Why a Focus Session on endoscopic third ventriculostomy in infants?

Abstract

Since its “renaissance” in the late 1980s, endoscopic third ventriculostomy (ETV) gained a growing acceptance and, eventually, an established place in the surgical treatment of obstructive hydrocephalus. It soon became clear, however, that a part of the patients undergoing that endoscopic procedure eventually failed and that the chance of curing the hydrocephalus by endoscopy alone (without a shunt) depended on several factors, from which patient’s age and etiology of hydrocephalus are the most important. Most pediatric neurosurgeons agree that ETV has a higher failure rate in infants as opposed to children, adolescents, or adults. As some of us (not all) have found very low success rates in the first months of life, the question of whether this procedure should be offered at all to our youngest patients or whether it should be reserved to infants beyond the first or second year of life was raised. Similar considerations concern the role of etiology: there is general consensus that patients with isolated aqueductal stenosis are “good candidates” for ETV, whereas newborns with hydrocephalus in the context of myelomeningocele should be treated with shunts. But what kind of treatment should be chosen in other etiologies? How should mixed forms of obstructive/absorptive hydrocephalus be dealt with? Which kind of preoperative imaging is indispensable? Are there differences between ETV and shunts in the first year of life, with respect to complications or neurologic long-term outcome? This series of articles is intended to give an actual overview over the different important aspects of ETV in infants, particularly in the first year of life. The role of preoperative imaging, frequency and type of complications, and neurologic development after ETV vs shunt are dealt with, as well as the impact of age on success rate, indications for ETV in pathologies different from isolated aqueductal stenosis, or the relevance of a “spectrum classification” of absorptive vs obstructive hydrocephalus for the choice of the appropriate treatment procedures. Of course, this Focus Session not only gives more or less established answers, but also addresses questions that still remain open. In particular, the important issue of final neurodevelopmental outcome of children treated by ETVor shunt can be dealt with only by a prospective and randomized study, following the patients over years, as is intended to be realized by the ongoing International Infant Hydrocephalus Study (IIHS). While this Focus Session reflects our present knowledge, we are optimistic that the future will clarify questions that at the moment must be left unanswered. Childs Nerv Syst (2006) 22:1527 DOI 10.1007/s00381-006-0188-2