Endoscopic Third Ventriculostomy in Obstructive Hydrocephalus: Surgical Technique and Pitfalls
Background: Reviewing our experience in the variety of pathological entities causing obstructive hydrocephalous, we evaluate the effectiveness of endoscopic treatment, with particular attention to surgical technique, nuances, and pitfalls.
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Abstract Background: Reviewing our experience in the variety of pathological entities causing obstructive hydrocephalous, we evaluate the effectiveness of endoscopic treatment, with particular attention to surgical technique, nuances, and pitfalls. Materials and methods: We reviewed the cases of 57 consecutive patients with obstructive hydrocephalus of various origins in the last 9 years. They were treated by endoscopic third ventriculostomy (ETV). A septostomy was also performed in ten cases. Operative videos were reassessed, and surgical nuances reconsidered. Results: ETV was accomplished in all but three cases. The overall rate of good results (shunt-independent patients with clinical remission or improvement) was 81.5% (44/54). From ten patients with ETV failure, five were re-ETVed successfully, and five were shunted. Patients with benign aqueductal stenosis and tumor compressing the aqueduct received the greatest benefit from the ETV. There were no permanent morbidities or any mortality. Fundamentals of preoperative planning, postoperative evaluation, and technical pitfalls have been considered. Conclusion: ETV for obstructive hydrocephalus of various origins is safe and effective, and should be considered as a first-line treatment. Familiarity with the ventricular anatomy and its variations in hydrocephalus is key to success. Preoperative planning is mandatory. Awareness of potential pitfalls minimizes the risk. Keywords Endoscopic third ventriculostomy (ETV) • Obstructive hydrocephalus • Aqueductal stenosis • Pitfalls • Cine MRI
Introduction The first ever endoscopic third ventriculostomy (ETV) was performed in 1923 by William Mixter, an urologist who used an urethroscope for the purpose [12]. Tracy J. Putnam then borrowed this urethroscope and modified it to optimize its use for the ventricular system. He specifically designed his ventriculoscope for cauterization of the choroid plexus in children with hydrocephalus [15]. Until the 1950s, various efforts were made to improve the technique, but technical limitations of the endoscope led to high mortality and morbidity rates [6]. At that point, valve-regulated shunt systems were introduced and gained great popularity. Since then they have been widely used to treat hydrocephalous. Nevertheless, high complication and failure rates have been reported, and an ideal shunt system still does not exist. More recently, in the 1980s and first half of the 1990s, the concept of minimally invasive neurosurgery led to a renewed interest in neuroendoscopy [6]. Since then numerous indications for ETV have been established, and the procedure has become the treatment of choice for obstructive hydrocephalus [2, 5–7, 9, 10, 21]. In the present study, the authors report their experience in treating obstructive hydrocephalus of various origins by ETV. The effectiveness of endoscopic treatment has been evaluated within the various patient subgroups in terms of etiology. Particular attention has been paid to the technique’s nuances and pitfalls, and for that purpose all operative v
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