Endoscopic 3rd ventriculostomy is procedure of choice in obstructive hydrocephalus in which stoma is formed in floor of 3rd ventricle .

1. ENDOSCOPIC THIRD
VENTRICULOSTOMY
DR.MUMTAZ ALI NAREJO
CONSULTANT NEUROSURGEON

2. OUTLINES
• Neuroendoscopic
Anatomy of 3rd V
• Indications
• Contraindications
• Complications
• Ventriculoscope set & O.T
• Ventricular irrigation
• Procedure
• Postop care
• Pearls

3. NEUROENDOSCOPIC ANATOMY 3rd VENTRICLE

5. INDICATIONS
• Obstuctive HCP
• Shunt infections
• Post-shunting
subdural hematoma
• Slit Ventricle Syndrom
• NPH
• DESH
• Pineal gland
tectal & PF tumors
• DWM
• Chiari type 1

6. CONTRAINDICATIONS
• Communicating HCP
• Low ETV success rate
• Extensive scarring of Prepontine cistern
• SAH
• Agenesis of corpus callosum
• Fused fornices with isolated 3rd V
• Thickened 3rd ventricle floor
• Pinpoint/Faint foramen monro
• Dec space between BA & DS

7. COMPLICATIONS
• Hypothalamic injury
• Injury to pituitary stalk or gland
• Transient 3rd and 6th nerve palsies
• Injury to basilar A, PComA, or PCA
• Uncontrollable bleeding
• Cardiac arrest
• Traumatic basilar artery aneurysm
• Injury to Fornix
• Injury to thalamostriate & septal vein
• Injury to Thalamus
• ETV failure 10-50%

9. ETV SUCCESS SCORE
• <40% =Low Chance
• 50-70%=Intermediate
• >80%=Highest
• 1 from each category=3
• 76% (72 of 95 patients)
6 Patient = 2nd ETV
3patients
Partially functioning shunts

11. SUCCESS RATE
• OverAll =56%
• Non-tumoral Aqs=60-90%
• Tectal tumors: 88%
• Untreated Acquired Aqs = Highest
• Infants = Poor
• Low success rate 20%:
Tumor
Previous shunt
Previous SAH
Previous whole brain radiation
Significant adhesion

13. VENTRICULAR
IRRIGATION
• an intermittent /continuous
• operative field
• maintain ventricular volumes
& working space
• stop low-pressure
venous bleeding
• 20- to 50-mL syringe
• Ringer’s lactate heated to 37.5°C
• Hypothalmus injury

14. PROCEDURE
• Rigid endoscope
• Position :15 degree
• Incision :Curvlinear
• Kochers Point:Burr
• Durotomy : cruciate form
• LV=>Foramen monro=>3rd V
• Fixate sheath
• Visualization = Floor of 3rd V
• BA & Mamillary bodies
• If not seen=Abort

15. PROCEDURE
• Location Of opening :
Midline:
Avoids PCOM & PCA
In Tuberum cinerum
Posterior : Infundibular recess
Anterior : Mamillary bodies
Anterior : Tip of BA
• Rubbing through floor 3rd V
Probe or decq forcep
• Hydrodissection/Bipolar
• Avoid Laser

16. PROCEDURE
• Opening : enlarged
Decq forcep
3F fogarty balloon
4-9mm
• Surety
• Web membrane/liliquist
Certain vessels
Diluted iohexol
intrathecal contrast
• CT scan after 1 hour
• T2WI sagittal thin slice sequence
drop-out of T2 signal at stoma of ETV
CISS/FIESTA:floor of 3rd V , thickness , bowing ,clivius & BA proximity

18. POSTOP
• Seizures
• Blood pressure lability
• Bradycardia
• Hyperthermia
• Diabetes insipidus
• Antiobiotics : 24 hour
• AEM:24-48 hours
• High dose dexamethasone
prevent inflammation
& stoma closure

19. • Neuroendoscopy provides monocular vision inside small structures. Slow and gentle
movements are safe and allow for depth perception.
• The etiology of hydrocephalus, clinical status, and results of imaging can all help
determine which patients are ideal candidates for ETV. The ETVSS is a valuable tool
for properly selecting patients for the procedure.
• Excessive manipulation while in the foramen can lead to damage of the anterior
column of the fornix, which can result in a significant loss of quality of life.
• A key principle in neuroendoscopy is to always maintain the instrument in your field
of view. To accomplish this goal, keep the endoscope behind the instrument tip, and
advance the instrument and endoscope in small successive steps.
• Identify the relevant anatomy initially. Do not assume that the endoscope has
entered the ipsilateral ventricle.
• Both the tuber cinereum and the membrane of Liliequist, when present, must be
perforated. The best way to ensure entry into the prepontine cistern is to have a
clear view of the basilar artery.
• Intraoperative bleeding generally stops with gentle irrigation. Aggressive cautery
should be avoided. An EVD should be left in place if there is significant
hemorrhaging.
• Unfavorable anatomic characteristics include small ventricles, a large massa
intermedia, and a small space between the dorsum sella and basilar artery.

20. REFRENCES
• Greenberg Handbook of Neurosurgery 10th edition
• Youmans & winn text book of Neurological surgery 8th edition
• Neurosurgical Atlas
• Google

21. THANKS