Over the last 15 years, neuroendoscopy has grown in a big way across India. There are several centers practicing neuroendoscopy for various cranial and spinal procedures. A group of like-minded neurosurgeons in India, interested in neuroendoscopy, came together informally to create a study group in 2005 to discuss and exchange their ideas and experience. This later paved the way for the official formation of Neuroendoscopy Study Group of India.

1. 1
With wide experience of neurosurgeons across the globe
and encouraging results, the endoscopic treatment of hydro-
cephalus has made a mark of universal acceptance. From
what was considered as treatment option for hydrocepha-
lus due to aqueductal stenosis only, it has had ramifications
in all types of hydrocephalus. Most of the educated patients
ask for the option of endoscopic treatments. Even those who
have had insertion of ventriculoperitoneal (VP) shunt pre-
viously often come to explore the possibility of removal of
shunt and substituted treatment with endoscope.
The additional advantage of endoscope has been a bet-
ter understanding of ventricular anatomy, the response of
ependyma to foreign body, and perhaps improved knowl-
edge of cerebrospinal fluid (CSF) dynamics.
The VP shunt has done a remarkable service to the patient
of hydrocephalus for the last seven decades. However, popu-
larity of shunt has been severely dented by endoscope and
endoscopy may completely replace shunt over a decade time
at some of the centers. VP shunt may perhaps have a role left
over in the treatment of failed endoscopic third ventriculos-
tomy (ETV).
The current indications, success, and complications are
changing every 5 years. The present understanding has been
summarized here for the benefits of the students.
History
Bozzinni (1806) is credited for visualization of internal
organs using candle lights. Original efforts to see inside brain
was made by Lespinasse in 1910 using cystoscope.1
Dandy,
the father of neuroendoscopy, attempted endoscopic fulgu-
ration of choroid plexus with 80% mortality.2
Mixter (1923)
did first third ventriculocisternotomy.3
The major revolu-
tion in neuroendoscopy was the development of Hopkins
solid rod system in 1960. Since then several modifications
of endoscope are being introduced in the market. Another
advancement in endoscopy had been the development of
3 chip CCD camera (above 800 horizontal lines) and high-
resolution monitor for better image quality. Large screen
monitor results in image pixilation. For better image, the
resolution of monitor shall not exceed that of camera. Cur-
rently, the evolution of three-dimensional (3D) endoscope
may provide a superior orientation ability and optics. Xenon
light is superior to halogen for neuroendoscopy.
Types of Endoscopic Procedures Used
in Hydrocephalus
Endoscopic Third Ventriculostomy
The most commonly used procedure which is currently per-
formed for all types of hydrocephalus. The opening is made
in the floor of third ventricle and after opening of second
(Lilliquest) or third membrane communication is estab-
lished between third ventricle and prepontine/interpedun-
cular cisterns.
The site of burr hole and site of ETV is best calculated
on mid-sagittal T1 sequence of magnetic resonance imaging
(MRI). We select our burr hole in such a manner that it forms
a straight line with point of perforation of the third ventricle.
The burr hole site may have to be modified if ETV is to be
combined with aqueductoplasty. Virtual 3D MR reconstruc-
tion may be helpful for the beginners.4
Perforation of the floor is done with blunt tip of cautery
without pressing the paddle. Further enlargement of floor
is done with 3F Fogarty single balloon catheter. Sometime,
double balloon catheter or angioplasty catheter with cylin-
drical balloon can also be used.
It is mandatory to examine second or third membrane
which needs to be opened for the success of ETV. To and fro
movements of the margins of the ostomy are not necessary
indicator of adequate ETV. Sometime, second membrane can
be present as low as mid-basilar point.
The clinical success of ETV after a satisfactory anatomi-
cal communication is dependent on normal absorption of
CSF in the brain. There are no noninvasive tests available to
document the adequacy of normal CSF absorption; hence,
the success of ETV cannot be entirely predicted in all cases.
The clinical betterment following ETV is determined
by several factors, the age of the patient remains the most
important.5–13
In most of the published literature, the age of
more than 1 year has been found to be associated with better
outcome. This perhaps is related to well-developed absorp-
tion ability of the CSF by the brain.
Fulguration of choroid plexus: Choroid plexuses are
believed to be the only site of CSF formation and hence
are targeted in fulguration.14
There are reports of bulky
choroid plexus in acute phase of tubercular meningi-
tis as additional source of overproduction.15
Generally,
Daljit Singh
Hydrocephalus: Role of Endoscopic
Third Ventriculostomy1
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2. Clinical Neuroendoscopy2
niation with ETV. It is important to review the mid-sagittal
MRI in tumor cases so as to assess the prepontine cistern and
displaced basilar artery in such cases.
Enlarged cistern magna, Dandy–Walker cyst and fourth
ventricular outlet obstruction have shown to be benefited
with ETV.37–39
Certain Special Conditions for
Endoscopic Third Ventriculostomy
Surplus floor: In some cases, the floor of the third ventricle is
too steep with large third ventricle. In such cases, it may be
difficult to puncture the floor. Moreover, routine ETV in such
cases leads to overhanging margins on ostomy site which
can result in ostomy closure. Coagulation of lateral sides ETV
can prevent such complications.
Small space for ETV: Sometime, floor of ETV is very
small and it may not be possible to puncture the floor
directly. In such situations, it is advisable to open the
floor over the bony landmark of clivus/dorsum sella
and to expand the opening laterally.
Thick Floor of Third Ventricle
In patient with postinfection hydrocephalus (PIH) or with
shunt infection, the floor may be thick to perforate. It can be
opened with gentle pressure of the cautery without pressing
the paddle or with minimal current.
PIH: What was believed to be a relative contraindica-
tion, PIH is added indication for ETV in several series from
South Asia. The leading cause of PIH being tuberculosis has
had special attentions by several authors. The success of ETV
in such cases is dependent on the stage of tubercular men-
ingitis (TBM), clinical grade of TBM, age of the patient, and
adequacy of ETV.40–45
The pyogenic infections produce more
scarring 30 and loculations.46
The posttubercular hydrocephalus can be of both
obstructive and communicating types. Although ETV
releases obstruction at aqueduct of Sylvius or at outlet lev-
els, its role in communicating hydrocephalus is debated
even now. Proponent of ETV in TBM believe that it washes
away the exudates, allows the CSF flow in previously inac-
cessible area, and decreases transventricular pressure gra-
dient as mechanisms for improvements. Overall, success
rate in TBMH ranges from 70 to 82%. Some authors practice
repeated lumbar puncture in failures.
Hydrocephalus in Neural Tube Defects
and Chiari Malformation
The exact mode by which ETV work in this indication is still
unclear. ETV is more beneficial in association with aqueductal
stenosis. The overall success is 50 to 60% with some authors
it is done on one side; however, it can be done bilater-
ally in cases of absent septum pellucidum. Sometime,
ETV can be combined with fulguration for additional
benefits. Fulguration has been recommended in neo-
natal hydrocephalus and in Chiari malformations.
Monroplasty: The foramen of Monro is opened in
asymmetrical ventriculomegaly wherein one of the
lateral ventricles is larger than others. Such asym-
metry is seen in conditions such as shunt infections,
neurocysticercosis (NCC), and postmeningitis.
Aqueductoplasty: The procedure is done to open the
membrane present in the first part of aqueduct. The
short-segment stenosis yield better results than long-
segment obstruction. It requires extensive experience
of handling the flexible endoscope. Aqueductoplasty
can be supplemented with stent placement.16
The out-
come is dependent on the patency of fourth ventricle
outlets and absorption of CSF as in ETV.
MagendoLuschcoplasty/MagendostomyLuschcostomy:
After performing aqueductoplasty, the fourth
ventricle outlet can be opened with flexible scopes.
There are no published series of such procedure as
of now.
Septoplasty: Multisegment hydrocephalus can be
affectively treated with endoscope. The idea behind is
to combine the various or most of the loculated fluid-
filled area as one chamber following which they can
be drained by a shunt tube or ETV. The exact etiology
of multiloculated hydrocephalus is not clear. It may be
the result of infection, ventriculitis, ependymitis, or
poor embryological development.
Indications
The most consistent reports have been on the good outcome
of ETV in aqueductal stenosis with success rate ranging from
70 to 90%.17–19
It can be productive in both primary as well as
secondary aqueductal stenoses. Most authors have reported
inferior outcome in infants which could be related to poor
absorption ability of infants and younger kids.20–27
Good outcome has been shown with triventriculomegaly,
presence of periventricular ooze, and good size ostomy.28,29
Radiological recovery takes longer period than clini-
cal improovment.30–32
After ETV, some patients may remain
symptomatic for 10 days. This period referred as adaptation
period is a time for CSF dynamics to adjust via new open-
ing. Some centers recommend repeated lumbar drainage for
about a week time to cover adaptation period. We, however,
feel that lumbar puncture (LP) drainage may further alter the
CSF pressure and may actually be harmful for the flow of CSF
via new ETV site.
ETV in posterior fossa tumors and brain stem tumors have
yielded good results leading to prevention of shunt place-
ment.33–36
Unlike VP shunt, there is no risk of reverse her-
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3. 3Hydrocephalus: Role of Endoscopic Third Ventriculostomy
in selected cases and re-ETV shows similar results as pri-
mary ETV. Results of re-ETV are better than primary ETV in
children.
Rescue Endoscopic Third Ventriculostomy
Goyal et al66
reported a situation wherein repeated shunt
failure of 13 times had no suitable site in abdomen to allow
a fresh insertion. ETV was the only remedy in such case with
good follow-up of 3 years. Such situations can be seen some-
time in busy neurosurgical centers.
Complications of Endoscopic Third
Ventriculostomy
Although a safe procedure, complication following ETV in a
large series was around 8 to 10%. The fatal complications are
usually rare but can happen with rupture of basilar artery or
its branches.67–72
Complications can be broadly classified as intraopera-
tive and postoperative. Intraoperative complications include
severe hemodynamic changes during perforation of floor
and irrigation of cavity. Although bradycardia is reported
by many, the tachycardia preceding bradycardia has been
observed by Ganjoo et al.73
The hemodynamic changes are
temporary but need to be observed diligently. In our center
putting an arterial line is obligatory so as to have continuous
monitoring of pulse and BP. In the event of any remarkable
deviation from the baseline, surgeon is immediately warned
by the anesthetist so as to modify or withhold the step being
performed.
Minor bleeding during the procedure can be controlled
by continuous irrigation and at time occluding the outflow
channel of irrigation fluid. This produces a tamponade effect
within ventricle and stops the bleeding. This step has to be
monitored for any hemodynamic changes.
Coagulation of bleeding sources can be obtained by cau-
terization. Major bleed, however, is difficult to manage and
may require placement of external drain and continuous
irrigation to avoid blockage of tubings.
Damage to fornix, thalamus, septal, and thalamostriate
vein can result during surgery and may cause moderate to
severe neurological deficits.
Postoperative complications are often the results of
improper selection of case. Patients with large ventricle
and age less than 1 year form subdural hygroma. There is
no way to prevent as it is due to sudden load of fluid in the
brain from one to another compartment. It may require
repeated tapping or placement of subdural drain. The CSF
leak from the incision site occurs in such cases. Such leak in
most cases can be managed with additional sutures. There
is risk of meningitis; hence, prophylactic antimeningitic is
recommended.
reporting a higher success (78%) when ETV is combined
with choroid plexus fulguration.47–51
It may be imperative to
suggest that in these cases, there may be over production of
CSF as well. Chiari malformations of both types, that is, types
1 and II, have shown improvement following ETV with later
have better results (94%).
Hydrocephalus due to Hemorrhage
With limited visibility in patient with hemorrhage of any
etiology, the ETV has not been very popular. The effect of
the bleed in technical hindrance in performing ETV can be
improved by thorough washing of ventricular cavity with
ringer lactate at body temperature.
The subependymal hemorrhage associated with prema-
ture baby gives tiger skin appearance in ventricular wall.
There are associated defective arachnoid villi in such cases
leading to poor absorption and failures.52–55
The success rate
is further compromised due to small age of the patients. In
subarachnoid hemorrhage due to aneurysm rupture, there
can be limited short-term advantages and may avoid place-
ment of external drain.
Endoscopic Third Ventriculostomy
in Shunt Dysfunction
One of the newly added indications of ETV has been shunt
failures. Although it provides an opportunity for freedom
from shunt, the factors for the success of ETV in such cases
is same as that in primary ETV in nonshunted cases.56–61
Although success rate has been reported from 63 to 80%, the
freedom from shunt has not been widely reported. It has
been suggested by some that shunt should not be blindly
removed after performing ETV. They showed neovasculari-
zation of tube from surrounding ependyma which can be a
source of potential life-threatening bleed while removing
shunt tube.
Ostomy Closure and Repeat Endoscopic
Third Ventriculostomy
Failure of ETV occurs in 8 to 60%. Early failures are due
to wrong selection or inadequate ETV. Late failures are
due to true restenosis. Re-ETV can be performed in the
same way as primary ETV. The success of re-ETV in early
and late failures is 50 and 78%, respectively.62–65
The pro-
cedure involves careful scrutiny of cases and cine MRI is
helpful to document adequacy of stoma. The stoma closure
involves a complex procedure wherein exudative response
is converted in fibrous reaction and intraoperative bleed-
ing, overhanging margins of ETV and presence of shunt
tube are predisposing factors for ostomy closure. Failure to
open second membrane, poor size ostomy, and infection
results in failure of ETV. The procedure can be repeated
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4. Clinical Neuroendoscopy4
tectal plate gliomas. Neurosurgery 2002;51(1):63–67, discussion
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Hypothermia, fever, and other hypothalamic dysfunction
have also been reported following ETV. There can be foreign
body reaction to shunt which can lead to adhesion formation
and bleeding.74
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