Efficacy of Combined Endoscopic Third Ventriculostomy and Choroid Plexus Cauterization in Treatment of Hydrocephalus

Overview

Hydrocephalus remains one of the most common conditions encountered in neurosurgery, traditionally managed by ventriculoperitoneal (VP) shunting. Despite its effectiveness, shunt dependency is associated with certain complications including infection, obstruction, and repeated revisions, leading to increased morbidity and healthcare burden. Over the last 70 years, cerebrospinal fluid (CSF) shunting and more recently endoscopic third ventriculostomy (ETV) have been the mainstays of hydrocephalus treatment. In recent years, choroid plexus cauterization (CPC) has re-emerged as an additional treatment strategy. In combination with ETV, CPC increases the chances of successfully treating some cases with hydrocephalus, than ETV alone. Endoscopic Third Ventriculostomy (ETV) has emerged as an alternative physiological treatment by creating a bypass for cerebrospinal fluid (CSF) flow. However, its success is limited in infants and in other varieties of hydrocephalus. The addition of Choroid Plexus Cauterization (CPC), which reduces CSF production, has been shown to improve outcomes when combined with ETV, particularly in younger patients. The idea is based on the principle that ablation of the predominant source of CSF secretion within the brain, choroid plexus (CP), reduces CSF production. In addition, CPC may reduce CSF pulsatility, an effect which may be potentiated when combined with ETV, which might reduce intraventricular pulsations by serving as a pulsation absorber. These effects, in combination, may tip the balance in favour of CSF absorption and negate the need for shunting in a proportion of patients. The combined ETV-CPC approach, popularized by Benjamin Warf, has demonstrated promising results in reducing shunt dependence, especially in resource-limited settings. However, variability in success rates persists due to differences in patient selection, etiology, and surgical expertise. This study aims at evaluation of the efficacy of combined ETV-CPC as a primary treatment modality for hydrocephalus and to identify predictors of surgical success and failure, thereby optimizing patient selection and improving outcomes.