Endoscopic Third Ventriculostomy In Patients Research Articles

Outcomes of Endoscopic Third Ventriculostomy in Treating Obstructive Hydrocephalus

Background: Obstructive hydrocephalus poses significant treatment challenges, often necessitating innovative surgical interventions to alleviate symptoms and improve patient outcomes. Endoscopic third ventriculostomy (ETV) has emerged as a viable alternative to traditional shunting procedures, offering the promise of a less invasive approach with potentially lower complication rates. This study seeks to deepen our understanding of ETV's effectiveness and safety, shedding light on its role in the current treatment paradigm for obstructive hydrocephalus.
 Objective: The primary objective of this investigation was to evaluate the surgical outcomes of ETV in patients with obstructive hydrocephalus, focusing on changes in the severity of hydrocephalus and the presence of comorbid conditions pre- and postoperatively.
 Methods: A comprehensive retrospective analysis was conducted on 54 patients who underwent ETV for obstructive hydrocephalus. Patients were selected based on specific inclusion and exclusion criteria to ensure a homogenous study population. Preoperative and postoperative assessments included the severity of hydrocephalus and the identification of comorbid conditions, with outcomes measured at 6 and 12 months post-surgery. Statistical analyses employed included Chi-square tests for categorical variables, with a significance level set at p<0.05.
 Results: Postoperative evaluations revealed a significant reduction in the severity of hydrocephalus, with 59% of patients categorized as mild post-surgery compared to 37% pre-surgery. Severe hydrocephalus was reduced from 30% to 11%. However, the presence of comorbid conditions showed no significant change postoperatively (41% pre-surgery vs. 37% post-surgery, p>0.05). The complication rate was minimal, indicating the procedure's safety.
 Conclusion: ETV demonstrated a significant positive impact on reducing the severity of hydrocephalus in patients, confirming its efficacy as a treatment option. However, its effect on comorbid conditions was less pronounced, suggesting a need for integrated care strategies. These findings support the continued use and further study of ETV in the treatment of obstructive hydrocephalus.

Dorsum Sellae as Key Landmark in ETV With Disminished Prepontine Cistern: Technical Note and Case Series.

One of the key aspects in the surgical technique of endoscopic third ventriculostomy (ETV) is the perforation of the floor of the third ventricle because of the high risk of injuring vital structures located in that region. According to the standard technique, this perforation should be performed in the midline halfway between mammillary bodies and the infundibular recess to avoid damage to the structures. This can be performed without excessive complications when the diameter of the prepontine cistern is wide. However, in situations where the diameter is reduced (defined in the literature as having a prepontine interval [PPI] ≤1 mm), the probability of complications increases exponentially.In this article, we propose using dorsum sellae as a key point to safely perform ETV in patients with a decreased PPI, guiding the trajectory and its marking using neuronavigation. A review was conducted on the latest 100 ETV procedures performed by our team in the past 5 years. The measurement of the PPI was conducted using archived preoperative MRI imaging studies, specifically between the dorsum sellae and the basilar artery. In cases where the PPI was ≤1 mm and, therefore, the use of the dorsum sellae was applied as a reference point, the technical results and procedural functions were documented. In the cohort, 7 patients with a PPI ≤1 mm were identified. In all 7 cases, fenestration of the tuber cinereum was successfully performed without causing vascular damage or associated complications. ETV was successful in 6 patients, with only one experiencing ETV failure necessitating the placement of a ventriculoperitoneal shunt. The utilization of the dorsum sellae as a reference point to perform ETV in reduced PPI constitutes a safe alternative to the classical technique.

Role of endoscopic third ventriculostomy in patients undergoing resection of pulvinar area lesions: Preliminary clinical results

BackgroundPatients with pulvinar area lesions may develop hydrocephalus at any stage. The role of endoscopic third ventriculostomy (ETV) in this setting remains unclear. MethodWe retrospectively enrolled 15 patients with a mean age of 43 years who underwent endoscopic resection of pulvinar area lesions using the supracerebellar infratentorial approach (SCITA). We compared the different modalities of hydrocephalus management and their outcomes. ResultsNine of 15 patients (60.0%) had preoperative obstructive hydrocephalus. Five patients underwent ETV before tumor resection, and none developed postoperative hydrocephalus. Four patients underwent one-stage surgery for tumor removal, and one patient with a polymorphous low-grade neuroepithelial tumor of the young required postoperative ETV. Another patient with diffuse astrocytoma and hydrocephalus underwent concurrent lamina terminalis fenestration and endoscopic resection via the SCITA, which resulted in the resolution of hydrocephalus. The preoperative ETV group had no major postoperative complications, while the non-ETV group had three (0/5 vs. 3/4, P = 0.048). The ETV group also had a shorter intensive care unit stay; however, the difference was not significant (1.2 vs. 2.8; P = 0.188). ETV was effective in alleviating symptoms of postoperative hydrocephalus in patients with midbrain-invading tumors. ConclusionEndoscopic surgery via the SCITA can address both tumor and hydrocephalus issues in some cases but has a higher surgical risk and postoperative hydrocephalus rate. Preoperative ETV can prevent these complications and improve postoperative outcomes.

Predicting endoscopic third ventriculostomy success in pediatric shunt dysfunction: a monocentric retrospective case series of 70 consecutive children, systematic review, and meta-analysis.

The outcome of endoscopic third ventriculostomy (ETV) in children who had previously received shunts and who were experiencing shunt dysfunction is still discussed in terms of efficacy (success rate from 40% to 80%) and safety (0%-32.5% of complications). Reported predictive factors of secondary ETV failure are age, early onset of hydrocephalus, and prematurity. The best surgical strategy in the different subgroups of patients with shunt dysfunction is still debated. Therefore, the authors aimed to identify subgroups of patients in whom shunt treatment was associated with favorable outcome of ETV, to define the role of ETV in patients with global rostral midbrain dysfunction syndrome. This study was a monocentric retrospective case series and a meta-analysis of children who had previously received shunts and who underwent secondary ETV for shunt dysfunction between 2012 and 2022. Clinical and MRI features were examined, along with surgical outcome, etiology of hydrocephalus, and preoperative ETV Success Score. Univariate and multivariate analyses were performed to find predictors of outcome of secondary ETV. Youden's J index was calculated on age distribution to find an optimal age cutoff. Systematic review of the literature and a meta-analysis were performed according to the PRISMA statement. Seventy consecutive patients were included. The overall success rate of secondary ETV was 63%. Primary obstructive hydrocephalus, age ≥ 36 months, and the presence of aqueductal obstruction were predictors of ETV success. Multivariate analysis found that age < 36 months, primary inflammatory hydrocephalus, and presence of fourth ventricular obstruction were associated with ETV failure. All patients with global rostral midbrain dysfunction syndrome experienced clinical and radiological improvement after ETV. The meta-analysis showed that postinflammatory etiology and age < 36 months were predictors of ETV failure. ETV is safe and effective for children with obstructive hydrocephalus experiencing shunt dysfunction, notably in cases of primary obstructive hydrocephalus with aqueductal stenosis, and among children whose age was ≥ 36 months who had postinflammatory hydrocephalus.

The Comparison of Outcome of Ventriculoperitoneal Shunts vs. Endoscopic Third Ventriculostomy in Patients with Idiopathic Normal Pressure Hydrocephalus

Objective: To compare functional outcomes in terms of INPGHS score and overall improvement in patients of iNPH treated with ETV vs. VP shunting. Materials &amp; Methods: A Randomized control trial was conducted for 6 months at the Department of Neurosurgery, Rawalpindi Medical University and Allied Hospitals, Rawalpindi. 62 patients (31 in each group) were enrolled &amp; allocated into two groups. In group A patients ETV was done and in group B VP shunting. Post-operatively, Patients were followed up for 1 month. Results: The mean age of the patients in the ETV &amp; VP shunting groups was 63.19 ± 6.95 &amp; 63 ± 6.82 years respectively. Males were 64.5% (n = 20) in both groups. Improvement was noted in 9 (29%) patients in the ETV group &amp; 15 (48.4%) patients in the latter group (p-value = 0.118). Conclusion: Ventriculoperitoneal shunts are superior to endoscopic third ventriculostomy in terms of functional neurological outcomes and improvement in symptoms. Keywords: Endoscopic Third Ventriculostomy, Ventriculoperitoneal Shunt, Idiopathic Normal Pressure Hydrocephalus Grading Scale (iNPHGS), Aqueductal CSF Stroke Volume (ACSV).

Surgical Outcome of Endoscopic Third Ventriculostomy in Patients Having High ETV Success Score: One-Year Experience at a Tertiary Care Hospital

Background &amp; Objective: Endoscopic third Ventriculostomy (ETV) is an accepted alternative to VP shunt in patients with obstructive hydrocephalus. We will share our experience and outcome.&#x0D; Materials &amp; Methods: Thirty consecutive ETV cases performed by a single surgeon during 1 year in patients with an ETV success score of 60 or higher were included in this study. Patients’ demographics, outcomes, and complications are reported.&#x0D; Results: (60%) were male and 12 (40%) were female. The mean age in our study was 6.1 years ± 9 (mean ± SD). Posterior fossa tumor was the most common etiology in our series (46.6%) followed by aqueductal stenosis (23.3%). Eighty percent of our patients did not experience an ETV failure. The complication rate was 20%. Inadequate ventriculostomy in 6.6% of the patients was the commonest complication.&#x0D; Conclusion: ETV is safe and effective in patients with high ETV success scores.

Effectiveness and success rates of endoscopic third ventriculostomy in patients under 2 years old

Objective: Endoscopic third ventriculostomy (ETV) stands out as an important option in the treatment of hydrocephalus without shunts. Endoscopic third ventriculostomy (ETV) has become more popular due to recent technical developments in endoscopic systems. But the urge of the physician, to provide a shuntfree survival for his patients, leads to performing the procedure in a unsuitable group of patients. Compared with shunt surgery, ETV presents a more physiological solution for the treatment of hydrocephalus. ETV is accepted as the first-line treatment method in many centers in appropriate cases in the treatment of obstructive hydrocephalus. The aim of this study is to examine the results of patients under the age of two underwent endoscopic third ventriculostomy. Methods: 79 patients who underwent ETV between 2011 and 2020 in our clinic and who were under 2 years of age at the time of operation were retrospectively analyzed. Results: 45 of 79 patients were male babies and 34 were female babies. The average age of the patients is 7 months (1 day - 22 months). In 39 (49.3%) patients, there was no need for repeat surgery in their follow-up after ETV. ETV procedure was repeated in 5 (6.3%) patients, and ventriluloperitoneal shunt (VPS) surgery was performed in 2 (2.5%) patients. In 13 patients, ventriculoperitoneal shunt was applied from the anterior and presented with shunt dysfunction. VPS surgery was not performed again after ETV in 3 (23%) of 13 patients after ETV. Conclusions: ETV can also be applied to patients younger than two years of age, and this treatment can give patients the chance to live a life independent of shunt.

Endoscopic third ventriculostomy in patients with myelomeningocele after shunt failure.

Myelomeningocele (MMC) is the most frequent form of spina bifida. Moreover, 90% of patients with MMC have hydrocephalus and require shunt placement. However, shunt failure management in such patients typically involves several shunt revisions, increasing the risk for morbidity and mortality. In this study, we report our experience with endoscopic third ventriculostomy (ETV) in MMC patients with shunts in a Brazilian institution. Patients with MMC who presented with shunt failure and underwent ETV alone between January 1996 and December 2016 were included in this study. Patients who had undergone endoscopic choroid plexus cauterization (CPC) or had non-shunted MMC hydrocephalus were excluded. Various data related to the ETV procedure were collected for each patient, including features, operative characteristics, complications, and ETV success. The follow-up period for the patients was 6-12months. ETV success scores (ETVSSs) were calculated retrospectively for each patient to compare the predicted success of the procedure with the actual success at 6months after ETV. Forty-three MMC patients with shunt failure were included in this study. Of them, 16 (37.2%) had a previous central nervous system (CNS) infection and 4 (9.3%) had complications. Two neuroendoscopies were interrupted, one because of anatomic impossibility due to thickening of the interthalamic adhesion, obliterating the floor of the third ventricle, and another because of intraoperative hemorrhage. One patient developed hyponatremia during the postoperative period, whereas another developed reversible paresis of the oculomotor nerve. The ETVSS predicted a success rate of 49.6% compared with the actual ETV success rate of 53.48% (23 patients) at 6months. At 12months, the actual success rate was 41.9% (18 patients). All patients survived the procedure. Our findings indicate that ETV is an effective procedure for managing MMC-related hydrocephalus after shunt failure. The expertise of the neurosurgeon in neuroendoscopy procedures is often the deciding factor when choosing a management option. Accordingly, less experienced neurosurgeons should be warned of the risks of this procedure.

OBSTRUCTIVE HYDROCEPHALUS;

Introduction: Management of Hydrocephalus has always amazed and challenged clinicians throughout the history of medicine. The traditional treatment for all forms of hydrocephalus has been the implantation of Ventriculoperitoneal Shunt (VPS) system. Because of deployment of implant, this procedure inherently associated with certain common complications, infection approximately 24.6% of all shunt operations. Moreover, the risk of postoperative seizures is 25% and intracranial hemorrhage is 3.5%. Endoscopic Third Ventriculostomy (ETV) is a surgical procedure that allows the Cerebrospinal Fluid (CSF) to flow directly from the third ventricle to the basal cisterns and subarachnoid spaces, ETV has been established as a safe treatment for obstructive hydrocephalus because in this procedure there is no implant is deployed, that’s why rate of post operative complications is low as compare to VPS as intracranial infection found in 8% patient, intracranial hemorrhage in 5%and 1% patient developed seizure post ETV. Objectives: Objective of this study is to determine the frequency of short term complications of endoscopic third ventriculostomy in obstructive hydrocephalus. Study Design: Descriptive case series. Setting: Department of Neurosurgery, Lahore General Hospital, Lahore. Duration with Dates: Six months: from 01-07-2011 to 31-12-2011. Methods: This was a prospective study of in which 45 patients underwent Endoscopic third ventriculostomy for Obstructive hydrocephalus. The outcome of interest was to assess the frequency of complications like infection, hemorrhage and seizures following the ETV in patient with obstructive hydrocephalus. Data was collected on a specially designed Performa. Demographic details, signs and symptoms at presentation, details of post operative evaluation (mortality and neurological deficiency) were noted. Results: A total of 45 patients underwent in ETV for the treatment of obstructive hydrocephalus. Complications were observed in eight (17.8%) cases in which five patients had only one complication and three patients had multiple (two) complications. Regarding type of complication, Infection was observed in six (13.3%) cases, hemorrhage was observed in four (8.9%) cases and wound CSF leakages was seen in only one (2.2%) case. Conclusion: Endoscopic third ventriculostomy is recent advances in the management of obstructive hydrocephalus, it has lesser complications (Infection, Hemorrhage, seizures) and long term failure rate is low as compare to the traditional treatment of obstructive hydrocephalus.

213 Efficacy of Endoscopic Third Ventriculostomy (ETV) After Shunt Malfunction in the Pediatric Age Group

Abstract INTRODUCTION ETV is increasingly used in place of shunt revision for shunt malfunction (secondary ETV). In this meta-analysis, we sought to explore the impact of hydrocephalus aetiology on outcome of secondary versus primary ETV in the pediatric age group. METHODS Systematic and independent MEDLINE searches by two authors. Inclusion criteria: (1) studies including a predominance of children and adolescents ( = 18); (2) description of clinical outcomes after secondary ETV. ETV success was defined as the lack of need for a shunt. RESULTS &gt;Fifteen studies were included. 519 patients underwent a secondary ETV for shunt malfunction (85%) or infection (15%). The mean age was 9.8 years (95% CI 7.9-11.8 years). Aetiology of hydrocephalus was: chiari malformation (31.5%), aqueductal stenosis (29.3%), intraventricular haemorrhage (17.7%), meningitis (13.1%) and tumours (8.4%). The overall ETV success rate was 70.5% over a median follow-up period of 45.5 months (range 1–190 months). For acqueductal stenosis and tumours, there was no significant difference in success rate between primary and secondary ETV (OR = 1.19, 95% CI 0.46-3.11; P = 0.74). Secondary ETV had a significantly higher success rate than primary ETV in patients with hydrocephalus due to chiari malformation (OR = 5.57, 95% CI 2.81-11.00; P &lt; 0.001) and haemorrhage or infection (OR = 5.79, 95% CI 2.46-13.61; P &lt; 0.001). CONCLUSION The efficacy of secondary ETV varies depending on hydrocephalus aetiology. Secondary ETV may be more efficacious than primary ETV in certain disease states due to a state of acquired acqueductal stenosis with chronic CSF diversion.

Role of Endoscopic Third Ventriculostomy in Shunt Malfunction

Background Shunt placement was a standard treatment for patients with hydrocephalus. The risk of shunt malfunction is quite high. Endoscopic third ventriculostomy (ETV) for hydrocephalus is an important advancement for patients with hydrocephalus. The aim is to study the role of ETV in patients with ventriculoperitoneal shunt malfunction. Methods A prospective study of 21 patients with shunt malfunction, who underwent secondary ETV instead of shunt revision, was conducted in Department of Neurosurgery, PGIMER, and Dr. RML Hospital, New Delhi. Patients data included age, cause of hydrocephalus, number of previous shunt surgeries, and outcome after ETV. Shunt was removed in all patients at the time of ETV. Success was defined as shunt independence till the last follow-up. Results There were 17 males and 4 females. The age range was 2 months to 53 years. Eleven patients had communicating and 10 patients had noncommunicating hydrocephalus. Overall success rate of ETV was 61.90% with 80% (8/10) in noncommunicating and 45.45% (5/11) in communicating hydrocephalus. None of the possible contributing factors for successful ETV, including age (p = 0.088), the etiology of hydrocephalus (p = 0.296), and number of previous shunt surgeries (p = 0.399), were statistically significantly correlated with outcome in our series. Overall complication rate was 14.2%. No death was reported. Conclusion ETV is an effective alternative for patients who present with shunt malfunction. Age, etiology, type of hydrocephalus, and number of shunt revisions did not have a significant impact on outcome of ETV.

Endoscopic transventricular exploration with biopsy of the basal cisterns and the role of endoscopic third ventriculostomy in patients suffering with basal cistern meningitis and consecutive hydrocephalus

Objectives: The purpose of this work is to elucidate the efficacy of endoscopic basal cisterns exploration, biopsy, and third ventriculostomy (ETV) in patients with basal cistern meningitis and arachnoiditis.Materials and Methods: The cases and videos of all patients in whom flexible neuroendoscopy was performed during the period of January 2005–June 2012 at the University Hospital ‘Dr. Ignacio Morones Prieto’ in San Luis Potosí, México. A group of 47 patients with radiological diagnosis of basal meningitis, arachnoiditis, and negative cerebrospinal fluid analysis were included.Results: From the 28 (60%) patients with histological diagnosis, 22 (47%) were made from biopsy from the arachnoid membranes of the basal cisterns only, 4 (9%) only from the cerebral cortex, and 2 (4%) from both sites. There were no complications related to the endoscopic procedure. In 23 patients from the 42 with hydrocephalus, ETV was successful. The grade of diagnostic accuracy of both biopsies in detect etiology was 68% (28 of 47 patients), the diagnostic accuracy of arachnoid biopsy was 60%, and diagnostic accuracy of convexity brain biopsy was 21% with 24 and 6 patients, respectively.Discussion: Endoscopic transventricular biopsy of the basal cisterns seems to be a safe and a relatively accurate procedure. As longs as frozen subarachnoid space was not seen, the possibilities of performing ETV in hydrocephalus condition are elevated depending on the causal micro-organism.

Endoscopic Third Ventriculostomy for Patients with Previous Ventriculoperitoneal Shunt Insertion

Background Definitive treatment of hydrocephalus has many options including treatment of the cause, choroid plexus cauterization, ventriculoperitoneal (VP) shunt insertion, and endoscopic third ventriculostomy (ETV). The last two are the most commonly used. In cases of repeated VP shunt complications, ETV is suggested as an alternative option with some doubts regarding the effect of shunt dependency.

Role of Endoscopic Third Ventriculostomy in the Management of Myelomeningocele-Related Hydrocephalus: A Retrospective Study in a Single French Institution

Treatment of hydrocephalus related to myelomeningocele (MM) is debated. Endoscopic third ventriculostomy (ETV) has been proposed with contrasting results. We report our experience in the management of hydrocephalus related to MM and the advantages of ETV. From 1994 to 2012, we treated 97 patients with MM. Seventy patients developed a hydrocephalus needing a surgical treatment. Three types of procedures were used: ETV with concomitant choroid plexus coagulation (CPC), ETV with concomitant ventriculoperitoneal shunt (VPS), or VPS. Thirty-two patients had an ETV with CPC, 20 patients had an ETV and a concomitant VPS, and 18 patients had a VPS. No perioperative complications were reported. Fifty-two patients underwent an ETV. The overall success rate of ETV was approximately 70%. VPS in patients with MM leads to complications. Two common arguments are reported against ETV. The first is the variability of the anatomy of the ventricle leading to possible operative complications. The second is the immaturity of the Pacchioni granulations. For us, the modified anatomy does not prevent performing ETV. Regarding the issue of cerebrospinal fluid absorption in failed ETV, the adjunction of a shunt helps to control hydrocephalus until the maturation of the Pacchioni system. Preoperative imaging helps the surgical decision to predict in which patients the ETV can be realized without risks. ETV in patients with MM is a secure procedure with low rates of failure and no mortality, and it reduces the rate of shunt implantation.

Endoscopic third ventriculostomy for the treatment of hydrocephalus: An alternative to shunting

Endoscopic third ventriculostomy (ETV) is a common alternative method for the management of hydrocephalus in selected patients. A retrospective chart review was conducted to review our experience with ETV for patients with a variety of causes for hydrocephalus. A total of 67 children with median age of 10.8 years (range= 8 weeks to 21 years) underwent 76 ETVs from July 1992 to June 2003. Two procedures were abandoned due to anatomical distortion. The medical records, operative reports, and imaging studies, were retrospectively reviewed with regard to outcome, complications and patency rate. Treatment failure was defined as the need to shunt the patient within 4 weeks of performing the ETV. The overall success rate was 83% with a mean follow-up 40.8 months. Nine patients underwent 11 repeat ETVs at an average interval period of 24 months with a patency rate of 90% following the second procedure. Ten of eleven patients who underwent re-ETV were ultimately shunt-independent. The highest success rates were achieved for obstructive hydrocephalus from midbrain/tectal tumor (100%, n = 4), pineal tumor (100%, n = 3), intraventricular tumor or cyst (100%, n = 2), and post-infectious hydrocephalus (100%, n = 1). Lower patency rates were noted in patients with Chiari malformation (0%, n = 1) and posterior fossa tumors (63%, n = 8). Due to the efficacy of ETV, it should be considered as the primary procedure, rather than ventricular peritoneal shunts, in carefully selected children. The reliability rate is dependent upon the age and etiology of hydrocephalus.

Endoscopic third ventriculostomy (ETV) for idiopathic normal pressure hydrocephalus (iNPH).

Idiopathic normal pressure hydrocephalus (iNPH) is a type of communicating hydrocephalus also known as non-obstructive hydrocephalus. This type of hydrocephalus is caused by impaired cerebrospinal fluid reabsorption without any obstruction in the ventricular system and is associated with normal cerebrospinal fluid pressure. It is characterised clinically by gait disturbance, cognitive dysfunction, and urinary incontinence (known as the Hakim-Adams triad). The exact cause of iNPH is unknown. It may be managed conservatively or treated surgically by inserting a ventriculoperitoneal (VP) or ventriculoatrial (VA) shunt. However, a substantial number of patients do not respond well to surgical treatment, complication rates are high and there is often a need for further surgery. Endoscopic third ventriculostomy (ETV) is an alternative surgical intervention. It has been suggested that ETV may lead to better outcomes, including fewer complications. To determine the effectiveness of ETV for treatment of patients with iNPH compared to conservative therapy, or shunting of CSF using VP or VA shunts.To assess the perioperative and postoperative complication rates in patients with iNPH after ETV compared to conservative therapy, VP or VA shunting. We searched for eligible studies using ALOIS: a comprehensive register of dementia studies, The Cochrane Central Register of Controlled Trials (CENTRAL) and several bibliographic databases such as MEDLINE (Ovid SP), EMBASE (Ovid SP), PsycINFO (Ovid SP), CINAHL (EBSCOhost) and LILACS (BIREME).We also searched the Database of Abstracts of Reviews of Effects (DARE) to identify potentially relevant reviews. The search strategy was adapted for other databases, using the most appropriate controlled vocabulary for each. We did not apply any language or time restrictions. The searches were performed in August 2014. We included randomised controlled trials (RCTs) of ETV treatment of iNPH. Patients had to have at least two symptoms of the Hakim-Adams triad. Exclusion criteria were obstructive causes of hydrocephalus, other significant intracranial pathology and other confirmed causes of dementia. The eligible comparators were conservative treatment or shunting using VP and VA shunts. Two review authors independently screened search results, selected eligible studies, assessed risk of bias and extracted data. We contacted trial authors for additional data. Only one study met the inclusion criteria: an RCT comparing effectiveness of ETV and non-programmable VP shunts in 42 patients with iNPH. The study was conducted in Brazil between 2009 and 2012. The overall study risk of bias was high. The primary outcome in the study was the proportion of patients with improved symptoms one year after surgery, determined as a change of at least two points on the Japanese NPH scale. Due to imprecision in the results, it was not possible to determine whether there was any difference between groups in the proportion of patients who improved 3 or 12 months after surgery (3 months: odds ration (OR) 1.12, 95% confidence interval (CI) 0.26 to 4.76, n = 42; 12 months: OR 2.5, 95% CI 0.62 to 10.11, n = 38). We were unable to estimate the effect of treatment on other efficacy outcomes (cognition, balance, function, gait and mobility) because they were inadequately reported. Of the 26 patients in the VP shunting group, 5 developed subdural hematoma postoperatively, while there were no complications among the 16 patients in the ETV group (OR 0.12, 95% CI 0.01 to 2.3, n = 42), but the estimate was too imprecise to determine whether this was likely to reflect a true difference in complication rates. This was also the case for rates of further surgical intervention (OR 1.4, 95% CI 0.31 to 6.24, n = 42). There were no deaths during the trial. We judged the quality of evidence for all outcomes to be very low because of a high risk of selection, attrition and reporting bias and serious imprecision in the results. The only randomised trial of ETV for iNPH compares it to an intervention which is not a standard practice (VP shunting using a non-programmable valve). The evidence from this study is inconclusive and of very low quality. Clinicians should be aware of the limitations of the evidence. There is a need for more robust research on this topic to be able to determine the effectiveness of ETV in patients with iNPH.

Endoscopic third ventriculostomy in patients with communicating hydrocephalus

Objective To explore the mechanism and indication of endoscopic third ventriculostomy in patients with communicating hydrocephalus.Methods The clinical date of 18 cases of communicating hydrocephalus treated with ETV were analyzed retrospectively.Results 11 patients' MRI showed abnormal enlargement of the fourth ventricle and outward expansion of the cerebral aqueduct outflow like a horn,and among these patients 9 patients obtained satisfying postoperative results.However,the other 7 patients without this imageology character required shunt insertion.Conclusions Endoscopic third ventriculostomy is an effective method for the treatment of communicating hydrocephalus,and the mechanism of proximal extraventricular intracisternal cerebrospinal fluid pathway obstruction could explain.Abnormal enlargement of the fourth ventricle and outward expansion of the cerebral aqueduct outflow like a horn in MRI may be one of the most important indication of ETV in patients with communicating hydrocephalus. Key words: Endoscopes; Hydrocephalus; Third ventricle

Endoscopic Third Ventriculostomy in Patients with Shunt Malfunction

This paper presents data from a retrospective study of endoscopic third ventriculostomy (ETV) in patients with shunt malfunction and proposes a simple and reasonable post-operative protocol that can detect ETV failure. We enrolled 19 consecutive hydrocephalus patients (11 male and 8 female) who were treated with ETV between April 2001 and July 2010 after failure of previously placed shunts. We evaluated for correlations between the success rate of ETV and the following parameters : age at the time of surgery, etiology of hydrocephalus, number of shunt revisions, interval between the initial diagnosis of hydrocephalus or the last shunt placement and ETV, and the indwelling time of external ventricular drainage. At the time of ETV after shunt failure, 14 of the 19 patients were in the pediatric age group and 5 were adults, with ages ranging from 14 months to 42 years (median age, 12 years). The patients had initially been diagnosed with hydrocephalus between the ages of 1 month 24 days and 32 years (median age, 6 years 3 months). The etiology of hydrocephalus was neoplasm in 7 patients; infection in 5; malformation, such as aqueductal stenosis or megacisterna magna in 3; trauma in 1; and unknown in 3. The overall success rate during the median follow-up duration of 1.4 years (9 days to 8.7 years) after secondary ETV was 68.4%. None of the possible contributing factors for successful ETV, including age (p=0.97) and the etiology of hydrocephalus (p=0.79), were statistically correlated with outcomes in our series. The use of ETV in patients with shunt malfunction resulted in shunt independence in 68.4% of cases. Age, etiology of hydrocephalus, and other contributing factors were not statistically correlated with ETV success. External ventricular drainage management during the immediate post-ETV period is a good means of detecting ETV failure.

Ostomy closure and the role of repeat endoscopic third ventriculostomy (re-ETV) in failed ETV procedures

Endoscopic third ventriculostomy (ETV) has replaced shunt surgery for several indications. Failure of ETV secondary to restenosis can result in recurrence of symptoms of raised intracranial pressure. To analyze the rates of restenosis due to ostomy closure and factors resulting in failures and to assess the role of re-ETV in such cases. Re-ETV was performed after counselling and obtaining informed consent. The technique of re-ETV was essentially the same as in primary ETV. Video analysis of primary ETV was performed before selecting a patient for re-ETV. Factors analyzed included age, gender, etiology of hydrocephalus, cerebrospinal fluid (CSF) findings, presence of shunt tube and adequacy of ETV and bleeding at the time of ETV. Thirty-two patients underwent re-ETV. The mean interval between the first ETV and re-ETV was 1.4 years (3 days to 2.9 years). Overall failure of ETV due to restenosis was 8.78%. The technical success rate of performing re-ETV was 93.2%. The overall clinical recovery following surgery was observed in 89% of the patients, three from early and 25 from delayed ETV failures. The radiological recovery was seen in 20 (63%) patients. The good flow of CSF via the re-ETV site was documented with cine mode magnetic resonance imaging (MRI) in seven patients. Unlike primary ETV, the success of re-ETV in children aged less than 2 years was 90% (P < 0.005). There were 56.25% failure of ETV in patients with previous infection or foreign body within the ventricle (P < 0.001). While the chances of restenosis were high in the procedure with some infections, the outcome was equally better. Gender of the patients and CSF findings had no influence on ostomy closure. re-ETV can be considered in carefully selected patients of failed ETV. It is more useful in delayed ETV failures and can be offered before a patient is advised VP shunt.

Endoscopic Third Ventriculostomy in Patients with Secondary Triventricular Hydrocephalus from a Haemorrhage or Ischaemia in the Posterior Cranial Fossa

The aim of this project was to evaluate the efficacy of endoscopic third ventriculostomy (ETV) in the treatment of acute hydrocephalus caused by a haemorrhage or ischaemia in the posterior cranial fossa. 21 patients who had acute triventricular hydrocephalus resulting from ischaemia in 8 cases, and from cerebellar haemorrhage in 13 cases were treated with endoscopic third ventriculostomy. This series was compared with a control group of 30 patients, with clinical neuroradiological characteristics comparable to the preceding group (18 acute post-haemorrhage hydrocephalus and 12 post-ischaemia in the posterior cranial fossa), treated by external ventricular drainage (EVD). All patients were monitored clinically and by brain computed axial tomography (CT) to measure the dimensions of the lateral and third ventricles. The criteria used to define efficacy were based on the image of the postoperative cerebral CT scan. No patient suffered haemorrhagic complications from surgical procedures or additional neurological deficits. There was no postoperative mortality or added morbidity. In all cases there was an improvement of intracranial hypertension. Clinical improvement was associated with a reduction of the ventricular dimensions documented by serial CT scans. We consider that, in selected cases, ETV can be suggested as the first choice treatment instead of the classic EVD. In the overall management of such patients, ETV has no or a very low rate of complications and allows shorter hospitalisation and earlier transfer to rehabilitative structures.