Endoscopic Third Ventriculostomy and Choroid Plexus Coagulation in Infants: Current Concepts and Illustrative Cases

Endoscopic Third Ventriculostomy And Choroid Plexus Coagulation …sup>1, Michael C Dewan2, , Neurololy India 04/07/23 15.
20
Home
REVIEW ARTICLE
Year : 2021 | Volume : 69 | Issue : 8 | Page : 514--519
Endoscopic Third Ventriculostomy And Choroid Plexus Coagulation in Infants:

Current Concepts and Illustrative Cases
Ronnie E Baticulon1, Michael C Dewan2,
1
Department of Neurosciences, Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
2
Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
Correspondence Address:
Dr. Ronnie E Baticulon
Division of Neurosurgery, Philippine General Hospital, Taft Avenue, Manila - 1000
Philippines
Abstract
Background: The global burden of pediatric hydrocephalus is high, causing significant morbidity and mortality
among children especially in low- and middle-income countries. It is commonly treated with
ventriculoperitoneal shunting, but in recent years, the combined use of endoscopic third ventriculostomy (ETV)
and choroid plexus coagulation (CPC) has enabled patients to live without a shunt. Objective: We aim to give
an overview of ETV+CPC for the treatment of hydrocephalus in infants, focusing on patient selection,
perioperative care, and long-term follow-up. Methods and Material: We summarize observational studies and
randomized trials on the efficacy and safety ETV+CPC, mainly from Uganda and North America. The equipment
needs and operative steps of ETV+CPC are enumerated. At the end of the article, three illustrative cases of
infants who underwent ETV+CPC with differing outcomes are presented. Results: The likelihood of success
following ETV+CPC is the highest among infants older than 1 month, those with noninfectious hydrocephalus
(e.g., aqueductal stenosis and myelomeningocele), and those previously without a shunt. Poor outcomes are
seen in patients with posthemorrhagic hydrocephalus or evidence of cisternal scarring. Failure of ETV+CPC
most commonly occurs within 3–6 months of surgery. Conclusions: ETV+CPC is an effective and safe
alternative to ventriculoperitoneal shunting in appropriately selected infants with hydrocephalus. Long-term
studies on functional and neurocognitive outcomes following ETV+CPC will help guide clinicians in decision
making, allowing as many children as possible to attain shunt freedom.
How to cite this article:

Baticulon RE, Dewan MC. Endoscopic Third Ventriculostomy And Choroid Plexus Coagulation in Infants: Current Concepts
and Illustrative Cases.Neurol India 2021;69:514-519
How to cite this URL:

Baticulon RE, Dewan MC. Endoscopic Third Ventriculostomy And Choroid Plexus Coagulation in Infants: Current Concepts
and Illustrative Cases. Neurol India [serial online] 2021 [cited 2023 Jul 4 ];69:514-519
Available from: https://www.neurologyindia.com/text.asp?2021/69/8/514/332270
Full Text
https://www.neurologyindia.com/printarticle.asp?issn=0028-3886;year=2021;volume=69;issue=8;spage=514;epage=519;aulast=Baticulon Page 1 of 9
Endoscopic Third Ventriculostomy And Choroid Plexus Coagulation …sup>1, Michael C Dewan2, , Neurololy India 04/07/23 15.20
Every year, almost 400,000 new cases of pediatric hydrocephalus are diagnosed globally.[1] Since the
introduction of silicone shunts in the late 1950s,[2] diversion of cerebrospinal fluid (CSF) to the peritoneal
cavity or other distal sites has been the main surgical treatment for this disease in most countries.
Ventriculoperitoneal shunting is an essential skill set among general neurosurgeons and pediatric
neurosurgeons alike,[3] and the life-saving operation may be performed even in primary hospitals.[4] Despite
advances in shunt technology, however, the failure rate during the first year of shunt implantation remains
between 20 and 40%.[5] Implementation of shunt protocols and the use of antibiotic-impregnated catheters
have reduced shunt infection rates to 2–6%, but figures vary widely across centers.[6],[7] To many children,
these shunt complications pose a life-long threat to neurocognitive function and may significantly impair their
quality of life.[8],[9]
With the goal of reducing shunt dependency, there has been renewed interest in the combined use of
endoscopic third ventriculostomy (ETV) and choroid plexus coagulation (CPC) among infants with
hydrocephalus, gaining momentum in the last two decades. While many studies supporting the efficacy and
safety of ETV+CPC were initially conducted in low-resource settings in East Africa,[10],[11],[12] completed
and ongoing prospective trials in North America are helping define the role of ETV+CPC in the contemporary
management of pediatric hydrocephalus.[13],[14],[15] In this article, we give an overview of ETV+CPC among
infants. Illustrative cases are provided to demonstrate clinical decision making for pediatric neurologists and
neurosurgeons who intend to incorporate ETV+CPC into their practice.
ETV+ CPC in young infants
The history of ETV and CPC for the treatment of hydrocephalus has been extensively discussed elsewhere.[2],
[16],[17] In 2005, working at Cure Children's Hospital of Uganda (CCHU), Benjamin Warf published his
analysis of 550 children who underwent either ETV alone or ETV+CPC.[11] These were mostly infants, with
58% of patients having postinfectious hydrocephalus. Warf showed that among patients less than 1-year old,
the addition of CPC to ETV increased the proportion of successful treatment from 47 to 66%. Success was
defined as being shunt-free on last follow-up, with a median duration of 9.2 months for the ETV+CPC cohort.
Further, the intervention was more likely to succeed in infants with hydrocephalus that was not infectious in
etiology, and in those with myelomeningocele. Subsequent studies in CCHU have demonstrated similarly good
outcomes in patients with aqueductal stenosis,[18] Dandy Walker complex,[19] encephaloceles,[20] and
congenital idiopathic hydrocephalus.[21]
Driven by these encouraging numbers from Uganda, neurosurgeons from around the world have since
published their own experiences with ETV+CPC. In Nigeria and Haiti, success rates of 75% (out of 20 patients)
and 52% (out of 82 patients), respectively, were reported after 6 months of follow-up.[22],[23] Among
patients that Warf treated in Boston, 57% did not require any additional surgery for hydrocephalus at 1 year.
[24] In this first ETV+CPC series in North America, scarring of the prepontine cistern and prior CSF diversion
were demonstrated to be additional predictors of poor outcome. A more recent prospective study from the
Hydrocephalus Clinical Research Network involving 191 patients demonstrated a 48% success rate for
ETV+CPC at 6 months, only slightly declining to 45% at 18 months.[14] ETV failure was more likely in patients
less than 1 month of age and in those with hydrocephalus from intraventricular hemorrhage of prematurity.
How does ETV+CPC work?
In the bulk flow model of CSF circulation,[25] CSF secreted predominantly by choroid plexus flows within and
exits the ventricular system to reach the intracranial and spinal subarachnoid space. CSF is subsequently
absorbed in the dural venous sinuses through arachnoid granulations. When hydrocephalus is obstructive in
nature (e.g., aqueductal stenosis), the rationale behind an ETV is fairly straightforward: an alternate pathway
from the third ventricle to the prepontine cistern is created, allowing CSF to bypass the obstruction. However,
as studies have shown, ETV alone is often inadequate for addressing hydrocephalus in young infants.[26],[27]
This is presumed to be because of insufficient CSF absorption through the arachnoid villi in this age group,
where other pathways such as periventricular capillary absorption may play a bigger role.[28] It is theorized
that by cauterizing choroid plexus in lateral ventricles, CSF production is reduced while waiting for absorption
pathways to mature, and over time, transition to adult circulation.[16]
Where these mechanisms fall short is in explaining how good outcomes have been achieved with ETV+CPC,
even when (1) hydrocephalus is idiopathic, where no obvious anatomic obstruction is apparent,[21] and (2)
CSF production persists from residual choroid plexus and extrachoroidal sources such as ependyma and
cerebral capillaries.[28]
Using the hydrodynamic model of CSF,[25] it is postulated that pediatric hydrocephalus is not just a
consequence of high-ventricular CSF pressure. Warf proposes that choroid plexus pulsation is also a significant
driver of ventricular enlargement.[21] Thus, coagulating choroid plexus decreases these rhythmic,
intraventricular forces during the cardiac cycle, especially important in a young infant whose brain parenchyma
has high compliance. CPC also leads to a consequent reduction in cerebral venous pressure, thereby increasing
capillary absorption of CSF. In keeping with this mechanism, the ETV stoma acts as a pulsation absorber,
dissipating pulsatile forces in the ventricular cavity to the basal cisterns. The combined effects of ETV
(“pulsation absorber”) and CPC (“pulsation reducer”) restore equilibrium between CSF production and
absorption in the infant brain.[21] The goal is a reduction in intracranial pressure to enable normal brain
growth and development.
Identifying ideal patients for ETV+CPC
Whether in East Africa or North America, it is evident from published literature that the benefits derived from
ETV+CPC vary among subgroups of patients. Thus, the onus is on the neurosurgeon to identify which infants
are suitable candidates for ETV+CPC. For clinicians, the ETV success score (ETVSS) developed by Kulkarni and
colleagues is a useful and externally validated tool for estimating the likelihood of success at 6 months
following an ETV.[29],[30] It considers three patient factors: age, etiology of hydrocephalus, and prior
shunting. To illustrate, a 6-month-old infant with aqueductal stenosis and no prior shunt has an ETVSS of 70,
whereas a 1-month-old infant with communicating hydrocephalus has an ETVSS of 20. Thus, it would be more
reasonable to offer ETV+CPC as primary treatment for hydrocephalus in the former. While a low ETVSS (≤ 40)
does not preclude ETV+CPC, parents must be counseled so that appropriate expectations are set. It is
important to communicate that there may be a need for early reintervention particularly within the first 3
months; this risk is weighed against shunt dependency with its life-long risk of multiple shunt revisions.
Neuroimaging is a requisite for safe neuroendoscopy. At the minimum, a computed tomography (CT) of the
brain should be obtained. It allows the neurosurgeon to establish an etiologic diagnosis, plot the trajectory for
the ETV, identify anatomic variations, and inspect the thickness of the third ventricular floor, adequacy of the
prepontine space, and the basilar artery's position and course. If septations, loculations, and/or abnormal
contrast enhancement are present, a transfontanel ventricular tap is useful to rule out active infection.
Magnetic resonance imaging (MRI) of the brain is ideal but may not always be feasible. T2-weighted sequences
in three planes provide sufficient information, supplemented by sagittal FIESTA/CISS sequence to show the
anatomy of the Liliequist membrane and any cisternal scarring. If extensive scarring and/or redundant
membranes are seen on MRI, it is prudent to proceed with VP shunting instead due to the high rate of ETV
failure seen in these patients.[31]
In limited-resource settings where only an ultrasound is available, neurosurgeons are advised to proceed with
caution. The third ventricular floor, prepontine space, and other posterior fossa structures are not clearly
delineated on an ultrasound—especially in cases of severe macrocephaly. Characteristics known to influence
ETV success, which may otherwise be apparent on MRI, may not be observed until the time of intraoperative
endoscopic inspection. It is reasonable in these limited facilities to adopt a “scope-first” paradigm: patients are
offered an upfront endoscopic approach with the understanding that a shunt may ultimately be deemed most
appropriate. In such cases, parents are counseled accordingly, and patients are positioned and prepped in the
operative suite for a possible VP shunt insertion. A low threshold is maintained for aborting the ETV procedure
when intraoperative findings warrant: an opaque third ventricle floor, heavy prepontine cistern scarring, or
nonvisualization of the basilar artery.
Equipment needs and surgical technique
In the illustrative cases that follow, ETV+CPC was performed at the Philippine General Hospital using a Karl
Storz flexible neuroendoscope, following the technique described by Warf.[11] The endoscope is held in place
using a scope holder that attaches to the bed frame [See [Figure 1]]. Under general anesthesia, the patient is
positioned supine with the head slightly elevated and turned 90° to the contralateral side. The head, neck, and
abdomen are prepped and draped in case the procedure needs to be converted to shunting. A semilunar
incision is made over the lateral portion of the anterior fontanel, corresponding to Kocher's point. The dural
opening is kept to a minimum, and after coagulation of pia, the lateral ventricle is cannulated using a blunt
trocar or 8 French feeding tube. CSF is obtained for analysis, and the neuroendoscope is introduced through
this newly created tract. The ventricular anatomy is inspected before navigating to the floor of the third
ventricle.{Figure 1}
ETV is performed first. The stoma is created using the tip of the bugbee wire without cautery. It is then
enlarged using a Fogarty balloon, or with experience, gentle traction in different directions, avoiding the
surrounding neurovascular structures. In most cases, it is possible to insert the flexible scope through the
stoma into the prepontine cistern. The aim is to completely perforate the Liliequist membrane, visualize the
naked basilar artery, and clear any redundant arachnoid tissue. At this point, the decision is made whether to
proceed to CPC or not. In patients ≥ 1-year old, ETV alone may be sufficient. In patients with cisterns that are
extensively scarred, particularly in postinfectious or posthemorrhagic hydrocephalus, it is preferable to leave a
shunt.
To perform CPC, the neurosurgeon must let the tip of the bugbee wire glide on the surface of the choroid
plexus, to and fro, applying monopolar diathermy until the vessels change in color from red/yellow-orange to
pale yellow. CPC is accomplished in a logical manner: beginning at the foramen of Monro, tracing the choroid
plexus to the atrium, coagulating the glomus, and finally, navigating to the temporal horn. The tip of the
monopolar electrode must not be buried within the choroid plexus, and careful attention is given to the
surrounding veins and ependyma. If necessary, a septostomy is created. CPC is then performed on the
contralateral side following the same sequence. Whenever possible, the neurosurgeon should aim for bilateral
complete CPC. Cauterizing >90% of choroid plexus in the lateral ventricles has been associated with a greater
chance of treatment success.[13],[14]
After CPC, the ETV is inspected to ensure patency and clear any blood clot or debris. The endoscope is gently
withdrawn, checking for bleeding along its tract. Watertight dural closure and meticulous apposition of galea
and skin are essential to reduce the risk of CSF leak and subsequent infection.
Rigid endoscopes, with their better optics and greater familiarity to the operator, have also been used to
accomplish ETV+CPC.[23] However, flexible endoscopes have the advantage of being able to maneuver to the
temporal horns even when ventricles are only moderately enlarged.[32] There is a learning curve with the
flexible endoscope, although it is less steep with prior experience in rigid neuroendoscopy. Formal training (i.e.,
working alongside CCHU neurosurgeons) has been associated with greater extent of CPC.[14]
Complications and postoperative care
A 2016 review of 11 studies with 524 patients showed that adverse events after ETV+CPC occurred in 3.7%,
with a mortality rate of 0.4%.[33] Complications included hemorrhage, CSF leak, meningitis, ventriculitis,
SIADH, subdural hygroma, and seizures. Perhaps the most dreaded intraoperative complication is bleeding, but
this is usually controlled with irrigation. If needed, gentle tamponade may be applied using the endoscope tip
or an inflated Fogarty balloon. In the event of major hemorrhage, the procedure is aborted, and an external
ventricular drain left in place. Head elevation and intermittent irrigation using lactated Ringers help reduce the
occurrence of pneumocephalus, overdrainage, and massive subdural collections. Because of the absence of
hardware, the risk of infection following ETV is low (~2%).[34],[35] Prophylactic antibiotics are given during
induction following institutional protocols, and layered closure is paramount.
Vomiting and fever are not uncommon during the first 72 h, and these are managed medically. Because of the
approximately 5% risk of postoperative seizures, some neurosurgeons have advocated for prophylactic
antiepileptics.[36] In the authors' practices, prophylactic antiepileptics are not routinely prescribed. Patients
are usually sent home within 3 days postop, unless they live far away, in which case they are kept admitted for
a bit longer to monitor for early complications.
Long-term follow-up
Compared with shunting, ETVs have a higher rate of early failure.[37] Most ETVs fail within 3–6 months
following surgery. In Warf's original ETV+CPC series, median time to failure was 1.4 months, and 75%
occurred within 2 months.[11] Corollary to this, an ETV that is still functioning at 6 months is likely to remain
patent beyond this period, while a shunt inserted at the same time in an identical patient will continue to be at
risk for failure. Therefore, follow-up is generally recommended at 2 weeks to check for wound complications;
subsequently, at 6 weeks, 3 months, and 6 months to monitor for early ETV failure; and then less frequently
thereafter.
The frequency of surveillance imaging depends largely on the setting. At Vanderbilt University Medical Center,
fast-sequence MRI is obtained at 2 weeks, 6 weeks, 3 months, 6 months, and 1-year postop. In contrast, at
the Philippine General Hospital, where capacity for imaging is limited and CT is more affordable and readily
available than MRI, post-op scans are advised at 6 months, but may be reasonably delayed to 1 year in
patients who are otherwise clinically improved. Patients with incomplete CPC, evidence of past infection, and
cisternal scarring need to be monitored closely because they are at a higher risk of failure. These are reflected
in CCHU's modified ETVSS[38] that has been used to reliably predict outcome after ETV+CPC in Uganda.
When ETV failure is suspected, ultrasound may be requested initially to assess the thickness of the cortical
mantle and size of the ventricles. It is known that ventriculomegaly may persist following an ETV, and the
presence of large ventricles alone—in the absence of definite progression and signs of raised intracranial
pressure—does not necessarily equate to ETV failure.[39] Dewan and colleagues recommend monitoring three
signs: bulging fontanel, rapid increase in head circumference as plotted on normal curves, and progression of
ventriculomegaly using either frontal and occipital horn ratio or Evan's index.[40]
Failure occurs because of two reasons: stoma closure or inability of ETV+CPC to restore equilibrium between
CSF production and absorption.[41] As such, many have advocated for repeat neuroendoscopy when a patient
presents with signs of ETV failure. Intraoperatively, if the stoma is found to be closed or occluded, it is
reopened (“redo/repeat ETV”), and any underlying arachnoid scarring or membrane is dissected free. On the
contrary, a patent stoma suggests that the latter reason is responsible for ETV failure, and in this scenario, a
VP shunt is inserted. ETVs that fail early (i.e., <3 months after initial surgery) are more likely to require shunt
placement.[41] Of note, among patients who eventually need a shunt following a failed ETV+CPC, the
endoscopic procedure does not seem to increase the subsequent risk of shunt infection or malfunction.[42]
To this day, questions on the long-term durability of ETV+CPC and its effect on neurocognitive development of
children with hydrocephalus have lingered, and this is the primary reason for the cautious adoption of
ETV+CPC elsewhere around the world. A randomized trial of 100 Ugandan infants with postinfectious
hydrocephalus showed no significant difference in cognitive outcome, using the Bayley Scales of Infant
Development at 12 months after either ETV+CPC or VP shunting.[43] Patients who underwent endoscopic
treatment had larger ventricles on postop imaging, but median brain volume was similar for both groups. This
highlights the importance of overall clinical assessment in the continuing care of children after ETV+CPC.
Illustrative cases
Case 1: Congenital hydrocephalus
An 11-month-old boy presented with macrocephaly and a bulging anterior fontanel [See [Figure 2]]. His
pediatrician started acetazolamide and requested for an MRI, which showed a posterior fossa cyst, likely to be
a Blake's pouch cyst, associated with supratentorial hydrocephalus. This relatively older infant had
noninfectious hydrocephalus, and thus, a favorable ETVSS of 70. ETV+CPC was performed. On follow-up, his
head circumference remained above average; however, the rate of growth had decelerated, and the
measurements plateaued over time. The anterior fontanel remained flat and eventually closed, despite
discontinuation of diuretics. Consistent with his clinical findings, repeat CT showed a decrease in the size of the
ventricles with an increase in the thickness of the cerebral cortex. The child has remained well and on par with
developmental milestones.{Figure 2}
Case 2: Idiopathic communicating hydrocephalus
A 6-month-old girl with no known history of perinatal infection was referred for evaluation due to progressive
macrocephaly and preferential downward gaze (“sunset eyes”). CT showed communicating hydrocephalus with
no abnormal enhancement [See [Figure 3]]. After discussion with the parents, ETV+CPC was offered (ETVSS:
40) and performed without complications. Postop, there was an initial reduction in head circumference.
However, at 4 months post-ETV, the increase in head circumference began to accelerate once more, associated
with a bulging fontanel. Repeat CT revealed progression of the ventriculomegaly. Redo endoscopy was
contemplated, but due to the etiology of the patient's hydrocephalus, the decision was made to proceed with
VP shunting. As expected, the head circumference stabilized, and surveillance scan showed regression of the
ventriculomegaly. Even with failure of ETV+CPC, the treatment outcome remained favorable, and she had no
delay in her neurocognitive development, emphasizing the importance of closely monitoring these patients.
{Figure 3}
Case 3: Shunt malfunction
A 6-month-old infant who previously underwent lumbar myelomeningocele repair and shunt insertion
presented with frontal bossing and a bulging fontanel, consistent with shunt malfunction [See [Figure 4]].
There were no signs of infection. His CT showed favorable anatomy for a safe ETV; hence, neuroendoscopy
was performed (ETVSS: 50). After ETV, the shunt was removed under direct visualization, cauterizing the
choroid plexus that had occluded the ventricular catheter and averting intraventricular hemorrhage. Bilateral
CPC was accomplished. The signs of raised intracranial pressure resolved and the patient remained shunt-free
on last follow-up. This illustrates that previously shunted patients, especially those with myelomeningocele and
aqueductal stenosis should be evaluated if they can be candidates for ETV+CPC when they are readmitted for
shunt failure, considering the positive outcomes this subgroup of children can realize.{Figure 4}
Conclusions
In appropriately selected infants, combined ETV+CPC is an effective and safe treatment for hydrocephalus. A
successful outcome is seen in approximately 50–70% of patients in most series, with greater likelihood of
shunt freedom among infants older than 1 month, those with noninfectious etiology such as aqueductal
stenosis and myelomeningocele, and those without prior shunting. ETV failure usually occurs within 3–6
months, particularly when CPC is incomplete, cisterns are scarred, and hydrocephalus is postinfectious in
origin. Studies on long-term functional and developmental outcomes will guide clinicians in future decision
making.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
1 Dewan MC, Rattani A, Mekary R, Glancz LJ, Yunusa I, Baticulon RE, et al. Global hydrocephalus
epidemiology and incidence: Systematic review and meta-analysis. J Neurosurg 2018;37:1-15.
2 Rachel RA. Surgical treatment of hydrocephalus: A historical perspective. Pediatr Neurosurg
1999;30:296-304.
3 Baticulon RE, Dewan MC, Wittayanakorn N, Aldana PR, Maixner WJ. Pediatric neurosurgery in Asia and
Australasia: Training and clinical practice. J Neurosurg Pediatr 2020;1–9. doi:
10.3171/2020.6.PEDS20399.
4 Dewan MC, Baticulon RE, Ravindran K, Bonfield CM, Poenaru D, Harkness W. Pediatric neurosurgical
bellwether procedures for infrastructure capacity building in hospitals and healthcare systems worldwide.
Childs Nerv Syst 2018;34:1837-46.
5 Kestle J, Drake J, Milner R, Sainte-Rose C, Cinalli G, Boop F, et al. Long-term follow-up data from the
Shunt Design Trial. Pediatr Neurosurg 2000;33:230-6.
6 Kestle JRW, Holubkov R, Douglas Cochrane D, Kulkarni AV, Limbrick DD, Luerssen TG, et al. A new
Hydrocephalus clinical research network protocol to reduce cerebrospinal fluid shunt infection. J
Neurosurg Pediatr 2016;17:391-6.
7 Mallucci CL, Jenkinson MD, Conroy EJ, Hartley JC, Brown M, Dalton J, et al. Antibiotic or silver versus
standard ventriculoperitoneal shunts (BASICS): A multicentre, single-blinded, randomised trial and
economic evaluation. Lancet 2019;394:1530-9.
8 Kulkarni AV, Shams I. Quality of life in children with hydrocephalus: Results from the Hospital for Sick
Children, Toronto. J Neurosurg 2007;107(Suppl 5):358-64.
9 Kulkarni AV, Hui S, Shams I, Donnelly R. Quality of life in obstructive hydrocephalus: Endoscopic third
ventriculostomy compared to cerebrospinal fluid shunt. Childs Nerv Syst 2009;26:75-9.
10 Shitsama S, Wittayanakorn N, Okechi H, Albright AL. Choroid plexus coagulation in infants with extreme
hydrocephalus or hydranencephaly. J Neurosurg Pediatr 2014;14:55-7.
11 Warf BC. Comparison of endoscopic third ventriculostomy alone and combined with choroid plexus
cauterization in infants younger than 1 year of age: A prospective study in 550 African children. J
Neurosurg 2005;103(Suppl 6):475-81.
12 Warf BC, Alkire BC, Bhai S, Hughes C, Schiff SJ, Vincent JR, et al. Costs and benefits of neurosurgical
intervention for infant hydrocephalus in sub-Saharan Africa. J Neurosurg Pediatr 2011;8:509-21.
13 Kulkarni AV, Riva-Cambrin J, Rozzelle CJ, Naftel RP, Alvey JS, Reeder RW, et al. Endoscopic third
ventriculostomy and choroid plexus cauterization in infant hydrocephalus: A prospective study by the
Hydrocephalus Clinical Research Network. J Neurosurg Pediatr 2018;21:214-23.
14 Riva-Cambrin J, Kestle JRW, Rozzelle CJ, Naftel RP, Alvey JS, Reeder RW, et al. Predictors of success for
combined endoscopic third ventriculostomy and choroid plexus cauterization in a North American setting:
A hydrocephalus clinical research network study. J Neurosurg Pediatr 2019;24:128-38.
15 Pindrik J, Riva-Cambrin J, Kulkarni AV, Alvey JS, Reeder RW, Pollack IF, et al. Surgical resource utilization
after initial treatment of infant hydrocephalus: Comparing ETV, early experience of ETV with choroid
plexus cauterization, and shunt insertion in the hydrocephalus clinical research network. J Neurosurg
Pediatr 2020:1-9. doi: 10.3171/2020.4.PEDS19632.
16 Zhu X, Di Rocco C. Choroid plexus coagulation for hydrocephalus not due to CSF overproduction: A
review. Childs Nerv Syst 2013;29:35-42.
17 Dewan MC, Naftel RP. The global rise of endoscopic third ventriculostomy with choroid plexus
cauterization in pediatric hydrocephalus. Pediatr Neurosurg 2017;52:401-8.
18 Warf BC, Tracy S, Mugamba J. Long-term outcome for endoscopic third ventriculostomy alone or in
combination with choroid plexus cauterization for congenital aqueductal stenosis in African infants. J
19 Warf BC, Dewan M, Mugamba J. Management of Dandy-Walker complex-associated infant hydrocephalus
by combined endoscopic third ventriculostomy and choroid plexus cauterization. J Neurosurg Pediatr
2011;8:377-83.
20 Warf BC, Stagno V, Mugamba J. Encephalocele in Uganda: Ethnic distinctions in lesion location,
endoscopic management of hydrocephalus, and survival in 110 consecutive children. J Neurosurg Pediatr
2011;7:88-93.
21 Warf BC. Congenital idiopathic hydrocephalus of infancy: The results of treatment by endoscopic third
ventriculostomy with or without choroid plexus cauterization and suggestions for how it works. Childs
Nerv Syst 2013;29:935-40.
22 Bankole OB, Ojo OA, Nnadi MN, Kanu OO, Olatosi JO. Early outcome of combined endoscopic third
ventriculostomy and choroid plexus cauterization in childhood hydrocephalus. J Neurosurg Pediatr
2015;15:524-8.
23 Shah AH, LaFortune Y, Ibrahim GM, Cajigas I, Ragheb M, Chen SH, et al. Endoscopic third
ventriculostomy with choroid plexus cauterization for the treatment of infantile hydrocephalus in Haiti. J
Neurosurg Pediatr 2020;25:1–6.
24 Stone SSD, Warf BC. Combined endoscopic third ventriculostomy and choroid plexus cauterization as
primary treatment for infant hydrocephalus: A prospective North American series. J Neurosurg Pediatr
2014;14:439-46.
25 Symss NP, Oi S. Theories of cerebrospinal fluid dynamics and hydrocephalus: Historical trend. J
26 Koch D, Wagner W. Endoscopic third ventriculostomy in infants of less than 1 year of age: Which factors
influence the outcome? Child's Nervous System 2004;20:405-11.
27 Fritsch MJ, Kienke S, Ankermann T, Padoin M, Mehdorn HM. Endoscopic third ventriculostomy in infants. J
Neurosurg 2005;103(Suppl 1):50–3.
28 Oi S, Di Rocco C. Proposal of “evolution theory in cerebrospinal fluid dynamics” and minor pathway
hydrocephalus in developing immature brain. Childs Nervous System 2006;22:662-9.
29 Kulkarni AV, Drake JM, Mallucci CL, Sgouros S, Roth J, Constantini S, et al. Endoscopic third
ventriculostomy in the treatment of childhood hydrocephalus. J Pediatr 2009;155:254-9.e1.
30 Kulkarni AV, Riva-Cambrin J, Browd SR. Use of the ETV success score to explain the variation in reported
endoscopic third ventriculostomy success rates among published case series of childhood hydrocephalus.
J Neurosurg Pediatr 2011;7:143-6.
31 Warf BC, Kulkarni AV. Intraoperative assessment of cerebral aqueduct patency and cisternal scarring:
Impact on success of endoscopic third ventriculostomy in 403 African children. J Neurosurg Pediatr
2010;5:204-9.
32 Wang S, Stone S, Weil AG, Fallah A, Warf BC, Ragheb J, et al. Comparative effectiveness of flexible
versus rigid neuroendoscopy for endoscopic third ventriculostomy and choroid plexus cauterization: A
propensity score-matched cohort and survival analysis. J Neurosurg Pediatr 2017;19:585-91.
33 Weil AG, Westwick H, Wang S, Alotaibi NM, Elkaim L, Ibrahim GM, et al. Efficacy and safety of endoscopic
third ventriculostomy and choroid plexus cauterization for infantile hydrocephalus: A systematic review
and meta-analysis. Childs Nerv Syst 2016;32:2119-31.
34 Bouras T, Sgouros S. Complications of endoscopic third ventriculostomy. J Neurosurg Pediatr 2011;7:643-
9.
35 Texakalidis P, Tora MS, Wetzel JS, Chern JJ. Endoscopic third ventriculostomy versus shunt for pediatric
hydrocephalus: A systematic literature review and meta-analysis. Childs Nervous System 2019;35:1283-
93.
36 Punchak M, Mbabazi-Kabachelor E, Ogwal M, Nalule E, Nalwoga J, Ssenyonga P, et al. The incidence of
postoperative seizures following treatment of postinfectious hydrocephalus in ugandan infants: A post
hoc comparison of endoscopic treatment vs shunt placement in a randomized controlled trial.
Neurosurgery 2019;85:E714-21.
37 Kulkarni AV, Drake JM, Kestle JRW, Mallucci CL, Sgouros S, Constantini S, et al. Endoscopic third
ventriculostomy vs cerebrospinal fluid shunt in the treatment of hydrocephalus in children: A propensity
score-adjusted analysis. Neurosurgery 2010;67:588-93.
38 Warf BC, Mugamba J, Kulkarni AV. Endoscopic third ventriculostomy in the treatment of childhood
hydrocephalus in Uganda: Report of a scoring system that predicts success. J Neurosurg Pediatr
2010;5:143-8.
39 Dewan MC, Lim J, Gannon SR, Heaner D, Davis MC, Vaughn B, et al. Comparison of hydrocephalus
metrics between infants successfully treated with endoscopic third ventriculostomy with choroid plexus
cauterization and those treated with a ventriculoperitoneal shunt: A multicenter matched-cohort analysis.
J Neurosurg Pediatr 2018;21:339-45.
40 Dewan MC, Lim J, Morgan CD, Gannon SR, Shannon CN, Wellons JC, et al. Endoscopic third
ventriculostomy with choroid plexus cauterization outcome: Distinguishing success from failure. J
41 Marano PJ, Stone SSD, Mugamba J, Ssenyonga P, Warf EB, Warf BC. Reopening of an obstructed third
ventriculostomy: Long-term success and factors affecting outcome in 215 infants. J Neurosurg Pediatr
2015;15:399-405.
42 Warf BC, Bhai S, Kulkarni AV, Mugamba J. Shunt survival after failed endoscopic treatment of
hydrocephalus. J Neurosurg Pediatr 2012;10:463-70.
43 Kulkarni AV, Schiff SJ, Mbabazi-Kabachelor E, Mugamba J, Ssenyonga P, Donnelly R, et al. Endoscopic
treatment versus shunting for infant hydrocephalus in Uganda. N Engl J Med 2017;377:2456-64.
Tuesday, July 4, 2023

Site Map | Home | Contact Us | Feedback | Copyright and Disclaimer
Cookie Settings

Endoscopic Third Ventriculostomy and Choroid Plexus Coagulation in Infants: Current Concepts and Illustrative Cases

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Endoscopic Third Ventriculostomy and Choroid Plexus Coagulation in Infants: Current Concepts and Illustrative Cases

Uploaded by

Copyright:

Available Formats

Endoscopic Third Ventriculostomy And Choroid Plexus Coagulation …sup>1</sup>, Michael C Dewan<sup>2</sup>, </b>, Neurololy India 04/07/23 15.

Endoscopic Third Ventriculostomy And Choroid Plexus Coagulation in Infants:

How to cite this article:

How to cite this URL:

ETV+ CPC in young infants

How does ETV+CPC work?

Identifying ideal patients for ETV+CPC

Equipment needs and surgical technique

Complications and postoperative care

Case 1: Congenital hydrocephalus

Case 2: Idiopathic communicating hydrocephalus

Case 3: Shunt malfunction

Financial support and sponsorship

There are no conflicts of interest.

Tuesday, July 4, 2023

You might also like