ETV Complications

In This Article
    Add a header to begin generating the table of contents

    Complications of Endoscopic Third Ventriculostomy

    Hydrocephalus can be treated by undergoing a surgical procedure called endoscopic third ventriculostomy (ETV) or endoscopic third ventriculostomy with choroid plexus cauterization (ETV/CPC). ETV and ETV/CPC can be alternative treatments to shunts in some cases.

    The most common complications with these two procedures are:

    1. The closing of the pathway that was surgically created with ETV; and
    2. Infection.

    Even with a successful ETV surgery, it is possible that the ETV might fail, sometimes because the hole in the ventricle closes. A malfunction can cause symptoms to develop quickly, which if not recognized and treated, can result in coma or possible death. It is important to recognize the signs and symptoms of an ETV failure so you can seek immediate medical attention.

    It’s critical to understand that ETV is a treatment, not a cure, for hydrocephalus.


    Signs and Symptoms of ETV Complications

    The symptoms of ETV failure may mimic other conditions, making it a challenge to identify what is causing the symptoms. In infants and toddlers, medication with which drowsiness is a side effect can mimic or mask signs of ETV failure. Use these medications with caution in those with hydrocephalus, especially infants and young children.


    Signs of ETV Failure

    ETV failure symptoms may present differently from person to person, but individuals with recurring failures tend to have similar symptoms each time. Contact your medical professional immediately if you notice any of the following following ETV or ETV/CPC treatment:

    Infants

    • Increased head size or rapid head growth
    • Bulging or tense fontanelle (soft spot on the baby’s head)
    • Prominent scalp veins
    • Vomiting
    • Less interest in feeding
    • Excessive tiredness
    • Difficulty waking up or staying awake (this symptom requires urgent attention as it can potentially lead to a coma)
    • Sunsetting eyes (a downward deviation of eyes, where the white part of the eye may be seen above the iris)
    • Fussiness
    • Developmental delays or missed milestones
    • Signs of infection, such as fever, redness, or swelling at the shunt site

    Toddlers

    • Changes in head size (less common)
    • Headaches
    • Vomiting
    • Loss of appetite
    • Excessive tiredness
    • Difficulty waking up or staying awake (this symptom requires urgent attention as it can potentially lead to a coma)
    • Vision problems (such as double or blurred vision)
    • Fussiness or seeming irritable (cries easily or without reason)
    • Loss of previous abilities (sensory or motor function)
    • Developmental delays or missed milestones
    • Signs of infection, such as fever, redness, or swelling at the shunt site

    Children and Adults

    • Headaches
    • Nausea and/or vomiting
    • Excessive tiredness
    • Difficulty waking up or staying awake (this symptom requires urgent attention as it can potentially lead to a coma)
    • Vision problems (such as double or blurred vision)
    • Irritability (changes in behavior or personality)Decline in academic or job performance
    • Loss of coordination of balance
    • Difficulty concentrating or focusing
    • Return of pre-treatment problems (adults)
    • Signs of infection, such as fever, redness, or swelling at the shunt site

    Adults with Normal Pressure Hydrocephalus (NPH)

    People who are diagnosed and treated with hydrocephalus in adulthood, including those with NPH, tend to revert to the symptoms they experienced before initial treatment when a malfunction occurs.

    These may include:

    • Mild dementia (forgetfulness, confusion, trouble thinking, or focusing)
    • Urgency to urinate or loss of bladder control
    • Difficulty walking
    • Poor balance
    • Falling
    • Feeling withdrawn or talking less
    • Mood changes
    • Return of pre-treatment problems
    • Signs of infection, such as fever, redness, or swelling at the shunt site

    Potential Complications During and After ETV and ETV/CPC Surgery

    New technologies have minimized the risks of ETV. The treatment may still result in complications, including fever, infection, and bleeding. Fortunately, these complications are often short-lived. However, in unusual circumstances, complications may be permanent.

    Symptoms may include:

    • Infection. Infection usually occurs in less than one percent of those treated surgically with ETV or ETV/CPC procedures.
    • Bleeding and Stroke. Attempts to create an opening in the ventricular floor during surgery may result in bleeding. Most of the time the bleeding is minor and clears with fluid irrigation during the procedure. Significant bleeding due to vessel injury beneath the floor of the third ventricle is very rare but can cause a catastrophic stroke; fortunately, this occurs in much less than 1% of cases.
    • Short-term memory loss. Since ETV may affect the fornix, hypothalamus, and the mammillary bodies – which are responsible for memory – the procedure may cause short-term memory loss. This is also an extremely rare complication.
    • Endocrinologic irregularities. The third ventricle is responsible for some hormonal function, and the opening made during treatment can very rarely impact endocrinologic activity.

    Trust Your Instincts to Make Informed Decisions
    An ETV issue may result in rapid and serious symptom development that demands urgent medical attention. It’s crucial to see your doctor or go to the emergency department, even if your symptoms don’t appear directly linked to hydrocephalus or the ETV. Acting quickly can help identify and address issues, preventing coma, brain damage, or death, particularly in children. As you learn more about potential complications, you’ll become adept at recognizing and understanding them.

    Most Common Tests to Assess ETV Failure

    Failed ETVs are not always straightforward and diagnosis can be challenging; however, it is critical that your doctor diagnose and treat an early ETV failure.

    Your doctor may use the following tests to determine whether an ETV has failed:

    CT scans. Using computed tomography, commonly known as CT scan, a computer uses x-ray beams to pass through a patient’s body to create images of the internal structures—in this case, the brain.

    Notes about CT Scans
    CT scans use radiation. While that raises concerns about exposure – particularly for those with hydrocephalus who rely on CT scans and MRIs multiple times over their lives to discover any treatment problems – new technology and techniques reduce the number of images captured and limit the amount of radiation exposure. You may hear terms like “low dose” and/or “rapid acquisition” CT scans.

    Generally, it is better to minimize radiation exposure as much as possible. However, this should not come at the expense of patient safety. Research the CT techniques used at your hospital, particularly the emergency room. If your doctor orders a CT scan, you might ask about the urgency of the situation and whether waiting for an MRI is possible.

    Magnetic Resonance Imaging (MRI). An MRI, like the CT scan, is a diagnostic technique that produces images of the brain—but unlike CT scanning, MRI does not use x-rays/radiation. Instead, MRI uses a very powerful magnet to scan the patient, and the magnetic signals create images for the computer to read. MRI is a painless procedure and has no known side effects, but might require a general anesthetic for very young or otherwise uncooperative patients.

    Notes about MRI Scans
    There are two types of MRI scans:

    • The Single Shot Fast Spin Echo (also called a “‘Quick Brain MRI”) is used to determine the size of the ventricles. It takes about three minutes and rarely requires sedation.
    • The full MRI, which takes 30 to 60 minutes and may require sedation, shows more minute details. Before the longer scans are performed, small children are given a sedative or general anesthetic to minimize movement that would cause image blurring.

    How is ETV Failure Treated

    When an ETV fails, it means that the opening created during the procedure has closed, or it is no longer allowing CSF to drain properly. The treatment for ETV failure depends on the specific situation, but there are a few common approaches:

    Re-Performing the ETV (Revision Surgery): In some cases, the ETV can be repeated. This involves another surgery to reopen the original hole. The surgeon will evaluate if this is a viable option based on a variety of factors including timing of the failure, anatomy, and the patient’s condition.

    Shunt Placement: If the ETV cannot be revised or is unlikely to succeed again, a shunt may be placed to help drain the excess cerebrospinal fluid. A shunt is a flexible tube system that diverts the fluid to another part of the body, such as the abdomen, where it can be absorbed.

    Imaging and Follow-Up: After ETV failure, imaging tests such as MRIs or CT scans are often used to assess the condition of the ventricles and determine the next course of action. Regular follow-up with the neurosurgeon is essential to monitor for any changes.

    The treatment plan for ETV failure is tailored to each individual and their specific needs, and the decision is made by the healthcare team based on the patient’s overall health and the reasons for the failure.


    When to Seek Treatment for ETV Failure

    ETV failure can be life-threatening and can occur at any time, although the majority of treatment failures occur within the first six months of the operation. Delayed failures can occur but are rare, and the ongoing risk of treatment failure over time is much less than it is for patients who are dependent on a shunt.


    Information you can trust! This article was produced by the Hydrocephalus Association, copyright 2024. We would like to thank the following individuals for their valuable contributions and expert input: Marion L. (Jack) Walker, MD, Abhaya Kulkarni, MD, PhD, FRCSC and William E. Whitehead, MD, MPH.

    Was this resource helpful?

    Yes
    No
    Thanks for your feedback!