Endoscopic 3rd Ventriculostomy-DR.MUMTAZ ALI NAREJO.pptx

Endoscopic 3rd ventriculostomy is procedure of choice in obstructive hydrocephalus in which stoma is formed in floor of 3rd ventricle .

1. ENDOSCOPIC THIRD VENTRICULOSTOMY DR.MUMTAZ ALI NAREJO CONSULTANT NEUROSURGEON

2. OUTLINES Neuroendoscopic Anatomy of 3 rd V Indications Contraindications Complications Ventriculoscope set & O.T Ventricular irrigation Procedure Postop care Pearls

3. NEUROENDOSCOPIC ANATOMY 3 rd VENTRICLE

4. INDICATIONS Obstuctive HCP Shunt infections Post-shunting subdural hematoma Slit Ventricle Syndrom NPH DESH Pineal gland tectal & PF tumors DWM Chiari type 1

5. CONTRAINDICATIONS Communicating HCP Low ETV success rate Extensive scarring of Prepontine cistern SAH Agenesis of corpus callosum Fused fornices with isolated 3 rd V Thickened 3 rd ventricle floor Pinpoint/Faint foramen monro Dec space between BA & DS

6. COMPLICATIONS Hypothalamic injury I njury to pituitary stalk or gland T ransient 3rd and 6th nerve palsies I njury to basilar A, PComA , or PCA U ncontrollable bleeding C ardiac arrest T raumatic basilar artery aneurysm Injury to Fornix Injury to thalamostriate & septal vein Injury to Thalamus ETV failure 10-50%

7. ETV SUCCESS SCORE <40% =Low Chance 50-70%=Intermediate >80%=Highest 1 from each category=3 76% (72 of 95 patients) 6 Patient = 2 nd ETV 3patients Partially functioning shunts

8. SUCCESS RATE OverAll =56% Non- tumoral Aqs =60-90% Tectal tumors: 88% Untreated Acquired Aqs = Highest Infants = Poor Low success rate 20%: Tumor P revious shunt P revious SAH P revious whole brain radiation S ignificant adhesion

9. VENTRICULAR IRRIGATION an intermittent /continuous operative field maintain ventricular volumes & working space stop low-pressure venous bleeding 20- to 50-mL syringe Ringer’s lactate heated to 37.5°C Hypothalmus injury

10. PROCEDURE Rigid endoscope Position :15 degree Incision : Curvlinear Kochers Point:Burr Durotomy : cruciate form LV=>Foramen monro =>3 rd V Fixate sheath Visualization = Floor of 3 rd V BA & Mamillary bodies If not seen=Abort

11. PROCEDURE Location Of opening : Midline : Avoids PCOM & PCA In Tuberum cinerum Posterior : Infundibular recess Anterior : Mamillary bodies Anterior : Tip of BA Rubbing through floor 3 rd V Probe or decq forcep Hydrodissection /Bipolar Avoid Laser

12. PROCEDURE Opening : enlarged Decq forcep 3F fogarty balloon 4-9mm Surety Web membrane/ liliquist Certain vessels Diluted iohexol intrathecal contrast CT scan after 1 hour T2WI sagittal thin slice sequence drop-out of T2 signal at stoma of ETV CISS/ FIESTA:floor of 3 rd V , thickness , bowing , clivius & BA proximity

13. POSTOP   S eizures B lood pressure lability Bradycardia Hyperthermia D iabetes insipidus Antiobiotics : 24 hour AEM:24-48 hours High dose dexamethasone prevent inflammation & stoma closure

14. Neuroendoscopy provides monocular vision inside small structures. Slow and gentle movements are safe and allow for depth perception.  The etiology of hydrocephalus, clinical status, and results of imaging can all help determine which patients are ideal candidates for ETV. The ETVSS is a valuable tool for properly selecting patients for the procedure. Excessive manipulation while in the foramen can lead to damage of the anterior column of the fornix, which can result in a significant loss of quality of life. A key principle in neuroendoscopy is to always maintain the instrument in your field of view. To accomplish this goal, keep the endoscope behind the instrument tip, and advance the instrument and endoscope in small successive steps. Identify the relevant anatomy initially. Do not assume that the endoscope has entered the ipsilateral ventricle. Both the tuber cinereum and the membrane of Liliequist , when present, must be perforated. The best way to ensure entry into the prepontine cistern is to have a clear view of the basilar artery. Intraoperative bleeding generally stops with gentle irrigation. Aggressive cautery should be avoided. An EVD should be left in place if there is significant hemorrhaging. Unfavorable anatomic characteristics include small ventricles, a large massa intermedia , and a small space between the dorsum sella and basilar artery.

15. REFRENCES Greenberg Handbook of Neurosurgery 10 th edition Youmans & winn text book of Neurological surgery 8 th edition Neurosurgical Atlas Google

16. THANKS