Preparing for ETV Surgery

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    The thought of having to undergo brain surgery is frightening and can be physically and emotionally taxing. That’s why it’s important to learn as much as you can about the procedure, get to know the medical professionals involved in your care, and know what to expect post-surgery. The best way to prepare for Endoscopic Third Ventriculostomy (ETV) surgery is by thinking about what questions you want to ask your professional healthcare team, and by being prepared to answer any questions they may have for you. By spending some time preparing for your surgery, you can help ensure that you have a successful procedure and recover faster.


    The Healthcare Team

    There are several people you will meet before surgery.

    The neurosurgeon. Surgery is carried out by a neurosurgeon (a specialist in surgery of the brain and nervous system). The surgery usually takes one to two hours. When you meet with your neurosurgeon before the surgery, you may want to ask about how long the surgery will take, the risks involved, and whether or not they will shave part of your hair. You may also want to ask about how long you will have to be in the hospital, and how soon you can return to your normal activities.

    The hospital office staff. When you arrive at the hospital on the day of your surgery, you will meet with a member of the hospital operating room staff who will make sure all your paperwork is in order. He or she will ask you to sign a surgical consent form, which states that you give your permission for the surgery to be performed. If you are under 18 years old, a parent or guardian will need to sign the surgical consent form for you.

    The nursing staff. A member of the nursing staff will review your medical history and ask about any allergies you may have and any medicines you may be taking. It may be helpful to make a list of your medical history, allergies, and medications before you leave for the hospital so you don’t forget. This is especially important for people with hydrocephalus. A condition associated with hydrocephalus, myelomeningoceles, also known as spina bifida, can cause some people to develop a potentially life-threatening allergy to latex. The nurse will also make sure that you are healthy enough to have surgery by checking your blood pressure, heart rate, temperature, and breathing rate.

    The anesthetist. The anesthetist is the healthcare professional whose job it is to make sure you do not feel any pain during your surgery. You will actually be sleeping throughout the procedure and wake up after it’s over. Your anesthetist may be a doctor (called an anesthesiologist) or a certified registered nurse anesthetist (or CRNA). This person will ask you about your height, weight, and age, as well as about any other surgeries you have had and whether you or a member of your family has ever had a problem with anesthesia.
    The anesthetist may also ask you about any allergies you have and any medications you are taking, even though you may have already discussed this with the nurse. He or she may also ask you other questions about your health and physical condition. Be prepared to answer these questions to the best of your ability, and prepare some questions of your own. You may want to ask about the type of anesthesia you will have, how it will be given to you, and if there are any side effects.


    Endoscopic Third Ventriculostomy (ETV) Surgery

    ETV surgery is a relatively short procedure that varies slightly depending upon the anatomy inside your brain.

    For more detailed information, visit ETV and ETV with CPC (choroid plexus cauterization).

    When it is time for your surgery, you will be brought into the operating room. There, you will have an intravenous (IV) line started, as well as to one or more devices to monitor you during and after surgery. These devices include:

    • Electrocardiogram (EKG —which monitors your heart rate.
    • Automatic blood pressure (BP) cuff—monitors your blood pressure.
    • Pulse oximeter-measures the amount of oxygen in your blood.

    You will likely be given general anesthesia, either through your IV line or with a special mask placed over your nose and mouth, which will make you fall asleep. A small amount of hair on your head may be shaved and some antiseptic solution will be scrubbed on your head to help prevent infection. Your neurosurgeon may also scrub antiseptic solution along your chest and abdomen in case the ETV is not successful and a ventriculoperitoneal (VP) shunt needs to be placed.

    A small incision is made behind the hairline on the right side of the head, followed by a small opening in the skull and the membrane surrounding the brain. An endoscope is passed through this opening into the ventricle. A small camera on the end of the endoscope allows the neurosurgeon to see the anatomy inside the brain as it is projected onto a TV screen. The neurosurgeon advances the endoscope to the floor of the third ventricle where a small opening is made. This allows the CSF to flow through the opening, bypassing the obstruction, so it can be absorbed through the CSF pathways.


    Choroid Plexus Cauterization Surgery

    In a select group of patients, the neurosurgeon may perform Choroid Plexus Cauterization (also referred to as Choroid Plexus Coagulation) (CPC) during an ETV surgery. This procedure is typically only performed in children under two. During this procedure, the neurosurgeon removes (burns away) the choroid plexus that is present in both lateral ventricles. It is thought that the addition of CPC to an ETV may improve the ETV success rate in this group of children but not in children over two years of age. ETV alone is not recommended for most children under two due to very low success rates.

    The reason(s) for the improvement in success rate is not known; however, some clinicians and scientists believe that decreasing pulsatility in the ventricles may help keep the ETV open. CPC decreases pulsatility because the choroid plexus contains a lot of vasculature (blood vessels), and, each time the heartbeats, the blood vessels pulsate (expand and contract). The expansion and contraction of the blood vessels causes the CSF in the ventricles to move. Removing the choroid plexus removes the blood vessels and therefore decreases pulsatility in the ventricles.

    It is important to note that the benefits and risks of CPC are not fully understood and that there is active research in this area. One important unanswered question is in what group of patients is CPC most effective in, in terms of subsequent ETV failure. Another is what are the long-term effects of choroid plexus removal on cognitive outcomes.


    What to Expect After ETV Surgery

    After ETV surgery, you will be moved from the operating room to the recovery room, where a nurse will watch you closely to make sure you are recovering well before moving you to your hospital room. The nurse will check your blood pressure, heart rate, breathing rate, and temperature. He or she will also check your brain function by asking you some questions after you wake up from the anesthesia. The nurse will also check your neurologic condition by asking you to move your arms, legs, fingers, and toes.

    When you wake up after surgery, expect to feel weak and tired. This is natural as your body starts to heal. Nurses will be there to help you, and they will want you to get up and get moving soon after surgery to help speed the recovery process. As you get better, you will be allowed to do more things, depending upon your neurological condition, such as eating solid foods again and getting up by yourself to use the bathroom. You will be discharged from the hospital as soon as your neurosurgeon feels you are ready, usually in a day or two after surgery. Your neurosurgeon will give you specific instructions about what you can and cannot do while you are recovering at home.

    When you get home from the hospital you will still need to rest. During this time, you will concentrate on building up your strength so you can return to school or work, which may take a few weeks. Your neurosurgeon will let you know when it is okay to return to all of your usual activities


    Outcomes of ETV or ETV with CPC Surgery

    “Success” in terms of the ETV procedure is usually considered (by patients and doctors alike) to be avoiding a shunt in a patient who would otherwise require one. Most doctors would categorize ETV as successful if a person later shows clinical evidence of normal intracranial pressure (ICP) and structural evidence of stable or decreased ventricular size. If someone was previously shunted, the shunt must be either removed or proved nonfunctional to demonstrate success.

    The success rate for ETV or ETV/CPC depends upon patient factors such as age, cause of hydrocephalus, and whether there is scarring in the space below the floor of the third ventricle. For some patients, such as those over the age of two with aqueductal stenosis, the chance for success of the ETV may be as high as 90%; however, for others, ETV or ETV/CPC may not be recommended because the chances for success are extremely low.

    The results of ETV are determined by assessing clinical signs of raised intracranial pressure in older children and adults, as well as head circumference measurements and fontanelle tension in infants. MRI and CT scans are important in follow up. It is important to note that, in some cases, ventricles may remain large, in spite of a return to normal intracranial pressure.

    Most failed ventriculostomy patients will remain shunt dependent. Doctors attribute failed procedures to the closure of the hole made during the procedure, the subarachnoid space’s inability to absorb the excess CSF or, alternatively, to a block to CSF flow within the subarachnoid pathways. Because CSF reabsorption pathways might require some time to normalize following ventriculostomy, it may not be possible to determine success immediately after the operation.

    Your neurosurgeon should be able to provide you with a reliable estimate of the likelihood for success in your particular situation prior to the operation. It’s critical that parents and patients understand that ETV is not always a permanent cure for hydrocephalus. Candid communication with your physician regarding the definition of success is important when considering ETV.

    The symptoms of ETV closure are usually the same as the symptoms that were present before ETV surgery.


    Information you can trust! This article was produced by the Hydrocephalus Association, copyright 2021. We would like to thank the following individuals for their valuable contributions and expert input: Marion L. (Jack) Walker, MD, and Cathy Cartwright, DNP, RN-BC, PCNS, FAAN.