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Neuroendoscopic third ventriculostomy

Neil Buxton

Neuroendoscopic third ventriculostomy is becoming increasingly popular as the primary mode of therapy for patients with noncommunicating hydrocephalus. In this article the author reviews the procedure and its indications, and highlights its complications. It can, without doubt, be recommended as the first line treatment for hydrocephalus and also in cases in which shunt malfunction or infection occurs.

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Endoscopic third ventriculostomy

George I. Jallo, Karl F. Kothbauer, and I. Rick Abbott

The traditional treatment for all forms of hydrocephalus has been the implantation of ventricular shunt systems; however, these systems have inherent tendencies toward complications such as malfunction and infection. A significant advance in the treatment of hydrocephalus has been the evolution of endoscopy. The recent technological advances in this field have led to a renewed interest in endoscopic third ventriculostomy as the treatment of choice for obstructive hydrocephalus. Although several different endoscopes are available, the authors favor a rigid one to perform a blunt fenestration of the third ventricle floor. This description of the technique stresses the nuances for successful completion of this procedure.

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A lesson in history: the evolution of endoscopic third ventriculostomy

Paul J. Schmitt and John A. Jane Jr.

hydrocephalus by using a urethroscope to access the lateral ventricles, where he performed a fulguration of the choroid plexus. 24 However, Walter Dandy is considered by most to be the father of neuroendoscopy. In 1922 Dandy described ventriculoscopy, 5 as well as a technique for performing the third ventriculostomy as a treatment for hydrocephalus via frontal and subtemporal approaches. 6 Dandy's open attempts at puncturing the floor of the ventricle were true skull base approaches. These challenging forays into the base of the brain yielded dissatisfaction with the

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Management of hydrocephalus in the patient with myelomeningocele: an argument against third ventriculostomy

Arthur E. Marlin

The majority of children with myelomeningocele will have associated hydrocephalus. The management of hydrocephalus can be one of the most trying problems in this patient population. Cerebrospinal fluid (CSF) diversion will be required in these children for the remainder of their lives. Blockage of the outlets of the fourth ventricle and communication of the fourth ventricle with the central canal provides a mechanism for compensation. The signs and symptoms of CSF diversion malfunction, either shunt or third ventriculostomy, can be quite subtle. The objective indications of these malfunctions are less available after third ventriculostomy than when using mechanical shunting. The ease with which the diagnosis of malfunction can be made becomes the major advantage of mechanical shunting over third ventriculostomy.

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Endoscopic third ventriculostomy for tumor-related hydrocephalus in a pediatric population

Pulak Ray, George I. Jallo, R. Y. H. Kim, Bong-Soo Kim, Sean Wilson, Karl Kothbauer, and Rick Abbott

Object

Endoscopic third ventriculostomy (ETV) has become a common alternative for managing hydrocephalus in select patients. Nevertheless, there is still controversy regarding the indications for ETV as the primary procedure, given its variable success rates. The purpose of this study is to review the authors' experience with ETV for a variety of patients.

Methods

A total of 43 children underwent ETV between July 1992 and June 2003. Their medical records, operative reports, and imaging studies, when available, were retrospectively reviewed with regard to outcome, complications, and patency rate. Treatment failure was defined as the need to place a shunt within 4 weeks of performing ETV in the patient.

There were 20 male and 23 female patients with a mean age of 9.6 years (range 8 weeks–21 years). The overall success rate was 69.8%, and the mean follow-up duration was 24.6 months. Six patients underwent eight repeated ETVs at a mean interval of 25 months, with a patency rate of 62.5% after the second procedure. Only two surgeries were aborted for anatomical reasons. The highest success rates (100% in each instance) were achieved for obstructive hydrocephalus resulting from midbrain/tectal tumor (four patients) and pineal tumor (three patients).

Conclusions

The ETV procedure is an effective management tool for obstructive hydrocephalus in children. It should be considered the primary procedure, rather than ventriculoperitoneal shunts, in carefully selected children. The success rate is dependent on the origin of the hydrocephalus.

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Management of hydrocephalus in pediatric patients with posterior fossa tumors: the role of endoscopic third ventriculostomy

Christian Sainte-Rose, Giuseppe Cinalli, Franck E. Roux, Wirginia Maixner, Paul D. Chumas, Maheir Mansour, Alexandre Carpentier, Marie Bourgeois, Michel Zerah, Alain Pierre-Kahn, and Dominique Renier

The authors conducted a study to evaluate the effectiveness of endoscopically guided third ventriculostomy in the pre- and postoperative management of hydrocephalus in pediatric patients who harbored posterior fossa tumors.

Between October 1, 1993, and December 31, 1997, a total of 206 consecutive children with posterior fossa tumors underwent surgery at Hôpital Necker-Enfants Malades in Paris. Ten patients in whom shunts were implanted at the referring hospital were excluded. The medical records and neuroimaging studies obtained in the remaining 196 patients were reviewed. These patients were categorized into three groups: 67 patients with hydrocephalus on admission in whom endoscopically guided third ventriculostomy was performed prior to tumor removal (Group A); 82 patients with hydrocephalus in whom preliminary third ventriculostomy was not performed and who were managed in a “conventional way” (Group B); and 47 patients without ventricular dilation on admission (Group C).

There was no significant difference between Group A and Group B patients with respect to age at presentation, evidence of metastatic disease, degree of tumor resection, or follow up. In the patients in Group A, however, more severe hydrocephalus was present (p < 0.01). Patients in Group C were, in this respect, different from the other two groups.

Ultimately, only four patients (6%) in Group A as compared with 22 patients (27 %) in Group B (p = 0.001) had progressive hydrocephalus requiring treatment following removal of the posterior fossa tumor. Sixteen patients (20%) in Group B underwent insertion of a ventriculoperitoneal shunt, which is similar to the incidence of this procedure reported in the literature and significantly different from that in Group A (p < 0.016). The other six patients in Group B (6%) were treated by endoscopically guided third ventriculostomy after tumor removal. In Group C, two patients (4%) with postoperative hydrocephalus underwent endoscopically guided third ventriculostomy.

In three of the patients who required placement of cerebrospinal fluid shunts several episodes of shunt malfunction occurred; these were ultimately managed by performing endoscopic third ventriculostomy and definitive removal of the shunt.

There were no cases of death and four cases of transient morbidity associated with the ventriculostomy.

Third ventriculostomy is feasible even in the presence of posterior fossa tumors (including brainstem tumors). When performed prior to posterior fossa surgery, it significantly reduces the incidence of postoperative hydrocephalus. Furthermore, it provides a valid alternative to the placement of permanent shunts in cases in which hydrocephalus develops following posterior fossa surgery, and it may negate the need for the shunt in cases in which the shunt malfunctions.

Although the authors acknowledge that the routine application of third ventriculostomy in selected patients may result in a proportion of patients undergoing an “unnecessary” procedure, they believe that because of patients' less complicated postoperative course, the low morbidity rate, and the high success rate of third ventriculostomy, further investigation of this protocol is warranted.

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Transcallosal approach for third ventriculostomy and removal of midbrain cavernous malformation

William T. Couldwell

Symptomatic brain stem cavernous malformations often present the dilemma of choosing an approach for their resection. Superior midline midbrain lesions are in a particularly challenging location, as they are less accessible via traditional lateral or posterior approaches. The author presents a case of a young woman who presented with a symptomatic cavernous malformation with surface presentation to the floor of the third ventricle. The lesion was causing sensory symptoms from local mass effect and hydrocephalus from occlusion of the Aqueduct of Sylvius. An approach was chosen to both perform a third ventriculostomy and remove the cavernous malformation. Through a right frontal craniotomy, a transcallosal–transforaminal approach was used to perform a third ventriculostomy. Through the same callosal opening, a subchoroidal approach was performed to provide access the cavernous malformation. The details of the procedure and nuances of technique are described in the narration.

The video can be found here: http://youtu.be/zKKnehp7l2c .

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Endoscopic third ventriculostomy for pediatric tumor-associated hydrocephalus

Brandon A. Sherrod, Rajiv R. Iyer, and John R. W. Kestle

management alone are ineffective. Endoscopic third ventriculostomy (ETV) was initially described in 1923 by William Mixter 25 as a treatment strategy for hydrocephalus and has appeal as a method to reduce the risk of introducing hardware-related infectious complications in children who need surgical treatment for hydrocephalus. Numerous studies have compared ETV and VPS in regard to efficacy and infection rates in treatment of pediatric hydrocephalus in general, with the consensus being that ETV reduces procedural infection risk, but the overall reoperation rates for

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Failure of third ventriculostomy in the treatment of aqueductal stenosis in children

Giuseppe Cinalli, Christian Sainte-Rose, Paul Chumas, Michel Zerah, Francis Brunelle, Guillaume Lot, Alain Pierre-Kahn, and Dominique Renier

Object

The goal of this study was to analyze the types of failure and long-term efficacy of third ventriculostomy in children.

Methods

The authors retrospectively analyzed clinical data obtained in 213 children affected by obstructive triventricular hydrocephalus who were treated by third ventriculostomy between 1973 and 1997. There were 120 boys and 93 girls. The causes of the hydrocephalus included: aqueductal stenosis in 126 cases; toxoplasmosis in 23 cases, pineal, mesencephalic, or tectal tumor in 42 cases; and other causes in 22 cases. In 94 cases, the procedure was performed using ventriculographic guidance (Group I) and in 119 cases by using endoscopic guidance (Group II). In 19 cases (12 in Group I and seven in Group II) failure was related to the surgical technique. Three deaths related to the technique were observed in Group I. For the remaining patients, Kaplan-Meier survival analysis showed a functioning third ventriculostomy rate of 72% at 6 years with a mean follow-up period of 45.5 months (range 4 days-17 years). No significant differences were found during long-term follow up between the two groups. In Group I, a significantly higher failure rate was seen in children younger than 6 months of age, but this difference was not observed in Group II. Thirty-eight patients required reoperation (21 in Group I and 17 in Group II) because of persistent or recurrent intracranial hypertension. In 29 patients shunt placement was necessary. In nine patients in whom there was radiologically confirmed obstruction of the stoma, the third ventriculostomy was repeated; this was successful in seven cases. Cine phase-contrast (PC) magnetic resonance (MR) imaging studies were performed in 15 patients in Group I at least 10 years after they had undergone third ventriculostomy (range 10–17 years, median 14.3 years); this confirmed long-term patency of the stoma in all cases.

Conclusions

Third ventriculostomy effectively controls obstructive triventricular hydrocephalus in more than 70% of children and should be preferred to placement of extracranial cerebrospinal shunts in this group of patients. When performed using ventriculographic guidance, the technique has a higher mortality rate and a higher failure rate in children younger than 6 months of age and is, therefore, no longer preferred. When third ventriculostomy is performed using endoscopic guidance, the same long-term results are achieved in children younger than 6 months of age as in older children and, thus, patient age should no longer be considered as a contraindication to using the technique. Delayed failures are usually secondary to obstruction of the stoma and often can be managed by repeating the procedure. Midline sagittal T2-weighted MR imaging sequences combined with cine PC MR imaging flow measurements provide a reliable tool for diagnosis of aqueductal stenosis and for ascertaining the patency of the stoma during follow-up evaluation.

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Pineal region tumors: an optimal approach for simultaneous endoscopic third ventriculostomy and biopsy

Peter F. Morgenstern, Nathan Osbun, Theodore H. Schwartz, Jeffrey P. Greenfield, Apostolos John Tsiouris, and Mark M. Souweidane

E ndoscopic biopsy has become a mainstay of the initial approach to tumors in the pineal region. Furthermore, approximately 90% of patients with these masses present with hydrocephalus requiring management. 16 , 22 Ventriculoperitoneal shunting or external ventricular drainage are options for management, but ETV offers a minimally invasive, safe method to treat hydrocephalus resulting from obstruction by the lesion. Endoscopic third ventriculostomy can be performed safely at the time of biopsy, 7 thus combining therapeutic and diagnostic functions and