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. 2020 Oct 19;15(4):926-930.
doi: 10.4103/ajns.AJNS_161_20. eCollection 2020 Oct-Dec.

Endoscopic Third Ventriculostomy: Role of Image Guidance in Reducing the Complications

Muhammad Samir Irfan Wasi  1 , Salman Sharif  2 , Yousuf Shaikh  2
Affiliations

Endoscopic Third Ventriculostomy: Role of Image Guidance in Reducing the Complications

Muhammad Samir Irfan Wasi et al. Asian J Neurosurg. .

Abstract

Introduction: Endoscopic third ventriculostomy (ETV) is performed by neurosurgeons around the world for the management of hydrocephalus. ETV has been associated with multiple complications, the most significant being iatrogenic injury to the fornix. We aim to establish the fact that the use of image guidance while planning a trajectory can reduce the incidence of complications as it significantly alters the usual approach for ETV, i.e., the coronal burr hole can be useful for young neurosurgeons to overcome the learning curve associated with the procedure.

Materials and methods: This is a prospective, observational study conducted at Liaquat National Hospital. In this study, 43 patients were included who underwent ETV for hydrocephalus. Complications were divided into three major groups: arterial hemorrhage, venous hemorrhage, and injury to neural structures (fornix, hypothalamus, and oculomotor nerve). The data were compared with studies showing the complications of ETV with and without usage of image guidance.

Results: Among the 43 patients who underwent ETV with image guidance, only two patients (4.65%) had iatrogenic fornix contusions. Neither of them developed memory impairment. None of the patients (0%) encountered other major iatrogenic complications, including injury to the mammillary body, basilar artery, or oculomotor nerve.

Conclusion: The use of image guidance can reduce trajectory-related complications, including hemorrhage and iatrogenic injuries to the fornix. This study showed that the altered trajectory was beneficial in avoiding major neurological structures while introducing an endoscope through the cortex into the ventricular system.

Keywords: Cerebrospinal fluid diversion; endoscopic third ventriculostomy; endoscopic third ventriculostomy complications; fornix injury; hydrocephalus; image guidance.

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Conflict of interest statement

There are no conflicts of interest.

Figures

Figure 1
Figure 1
Image guidance significantly alters the entry point from the conventional burr hole site. Shaded line: Indicates the coronal suture. The centre of incision marks the Kocker's point where an EVD was done in this patient previously and is also the site of conventional endoscopic third ventriculostomy incision. Cross mark indicates the entry point for endoscopic third ventriculostomy defined by the image guidance system which is significantly altered in relation to Kocker's point
Figure 2
Figure 2
Too anterior entry point can cause injury to fornix and brainstem. Too posterior entry point can cause injury to fornix and motor cortex. Correct entry point is essential to avoid such complications
Figure 3
Figure 3
Endoscopic view of endoscopic third ventriculostomy showing forniceal Grade 1 contusion
See this image and copyright information in PMC

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