Endoscopic third ventriculostomy - A physiological alternative to shunts as treatment for obstructive hydrocephalus in children

Background: The standard treatment for hydrocephalus is a ventriculoperitoneal shunt which is associated with high rate long-term morbidity. Seeking alternative treatments, neuroendoscopic third ventriculostomies (ETV) have been performed in patients with obstructive hydrocephalus. During this procedure, the third ventricular floor is perforated thus bypassing the pathological obstruction. In this procedure, no hardware is left and fluid pressures are more physiologically balanced compared to shunted cases. Study goals: To present our experience with endoscopic third ventriculostomy (ETV) in patients below the age of 18 years. Methods: Retrospective analysis of 112 ETV's: in 89 cases (group A) the hydrocephalus was secondary to aqueductal stenosis (primary or secondary). In 23 cases (group B) the hydrocephalus was secondary to other reasons. Results: A total of 70% of patients in group A did not need a shunt during their follow-up in comparison with 56% in group B. In a multivariable analysis - the only significant predictor for failure of the ETV was age below two years at the time of the procedure. Two patients died perioperatively. Both suffered from malignant disseminated tumors. One death was related to oncological reasons the other death was related to intraventricular bleeding secondary to the procedure. Perioperative morbidity was 23% (decreased to 8% during recent years). No permanent morbidity occurred. Conclusions: Endoscopic third ventriculostomy is the treatment of choice for obstructive hydrocephalus secondary to aqueductal stenosis among patients older than two years. In younger patients, future studies are needed to prove whether a shunt or a ventriculostomy are the preferred treatment.