Introduction: Endoscopic third ventriculostomy (ETV) has become the procedure of choice in the treatment of obstructive hydrocephalus. In certain cases standard ETV might not be technically possible or may engender significant risk. We present an alternative through the lamina terminalis (LT) by a transventricular, transforaminal approach with flexible neuroendoscopy. Indications, technique, neuroendoscopic findings and outcome are discussed.

Methods: Between 1994 and 2010, all patients who underwent endoscopic LT fenestration as an alternative to ETV were analyzed and prospectively followed up. The decision of performing a LT fenestration was made intraoperatively.

Results: Twenty-five patients underwent endoscopic LT fenestration, ranging in age from 7 months to 76 years (mean: 28.1 years). Patients had obstructive hydrocephalus secondary to: neurocysticercosis in 11 patients, neoplasms in 6, congenital aqueductal stenosis in 3, and other in 5. Thirteen (52%) patients had had at least one VP shunt that malfunctioned, six (24%) had undergone a previous endoscopic procedure. Intraoperative findings that lead to a LT fenestration were: ETV not feasible to perform, basal subarachnoid space not sufficient, adhesions in the third ventricle. No perioperative complications occurred. The mean follow-up period was 63.76 months. Overall, 19(76%) patients had resolutions of symptoms, no evidence of ventriculomegaly, and did not require another procedure. Six (24%) required a VP shunt.

Conclusions: Endoscopic transventricular transforaminal LT fenestration with flexile neuroendoscope is feasible with a low incidence of complications, it is a good alternative to the standard ETV. Adequate intraoperative assessment of ETV success is necessary to identify patients that will benefit.

Patient Care: Improve quality of life for those patients with obstructive hydrocephalus on whom ETV is not possible. Prevent the morbidity of possible complications of VP shunt failure and multiple revisions.

Learning Objectives: By the conclusion of this session, perticipants should be able to identify the utility of the endovascopic lamina terminalis fenestration, to know the indications, to decribed the operative technique and to know the limitations and possible complications.

References: Torres-Corzo J, Rangel-Castilla L. Endoscopic third ventriculostomy. Contemporary Neurosurgery. Aug 2006;28(17):1-8. Oertel JM, Vulcu S, Schroeder HW, Konerding MA, Wagner W, Gaab MR. Endoscopic transventricular third ventriculostomy through the lamina terminalis. J Neurosurg. Dec 2010;113(6):1261-1269. Souweidane MM. Anterior third ventriculostomy: an endoscopic variation on a theme. J Neurosurg. Dec 2010;113(6):1259-1260; discussion 1260. Torres-Corzo J, Rodriguez-della Vecchia R, Rangel-Castilla L. Bruns syndrome caused by intraventricular neurocysticercosis treated using flexible endoscopy. J Neurosurg. May 2006;104(5):746-748. Torres-Corzo JG, Tapia-Perez JH, Vecchia RR, Chalita-Williams JC, Sanchez-Aguilar M, Sanchez-Rodriguez JJ. Endoscopic management of hydrocephalus due to neurocysticercosis. Clin Neurol Neurosurg. Jan;112(1):11-16.