Endoscopic Third Ventriculostomy in the Pediatric Patient

*Juan Bosco Gonzalez*

#### **Abstract**

Endoscopic third ventriculostomy (ETV) is one of the two surgical procedures for the treatment of hydrocephalus, its main indication being obstructive hydrocephalus. Its efficacy is related to the age of the patient and the etiology of the hydrocephalus; however, more studies appear where ETV has gained ground beyond obstructive hydrocephalus, and despite the fact that there is still a lack of evidence to issue a grade of recommendation. ETV has shown to be useful even in communicating hydrocephalus and in patients younger than 6 months. This chapter shows a summary of the most important points to take into account in this procedure. Likewise, the third endoscopic ventriculostomy gives us the opportunity to continue studying the intraventricular dynamics of the cerebrospinal fluid, the ventricular anatomy, the pathology around or within the ventricular system and other details that can open doors for us to understand the concept of hydrocephalus, improve its treatment and improve known surgical techniques.

**Keywords:** endoscopic third ventriculostomy, hydrocephalus, choroid plexus coagulation, VP shunt, ventricular anatomy

#### **1. Introduction**

It was the German urologist Maximilian Carl-Friedrich Nitze who introduced the modern endoscope (**Figure 1**) [1, 2]. Viktor Lespinasse was the first neuroendoscopist in 1910. He treated two children with hydrocephalus by using a urethroscope to access the lateral ventricles, [1–4]. In 1922, Dandy described ventriculoscopy [5, 6], as well as a technique for performing the third ventriculostomy as a treatment for hydrocephalus *via* frontal and subtemporal. In another hand, William Mixter was the first surgeon to combine diagnostic ventriculoscopy with ventriculostomy. In 1923, he used a urethroscope to perform an ETV to treat noncommunicating hydrocephalus in a 9-yearold girl [7, 8].

By 1932, Dandy was again attempting an endoscopic choroid plexectomy [2].

In 1934, Tracy Putnam, following the work of Dandy and Mixter, developed instruments for intracranial procedures for the ventriculoscope. In 1935, John Scarff made modifications to Putnam's ventriculoscope, adding an irrigation system [8, 9]. In 1947, H. F. McNickle reported two cases of communicating hydrocephalus that responded to ventriculostomy [10].

**Figure 1.**



#### **Table 1.**

*Comparison of serum and cerebrospinal fluid.*

There were two reasons why neuroendoscopy had a recess at this time: one was Dandy's results, perhaps they were not the most encouraging with the first designs, and the second was in 1949 Frank Nulsen and Eugene Spitz introduced the concept of the shunt. In 1955, John Holter added a one-way valve to the device; Holter's invention was inspired by the death of his son, Casey, from the complications of myelomeningocele and hydrocephalus (**Table 1**) [2, 3].
