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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
BurrHolesite
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
Interpeduncular cistern
Mammllary Bodies
Infundibular recess
Third Ventricle
Endoscopic third ventriculostomy
Mammllary Bodies
Translucent Area
Endoscopic third ventriculostomy
Mammllary bodies
ETV Hole
Infundibular recess
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
Male
FemaleMale 51%
Female 49%
Results of ETV in infants
SuccessfulETV
Failed ETV
74 (85%)
13 (15%)
Endoscopic third ventriculostomy in various age group
0
10
20
30
40
50
60
70
80
90
Age group
<1yr
1-4yr
5-9yr
10-14yr
15-24
25-34yr
35-44yr
55-64yr
65+yr
No
. of
pa
tie
ntsVarious Age group
Endoscopic third ventriculostomy in infants
Pre mature lowbirth weight
Full termnormal birthweight
7 (8%)
80 (92%)
Endoscopic third ventriculostomy in infants
0%
10%
20%
30%
40%
50%
60%
Pre mature/ Full term
Pre mature lowbirth weight
Full termnormal birthweight
Fa
ilure
rat
e E
TV
57%
11.3%
Fishers exact test, P =0.03).
Age wise success rate of ETV
0102030405060708090
100
Age group
<1yr
1-4yr
5-9yr
10-14yr
15-24yr
25-34yr
45-54yr
55-64yr
65+yr
Su
cces
s ra
te
Age wise success P >0.05
ETV Success rate in relation to pathology
0
10
20
30
40
50
60
70
80
90
100
tumor Stenosis TBM IVH Menin.
Faliure
Success
Complications in ETV
0123456789
10
Complications
Infection
CSF leak
Minor Bleed
Stoma block
Complexhydrocephalus
Per
cen
tag
e
11
14
9
18
7
6
8
5
10
4
Incidence of ETV & VP Shunt failure in relation to time
020406080
100
0 month 2yrsETV
ETV
VP Shunt
Time after surgery
Per
cen
tag
e
Re ETV
0
1
2
3
4
5
6
7
8
Results Re ETV
Successful ReETV
Failed Re ETV
88.8%
1
8
11.2%No
of
pat
ien
ts
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