Objectives: To evaluate the role of endoscopic third ventriculostomy (ETV) as a primary treatment for hydrocephalus in children less than 1 year old and to determine its impact as a whole on the reduction of shunts necessary in a new population of hydrocephalic infants. Methods: Data were collected prospectively on 47 infants with newly diagnosed hydrocephalus of all aetiologies who were referred between 1st April 1998 and 30th September 2000. Twenty-one patients (median age 6 weeks, range 34 weeks of gestation to 10 months) underwent ETV, while the remaining 26 patients had insertion of a ventriculoperitoneal shunt. Anatomical criteria and demonstration of third ventricle outflow obstruction on preoperative magnetic resonance imaging were used to select patients for ETV. Results: There was no mortality or major morbidity following ETV. The median follow-up period was 18 (range 8–36) months. During the follow-up period, the ETV remained patent in 7 (33%) of the 21 patients. Of the 14 patients with failed ETV, 11 had insertion of a ventriculoperitoneal shunt, while 3 have undergone successful redo ETV. Therefore, in total 10 patients (48%) of the ETV group remain shunt independent. The best results were obtained in patients with congenital aqueduct stenosis with 71% (5 of 7 patients) success rate, while patients with posthaemorrhagic hydrocephalus did particularly badly with only 1 of 10 patients having a successful ETV. Overall, 10 of 47 (21%) infants with newly diagnosed hydrocephalus have avoided a shunt. Conclusions: Our results suggest that the selective use of ETV as the primary treatment in infants with hydrocephalus is safe and can lead to a reduction in the shunted population of all newly diagnosed hydrocephalic infants by up to 21%. Success of ETV is aetiology, not age dependent.

Object: The authors analyzed the role of endoscopic third ventriculostomy (ETV) as a primary treatment for hydrocephalus and also as an alternative to shunt revision for malfunctioning and infected ventriculoperitoneal (VP) shunts. Methods: A retrospective analysis of clinical notes, operation records, and magnetic resonance imaging procedures before and after ventriculostomy was performed to determine the success or failure of ETVs in 170 patients who underwent a primary ETV and in 63 patients who underwent an ETV for shunt malfunction (secondary ETV). The patients' data were derived from an endoscopy database inaugurated in 1998. Of the 63 patients with shunt malfunctions, 49 patients (78%) had mechanical malfunction only and 14 patients (22%) had both infection and malfunction. Seventy-four percent (126 of 170) of patients in the primary ETV group and 70% (44 of 63) of patients in the secondary ETV had a successful outcome at the time of analysis. The success rate for ETVs in cases involving a mechanical shunt malfunction alone was 67% (33 of 49) compared with 79% (11 of 14) in those cases involving an infected shunt. The origin of the hydrocephalus in the primary and shunt malfunction groups was evaluated as a factor contributing to the success of the ETV. In the primary group, patients with a history of intraventricular hemorrhage (IVH) and meningitis as a cause for hydrocephalus had a poor rate of success after the ETV—27% (four of 15) and 0% (none of two), respectively. This pattern was not seen in the series involving shunt malfunction after the ETV, with 71% (five of seven) and 75% (three of four) of cases having a hydrocephalus origin of IVH and meningitis, respectively, in which a successful outcome was attained. A two-way mixed-model analysis of variance yielded a significant effect for origin (p = 0.011), a significant interaction between group and origin (p = 0.028), and a marginally nonsignificant effect of group (p = 0.0686). More than 95% of failures were evident within 1 month of the ETV in both groups. Complications were minimal in both groups, and there were no procedure-related deaths. Conclusions: An ETV is a safe procedure with few complications and a high success rate in both primary and secondary groups. An ETV to address shunt malfunction, unlike a primary ETV, is not particularly origin specific. A bonus is its success in dealing with infected shunts. Most failures will be evident early, but long-term follow up is vital.