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Updated: Mar 20, 2026
Author Spotlight: A Single-Entry Point Endoscopic Intraventricular Approach for Third Ventriculostomy and Pineal Biopsy
Published on: June 28, 2024
Endoscopic third ventriculostomy in children: prospective, multicenter results from the Hydrocephalus Clinical
Abhaya V Kulkarni1, Jay Riva-Cambrin2, Richard Holubkov3
1Hospital for Sick Children, University of Toronto, Ontario.
Insights
Endoscopic third ventriculostomy (ETV) is a safe and effective treatment for pediatric hydrocephalus, with serious complications being rare. Preoperative ETV Success Score and intraoperative visualization of the basilar artery predict successful outcomes.
Area of Science:
- Neurosurgery
- Pediatric Neurosurgery
- Hydrocephalus Management
Background:
- Endoscopic third ventriculostomy (ETV) is an established treatment for pediatric hydrocephalus.
- Accurate data on ETV morbidity, complications, and efficacy in children are crucial for treatment planning.
Purpose of the Study:
- To prospectively evaluate the morbidity, complication incidence, and efficacy of ETV in children.
- To determine if intraoperative predictors enhance the predictive value of preoperative predictors for ETV success.
Main Methods:
- Prospective, multicenter study of children undergoing their first ETV (without choroid plexus cauterization) at 7 Hydrocephalus Clinical Research Network (HCRN) centers.
- Follow-up for a minimum of 18 months, with prospectively collected data on patient characteristics, ETV failure, and postoperative complications.
Main Results:
- 336 children underwent ETV; 18.8% had prior shunts. Common etiologies included aqueductal stenosis (24.8%) and tectal lesions (21.2%).
- Visible forniceal injury occurred in 16.6%; severe bleeding and major arterial injury were rare (≤1.8%). Common complications included CSF leak (4.4%) and hyponatremia (3.9%).
- Two-year failure-free survival was 57.8%. The ETV Success Score (ETVSS) and visualization of a "naked" basilar artery predicted ETV success.
Conclusions:
- ETV in children has a low incidence of serious complications.
- The ETVSS is a significant predictor of ETV success.
- Intraoperative visualization of a "naked" basilar artery is an additional predictor of ETV success.
Abstract:
OBJECTIVE Endoscopic third ventriculostomy (ETV) is now established as a viable treatment option for a subgroup of children with hydrocephalus. Here, the authors report prospective, multicenter results from the Hydrocephalus Clinical Research Network (HCRN) to provide the most accurate determination of morbidity, complication incidence, and efficacy of ETV in children and to determine if intraoperative predictors of ETV success add substantially to preoperative predictors. METHODS All children undergoing a first ETV (without choroid plexus cauterization) at 1 of 7 HCRN centers up to June 2013 were included in the study and followed up for a minimum of 18 months. Data, including detailed intraoperative data, were prospectively collected as part of the HCRN's Core Data Project and included details of patient characteristics, ETV failure (need for repeat hydrocephalus surgery), and, in a subset of patients, postoperative complications up to the time of discharge. RESULTS Three hundred thirty-six eligible children underwent initial ETV, 18.8% of whom had undergone shunt placement prior to the ETV. The median age at ETV was 6.9 years (IQR 1.7-12.6), with 15.2% of the study cohort younger than 12 months of age. The most common etiologies were aqueductal stenosis (24.8%) and midbrain or tectal lesions (21.2%). Visible forniceal injury (16.6%) was more common than previously reported, whereas severe bleeding (1.8%), thalamic contusion (1.8%), venous injury (1.5%), hypothalamic contusion (1.5%), and major arterial injury (0.3%) were rare. The most common postoperative complications were CSF leak (4.4%), hyponatremia (3.9%), and pseudomeningocele (3.9%). New neurological deficit occurred in 1.5% cases, with 0.5% being permanent. One hundred forty-one patients had documented failure of their ETV requiring repeat hydrocephalus surgery during follow-up, 117 of them during the first 6 months postprocedure. Kaplan-Meier rates of 30-day, 90-day, 6-month, 1-year, and 2-year failure-free survival were 73.7%, 66.7%, 64.8%, 61.7%, and 57.8%, respectively. According to multivariate modeling, the preoperative ETV Success Score (ETVSS) was associated with ETV success (p < 0.001), as was the intraoperative ability to visualize a "naked" basilar artery (p = 0.023). CONCLUSIONS The authors' documented experience represents the most detailed account of ETV results in North America and provides the most accurate picture to date of ETV success and complications, based on contemporaneously collected prospective data. Serious complications with ETV are low. In addition to the ETVSS, visualization of a naked basilar artery is predictive of ETV success.
