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Background: Endoscopic third ventriculostomy (ETV) has been used predominantly in the pediatric population in the past. Application in the adult population has been less extensive, even in large neurosurgical centers. To our knowledge, this report is one of the largest adult ETV series reported and has the consistency of being performed at 1 center., Objective: To determine the efficacy, safety, and outcome of ETV in a large adult hydrocephalus patient series at a single neurosurgical center. In addition, to analyze patient selection criteria and clinical subgroups (including those with ventriculoperitoneal shunt [VPS] malfunction or obstruction and neurointensive care unit patients with extended ventricular drainage before ETV) to optimize surgical results in the future., Methods: We conducted a retrospective review of adult ETV procedures performed at our center between 2000 and 2014., Results: The overall rate of success (no further cerebrospinal fluid diversion procedure performed plus clinical improvement) of 243 completed ETVs was 72.8%. Following is the number of procedures with the success rate in parentheses: aqueduct stenosis, 56 (91%); communicating hydrocephalus including normal pressure hydrocephalus, nonnormal pressure hydrocephalus, and remote head trauma, 57 (43.8%); communicating hydrocephalus in postoperative posterior fossa tumor without residual tumor, 14 (85.7%); communicating hydrocephalus in subarachnoid hemorrhage without intraventricular hemorrhage, 23 (69.6%); obstruction from tumor/cyst, 42 (85.7%); VPS obstruction (diagnosis unknown), 23 (65.2%); intraventricular hemorrhage, 20 (90%); and miscellaneous (obstructive), 8 (50%). There were 9 complications in 250 intended procedures (3.6%); 5 (2%) were serious., Conclusion: Use of ETV in adult hydrocephalus has broad application with a low complication rate and reasonably good efficacy in selected patients.

Background: To review the outcome after endoscopic third ventriculostomy (ETV) for symptomatic, persistent hydrocephalus in three patients with perimesencephalic angiographically negative subarachnoid hemorrhage (PNH) who were dependent on an external ventricular drain (EVD)., Methods: All patients initially presented with severe headache, nuchal rigidity, confusion and lethargy (Hunt-Hess Grade II or III), and persistent, EVD-dependent hydrocephalus. Cranial CT images in each revealed acute hydrocephalus and perimesencephalic hemorrhage pattern with a heavy clot burden (Fisher grade 3). A 3D-CT angiogram on admission and two four-vessel cerebral angiograms failed to demonstrate a bleeding source. All three patients failed trial EVD clamping, with clinical deterioration and elevated intracranial pressure (ICP). ETV was performed with a 0-degree endoscope in a 4.6-mm irrigating sheath using an endoscopic-coring/"cookie-cut" technique. An EVD was left in place for postoperative ICP monitoring but was clamped., Results: ETV was accomplished in all patients. In one case, a tiny basilar tip aneurysm was seen during the endoscopic procedure. Intraoperatively, the prepontine cistern revealed dense, degraded blood products. Postprocedure ICP measurements were reduced to normal range. Clinical improvement, normal ICP readings, and/or radiographic evidence of resolution of hydrocephalus allowed uneventful removal of the EVD within 36-48 h post-ETV in all patients. All remained headache-free, with a normal neurological examination, during a follow-up period of 10, 11, and 12 months, respectively., Conclusion: To our knowledge, this is the first report of ETV for PNH with hydrocephalus and the first report of a basilar tip microaneurysm seen intraoperatively during ETV. ETV is a viable treatment option for refractory hydrocephalus secondary to a perimesencephalic pattern of subarachnoid hemorrhage (SAH). Its early application can avoid placement of a ventriculoperitoneal shunt, curtail the extended use of an EVD, and reduce the associated infection risks. Despite thorough angiographic investigation for an aneurysmal cause of SAH, a "microaneurysm" of the basilar artery was found at ETV. No complication or rebleeding was encountered.

Object: An opaque (neural) floor of the third ventricle is considered an obstacle to safe penetration of the floor of the third ventricle in endoscopic third ventriculostomy (ETV). The direct technique of endoscopic coring ("cookie cut") of the opaque (neural) floor of the third ventricle is described in 41 cases among a total of 101 consecutive adult ETVs., Methods: A 0° endoscope in a 4.6-mm irrigating sheath was used to press and core ("cookie cut") a section of the tuber cinereum, thereby exposing the underlying membranes and vasculature. Thereafter, the endoscopic apparatus was used to penetrate the membrane into the prepontine space., Results: Among 101 consecutive ETVs performed in adults, there were 41 instances of an opaque floor in which the coring technique was used. The basilar artery (BA) complex was in the intended path of penetration in 13 cases. There were no perioperative deaths or vascular injuries. No cases were aborted because of the opaque floor or the configuration of the BA complex. The clinical success rate in the opaque floor group was 80% (33 of 41 patients)., Conclusions: An opaque (neural) floor is frequently seen in adults during ETV. Removing the floor by the core ("cookie cut") method is a safe means of revealing the underlying BA complex and membranous structures prior to penetration into the prepontine cistern. On occasion, the BA complex may be in the path of penetration, and one can maneuver the endoscope to displace the vasculature to successfully accomplish the ETV.

Objective: To describe 2 cases of delayed endoscopic third ventriculostomy (ETV) failure in 2 adult patients initially successfully treated for normal pressure hydrocephalus by ETV. The cause of ETV failure was stoma closure, and this was documented in both instances by direct endoscopic inspection., Clinical Presentation: In the first case, a 67-year-old woman presented with progressive gait disturbance, incontinence, and memory problems. Brain magnetic resonance imaging exhibited ventricular dilation, including the fourth ventricle, disproportionate to cortical atrophy. In the second case, a 55-year-old man presented with progressive gait disturbance, urinary incontinence, memory problems, and headaches. Brain magnetic resonance imaging exhibited communicating hydrocephalus., Intervention: The first patient underwent an ETV with subsequent improvement in all symptom areas. Three years and 2 months later, she experienced a return of original symptoms and ventricular dilation on brain computed tomography, compared with previous postoperative scans. Direct endoscopic inspection of the third ventricular floor revealed stoma closure secondary to fibrotic scar. The patient subsequently underwent ventriculoperitoneal shunt placement that resulted in symptom improvement. The patient in the second case underwent an ETV that resulted in marked symptom improvement in all areas. Four years and 3 months later, he experienced a return of gait difficulties and headaches. Direct endoscopic inspection showed a lack of cerebrospinal fluid pulsations through the third ventricular stoma and dense arachnoid adhesions around the basilar artery. A repeat ETV was unsuccessful. Subsequent ventriculoperitoneal shunt placement resulted in symptom improvement., Conclusion: ETV may provide an effective treatment for patients with normal pressure hydrocephalus, a form of communicating hydrocephalus. Stoma closure can be a mechanism of delayed ETV failure in normal pressure hydrocephalus, consistent with reports of ETV failure in pediatric obstructive hydrocephalus.

Objective: Choroid plexus cysts are common in the developing fetus, and although often persisting into adulthood, they rarely represent the underlying cause of symptomatic unilateral ventriculomegaly. The case presented here highlights both the diagnostic obscurity and endoscopic management of a choroid plexus cyst in a symptomatic patient., Clinical Presentation: The patient is a 47-year-old white woman who presented with acute exacerbation of debilitating, diffuse, and postural headache, nausea, vomiting, early papilledema, and short-term memory loss. Cranial magnetic resonance imaging revealed an intraventricular mass obstructing the foramen of Monro on the left with ventriculomegaly. Cranial computed tomographic imaging demonstrated unilateral ventricular enlargement., Intervention: During stereotactic endoscopic exploration, a choroid plexus cyst was evident at the foramen of Monro. Endoscopic cauterization of the cyst resulted in a decrease in the size of the left lateral ventricle, with complete relief of the patient's headaches and resolution of her memory loss. She remained headache free at the time of a 3-year follow-up evaluation after surgery., Conclusion: Choroid plexus cysts remain a diagnostic challenge; their presence should be sought out in the face of ventricular asymmetry and symptomatic hydrocephalus. Endoscopic ablation offers a minimally invasive treatment for the management of these lesions.

Objectives: A serious catastrophic complication of endoscopic third ventriculostomy (ETV) is basilar artery (BA) damage. Although the BA has been discussed as the cause of haemorrhage and even pseudoaneurysm, variations of the posterior cerebral artery proximal segment (P1) and its protrusion into the third ventricle floor have not been emphasised. A series of cases are reported in which the P1 segment was located at the stoma during an ETV and was at risk of perforation. Precautionary techniques for complication avoidance are described., Methods: A retrospective review was performed of all ETVs performed in adults at our institution between 2004 and 2008. Cases were identified in which the P1 segment was noted to herniate into the stoma at the time of third ventricular floor fenestration., Results: Among 65 cases reviewed, six were identified in which the P1 segment significantly herniated into an area of the stoma at the time of third ventricular floor fenestration. In no case was the P1 segment injured by the ETV procedure. Each of the six patients had opaque third ventricle floors. A 'cookie cut' technique was used in which the opaque third ventricle floor was abraded to reveal the underlying translucent membrane, offering an improved view of arteries in the basilar cisterns. In four of six patients, ETV resulted in clinical improvement., Conclusions: The posterior cerebral artery P1 segment is potentially at risk during ETV in adults as well as in children. Awareness and proper precautions may help reduce injuries to either the P1 or the basilar apex during an ETV.