**Presentation of the Success Rate of ETV in Distinct Indication Cases of Hydrocephalus Indication Cases of Hydrocephalus**

**Presentation of the Success Rate of ETV in Distinct** 

DOI: 10.5772/intechopen.72889

Joachim M.K. Oertel and Akos Csokonay Additional information is available at the end of the chapter

Joachim M.K. Oertel and Akos Csokonay

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.72889

#### **Abstract**

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Endoscopic third ventriculostomy (ETV) is an endoscopic fenestration between the floor of the third ventricle and subarachnoid space. It is the procedure of choice for obstructive hydrocephalus (HC). The indication includes obstructive HC caused by aqueduct stenosis, tumors, brain infarction, cystic lesions, hematoma, postinfectious and posthemorrhagic HC, malformation of the fourth ventricle, and further uncommon indications. In this chapter, surgical techniques and the success rate of ETV in distinct indications will be presented and discussed. The overall success rate of ETV is reported at 60–90%. The outcome of the procedure depends highly on the underlying pathology and age. A very favorable outcome is reported in case of aqueduct stenosis (67–93.5%). High success rate is observed in case of cerebellar infarction (86%), tumors (56–81%), and intraventricular cysts (56–95%). In case of intraventricular hemorrhage (43–73%), infection (60–64%), anatomical aberration (21–80%), and communicating HC (65–72%), a significantly inferior success rate is reported. It is well known that ETV has a lower success rate in children (68–71%) compared to adults (70– 90%). The overall high clinical success rate in short-term and long-term follow-up confirms that ETV is the gold standard for treatment of occlusive HC. It is effective, safe, and simple.

**Keywords:** third ventriculostomy, hydrocephalus, neuroendoscopy, success rate, indication

#### **1. Introduction**

#### **1.1. Classification of hydrocephalus**

Walter Dandy classified hydrocephalus as "communicating" or "noncommunicating" type based on examinations with ventricle and lumbar puncture in 1913. He considered hydrocephalus as "noncommunicating" or "obstructive" if after the injection of a colored solution in the lateral

> © 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ventricle, the dye did not appear in the spinal fluid removed by lumbar puncture. In contrast, if this solution appeared, hydrocephalus was classified as "communicating" [1]. This classification was simple and useful to understand hydrocephalus, but first was found inadequate to understand the pathophysiology [2]. The proposed classification is hydrocephalus without obstruction (true communicating hydrocephalus) in case of choroid plexus papilloma and with obstruction at the level of venous outflow (skull base anomalies and congenital heart disease), arachnoid granulations (hemorrhage and infection), basal cisterns (hemorrhage and infection), outlets of fourth ventricle (infection and Chiari malformation), Sylvian aqueduct (congenital anomalies and tumor compression), and foramen of Monro (congenital anomalies, tumor, and postshunt ventricular asymmetry) [2]. Nonetheless, the classic nomenclature remained in clinical practice due to its simplicity.

the third ventricle and the subarachnoid space with preserved CSF absorption from subarachnoid space into the venous system [2, 14, 15]. In case of obstruction at the level of Pacchionian

Presentation of the Success Rate of ETV in Distinct Indication Cases of Hydrocephalus

http://dx.doi.org/10.5772/intechopen.72889

129

One of most common etiology of obstructive hydrocephalus is the aqueduct stenosis [16, 17] (**Figures 1** and **2**). The obstruction can be congenital or acquired. In 75% of cases, it is idiopathic. In remaining cases, it can be caused by infections, hemorrhages, or malformation of the central nervous system or can be related to genetic factors [16]. The first and best treatment option for this is ETV. Ventriculostomy has a good outcome regardless of etiology of the stenosis, whether it is congenital, acquired, or tumor-related obstruction [14]. However, the success rate is different in certain cases of the aqueduct stenosis. It depends on the etiology, age, clinical, and radiological characteristics [13]. In certain cases, as an alternative treatment or even simultaneous, aqueductoplasty may be performed [7, 18]. The result of aqueductoplasty is comparable with the success of ETV. As alternative treatment, it may be useful in case of thick and tough floor of the third ventricle preventing the hypothalamus or vessel injuries [18].

granulation and venous outflow, performing ETV is definitely not recommended [14].

**2.1. Aqueduct stenosis**

**Figure 1.** Aqueduct stenosis (MRI scan TRUFI sequence).

#### **1.2. History of neuroendoscopy**

The first neuroendoscopic procedure was introduced in 1910, when L'Espinasse performed a cauterization of plexus choroideus with a cystoscope. The other pioneer in neuroendoscopy was Walter Dandy. He published his results in 1913. Clarifying the physiology, Dandy performed plexectomy to cease the cerebrospinal fluid (CSF) production as a treatment for communicating hydrocephalus. In case of obstruction, he created an internal bypass for communication between the third ventricle and cortical subarachnoid space [2, 3].

The first endoscopic third ventriculostomy (ETV) was performed by William Mixter in 1923. This successful technique later served as a model for modern neuroendoscopy. He performed a perforation of the third ventricle floor by an intraventricular approach through the foramen of Monro. The invention of Hopkins optics, cold light sources, and digital cameras was a great development in the history of endoscopy. Following technical development and clinical application, neuroendoscopy spread over the world [3].

#### **1.3. Endoscopic third ventriculostomy nowadays**

For obstructive hydrocephalus, endoscopic third ventriculostomy is the procedure of choice. This is an endoscopic fenestration between the floor of third ventricle and subarachnoid space. The CSF flow can be restored and balanced out [4]. This procedure is considered effective, safe, and simple. The complication rate is lower as it has a lower infection rate; there is no foreign material and no overdrainage compared with shunt [4].

Nowadays, the use and role of endoscopic ventriculostomy expand continuously. It remains challenging to estimate and define the success of the procedure [5], even though many studies have overall focused on this topic [5–14].
