Endoscopic third ventriculostomy

Endoscopic third ventriculostomy (ETV) is a surgical procedure for treatment of hydrocephalus in which an opening is created in the floor of the third ventricle using an endoscope placed within the ventricular system through a burr hole. This allows the cerebrospinal fluid to flow directly to the basal cisterns, bypassing the obstruction. Specifically, the opening is created in the translucent tuber cinereum on the third ventricular floor.^[1]

Endoscopic third ventriculostomy
Specialty	neurosurgery
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Medical uses

The ETV procedure is used as an alternative to a cerebral shunt^[2] mainly to treat certain forms of noncommunicating obstructive hydrocephalus (such as aqueductal stenosis), but since the ETV was introduced as an accepted treatment modality the range of etiologies for which it is used has grown significantly. Whereas at first it was almost exclusively performed in patients with noncommunicating obstructive hydrocephalus (e.g. aqueductal stenosis or intracerebral tumor), in the present day patients with communicating obstructive hydrocephalus (e.g. post intracranial hemorrhage or post intracranial infection) also may be eligible for treatment by means of ETV.^{[citation needed]}

Complications

A major advantage of performing an endoscopic third ventriculostomy over placement of a cerebrospinal fluid shunt is the absence of an implanted foreign body. A shunt has risk of infection and failure for which subsequent surgery is needed. Complications of ETV include hemorrhage (the most severe being due to basilar artery rupture), injury to neural structures (e.g. hypothalamus, pituitary gland or fornix of the brain), and late sudden deterioration.^[3] Infection, hematoma, and cerebrospinal fluid leaks may present in the direct postoperative period.

Failure of treatment

Failure of the ETV occurs. This can be due to occlusion of the ventriculostomy (e.g. closure of the ventriculostomy, formation of subarachnoid membranes in the pontine cistern or other mechanisms). Although 60 - 90% of failures occur in the first few months after treatment, long-term failure also occurs (failures occurring after 7 years have been reported).^[4] In a very small subgroup of patients a complication of ETV can be rapid late deterioration.^[5] The mechanism is not clear.

Alternative treatment

When it is not possible to perform an ETV for different reasons, an alternative treatment is opening the lamina terminalis anterior to the third ventricle.^[6] The effectiveness of this approach is not certain.^[7]

The surgical treatment options for hydrocephalus are, as previously mentioned, implantation of a cerebral shunt and ETV. Especially in the youngest age group (younger than two years of age) it remains uncertain what is the superior treatment modality. Currently, a large international, multicenter study is conducted to address this issue. Patients under the age of two, diagnosed with aqueductal stenosis without a history of preterm birth or other associated brain anomalies are being included (International Infant Hydrocephalus Study).^[8][9]

Combined with choroid plexus cauterization

There is a discussion regarding the additional benefit of combining endoscopic third ventriculostomy with choroid plexus cauterization. This combined procedure is referred by the abbreviation "ETV/CPC" and has also been called the "Warf Procedure"^[10] after Dr. Benjamin Warf. There have been research studies published about the experience of authors with this procedure. The lion's share of the data that show favorable results is reported on patients in Africa.^[11] More recent studies from research groups in Western countries also show that the combination of ETV with choroid plexus cauterization seems to be effective, safe, and durable,^[12] and that predictions for success are similar to those of ETV alone.^[13] The degree of choroid plexus cauterization in infants might be dependent on the experience of the neurosurgeon (learning curve) and thus surgeons training might improve results.^[14] The ETV/CPC procedure is now being performed in a number of hospitals in US and Canadian cities, including Seattle, Washington; Houston, Texas; Calgary, Alberta; Toronto, Ontario; Salt Lake City, Utah; and Boston, Massachusetts.^[15]

Prediction of ETV success

The chances of success of treatment of a pediatric patient can be calculated using the ETV success score (ETVSS).^[16][17][18] The ETVSS is derived from patient age, etiology of hydrocephalus and history of previous cerebrospinal fluid shunt (e.g. ventriculo-peritoneal shunt). The percentage probability of ETV success = Age score + Etiology score + Previous shunt score. A two years old patient with hydrocephalus due to aqueductal stenosis, without previous shunt would have an 80% chance of success (40 for age + 30 for etiology + 10 for no previous shunt = 80).

ETVSS table^[16]

Score	Age	Etiology	Previous Shunt
0	< 1 month	Post-infectious	Previous shunt
10	1 month to < 6 months		No previous shunt
20		Myelomeningocele, intraventricular hemorrhage, non-tectal brain tumor
30	6 months to < 1 year	Aqueductal stenosis, tectal brain tumor, other etiology
40	1 year to < 10 years
50	≥ 10 years

The ETVSS was derived and validated without the use of adult data and it has inadequate discriminative ability in mixed adult and pediatric populations.^[19]

Second ETV

After a patient gets readmitted with recurrent clinical and radiological symptomatology of hydrocephalus, it is unclear what the next step in treatment should be. Implantation of a cerebrospinal fluid shunt or repeat ETV. Data suggest that a second ETV might be worthwhile if implantation of cerebrospinal fluid shunt can be avoided.^[20][21]

Training ETV

In most countries and neurosurgical centres, the ETV procedure is part of the basic neurosurgery training program. For the sake of teaching and practicing, various simulation models have been developed. Virtual reality simulators,^[22] and synthetic simulators.^[23][24] This allows neurosurgical trainees to practice skills in a low-risk environment. Educators can select either a virtual reality simulator or a physical model for the training of residents, the selection should be based on educational objectives. Where training focused on anatomy and using anatomical landmarks for decision making may better be aided with virtual reality model, the focus on familiarizing the resident with endoscopic equipment and developing manual dexterity may be better learned on a physical model.^[25] The technical skill and competency of a trainee can be evaluated using the Neuro-Endoscopic Ventriculostomy Assessment Tool (NEVAT).^[26]

References

1. Kahle, Kristopher T; Kulkarni, Abhaya V; Limbrick, David D; Warf, Benjamin C (2016). "Hydrocephalus in children". The Lancet. 387 (10020): 788–99. doi:10.1016/s0140-6736(15)60694-8. PMID 26256071. S2CID 27947722.
2. Hydrocephalus and Treatment: Shunts and Endoscopic Third Ventriculostomy, AboutKidsHealth.ca
3. Bouras, T.; Sgouros, S. (2013). "Complications of endoscopic third ventriculostomy". Journal of Neurosurgery. 79 (2 Supple): e9–12. doi:10.1016/j.wneu.2012.02.014. PMID 22381818.
4. Vulcu, Sonja; Eickele, Leonie; Cinalli, Giuseppe; Wagner, Wolfgang; Oertel, Joachim (2015-07-31). "Long-term results of endoscopic third ventriculostomy: an outcome analysis". Journal of Neurosurgery. 123 (6): 1456–1462. doi:10.3171/2014.11.jns14414. PMID 26230473.
5. Drake, J.; Chumas, P.; Kestle, J.; Pierre-Kahn, A.; Vinchon, M.; Brown, J.; Pollack, I.F.; Arai, H. (2006). "Late rapid deterioration after endoscopic third ventriculostomy: additional cases and review of the literature". Journal of Neurosurgery. 105 (2 Supple): 118–26. doi:10.3171/ped.2006.105.2.118. PMID 16922073. S2CID 41357365.
6. Oertel, Joachim M. K.; Vulcu, Sonja; Schroeder, Henry W. S.; Konerding, Moritz A.; Wagner, Wolfgang; Gaab, Michael R. (2010). "Endoscopic transventricular third ventriculostomy through the lamina terminalis". Journal of Neurosurgery. 113 (6): 1261–9. doi:10.3171/2010.6.JNS09491. PMID 20707616. S2CID 9327180.
7. Komotar, Ricardo J.; Hahn, David K.; Kim, Grace H.; Starke, Robert M.; Garrett, Matthew C.; Merkow, Maxwell B.; Otten, Marc L.; Sciacca, Robert R.; Connolly, E. Sander (2009). "Efficacy of lamina terminalis fenestration in reducing shunt-dependent hydrocephalus following aneurysmal subarachnoid hemorrhage: A systematic review". Journal of Neurosurgery. 111 (1): 147–54. doi:10.3171/2009.1.JNS0821. PMID 19284236. S2CID 28475913.
8. Sgouros, S.; Kulkharni, A. V.; Constantini, S. (2005-10-15). "The international infant hydrocephalus study: concept and rational". Child's Nervous System. 22 (4): 338–345. doi:10.1007/s00381-005-1253-y. ISSN 0256-7040. PMID 16228238. S2CID 25533719.
9. Constantini, S.; Sgouros, S.; Kulkarni, A. (2013). "Neuroendoscopy in the youngest age group". World Neurosurgery. 79 (2 Supple): S23.e1–11. doi:10.1016/j.wneu.2012.02.003. PMID 22381849.
10. "Neurosurgeons challenged to eliminate all infant deaths from hydrocephalus". EurekAlert. Retrieved 14 January 2016.
11. Warf, B.C.; Tracy, S.; Mugamba, J. (2012). "Long-term outcome for endoscopic third ventriculostomy alone or in combination with choroid plexus cauterization for congenital aqueductal stenosis in African infants". Journal of Neurosurgery. Pediatrics. 10 (2): 108–11. doi:10.3171/2012.4.PEDS1253. PMID 22747094.
12. Stone, S.S.; Warf, B.C. (2014). "Combined endoscopic third ventriculostomy and choroid plexus cauterization as primary treatment for infant hydrocephalus: a prospective North American series". Journal of Neurosurgery. Pediatrics. 14 (5): 439–46. doi:10.3171/2014.7.PEDS14152. PMID 25171723.
13. Riva-Cambrin, Jay. "ETV+CPC Success and Evolving Indications over Time: A Prospective HCRN Study". Hydrocephalus Clinical Research Network. Retrieved 7 March 2016.
14. Kulkarni, A.V.; Riva-Cambrin, J.; Browd, S.R.; Drake, J.M.; Holubkov, R.; Kestle, J.R.; Limbrick, D.D.; Rozzelle, C.J.; Simon, T.D.; Tamber, M.S.; Wellons, J.C.3rd.; Whitehead, W.E.; Hydrocephalus Clinical Research Network. (2014). "Endoscopic third ventriculostomy and choroid plexus cauterization in infants with hydrocephalus: a retrospective Hydrocephalus Clinical Research Network study". Journal of Neurosurgery. Pediatrics. 14 (3): 224–9. doi:10.3171/2014.6.PEDS13492. PMID 24995823.{{cite journal}}: CS1 maint: numeric names: authors list (link)
15. Ruparell, Asha. "New neurosurgery saves lives in Calgary by treating hydrocephalus, 'water in the brain'". Global News. Retrieved 25 May 2016.
16. Kulkarni, A.V.; Drake, J.M.; Mallucci, C.L.; Sgouros, S.; Roth, J.; Constantini, S.; Canadian Pediatric Neurosurgery Study Group (2009). "Endoscopic third ventriculostomy in the treatment of childhood hydrocephalus". Journal of Pediatrics. 155 (2): 254–9. doi:10.1016/j.jpeds.2009.02.048. PMID 19446842.
17. Durnford, Andrew J.; Kirkham, Fenella J.; Mathad, Nijaguna; Sparrow, Owen C. E. (2011-11-01). "Endoscopic third ventriculostomy in the treatment of childhood hydrocephalus: validation of a success score that predicts long-term outcome". Journal of Neurosurgery: Pediatrics. 8 (5): 489–493. doi:10.3171/2011.8.PEDS1166. ISSN 1933-0707. PMID 22044375.
18. Breimer, G. E.; Sival, D. A.; Brusse-Keizer, M. G. J.; Hoving, E. W. (2013-05-05). "An external validation of the ETVSS for both short-term and long-term predictive adequacy in 104 pediatric patients". Child's Nervous System. 29 (8): 1305–1311. doi:10.1007/s00381-013-2122-8. ISSN 0256-7040. PMID 23644629. S2CID 24475766.
19. Labidi, M.; Lavoie, P.; Lapointe, G.; Obaid, D.; Weil, A.G.; Bojanowski, M.W.; Turmel, A. (2015-07-24). "Predicting success of endoscopic third ventriculostomy: validation of the ETV Success Score in a mixed population of adult and pediatric patients". Journal of Neurosurgery. 123 (6): 1447–1455. doi:10.3171/2014.12.JNS141240. PMID 26207604.
20. Peretta, P.; Cinalli, G.; Spennato, P.; Ragazzi, P.; Rugierro, C.; Aliberti, F.; Carlino, C.; Cianciulli, E. (2009). "Long-term results of a second endoscopic third ventriculostomy in children: retrospective analysis of 40 cases". Neurosurgery. 65 (3): 539–47. doi:10.1227/01.NEU.0000350228.08523.D1. PMID 19687699. S2CID 22505364.
21. Marano, Paul J.; Stone, Scellig S. D.; Mugamba, John; Ssenyonga, Peter; Warf, Ezra B.; Warf, Benjamin C. (2015-02-06). "Reopening of an obstructed third ventriculostomy: long-term success and factors affecting outcome in 215 infants". Journal of Neurosurgery: Pediatrics. 15 (4): 399–405. doi:10.3171/2014.10.peds14250. PMID 25658247.
22. Choudhury, N.; Gelinas-Phaneuf, F.; Delorme, S.; Del Maestro, R. (2013). "Fundamentals of neurosurgery: virtual reality tasks for training and evaluation of technical skills". World Neurosurgery. 80 (5): e9–19. doi:10.1016/j.wneu.2012.08.022. PMID 23178917. S2CID 3028199.
23. Breimer, G.E.; Bodani, V.; Looi, T.; Drake, J.M. (2015). "Design and evaluation of a new synthetic brain simulator for endoscopic third ventriculostomy". Journal of Neurosurgery. Pediatrics. 15 (1): 82–8. doi:10.3171/2014.9.PEDS1447. PMID 25360853. S2CID 10586172.
24. Zymberg, S.; Vaz-Guimaraes Filho, F.; Lyra, M. (2010). "Neuroendoscopic training: presentation of a new real simulator". Minimally Invasive Neurosurgery. 53 (1): 44–6. doi:10.1055/s-0029-1246169. PMID 20376746. S2CID 37521372.
25. Breimer, Gerben E.; Haji, Faizal A.; Bodani, Vivek; Cunningham, Melissa S.; Lopez-Rios, Adriana-Lucia; Okrainec, Allan; Drake, James M. (June 2016). "Simulation-based Education for Endoscopic Third Ventriculostomy". Operative Neurosurgery. 13 (1): 89–95. doi:10.1227/NEU.0000000000001317. PMID 28931258.
26. Breimer, Gerben E.; Haji, Faizal A.; Hoving, Eelco W.; Drake, James M. (2015-05-01). "Development and content validation of performance assessments for endoscopic third ventriculostomy". Child's Nervous System. 31 (8): 1247–1259. doi:10.1007/s00381-015-2716-4. ISSN 0256-7040. PMID 25930722. S2CID 24043065.

External links

• Video and more about the ETV procedure from an article on Medscape