Endoscopic Third Ventriculostomy in Obstructive Hydrocephalus: Surgical Technique and Pitfalls

Background: Reviewing our experience in the variety of pathological entities causing obstructive hydrocephalous, we evaluate the effectiveness of endoscopic treatment, with particular attention to surgical technique, nuances, and pitfalls. Materials and methods: We reviewed the cases of 57 consecutive patients with obstructive hydrocephalus of various origins in the last 9 years. They were treated by endoscopic third ventriculostomy (ETV). A septostomy was also performed in ten cases. Operative videos were reassessed, and surgical nuances reconsidered. Results: ETV was accomplished in all but three cases. The overall rate of good results (shunt-independent patients with clinical remission or improvement) was 81.5% (44/54). From ten patients with ETV failure, five were re-ETVed successfully, and five were shunted. Patients with benign aqueductal stenosis and tumor compressing the aqueduct received the greatest benefit from the ETV. There were no permanent morbidities or any mortality. Fundamentals of preoperative planning, postoperative evaluation, and technical pitfalls have been considered. Conclusion: ETV for obstructive hydrocephalus of various origins is safe and effective, and should be considered as a first-line treatment. Familiarity with the ventricular anatomy and its variations in hydrocephalus is key to success. Preoperative planning is mandatory. Awareness of potential pitfalls minimizes the risk.