Hyponatremia following endoscopic third ventriculostomy: a report of 5 cases and analysis of risk factors

Object Electrolyte and endocrinological complications of endoscopic third ventriculostomy (ETV) are infrequent but serious events, likely due to transient hypothalamic-pituitary dysfunction. While the incidence of diabetes insipidus is relatively well known, hyponatremia is not often reported. The authors report on a series of 5 patients with post-ETV hyponatremia. Methods The records of patients undergoing ETV between 2008 and 2010 were reviewed. All ETVs were performed with a rigid neuroendoscope via a frontal bur hole, standard third ventricle floor blunt perforation, Fogarty catheter dilation, and intermittent normal saline irrigation. Postoperative MR images were evaluated for endoscope tract injury as well as the trajectory from the bur hole center to the fenestration site. Results Thirty-two patients (20 male and 12 female) underwent ETV. Their median age was 6 years (range 3 weeks–28 years). Hydrocephalus was most commonly due to nontumoral aqueductal stenosis (43%), nontectal tumor (25%), or tectal glioma (13%). Five patients (16%) had multicystic/loculated hydrocephalus. Five patients (16%) developed hyponatremia between 1 and 8 days following ETV, including 2 patients with seizures (1 of whom was still hospitalized at the time of the seizure and 1 of whom was readmitted as a result of the seizure) and 3 patients who were readmitted because of decline in their condition following routine discharge. No hypothalamic injuries were noted on imaging. Univariate risk factors consisted of age of 2 years or less (p = 0.02), presence of cystic lesions (p = 0.02), and ETV trajectory angle 10° or more from perpendicular (p = 0.001). Conclusions Endoscopic third ventriculostomy is a well-tolerated procedure but can result in serious complications. Hyponatremia is rare and may be more likely in younger patients or those with cystic loculations. Patients with altered craniometry may be at particular risk with a rigid endoscopic approach requiring greater manipulation of subforniceal or hypothalamic structures.

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Predictors of endoscopic third ventriculostomy ostomy status in patients who experience failure of endoscopic third ventriculostomy with choroid plexus cauterization

Journal of Neurosurgery Pediatrics ◽

10.3171/2019.2.peds18743 ◽

2019 ◽

Vol 24 (1) ◽

pp. 41-46

Author(s):

Andrew T. Hale ◽

Amanda N. Stanton ◽

Shilin Zhao ◽

Faizal Haji ◽

Stephen R. Gannon ◽

...

Keyword(s):

Choroid Plexus ◽

Endoscopic Third Ventriculostomy ◽

Third Ventricle ◽

Aqueductal Stenosis ◽

Third Ventriculostomy ◽

Time To Failure ◽

Chi Square ◽

Significant Difference ◽

Chi Square Test ◽

Choroid Plexus Cauterization

OBJECTIVEAt failure of endoscopic third ventriculostomy (ETV) with choroid plexus cauterization (CPC), the ETV ostomy may be found to be closed or open. Failure with a closed ostomy may indicate a population that could benefit from evolving techniques to keep the ostomy open and may be candidates for repeat ETV, whereas failure with an open ostomy may be due to persistently abnormal CSF dynamics. This study seeks to identify clinical and radiographic predictors of ostomy status at the time of ETV/CPC failure.METHODSThe authors conducted a multicenter, retrospective cohort study on all pediatric patients with hydrocephalus who failed initial ETV/CPC treatment between January 2013 and October 2016. Failure was defined as the need for repeat ETV or ventriculoperitoneal (VP) shunt placement. Clinical and radiographic data were collected, and ETV ostomy status was determined endoscopically at the subsequent hydrocephalus procedure. Statistical analysis included the Mann-Whitney U-test, Wilcoxon rank-sum test, t-test, and Pearson chi-square test where appropriate, as well as multivariate logistic regression.RESULTSOf 72 ETV/CPC failures, 28 patients (39%) had open-ostomy failure and 44 (61%) had closed-ostomy failure. Patients with open-ostomy failure were older (median 5.1 weeks corrected age for gestation [interquartile range (IQR) 0.9–15.9 weeks]) than patients with closed-ostomy failure (median 0.2 weeks [IQR −1.3 to 4.5 weeks]), a significant difference by univariate and multivariate regression. Etiologies of hydrocephalus included intraventricular hemorrhage of prematurity (32%), myelomeningocele (29%), congenital communicating (11%), aqueductal stenosis (11%), cyst/tumor (4%), and other causes (12%). A wider baseline third ventricle was associated with open-ostomy failure (median 15.0 mm [IQR 10.3–18.5 mm]) compared to closed-ostomy failure (median 11.7 mm [IQR 8.9–16.5 mm], p = 0.048). Finally, at the time of failure, patients with closed-ostomy failure had enlargement of their ventricles (frontal and occipital horn ratio [FOHR], failure vs baseline, median 0.06 [IQR 0.00–0.11]), while patients with open-ostomy failure had no change in ventricle size (median 0.01 [IQR −0.04 to 0.05], p = 0.018). Previous CSF temporizing procedures, intraoperative bleeding, and time to failure were not associated with ostomy status at ETV/CPC failure.CONCLUSIONSOlder corrected age for gestation, larger baseline third ventricle width, and no change in FOHR were associated with open-ostomy ETV/CPC failure. Future studies are warranted to further define and confirm features that may be predictive of ostomy status at the time of ETV/CPC failure.

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Endoscopic diagnosis of an MRI-occult, low-grade glioma with ependymal dissemination

Journal of Neurosurgery Pediatrics ◽

10.3171/2015.3.peds14444 ◽

2015 ◽

Vol 16 (4) ◽

pp. 377-382 ◽

Cited By ~ 5

Author(s):

Konstantinos Margetis ◽

Prajwal Rajappa ◽

William Cope ◽

David Pisapia ◽

Mark M. Souweidane

Keyword(s):

Endoscopic Third Ventriculostomy ◽

Third Ventricle ◽

Surgical Pathology ◽

Third Ventriculostomy ◽

Low Grade ◽

The Third ◽

The Brain ◽

Tectal Glioma ◽

Triventricular Hydrocephalus ◽

Multiple Nodules

A 21-year-old man presented with triventricular hydrocephalus due to a tectal mass. He underwent an endoscopic third ventriculostomy, and multiple nodules were identified at the floor of the third ventricle intraoperatively. Surgical pathology of one of these lesions demonstrated that the tissue represented a low-grade astrocytoma. The case highlights the existing potential of neuroendoscopy to reveal neuroimaging-occult lesions, in spite of the significant advances of MRI. Furthermore, the combination of the age of the patient, the nonenhancing MRI appearance, and the multifocality of the lesions constitutes a rare and interesting neoplastic presentation within the brain. The constellation of findings likely represents dissemination of a low-grade tectal glioma via the CSF compartment.

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Bilateral occlusion of the foramina of Monro after third ventriculostomy

Journal of Neurosurgery ◽

10.3171/2012.2.jns111735 ◽

2012 ◽

Vol 116 (6) ◽

pp. 1333-1336 ◽

Cited By ~ 7

Author(s):

Ehab El Refaee ◽

Joerg Baldauf ◽

Henry W. S. Schroeder

Keyword(s):

Magnetic Resonance Imaging ◽

Endoscopic Third Ventriculostomy ◽

Rare Complication ◽

Third Ventricle ◽

Aqueductal Stenosis ◽

Third Ventriculostomy ◽

Resonance Imaging ◽

Foramen Of Monro ◽

Neurological Improvement ◽

Occlusive Hydrocephalus

Occlusion of both foramina of Monro following third ventriculostomy is a very rare complication. The authors present the case of a 30-year-old female who underwent endoscopic third ventriculostomy (ETV) for occlusive hydrocephalus due to aqueductal stenosis. Thirty months after the ETV, she reported recurrent headaches. Magnetic resonance imaging demonstrated bilateral enlargement of the lateral ventricles with a collapsed third ventricle caused by bilateral stenosis of the foramina of Monro. Left-sided endoscopic foraminoplasty and stenting of the left foramen of Monro were performed with immediate neurological improvement.

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Endoscopic stent placement for treatment of secondary bilateral occlusion of the Monro foramina following endoscopic third ventriculostomy in a patient with aqueductal stenosis

Journal of Neurosurgery ◽

10.3171/jns-07/08/0416 ◽

2007 ◽

Vol 107 (2) ◽

pp. 416-420 ◽

Cited By ~ 29

Author(s):

Hiroshi Mori ◽

Toshiro Koike ◽

Tsuyoshi Fujimoto ◽

Kenichi Nishiyama ◽

Junichi Yoshimura ◽

...

Keyword(s):

Lateral Ventricle ◽

Endoscopic Third Ventriculostomy ◽

Third Ventricle ◽

Aqueductal Stenosis ◽

Septum Pellucidum ◽

Third Ventriculostomy ◽

Slit Ventricle Syndrome ◽

Endoscopic Stent ◽

Slit Ventricle ◽

The Right

✓ Nontumoral bilateral occlusion of the Monro foramina is a rare clinical condition. Treatment includes shunt placement, endoscopic procedures, or both. The authors describe the case of a 22-year-old woman who had previously undergone placement of a ventriculoperitoneal shunt via a right frontal approach for management of triventricular dilation due to aqueductal stenosis. Six years postoperatively she presented with right-sided slit-ventricle syndrome and stenosis of the right Monro foramen, which was treated with an endoscopic third ventriculostomy and fenestration of the septum pellucidum. Two years later she presented with bilateral lateral ventricular dilation. Inspection of the right lateral ventricle with a fiberscope revealed occlusion of the septum pellucidum fenestration; on observation, the right Monro foramen was covered by thick, tough granulation tissue and the left was occluded by thin membranous tissue. Repeated fenestration of the septum pellucidum and left Monro foraminoplasty were therefore performed by perforating this thin tissue. A stent was then introduced into the third ventricle via the right lateral ventricle, the fenestration in the septum pellucidum, and the left Monro foramen. The authors note that fiberscopes are in general more maneuverable than rigid endoscopes and conclude that they are particularly useful for the treatment of this type of hydrocephalus.

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Late-onset occlusion of the Monro foramina after endoscopic third ventriculostomy in adults: Case discussion and review of the literature

Surgical Neurology International ◽

10.25259/sni_519_2020 ◽

2020 ◽

Vol 11 ◽

pp. 326

Author(s):

Sara Fabbro ◽

Francesco Tuniz ◽

Daniele Piccolo ◽

Antonio Cramaro

Keyword(s):

Endoscopic Third Ventriculostomy ◽

Late Onset ◽

Third Ventricle ◽

Rare Condition ◽

Aqueductal Stenosis ◽

Endoscopic Procedure ◽

Third Ventriculostomy ◽

Foramen Of Monro ◽

Choice Procedure ◽

First Choice

Background: Few cases of adult idiopathic occlusion of the foramen of Monro (AIOFM) are described in the literature. The diagnosis of AIOFM after an endoscopic procedure is even more infrequent. Case Description: We described the case of a 50-year-old woman who developed bilateral membranous occlusion of both Monro foramina 20 years after an endoscopic third ventriculostomy (ETV) for triventricular hydrocephalus due to an aqueductal stenosis. The patient underwent an endoscopic treatment (left foraminoplasty and septostomy) to check the patency of the stoma on the floor of the third ventricle. After the endoscopic procedure, the symptoms improved and the postoperative magnetic resonance imaging (MRI) demonstrated the resolution of the biventricular hydrocephalus. Conclusion: Bilateral occlusion of both FM with consequent bilateral lateral ventricles enlargement is an extremely rare condition, especially if we consider the cases of biventricular hydrocephalus after endoscopic procedures. In our opinion, an endoscopic approach should be attempted as first choice procedure, avoiding any intraventricular stent or shunt placement.

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Endoscopic Third Ventriculostomy in Infants Less than One Year of Age: A Short Series of 14 Cases

Pediatric Neurosurgery ◽

10.1159/000513359 ◽

2021 ◽

Vol 56 (2) ◽

pp. 105-109

Author(s):

Sarita Chowdhary ◽

Shyamendra Pratap Sharma ◽

Pranaya Panigrahi ◽

Manoj Kumar Yadav ◽

Shiv Prasad Sharma

Keyword(s):

Endoscopic Third Ventriculostomy ◽

Obstructive Hydrocephalus ◽

Aqueductal Stenosis ◽

Csf Shunt ◽

Third Ventriculostomy ◽

Occipital Encephalocele ◽

Shunt Implantation ◽

Permanent Morbidity ◽

One Year

Background: Endoscopic third ventriculostomy (ETV) is currently considered as an alternative to cerebrospinal fluid (CSF) shunt systems in the treatment of obstructive hydrocephalus. This procedure allows the CSF to drain in the basal cisterns and reabsorbed by arachnoid granulations, and avoiding implantation of exogenous material. Aims and Objectives: The purpose of this study was to assess the success rate of ETV in infants less than 1 year of age with congenital noncommunicating hydrocephalus. Material and Methods: This study was a 2-year prospective study from August 2017 to July 2019. ETVs were performed in 14 patients younger than 1 year with diagnosis of noncommunicating hydrocephalous. A failure was defined as the need for shunt implantation after ETV. Phase-contrast MRI of the brain was done after 6 months to see patency of ETV fenestration and CSF flow through ventriculostomy. Results: ETV was tried in 18 patients and successfully performed in 14 patients. Out of the 14 patients, shunt implantation after ETV was performed in 3 patients (failed ETV). In the successful cases, etiology was idiopathic aqueductal stenosis in 8, shunt complications in 2, and 1 case was a follow-up case of occipital encephalocele; the mean age was 7.7 months (range 3–12). In the 3 failed cases, etiology was aqueductal stenosis, mean age was 7.6 months (range 3–11). In all ETVs, failed patients MPVP shunting was done. Follow-up of nonshunted patients was done from 6 to 24 months (mean 15 months). There was no mortality or permanent morbidity noted following ETV. Conclusion: ETV is a good surgical procedure for less than 1-year-old children.

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Anterior endoscopic transcortical approach to a pineal region cavernous hemangioma

Neurosurgical Focus: Video ◽

10.3171/2021.4.focvid215 ◽

2021 ◽

Vol 5 (1) ◽

pp. V15

Author(s):

Jiuhong Li ◽

Jiaojiang He ◽

Lunxin Liu ◽

Liangxue Zhou

Keyword(s):

Cavernous Hemangioma ◽

Endoscopic Third Ventriculostomy ◽

Third Ventricle ◽

Pineal Region ◽

Postoperative Adhesion ◽

Third Ventriculostomy ◽

Back Side ◽

Coronal Suture ◽

The Third ◽

Transcortical Approach

A 57-year-old female presented with headache and dizziness for 3 months. Preoperative MRI revealed a lesion located at the pineal region and back side of the third ventricle, accompanied by hydrocephalus. The infratentorial supracerebellar approach may cause visuomotor, acousticomotor, and hearing disturbances. With the patient in a supine position, the authors used a frontal linear incision that was 3 cm anterior to the coronal suture and 2 cm away from the midline and an anterior endoscopic transcortical approach, which could achieve endoscopic third ventriculostomy, alleviating and preventing hydrocephalus due to postoperative adhesion and resection of the lesion at the same time. The pathological diagnosis was cavernous hemangioma. The video can be found here: https://stream.cadmore.media/r10.3171/2021.4.FOCVID215.

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Endoscopic third ventriculostomy in obstructive hydrocephalus due to giant basilar artery aneurysm

Journal of Neurosurgery ◽

10.3171/2008.7.jns0887 ◽

2009 ◽

Vol 110 (1) ◽

pp. 14-18 ◽

Cited By ~ 19

Author(s):

Joachim M. K. Oertel ◽

Yvonne Mondorf ◽

Michael R. Gaab

Keyword(s):

Basilar Artery ◽

Endoscopic Treatment ◽

Endoscopic Third Ventriculostomy ◽

Obstructive Hydrocephalus ◽

Third Ventricle ◽

Clinical Signs ◽

Artery Aneurysm ◽

Third Ventriculostomy ◽

Upward Displacement ◽

Age Range

Obstructive hydrocephalus due to giant basilar artery (BA) aneurysm is a rare finding, and endoscopic treatment has not been reported. Here the authors present their experience with endoscopic third ventriculostomy (ETV) in obstructive hydrocephalus due to giant BA aneurysm. Between December 2000 and March 2007, 3 patients (2 men and 1 woman; age range 32–80 years) underwent an ETV for the treatment of obstructive hydrocephalus caused by a giant BA aneurysm. All 3 patients presented with cephalgia, nausea, vomiting, and a variable decrease in consciousness. An obstructive hydrocephalus caused by a giant BA aneurysm was found in each case as the underlying pathological entity. Intraoperatively, a narrowing of the third ventricle by upward displacement of the tegmentum was found in all 3 patients. A standard ETV was performed and included an inspection of the prepontine cisterns. The endoscopic treatment was successful in all patients with respect to clinical signs and radiological ventricular enlargement. No complications were observed. In all, the endoscopic ventriculostomy was proven to be a successful treatment option in obstructive hydrocephalus even if it is caused by untreated giant BA aneurysm.

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