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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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A re-evaluation of the Endoscopic Third Ventriculostomy Success Score: a Hydrocephalus Clinical Research Network study

Leonard H. Verhey, Abhaya V. Kulkarni, Ron W. Reeder, Jay Riva-Cambrin, Hailey Jensen, Ian F. Pollack, Brandon G. Rocque, Mandeep S. Tamber, Patrick J. McDonald, Mark D. Krieger, Jonathan A. Pindrik, Jason S. Hauptman, Samuel R. Browd, William E. Whitehead, Eric M. Jackson, John C. Wellons III, Todd C. Hankinson, Jason Chu, David D. Limbrick Jr., Jennifer M. Strahle, John R. W. Kestle, and for the Hydrocephalus Clinical Research Network

T he Endoscopic Third Ventriculostomy Success Score (ETVSS) was published in 2009 and provided a tool to predict the percentage chance of endoscopic third ventriculostomy (ETV) success using the preoperative demographic factors of age, etiology of hydrocephalus, and presence of a previous shunt. The ETVSS has been independently externally validated by others. 1 – 5 The ETVSS was developed from an international cohort of patients, the vast majority of whom had undergone ETV between 1995 and 2006. Anecdotally, there have been questions about the accuracy of

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Endoscopic third ventriculostomy in children: prospective, multicenter results from the Hydrocephalus Clinical Research Network

Abhaya V. Kulkarni, Jay Riva-Cambrin, Richard Holubkov, Samuel R. Browd, D. Douglas Cochrane, James M. Drake, David D. Limbrick, Curtis J. Rozzelle, Tamara D. Simon, Mandeep S. Tamber, John C. Wellons III, William E. Whitehead, John R. W. Kestle, and for the Hydrocephalus Clinical Research Network

E ndoscopic third ventriculostomy (ETV) is now well established as an effective treatment for many children with hydrocephalus. Small and large case series on the procedure are well documented in the medical literature, but a paucity of multicenter prospective data remains. 2 , 20 This absence of data has limited our ability to definitively answer important questions about ETV complications and efficacy. Especially lacking are accurate data regarding intraoperative events and the impact such events may have on ETV success. While the ETV Success Score

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Combined endoscopic third ventriculostomy and choroid plexus cauterization as primary treatment for infant hydrocephalus: a prospective North American series

Clinical article

Scellig S. D. Stone and Benjamin C. Warf

I n 2005, Warf first reported the technique and results of combining endoscopic third ventriculostomy (ETV) with bilateral endoscopic lateral ventricle choroid plexus cauterization (CPC) to treat hydrocephalus in infants. 13 Subsequently, the efficacy of the procedure has been demonstrated among distinct etiologies of hydrocephalus in infants, with overall long-term success of more than 60% for all patients if the prepontine cistern is not obstructed by arachnoid scarring. 14 , 16–19 , 22 , 23 With the exception of 2 studies from US institutions of ETV

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Endoscopic third ventriculostomy with choroid plexus cauterization: predictors of long-term success and comparison with shunt placement for primary treatment of infant hydrocephalus

Benjamin C. Warf, Daniel S. Weber, Emily L. Day, Coleman P. Riordan, Steven J. Staffa, Lissa C. Baird, Katie P. Fehnel, and Scellig S. D. Stone

C ombined endoscopic third ventriculostomy (ETV) with choroid plexus cauterization (CPC) has provided an alternative to ventriculoperitoneal shunt (VPS) placement for hydrocephalus treatment in very young children since its introduction in 2005. 1 Moreover, its successful broader adoption, particularly in low-resource countries, as a new public health strategy for treating infant hydrocephalus was recently demonstrated. 2 Numerous studies from several sites have evaluated its efficacy in infants and with a variety of etiologies, including short

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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 and repeat endoscopic third ventriculostomy in pediatric patients: the Dutch experience

Gerben E. Breimer, Ruben Dammers, Peter A. Woerdeman, Dennis R. Buis, Hans Delye, Marjolein Brusse-Keizer, and Eelco W. Hoving

E ndoscopic third ventriculostomy (ETV) has become the standard treatment for obstructive hydrocephalus. 29 Its range of indications has extended to communicative hydrocephalus as well. 29 , 49 Unfortunately, to date, no treatment modality guarantees a permanent solution for hydrocephalus. 32 Therefore, when primarily treating hydrocephalus, the apparent benefits and disadvantages of ETV and shunting have to be weighted and considered. 10 , 16 , 18 , 30 , 36 , 38 , 41 , 61 To facilitate neurosurgeons in the process of patient selection for ETV, a predictive

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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


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.


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).


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.