 VP Ventriculitis
12a,b F 2 months Aqueductal stenosis 15 days VP CSF leak, meningitis
IVH Intraventricular hemorrhage, CSF cerebrospinal fluid, TDI transient diabetes insipidus, SDH subdural hemorrhage, VP
ventriculoperitoneal shunt
a
At second third ventriculostomy
b
Before 1998

value (p=0.035). More specifically, all the ones with either
an infectious or hemorrhagic complication required sub-
sequent VPS. Conversely, patients experiencing diabetes
insipidus or seizures without additional complications did
not need a shunt (Table 2). Interestingly, most of the
children with complications were under 12 months of age
(8 of 12) and those complications occurred before 1998
(9 of 12).
ETV failures
After the first ETV, the overall failure rate was 37%
(46/122). In 65% of the cases, failure occurred before
6 weeks after initial ETV with the latest one presenting
6 years after initial ETV. Mean time to failure was
26.7 weeks, and median time to failure was approximately
5 weeks. Nevertheless, statistical differences were ob-
served when different variables were analyzed.
The success rate is better when ETV is performed after
1 year of age than during the first year. A total of 36 ETVs
were successfully completed in infants under 12 months,
with a significant failure rate of 55.6% (20/36). This failure
rate was significantly (p=0.012) higher than that of the
older age group (Fig. 1).
When considering etiology of the hydrocephalus, we
could also find different outcomes (Table 3). In patients
with obstruction at the posterior fossa, the success rate was
75%, followed by children with stenosis at the level of the
aqueduct of Sylvius with a 64% of favorable outcome.
Patients with congenital hydrocephalus other than aque-
ductal stenosis (Chiari type I and Dandy–Walker), myelo-
age
1,0
older than one
year
younger than
one year
0,8 censored
censored
Acummulative survival

Table 2 Association of complications and ETV failures 0,6

Total Failures

Transient diabetes insipidus 2 0 0,4

CSF leak 3 2
CSF leak with meningitis 2 2
0,2
Meningitis/ventriculitis 2 2
Seizure 1 0
Seizure with moderate bleeding 1 1 0,0
Severe bleeding (IVH/SDH) 1 1
12 8 0 1000 2000 3000 4000
time to failure
CSF Cerebrospinal fluid, IVH intraventricular hemorrhage, SDH
subdural hematoma Fig. 1 Ventriculostomy survival according to patients’ age
 509

Table 3 Etiology and failure distribution 1,0 causes

1
Completed Total failures Failed/total 2
1-censored
procedures (%) <1 year
0,8 2-censored

Aq. stenosis 35 16 (46) 10/18

Acummulative survival
Pineal region 10 4 (40) 1/1
0,6
Tectal glioma 22 4 (18) 0/1
IVH 7 5 (71) 3/5
IVH/meningitis 4 2 (50) 12
0,4
Meningitis 4 1 (25) 14
MM 3 2 (66) 2/3
PF benign 7 4 (57) 0 0,2
PF malignant 16 4 (25) 1/1
Brainstem tumor 8 0 0
Chiari type I 5 3 (60) 1/1 0,0

Dandy–Walker 1 1 (100) 0
0 1000 2000 3000 4000
122 46 (37) 20 (55%) time to failure
Aq. stenosis Aqueductal stenosis, IVH intraventricular hemorrhage, Fig. 3 Ventriculostomy survival according to hydrocephalus etiol-
MM myelomeningocele, PF posterior fossa ogy (II): 1 aqueductal stenosis, tectal gliomas, pineal tumors, and
cerebellar and brainstem tumors; 2 Chiari type I, Dandy–Walker
malformation, intraventricular hemorrhage and/or meningitis,
meningocele, and IVH/meningitis fared worse with a myelomeningocle
success rate of 34, 34 and 47%, respectively. These values
were not statistically significant with p=0.087 (Fig. 2).
Nevertheless, if we combine the patients in whom there is a We also subdivided the patients in two groups depending
clear anatomical lesion causing hydrocephalus (posterior on the year that EVT was performed: from 1993 to 1997
fossa tumors, pineal region tumors, tectal glioma, and and from 1998 to 2004. The latter group of patients had a
aqueductal stenosis) vs those with other lesions (IVH, statistically significant better outcome (p=0.009) of 72.3 vs
meningitis, MM, Dandy–Walker, and Chiari), we found a 49.1% in our early experience (Fig. 4).
statistically better outcome for the first group (p=0.026) Finally, when analyzing the patients depending on
(Fig. 3). whether or not an EVD or an Ommaya reservoir was
inserted, statistically significant differences were also
found (p<0.005). CSF diversion with an EVD proved to
1,0 causes
1
2
3
0,8 4
5
ETV Date
Acummulative survival

1-censored 1,0
Before 98
2-censored
After 98
0,6 3-censored
1-censored
4-censored
0,8 2-censored
5-censored
Acummulate survival

0,4

0,6

0,2

0,4

0,0

0 1000 2000 3000 4000 0,2

time to failure

0,0
Fig. 2 Ventriculostomy survival according to hydrocephalus etiol-
ogy (I): 1 aqueductal stenosis, tectal gliomas and pineal tumors; 2 0 1000 2000 3000 4000
cerebellar and brainstem tumors; 3 Chiari type I and Dandy–Walker time to failure
malformation; 4 intraventricular hemorrhage and/or meningitis; 5
myelomeningocele Fig. 4 Ventriculostomy survival according to date of the ETV
510
1,0
0,8
Acummulative survival
0,6
0,4
0,2
0,0
0 1000 2000 3000
time to failure
Fig. 5 Ventriculostomy survival according to CSF diversion after
ETV. EVD External ventricular drainage
worsen the outcome, lowering the success rate to 40 vs
87.5% in patients with an Ommaya reservoir and 67.9% in
children with neither an EVD or subcutaneous reservoir
(Fig. 5).
Discussion
Currently, endoscopic third ventriculostomy is considered
the initial treatment of choice for patients with non-
communicating hydrocephalus with different etiologies.
Nonetheless, this procedure has also been used in some
patients with hemorrhage and infection, which typically
show features of communicating hydrocephalus. In several
series, there are reports of third ventriculostomy compli-
cation rate being between 0 and 20% [2, 13, 15–21]. The
majority of reported complications are transitory [10, 12,
14, 19, 20, 22]. Beems and Grotenhuis [15] claim that
complications present after 1 month are still present after
6 months. However, there are reports of permanent and
fatal complications after third ventriculostomy [7, 13, 21,
23, 24]. A myriad of complications and adverse events
have been described: intraventricular hemorrhage, epidural
hematoma, chronic subdural hematomas, infection, CSF
leak, heart rate changes with severe bradycardia during the
procedure, respiratory arrest, seizures, enlarging pseudo-
meningocele, hemiparesis, seizures, diabetes insipidus,
amenorrhea, hyperphagia and weight gain, oculomotor
plasy, and speech delay [1, 7, 9, 10, 12–14, 16, 19, 23, 25–
29]. The mortality rate of ETV is 0–1%, and it is usually
acute following a vascular injury during the procedure.
Nevertheless, there can also be delayed fatalities due to
secondary infection or acute hydrocephalus after ventric-
ulostomy closure [13, 30].
CSF Diversion Avoidance of early complication
EVD
Ommaya
Nothing Complication avoidance starts with patient selection. ETV
EVD-censored
Ommaya-
should not be performed if CSF is already flowing
censored unimpeded between the ventricles and the interpeduncular
Nothing-
censored cisterns. Moreover, ETV is not a good option if it is
technically impossible to manipulate the endoscope within
the ventricular system for good visualization of the floor of
the third ventricle [31]. Sometimes, the latter is only
realized during surgery. At that time it is safer, and
probably prudent, not to pursue ETV if a good spot for
perforation of the floor is not identifiable. This is usually
the case in post-infectious and post-hemorrhagic hydro-
cephalus, as well as in patients with myelomeningocele.
Visualization of the anatomical landmarks is paramount.
4000
Burr hole placement and endoscope trajectory is also
important. The ideal trajectory is the one completely
perpendicular to the area located between the mammillary
bodies and the infundibulum. Placing the burr hole over the
coronal suture and at the mid-papillary line allows the
surgeon to avoid big archs during endoscopic navigation to
the midline of the floor of the third ventricle, thus
decreasing the chances of injuring the fornix and the
structures on the lateral aspect of the interpeduncular
cistern (i.e., oculomotor nerve).
There are several ways to open a stoma in the floor of the
third ventricle, and some of the complications might be
related to these different surgical techniques. In our
experience, we used either a Fogarty balloon (number 3
French) catheter or the head of the NeuroPEN endoscope to
fenestrate the floor of the third ventricle. However, using
the latter technique does not give the surgeon a good visual
control at the time of the fenestration, as the optics are
obscured by the floor of the ventricle. The authors did not
have any vascular or endocrinological complications by
fenestrating the floor just behind the posterior end of the
vascular stain of the tuber cinerium. The stoma is widened
by passing the catheter over the endoscope. The slotted
ventricular catheter has a larger outer diameter (2.8 mm)
than the innervision catheter (2.5 mm); thus, a larger hole is
created by the former. Other methods, such as laser and
water jet, blunt perforation with a leukotome, a semi-sharp
probe, forceps, ultrasonic probe, and monopolar cautery,
have been described [13, 32]. The opening is enlarged from
2.5 to 5 mm. During this step, complication avoidance
includes a careful preoperative plan with assessment of the
size of the third ventricle and the basal cisterns, as well as
the position of the basilar artery in sagittal sections of the
MRI. Sharp instruments should always be avoided while
perforating the floor of the third ventricle when its anatomy
is obscure as this could lead to a basilar artery injury. In
addition, brisk and prolonged inflation of the Fogarty
balloon can result in damage to the structures in the basal
cisterns and hypothalamus, specially the supraoptic nucle-
us that is located on the anterior–lateral aspect of the floor
of the third ventricle. Endocrine abnormalities can also be

prevented by avoiding traction of the floor of the third
ventricle with an inflated Fogarty balloon. Using any sort
of thermal energy such as monopolar cautery or laser is
discouraged as it increases the chances of a vascular or
hypothalamic injury [32]. A careful monitoring of urinary
output and electrolytes in the immediate postoperative
period is needed to detect diabetes insipidus. In addition,
metabolic disturbance can lead to seizure disorder in the
following days after ETV.
Although no or little hemorrhage are expected during
EVT, sometimes bleeding can be troublesome. Minimal
bleeding can be easily controlled with gentle irrigation. In
the event of massive hemorrhage, profuse irrigation and
patience must be used; if a bleeding point can be identified
after irrigation, though difficult due to obscured vision,
bipolar cautery or balloon inflation on the source of
hemorrhage can help with hemostasis. Placement of EVD
is a valuable option for postoperative management of
intraventricular hemorrhage.
When irrigating during surgery, attention must be paid to
the infusion rate as well as the temperature of the irrigation
solution; aggressive irrigation can lead to increased ICP
with severe bradycardia [26], and cold saline infusion can
produce altered mental status after surgery. It is also
important to make sure that there is a patent inward and
outward flow of the irrigation solution, as small volume
changes can lead to dramatic intracranial pressure changes.
This parameter can be monitored by connecting an arterial
line transducer to both the endoscope irrigating channel
and the anesthesia monitor using a three-way tap. In
addition, Van Aalst et al. [33] have demonstrated an acute
distortion of the anatomy of the third ventricle after profuse
irrigation during ETV. This can also increase the rate of
complications secondary to poor identification of the
anatomical landmarks.
The last step to avoid early complications is a good
wound closure. Instead of a burr hole for ETV directly
underneath a skin incision, we routinely use a semicircular
incision that allows us to create a small pericranial flap that
will be closed separately creating an additional layer. CSF
leak or persistent bulging under the incision is a sign of
ventriculostomy failure, and increases the risk of menin-
gitis. However, one might expect an increased ICP on the
first few days because restoration of CSF absorption at the
arachnoid granulations is not immediate, and there is a so-
called adaptation period [34, 35]. Lumbar punctures after
technically successful third ventriculostomy in the postop-
erative period may promote flow through the stoma while
normal CSF absorption is restored. Identifying anatomical
landmarks and perforating the floor of the third ventricle is
generally more challenging in re-operations. Wound heal-
ing is also not as good in previously operated tissue than in
a virgin scalp. Finally, when performing an ETV on a
patient with VPS, removing all the shunt hardware can
minimize the risk of infection [21].
511
Prevention of ventriculostomy failure
We identified several groups of patients that had a higher
failure rate than the rest. First of all, our success rate in
patients younger than 1 year of age was only 44.4% with
statistical significance p=0.012 compared to their counter-
parts above that age. This finding was also noticed by
numerous authors [31, 36, 37]. This might reflect a low
capacity of the subarachnoid space for CSF reabsorption—
arachnoid granulations are not fully mature until fontanel
closure—, tendency for formation of new arachnoid
membranes, and need of a higher pressure difference as
some of the pressure gradient is lost in distending the
fontanels rather than opening the arachnoid villi. However,
a recent report by Gorayeb et al. [38] shows better results
after ETV during infancy.
A second set of patients that had statistically higher
ventriculostomy failure were the ones that developed
complications. Sixty six percent (8 of 12) of these patients
required VPS placement, specifically those that had either a
hemorrhagic or infectious complication. Diabetes insipi-
dus, CSF leak, or seizures alone did not increase the failure
rate. This might reflect an additional poor reabsorption
component after arachnoid villi damage secondary to blood
debris or infection. If a second ETV was performed, we had
less chance of success (35.7%) than the initial ETV
(64.3%) with p=0.035 on chi-square analysis. Schroeder et
al. [13] also found a higher ETV risk in repeated ETVs. In
contrast, Cinalli et al. [39] claims that repeated ETV has a
65% success rate and no higher complications.
Most of the failures (66%) happen within the first
6 weeks (early failure). Early clinical response frequently
has a high correlation with good outcome [17]. None-
theless, there is usually a partial clinical and radiological
response that makes evaluation of the procedure more
challenging compared to patient evaluation after standard
shunting. Early failures after a proper ETV are usually
secondary to absorption problems, while late failures might
be due to stoma closure. In the latter cases, a repeated ETV
can be performed, especially if the first one was successful
[26, 40]. In the more recent ETV cases, we have been
routinely implementing an Ommaya reservoir. With this
subcutaneous reservoir, we can gain access to the CSF and,
therefore, we can monitor ICP, drain CSF if necessary and,
more important, potentially expedite emergency treatment
in cases with acute hydrocephalus after delayed ventricu-
lostomy failure [24, 30]. Additionally, contrast dye can be
injected through the reservoir to confirm stoma patency on
CT, as flow MRI and ventricular size change are not
infallible to detect ventriculostomy patency [26, 41].
Leaving an EVD after ETV presents several disadvantages:
it provides only transient access to the ventricular system, it
may add risk of infection, and it may decrease the CSF flow
through the ventriculostomy. It is important to initially
maintain a high-pressure gradient through the ventriculos-
tomy [17].
512

Finally, as in all surgical procedures, there is a learning
curve for ETV [20]. Our results since 1998 are significantly
better than in the previous years. This learning process
includes good patient selection that usually decreases the
chance of failure, as well as some technical considerations
that can help in avoiding early complications. Seventy-five
percent of our complications occurred before 1998 and,
interestingly, the delayed failure rate was significantly
higher in that period of time. Being familiar with endos-
copy instruments and procedures and experiencing a
sufficient case load is needed to maintain a good success
rate of this valuable procedure for hydrocephalic children.
Acknowledgement We would like to thank Susana Ochoa M.S.
from Hospital Sant Joan de Deu Foundation for her thoughtful
suggestions and statistical analyses.

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