Vernon L Velho

Title: Extra-axial third ventriculostomy: Rescue surgery for failed treatment of hydrocephalus

Abstract

Background:

Hydrocephalus management becomes increasingly complex following failure of ventriculoperitoneal shunts or endoscopic third ventriculostomy (ETV). Repeated shunt revisions and redo ETVs are associated with higher complication rates and long-term shunt dependency. Extra-Axial Third Ventriculostomy (EA-TV) has been proposed as an alternative rescue surgical procedure that restores physiological cerebrospinal fluid (CSF) circulation by bypassing obstructed pathways. This study evaluates the effectiveness and safety of EA-TV in patients with failed prior CSF diversion procedures.

Methods:

This prospective observational study was conducted over a two-year period and included 50 patients with hydrocephalus who presented with either failed ventriculoperitoneal shunts or failed primary ETV. Thirty-two patients had shunt failure and eighteen had failed ETV. All patients underwent Extra-Axial Third Ventriculostomy using a standardized surgical technique. Clinical outcomes were assessed based on improvement of symptoms related to raised intracranial pressure, while radiological outcomes were evaluated using postoperative neuroimaging. The primary endpoint was shunt-free survival without the need for additional CSF diversion procedures. Patients were followed for a minimum duration of 12 months.

Results:

EA-TV was successfully performed in all 50 patients. Clinical improvement was observed in 42 patients (84%), with marked reduction in symptoms such as headache, vomiting, and altered sensorium. Radiological improvement or stabilization of ventricular size was noted in 40 patients (80%). At final follow-up, 41 patients (82%) remained shunt-free without requiring further surgical intervention. Postoperative complications were minimal and included transient CSF leak in two patients (4%) and low-grade fever in three patients (6%), all of which resolved with conservative management. No major neurological deficits or mortality were recorded.

Conclusion:

Extra-Axial Third Ventriculostomy is a safe and effective rescue surgical option for hydrocephalus following failed shunt surgery or failed ETV. It offers favorable clinical and radiological outcomes with low complication rates and significantly reduces shunt dependency. EA-TV should be considered a valuable alternative in the management of complex and refractory hydrocephalus.

Key Messages:

• Extra-Axial Third Ventriculostomy is an effective rescue strategy

EA-TV provides a reliable surgical alternative for patients with hydrocephalus after failed shunt surgery or failed ETV, achieving high rates of clinical improvement and shunt-free survival in complex cases.

• Sustained benefit with low complication rates

Over a two-year experience, EA-TV demonstrated durable clinical and radiological improvement with minimal morbidity and no mortality, supporting its safety and long-term effectiveness.

• Reduction in long-term shunt dependency and neurological burden

Successful EA-TV minimizes the need for repeated shunt revisions, potentially reducing chronic neurological morbidity and improving long-term quality of life for patients with refractory hydrocephalus.