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Endoscopic third ventriculostomy

Dr Vishal Gajbhiye
Dr Yadav YR

NSCB Govt Medical


College, Jabalpur, MP
Endoscopic third ventriculostomy

Introduction: Third ventriculostomy is 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 interpenduncular
cistern.
•The objective of this procedure is to reduce
pressure in the ventricle without using a shunt.
•Third ventriculostomy is usually a one-time
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

MRI Scan is
Preferred
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
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.
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


Male 51% Female
Results of ETV in infants

13 (15%)

Successful
ETV
Failed ETV
74 (85%)
Endoscopic third ventriculostomy in
various age group

Various Age group

90
80 <1yr
70 1-4yr
No. of patients

60 5-9yr
50 10-14yr
40 15-24
30 25-34yr
20 35-44yr
10 55-64yr
0 65+yr
Age group
Endoscopic third ventriculostomy in
infants

7 (8%)

Pre mature low


birth weight

Full term
80 (92%) normal birth
weight
Endoscopic third ventriculostomy in
infants
Fishers exact test, P =0.03).
60%

50%
Failure rate ETV

40% Pre mature low


birth weight
57%
30%
Full term
20% normal birth
weight
10%
11.3%
0%
Pre mature/ Full term
Age wise success rate of ETV
Age wise success P >0.05

100
90 <1yr
80 1-4yr
Success rate

70 5-9yr
60
10-14yr
50
15-24yr
40
25-34yr
30
20 45-54yr
10 55-64yr
0 65+yr
Age group
ETV Success rate in relation to
pathology
100
90
80
70
60
50 Faliure
40 Success
30
20
10
0
tumor Stenosis TBM IVH Menin.
Complications in ETV
10
10
9 8 Infection
8
7 6 CSF leak
Percentage

6 5
14 4
5 18 Minor Bleed
4 11
3 9 Stoma block
7
2
1 Complex
0 hydrocephalus
Complications
Incidence of ETV & VP Shunt
failure in relation to time

100
Percentage

80
60
40 ETV
20 VP Shunt
0 ETV
0 month 2yrs

Time after surgery


Re ETV
88.8%

8
7
6
No of patients

5 Successful Re
4 8 ETV
3 Failed Re ETV
11.2%
2
1
1
0
Results Re ETV
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