Endoscopic third ventriculostomy (ETV) was performed between July 1978 and July 1995 on 69 patients with hydrocephalus and myelomeningocele. Most of the patients had been previously shunted, although in 14 patients ETV was the initial treatment. Patient selection was based on preoperative imaging studies suggesting noncommunicating hydrocephalus. Only 2 patients exhibited transient hypothalamic dysfunction with complete resolution. Patients were assessed by their clinical status, imaging characteristics, and, in some cases, formal psychometric studies. The overall success rate was 72%, although selecting only patients who have been previously shunted or who were over 6 months of age at the time of endoscopy increases this to 80%. Our results indicate that ETV is a safe and effective means of treating hydrocephalus in the older spina bifida population and offers the hope of long-term, shunt-independent life for selected patients.

Improvements in the technology have made endoscopic third ventriculostomy safer than earlier technics of open third ventriculostomy as described by Scarf (14). Similarly, it is safer than the stereotactic technics used by Pierre-Kahn (10), Sayers (13), and Hoffman (4). The morbidity and mortality have decreased and the effectiveness has also increased (12, 15). Modern operations are based on Guiot's technique (2). In the management of hydrocephalus third ventriculostomy has to be compared with the treatment with intracranial shunts. Currently in our hands the procedure has a higher morbidity rate than a shunt operation. Our figures include those from our early experience (5)--more recent figures show a lower complication rate. We believe the higher morbidity is acceptable as the chance of being permanently cured is 80% in favourable cases.

Long-term extracranial shunting for hydrocephalus has numerous drawbacks related to shunt malfunction and infection. In some cases outcome has been very disappointing. We successfully managed 5 patients with acquired aqueductal stenoses with no significant morbidity by the use of an intracranial cerebrospinal fluid diversion, namely a third ventriculostomy. First advocated by Dandy, ventriculostomy was largely passed over in favor of extracranial procedures. With improved surgical techniques, however, ventriculostomy is now considered to be a viable alternative in selected cases. In a further 19 patients, we subsequently broadened our patient selection to include those with Arnold-Chiari malformations, congenital noncommunicating hydrocephalus, and tumors. Two thirds of these children remain without shunts and apart from 1 child developing hemiplegia postoperatively, there has been no significant morbidity. Although the best results have been seen in the late onset groups, even early onset, noncommunicating hydrocephalus has been successfully managed. Even in patients in whom third ventriculostomy has failed and who have subsequently required ventriculoperitoneal shunts, we anticipate that they will remain less dependent on shunts because their hydrocephalus is now communicating, which tends not to have such a rapid onset or extreme levels of raised intracranial pressure. (Neurosurgery 26:86-92, 1990)

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