Complications of endoscopic third ventriculostomy.

OBJECT: Endoscopic third ventriculostomy (ETV) is an established treatment for hydrocephalus. Most studies focus on success rate, and complications are insufficiently documented. The aim of this study was to perform a systematic review of ETV complications.

METHODS: A Medline search discovered 34 series of ETV with detailed complications reports (17 series involving exclusively pediatric patient populations, 6 series involving exclusively adults, and 11 series involving mixed adult and pediatric populations).

RESULTS: The analysis included 2985 ETVs performed in 2884 patients. The cause of hydrocephalus was aqueductal stenosis in 29.3% of patients, tumor in 37.6%, meningomyelocele in 7.6%, cysts in 2.6%, cerebellar infarct in 0.9%, Dandy-Walker malformation in 0.6%, and Chiari malformation Type I in 0.4%; 7.4% of the patients had posthemorrhagic hydrocephalus, 1.8% had postinfectious hydrocephalus, and 1.2% had normal pressure hydrocephalus. Hydrocephalus was due to other causes in 1.3% of cases and the cause was not reported in 9.8%. The overall complication rate was 8.5%. The rate of permanent morbidity was 2.38%; the rate of permanent neurological complications was 1.44% (hemiparesis, gaze palsy, memory disorders, altered consciousness), and the rate of permanent hormonal morbidity was 0.94% (diabetes insipidus, weight gain, precocious puberty). The rate of intraoperative hemorrhage rate was 3.7%; the rate of severe intraoperative hemorrhage was 0.6% (including a 0.21% rate of basilar rupture). The rate for intraoperative neural injury (thalamic, forniceal, hypothalamic, and midbrain injuries) was 0.24%. Central nervous system infections occurred in 1.81% of cases, CSF leak in 1.61%, and postoperative intracranial hematomas in 0.81% of cases. The early postoperative mortality rate was 0.21% (6 patients died; 2 of sepsis and 4 of hemorrhage). Another 2 children suffered delayed "sudden death" (one after 25 months and the other after 60 months), caused by acute hydrocephalus due to stoma occlusion. There were no significant differences between series involving pediatric or adult patient populations or series with fewer than 100 or more than 100 patients. All reported deaths were in series involving more than 100 patients.

CONCLUSIONS: Endoscopic third ventriculostomy can be regarded as a low-complication procedure, with an overall complication rate of 8.5%, permanent morbidity rate of 2.4%, mortality rate of 0.21%, and delayed "sudden death" rate of 0.07%.