we retrospectively reviewed seventeen infants with hydrocephalus who were treated in our department by etv from jul .
this study included 17 patients between the ages of 51 days and 337 days , with an average age of 143 days , 9 males and 8 females , 4 han people and 13 hui people .
of the 17 patients there were 5 cases with encephalitis history , 2 cases with cerebral hemorrhage , and 10 cases of congenital hydrocephalus . among the 10 cases with congenital hydrocephalus , were congenital aqueductal stenosis in 6 cases , chiari malformation in 2 cases , and dandy walker syndrome in 2 cases .
cine phase contrast magnetic resonance imaging ( pc cine mri ) scan shows obstructive hydrocephalus in all cases .
the patient is placed supine and the head is elevated 20 - 30 to minimize excessive cerebral spinal fluid ( csf ) loss .
a hook incision is made in the scalp 3 cm in diameter just lateral to the midline and anterior to the coronal suture .
after a burr - hole approximately 1 cm diameter is created in the frontal bone , the dura is opened in cruciate fashion and the edges are suspended .
14 peel - away catheter is then used to cannulate the frontal horn of the lateral ventricle .
the foramen of monro is located by following the choroid plexus , septal veins , and thalamostriate veins , and the endoscope is passed through this opening and placed into the third ventricle .
once the endoscope is in the third ventricle the cast shadow of basilar artery / posterior cerebral artery , the infundibular recess , and the bilateral mamillary bodies can be observed ( fig .
fenestration is performed in the slight avascular area at the midway between the infundibular recess and the mamillary bodies ( fig .
a special tongs type grab is used for fenestration , and the edges of the orificium fistulae in 5 mm diameter are then coagulated .
the lilliquest membrane is opened through the orificium fistulae under the endoscope so that there is full communication between the third ventricle and the basal cistern ( fig .
after exploring pulsation of the basilar artery and posterior cerebral artery through the orificium fistulae the endoscope is withdrawn .
while repeatedly rinsing with 0.9% nacl , a latin sponge is used to close the punctured pathway and the dura is sutured tightly , mending the periosteum if necessary , and the skull is closed . after surgery
multiple ( 2x-3x ) lumbar puncture was performed for a period of 7 days in order to promote csf circulation , release hemorrhagic csf , and alleviate the discomfort .
ct or mri was performed 7 days and 30 days after surgery to explore the narrowing of the ventricular system ( fig . 2 , 3 ) .
this study included 17 patients between the ages of 51 days and 337 days , with an average age of 143 days , 9 males and 8 females , 4 han people and 13 hui people .
of the 17 patients there were 5 cases with encephalitis history , 2 cases with cerebral hemorrhage , and 10 cases of congenital hydrocephalus . among the 10 cases with congenital hydrocephalus , were congenital aqueductal stenosis in 6 cases , chiari malformation in 2 cases , and dandy walker syndrome in 2 cases .
cine phase contrast magnetic resonance imaging ( pc cine mri ) scan shows obstructive hydrocephalus in all cases .
the patient is placed supine and the head is elevated 20 - 30 to minimize excessive cerebral spinal fluid ( csf ) loss .
a hook incision is made in the scalp 3 cm in diameter just lateral to the midline and anterior to the coronal suture .
after a burr - hole approximately 1 cm diameter is created in the frontal bone , the dura is opened in cruciate fashion and the edges are suspended .
14 peel - away catheter is then used to cannulate the frontal horn of the lateral ventricle .
the foramen of monro is located by following the choroid plexus , septal veins , and thalamostriate veins , and the endoscope is passed through this opening and placed into the third ventricle .
once the endoscope is in the third ventricle the cast shadow of basilar artery / posterior cerebral artery , the infundibular recess , and the bilateral mamillary bodies can be observed ( fig .
fenestration is performed in the slight avascular area at the midway between the infundibular recess and the mamillary bodies ( fig .
a special tongs type grab is used for fenestration , and the edges of the orificium fistulae in 5 mm diameter are then coagulated .
the lilliquest membrane is opened through the orificium fistulae under the endoscope so that there is full communication between the third ventricle and the basal cistern ( fig .
after exploring pulsation of the basilar artery and posterior cerebral artery through the orificium fistulae the endoscope is withdrawn .
while repeatedly rinsing with 0.9% nacl , a latin sponge is used to close the punctured pathway and the dura is sutured tightly , mending the periosteum if necessary , and the skull is closed . after surgery
multiple ( 2x-3x ) lumbar puncture was performed for a period of 7 days in order to promote csf circulation , release hemorrhagic csf , and alleviate the discomfort .
ct or mri was performed 7 days and 30 days after surgery to explore the narrowing of the ventricular system ( fig . 2 , 3 ) .
of the 17 postoperative infants the skull and ventricular system of 7 cases shrank : 1 case with encephalitis history , 1 cases with cerebral hemorrhage , 4 cases with congenital aqueductal stenosis , and 1 case with chiari malformation , yielding an effective rate of 41.2% . 1 case failed because of severe ventricle inflammatory adhesion , excessive exudation , and vague basilar artery . in the remaining 9 cases
whose ventricles were unchanged , ventriculoperitoneal shunt was performed for 4 cases , 5 cases gave up the further operation .
intraoperatively , 2 cases with small artery hemorrhage were repeatedly rinsed with 0.9% nacl and the bleeding gradually stopped .
of the 17 postoperative infants the skull and ventricular system of 7 cases shrank : 1 case with encephalitis history , 1 cases with cerebral hemorrhage , 4 cases with congenital aqueductal stenosis , and 1 case with chiari malformation , yielding an effective rate of 41.2% . 1 case failed because of severe ventricle inflammatory adhesion , excessive exudation , and vague basilar artery . in the remaining 9 cases
whose ventricles were unchanged , ventriculoperitoneal shunt was performed for 4 cases , 5 cases gave up the further operation .
intraoperatively , 2 cases with small artery hemorrhage were repeatedly rinsed with 0.9% nacl and the bleeding gradually stopped .
it is thought that the ventricular system may develop at an important and specific embryonic time period of neural stem cell proliferation and differentiation in the brain .
there are many factors influencing the incidence of infantile hydrocephalus7 ) such as : asphyxia in perinatal period , hypoxic ischemic encephalopathy , intracranial hemorrhage , premature birth , hyperbilirubinemia , and perinatal infection ; the genetic factors can not be excluded as well11 ) .
gansu province is located in the upper region of the yellow river in northwestern china .
it has a population of 26 million ( 2009 ) and has a large concentration of hui chinese in linxia hui autonomous prefecture . in this study we noticed that most infants with infantile hydrocephalus were hui chinese from the linxia area ( 68.4% ) .
very recently a specific clinical syndrome or genetic cause was found to correlate with infantile hydrocephalus in a minority in united states ( they did not mention which syndrome it is)8 ) .
this scientific result inspires us to investigate the possible etiological factors for hui chinese in gansu china in our future work .
the second cause we feel it important is hui chinese have an early marriage and pregnancy custom . for these 13 cases ,
the average maternal ages are only 17.2 years old to give birth , this might be consistent with most research believed maternal component is a significant cause for infantile hydrocephalus4 ) .
currently etv is the first choice for csf shunt therapy in patients with obstructive hydrocephalus ; additionally , the prevailing view is that it can be applied to communicating hydrocephalus9 ) .
it thereupon popularizes etv to infantile hydrocephalus and congenital hydrocephalus , but the effect is still controversial .
some scholars2,6 ) believe that it is not suitable for infants younger than 2 years old , especially under 1 year old due to the incomplete absorption system of csf , the orificium fistulae is reclosed , or new membrane formed postoperatively . in 2008 lipina et al.3 ) reported that 14 patients under 6 months that presented with obstructive hydrocephalus were treated with etv .
the etiology of hydrocephalus was congenital aqueduct stenosis in five patients , posthemorrhagic obstruction in eight patients , and combination of posthemorrhagic and postinfection in one patient .
they recommend etv as the method of choice in children younger than 6 months of age . in 2010 ogiwara et al.5 ) investigated 23 patients younger than 6 months that presented with obstructive hydrocephalus and were treated endoscopically .
the etiology of hydrocephalus was congenital aqueduct stenosis in 11 patients , posthemorrhagic obstruction in six patients , myelomeningocele in two patients , postmeningitis in two patients , chiari i malformation in one patient , and dandy walker variant in one patient .
3 months of age , success rate was 25.0% . in patients from 3 to 6 months of age ,
based on the above data , etv should be the first method of choice for hydrocephalus in children younger than 6 months of age , especially in patients older than 3 months of age .
gallo et al.1 ) reviewed 23 patients younger than 6 months and without a previous history of shunting underwent etv in their institution between 2003 and 2009 .
total success rate was 39.1% . in the successful cases , median age was 140 days , whereas in the unsuccessful cases it was 47 days .
the patients ' basic body situation should be taken in consideration before the etv performed , such as age , the tolerance of a ventriculoperitoneal shunt , and the incident rate of complications . in our study of 17 patients , 7 cases improved remarkably : their heads and ventricles shrank , cerebral cortexes thickened morphologically .
compared with a ventriculoperitoneal shunt , etv has its own advantages : no foreign object ( shunt tubing and valve ) implanted in the body thus avoiding the catheter related complications such as shunt occlusion , infection , over drainage , abdominal complications , the danger of an infant 's thin skin being punctured by catheter , and need for shunt revision with increased age .
after accept etv , the csf is close to the physiologic circulation , meanwhile , some other procedure can be done intraoperatively : pellucid septostomy , aqueductoplasty , cyst fenestration , etc .
our data showed there are fewer postoperative complications , less bleeding , fever , and subdural collection of fluid after surgery . in summary , because of their thin skin and younger age the treatment of infantile hydrocephalus is very difficult .
considering all the benefits mentioned above , we conclude etv is the best treatment choice for infantile hydrocephalus
. we will explore the possible pathogenic factors for infants in future studies so we can avoid or prevent hydrocephalus occurred early .
it is thought that the ventricular system may develop at an important and specific embryonic time period of neural stem cell proliferation and differentiation in the brain .
there are many factors influencing the incidence of infantile hydrocephalus7 ) such as : asphyxia in perinatal period , hypoxic ischemic encephalopathy , intracranial hemorrhage , premature birth , hyperbilirubinemia , and perinatal infection ; the genetic factors can not be excluded as well11 ) .
gansu province is located in the upper region of the yellow river in northwestern china .
it has a population of 26 million ( 2009 ) and has a large concentration of hui chinese in linxia hui autonomous prefecture . in this study we noticed that most infants with infantile hydrocephalus were hui chinese from the linxia area ( 68.4% ) .
very recently a specific clinical syndrome or genetic cause was found to correlate with infantile hydrocephalus in a minority in united states ( they did not mention which syndrome it is)8 ) .
this scientific result inspires us to investigate the possible etiological factors for hui chinese in gansu china in our future work .
the second cause we feel it important is hui chinese have an early marriage and pregnancy custom . for these 13 cases ,
the average maternal ages are only 17.2 years old to give birth , this might be consistent with most research believed maternal component is a significant cause for infantile hydrocephalus4 ) .
currently etv is the first choice for csf shunt therapy in patients with obstructive hydrocephalus ; additionally , the prevailing view is that it can be applied to communicating hydrocephalus9 ) .
it thereupon popularizes etv to infantile hydrocephalus and congenital hydrocephalus , but the effect is still controversial .
some scholars2,6 ) believe that it is not suitable for infants younger than 2 years old , especially under 1 year old due to the incomplete absorption system of csf , the orificium fistulae is reclosed , or new membrane formed postoperatively . in 2008 lipina et al.3 ) reported that 14 patients under 6 months that presented with obstructive hydrocephalus were treated with etv .
the etiology of hydrocephalus was congenital aqueduct stenosis in five patients , posthemorrhagic obstruction in eight patients , and combination of posthemorrhagic and postinfection in one patient .
they recommend etv as the method of choice in children younger than 6 months of age . in 2010 ogiwara et al.5 ) investigated 23 patients younger than 6 months that presented with obstructive hydrocephalus and were treated endoscopically .
the etiology of hydrocephalus was congenital aqueduct stenosis in 11 patients , posthemorrhagic obstruction in six patients , myelomeningocele in two patients , postmeningitis in two patients , chiari i malformation in one patient , and dandy walker variant in one patient .
3 months of age , success rate was 25.0% . in patients from 3 to 6 months of age ,
, etv should be the first method of choice for hydrocephalus in children younger than 6 months of age , especially in patients older than 3 months of age .
gallo et al.1 ) reviewed 23 patients younger than 6 months and without a previous history of shunting underwent etv in their institution between 2003 and 2009 .
in the successful cases , median age was 140 days , whereas in the unsuccessful cases it was 47 days .
the patients ' basic body situation should be taken in consideration before the etv performed , such as age , the tolerance of a ventriculoperitoneal shunt , and the incident rate of complications . in our study of 17 patients ,
7 cases improved remarkably : their heads and ventricles shrank , cerebral cortexes thickened morphologically .
compared with a ventriculoperitoneal shunt , etv has its own advantages : no foreign object ( shunt tubing and valve ) implanted in the body thus avoiding the catheter related complications such as shunt occlusion , infection , over drainage , abdominal complications , the danger of an infant 's thin skin being punctured by catheter , and need for shunt revision with increased age .
after accept etv , the csf is close to the physiologic circulation , meanwhile , some other procedure can be done intraoperatively : pellucid septostomy , aqueductoplasty , cyst fenestration , etc .
our data showed there are fewer postoperative complications , less bleeding , fever , and subdural collection of fluid after surgery . in summary , because of their thin skin and younger age the treatment of infantile hydrocephalus is very difficult .
considering all the benefits mentioned above , we conclude etv is the best treatment choice for infantile hydrocephalus
. we will explore the possible pathogenic factors for infants in future studies so we can avoid or prevent hydrocephalus occurred early .
endoscopic third ventriculostomy is a safe and effective procedure for the treatment of infantile hydrocephalus .
 objectiveto investigate the efficacy of endoscopic third ventriculostomy ( etv ) for infantile hydrocephalus.methodsretrospectively reviewed the 17 infantile hydrocephalus cases who were treated with etv between july 2009 and june 2013 . 
 the study includes 17 patients ( 4 han and 13 hui ) between the ages of 51 and 337 days . 
 five cases with encephalitis history and 2 cases with cerebral hemorrhage , with the remaining 10 cases congenital hydrocephalus . 
 etvs were performed for all patients with 1 case failing because the severe ventricle inflammatory adhesion , excessive exudation , and vague basilar artery.resultsamong the 16 successful cases 7 cases improved remarkably : heads and ventricles reduced and cerebral cortexes thickening morphologically . 
 the ventricles of the remaining cases were unchanged.conclusionthe ethnic minority account for the majority of the patients in this study . 
 etv is effective for infantile obstructive hydrocephalus . 