Endoscopic third ventriculostomy for obstructive hydrocephalus due to intraventricular hemorrhage

Although endoscopic third ventriculostomy (ETV) is the first-line treatment for obstructive hydrocephalus due to various pathologies, its role in hemorrhage-related obstructive hydrocephalus is poorly defined. We report our experience with ETV for hemorrhage-related obstructive hydrocephalus, demonstrate it feasibility, and discuss potential advantages over more conventional treatment modalities.

We performed a retrospective analysis of 78 consecutive patients who underwent ETV in our institution between January 2003 and January 2011. We identified 17 consecutive patients who underwent ETV for obstructive hydrocephalus related to intraventricular hemorrhage (IVH).

ETV was performed in 9 men and 8 women (mean age: 58 years; range: 42-79). All patients had IVH (n = 17), either alone (n = 3) or with intracranial hemorrhage (n = 4) or subarachnoid hemorrhage (SAH) (n = 10). Endoscopic clot evacuation was performed in seven cases (41%). External ventricular drain (EVD) was avoided in two patients. 15 patients had external EVD, and EVD wean was performed on average 5 days post-ETV. Two patients died in the early postoperative period (< 1 month) from the initial cerebral insult. For the 15 surviving patients, the average modified Rankin Scale (mRS) at last follow-up (15 months; range: 1-48) was 2.4. Thus most surviving patients were independent (mRS < 3). Of those 15 patients, one died (malignancy) at last follow-up. Twelve patients (80%) were ventriculoperitoneal shunt-free. The three shunt-dependent patients had significant SAH (100%).

ETV with or without endoscopic clot evacuation is feasible for patients with hemorrhage-related obstructive hydrocephalus. Potential advantages include avoiding or reducing duration of EVD placement and preventing ventriculoperitoneal shunt placement. Further large prospective randomized trials are needed to evaluate the safety and efficacy of ETV with or without clot evacuation for IVH-related obstructive hydrocephalus.