Microanatomical basis for the third ventriculostomy

In the last few years, there has been a resurgence of interest in endoscopic third ventriculostomy as a treatment for obstructive hydrocephalus. Although various techniques have been used to perform this procedure, not enough emphasis has been placed on the microanatomical details of the third ventricle and surrounding cisterns in relation to this procedure. Using a surgical microscope we examined the microsurgical anatomy of the floor of the third ventricle floor and related subarachnoid cisterns in 20 adult brains using the "immersion technique" in conjunction with microsurgical dissection. We believe that the optimal place to fenestrate is the midline of the floor of the third ventricle, behind the infundibular recess and in front of the mammillary bodies, communicating the third ventricle with the anterior interpeduncular cistern, minimizing the risk for vascular lesions. Stereotactic third ventriculostomy is a safe and effective way of re-establishing normal cerebrospinal fluid flow dynamics in selected cases of obstructive hydrocephalus. However, in an endoscopic exposure only a small portion of the anatomy can be seen at any one time, and important neurovascular structures may be located adjacent to the endoscope, but outside of the visual range of the lens. A thorough understanding of the microanatomy of the neural and vascular structures surrounding the third ventricle and related cisterns is essential in order to improve surgical results avoiding complications.