Endoscopic Third Ventriculostomy for Hydrocephalus

Hydrocephalus is a condition characterized by the buildup of excess cerebrospinal fluid within the brain’s ventricles, often leading to an increase in head size. At Acıbadem, this neurological disorder is treated using an endoscopic procedure, which involves creating a small hole at the bottom of one of the ventricles to allow fluid drainage and relieve pressure. In Türkiye, Acıbadem Pediatric Neurosurgery Team pioneered this technique, with Professor Memet Özek performing the first endoscopic hydrocephalus surgery in 1992. To date, over 900 children with hydrocephalus have been successfully treated using this approach.

What is hydrocephalus?

Parents of patients often ask, “What is hydrocephalus?” when they first hear about the condition. Hydrocephalus definition is excessive fluid accumulation in the brain, which usually leads to increased pressure on brain tissues. Cerebrospinal fluid (CSF) is produced in the brain and spinal cord. It protects the brain from injuries, aids in brain nutrition, and regulates pressure by circulating around the brain and spinal cord. CSF is continuously produced and reabsorbed throughout the day. However, sometimes the cerebrospinal fluid produced is not absorbed by the central nervous system and begins to excessive accumulation in the brain. This condition, known as hydrocephalus, can harm brain tissue.

What is the main cause of hydrocephalus?

Common underlying factors of the disease include:

Bleeding secondary to premature birth (intraventricular hemorrhage)
Head trauma
Brain tumors and cysts
Brain infections
Congenital spinal anomalies (e.g., spina bifida)
Genetic (inherited) conditions
Developmental disorders

What are the symptoms of hydrocephalus?

It is a condition characterized by an abnormal accumulation of cerebrospinal fluid within the brain, leading to increased pressure and potential damage. Hydrocephalus symptoms may differ depending on age groups.

Hydrocephalus symptoms may include:

An abnormally large head
Downward-directed eyes (setting sun eyes)
Frequent drowsiness
Vomiting, nausea, restlessness, seizures, headache, diplopia
Bulged fontanelle, thin scalp, dilatation of blood vessels in the head (newborns)
Decline in walking, communication disorder, loss of sensorial and motor functions (children)

Hydrocephalus in adults may cause different signs. In these patients, hydrocephalus symptoms may involve balance problems, dementia, memory issues, and urinary incontinence.

What are the different types of hydrocephalus?

There are different types of hydrocephalus, which include:

Communicating hydrocephalus: Also known as non-obstructive hydrocephalus. It occurs when cerebrospinal fluid is blocked after it leaves the ventricles.
Non-communicating hydrocephalus: Also known as obstructive hydrocephalus. This type occurs when the flow of cerebrospinal fluid is blocked through one or more of the narrow passages connecting the ventricles. The standard treatment for this condition is an endoscopic procedure.
Normal pressure hydrocephalus: Hydrocephalus in adults is most commonly seen in this type. Although there is an accumulation of cerebrospinal fluid that enlarges the ventricles, there is little to no increase in pressure inside the ventricles.
Hydrocephalus ex-vacuo: It may stem from a head injury or stroke. Brain tissue around the ventricles shrinks, leading to cerebrospinal fluid accumulating in the ventricles to fill the extra space. Although the ventricles become enlarged, the pressure in the head typically remains normal.

How is hydrocephalus diagnosed?

This neurological disorder can be diagnosed at any age, though it is more common in children. It occurs in approximately 2 out of every 1,000 live births. The diagnosis is often made before birth, at birth, or during early infancy. If hydrocephalus is suspected, imaging tests may be ordered. Today, MRI is considered the gold standard for diagnosing hydrocephalus and determining the appropriate treatment.

What is the treatment of Hydrocephalus?

There is no medication treatment for hydrocephalus. It can be treated with surgical procedures that can only be performed by neurosurgeons. The surgical procedure will vary according to the underlying hydrocephalus causes.

It may be an obstruction that hinders the circulation of cerebrospinal fluid. In this case, surgery will be performed to eliminate the obstruction (tumor or cyst). Another hydrocephalus cause is a problem in the absorption of CSF without any anatomic obstruction. Intracerebral circulation pathways of the cerebrospinal fluid can be amended with surgical procedures to treat the hydrocephalus that arises out of all these causes. There are two major hydrocephalus treatments: endoscopic third ventriculostomy and shunt surgery.

How is hydrocephalus treatment? (Endoscopic third ventriculostomy (ETV))

Hydrocephalus may occur when an anatomic pathway is occluded for any reason in the brain. The solution is to create a new duct using an endoscope. Thus, the circulation of cerebrospinal fluid is restored. An endoscope allows surgery to be performed through fewer and smaller incisions.

If the anatomy allows and there is no contraindication, in Acıbadem Pediatric Neurosurgery clinic we primarily prefer this surgical technique, and the children can continue living without a foreign material (shunt) in their body.

Complaints of patients are relieved within a very short interval after the surgery. They should be closely followed up in the first two years. Both clinical evaluation and radiological examination are important.

What you need to know about endoscopic third ventriculostomy?

Today, EVT is the most advanced treatment approach for hydrocephalus. This procedure involves inserting a camera with a 2 mm diameter into the brain. Without open surgery, the device is moved through these gaps.It dilates an occluded area or performs a by-pass in order to restore circulation. If the disease is diagnosed early, the child can overcome the disease without any damage such as intellectual impairment or problems in social development, speech, comprehension, or everyday movements. In some cases, it is possible to discharge patients the next day after the operation.

Who is a candidate for endoscopic third ventriculostomy?

All children with obstructive hydrocephalus may be suitable candidates for the endoscopic approach. EVT surgery is considered the first treatment option in hydrocephalus due to an obstructive cause. However, hydrocephalus may develop for different reasons. All hydrocephalus treatments should be planned according to the patient’s specific situation.

What is the success rate of ETV hydrocephalus?

ETV is a highly feasible treatment for certain types of pediatric hydrocephalus, particularly obstructive cases. The literature indicates that the success rate of ETV can reach up to 90%.

Is ETV surgery permanent?

ETV may offer permanent solutions to large groups of patients. After the surgery, children can live healthy lives without a shunt system in their bodies. However, there is a risk of hydrocephalus recurrence in some patients. The created pathway may close, especially within the first six months after the operation. That’s why close follow-up is important for a certain period after the surgery.

How safe is ETV surgery?

Today, ETV is the most advanced and safest treatment for hydrocephalus. When a shunt system is used for treatment, potential complications include obstruction in the valve or catheter of the shunt system, kinking or disconnection of the shunt, under or over-drainage by the shunt, and shunt infections, which may necessitate removing and replacing the shunt system. On the other hand, when an endoscopic procedure is applied, these risks of complications are eliminated.

How much does (Endoscopic third ventriculostomy (ETV) surgery cost?

The exact cost of ETV surgery varies depending on the specific condition and hydrocephalus treatments plan. However, Acıbadem International Patient Center is happy to discuss your situation and provide a personalized cost estimate.

Endoscopic Third Ventriculostomy for Hydrocephalus in Turkey

Acıbadem is a global leader in endoscopic third ventriculostomy (ETV). It pioneers advancements in both clinical and academic fields, in Türkiye and worldwide. In 1992, Professor Memet Özek performed the first ETV surgery in Türkiye. He is now an active pediatric neurosurgeon at Acıbadem Healthcare Group. Professor Özek is also the Head of the Pediatric Neurosurgery Department at Acıbadem University. He has performed over 900 ETV procedures and authored a 1,900-page book on the subject.

Acıbadem Pediatric Neurosurgery is not only a national leader in treating hydrocephalus and other childhood neurological disorders but also a renowned and reputable neurosurgery clinic globally. This reputation attracts neurosurgeons from around the world. They join Acıbadem’s fellowship program in pediatric neurosurgery for advanced training in endoscopic techniques.

Why Acıbadem for Treatment?

Acıbadem is dedicated to congenital brain and spinal abnormalities, with unmatched expertise in treating them. Endoscopic hydrocephalus surgery is a significant, effective, and safe option for managing this neurological disorder. It provides a solution without the need for shunts. This is why it is preferred as the first treatment option at Acıbadem.

Additionally, patients with hydrocephalus are evaluated with a multidisciplinary approach in Acıbadem Pediatric Neurosurgery clinic for the accompanying clinical conditions, such as cerebral palsy and epilepsy. Pediatric neurosurgeons collaborate with specialists from Pediatric Neurology, Pediatric Physiotherapy, Pediatric Genetic Diseases, Neuroradiology, and Pediatric Clinical Psychology departments, whenever necessary.