ETV Presentation

Endoscopic third ventriculostomy

Dr Vishal Gajbhiye Dr Yadav YR

NSCB Govt Medical College, Jabalpur, MP


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.


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.


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.


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.


The primary requirement for ventriculostomy:

• Non communication hydrocephalus

• ventricular width of 7 mm or more

• No previous radiation treatment


Procedure


Skin incision

MRI Scan is Preferred


Steps of surgery

BurrHolesite


Identification of foramen of Monro


No significant movement


Endoscopic third ventriculostomy procedure:

• Hole in the floor of 3rd ventricle was made between Mammllary bodies and Infundibular recess


Interpeduncular cistern

Mammllary Bodies

Infundibular recess

Third Ventricle


Mammllary Bodies

Translucent Area


Mammllary bodies

ETV Hole

Infundibular recess


Lilliquest membrane should be ruptured

Basilar Artery

Brain stem perforators

Posterior Cerebral Artery


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.


• 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%)


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


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.


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


ETV Presentation

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