Historic back ground of Endoscopic Third ventriculostomy.

1. Historical Background of ETV
Abdi Ermolo (MD, Neurosurgeon )
St Peter Specialized hospital

2. Historical….
Faivre, in 1854 and Luschka, in 1855 were the first researchers to
suggest that the choroid plexus is the source of CSF
Cushing supported this hypothesis through intraoperative
observations .
Dandy, in 1918, demonstrated in an animal study that unilateral
hydrocephalus was produced when the 4th ventricle and lateral
ventricle are blocked together

3. Historical….
The modern endoscope was first introduced by German urologist
Maximilian Carl-Friedrich Nitze (1848–1906) in 1879.
Which opened the door for neurosurgeons to adapt endoscopy to
their procedures.

4. Historical….
Neuroendoscopy began in 1910.
The urologist Victor Lespinasse (1878–1946), using a cystoscope,
made the first attempt to treat hydrocephalus by destroying the
choroid plexus of two young patients.

5. Historical….
1
1922, Walter Dandy (1886–1946) also
used a cystoscope to visualize the
ventricles
 He noted that he was able to inspect
the lateral ventricle, the foramen of
Monro, the choroid plexus and even
the blood vessels in the wall of the
ventricle; thus the term
“ventriculoscopy” was used for the
first time.

6. Historical….
 William Jason Mixter (1880–1958)
performed the first-ever third
ventriculostomy in the treatment of a non-
communicating hydrocephalus using an
uretheroscope in 1923.
 His attempt was successful; the patient’s
head circumference decreased and the
pressure in the ventricles and the lumbar
cistern equilibrated

7. Historical….
• More than 10 years later, in 1934, Tracy Putnam (1894– 1975)
introduced the “ventriculoscope” aiming to perform the choroid
plexectomy that Dandy had performed with the cystoscope.
Putnam’s results were published in
1943, and he reported operating on 42 patients
with 11 intraoperative deaths.

8. Historical….
In 1932, Dandy also used a rigid Kelly cystoscope to inspect the
lateral ventricles in two hydrocephalic children .
Cauterization of the choroid plexus was attempted in one case. He
further detailed the technique of endoscopic coagulation of the
choroid plexus in 1938.
In the subsequent years, besides CPC, other surgical treatments of
hydrocephalus were introduced including ETV and CSF shunts.
In 1949, Frank Nulsen (1916–1994) and Eugene Spitz (1919–2006)
introduced the concept of the shunt

9. Historical….
 In a review, from 1934 to 1957, there were 95 cases of CPC.
The mortality rate was 15%, while the mean success rate was 60% with an
average follow-up period of 8 years.
On the other hand, there were 1087 cases of various kinds of CSF
shunt, including 230 VPS.
 The mean mortality rate was 10%, and the mean initial success rate was 60%
with an average follow-up time of 2 years

10. Historical….
The result of the reviews showed a shift from CPC to shunts, perhaps
due to poor and limited technology and
The shunt procedure was considered relatively easy, hence
ventriculostomy lost its luster and neurosurgeons became less
enthusiastic about it

11. Historical….
 In the 1960s, French neurosurgeon
Gerard Guiot (1912–1998) revived
the whole idea of neuroendoscopy
after its long sleep.
 His first ETV was successfully
performed on 8 August 1962 on a 40-
year-old man with a history of head
trauma

12. Historical….
The next generation of neuroendoscopy would arrive in the 1970s
based on a major contribution by British physicist Harold H. Hopkins
(1918–1994) whose innovative work paved the path toward rigid and
flexible endoscopes used today
In 1960, Karl Storz would couple the rod lens system of Hopkins with
a fiber optic light source.

13. Historical….
 Takanori Fukushima (born 1942) invented the
“ventriculofiberscope” and in 1973, became the first neurosurgeon
to use a flexible endoscope for ventriculostomies.

14. Historical….
 One of the most recent contributions to the
development of ETV came from Benjamin Warf of
the Boston Children’s Hospital.
 He reported the combination of both ETV and
CPC in order to yield better results in the
treatment of hydrocephalus especially in
developing countries.

15. Historical….
Based on that assumption, Warf conducted his ETV CPC trials in East
Africa,
His initial results in 2005 suggested that ETV-CPC was better than ETV
alone in patients younger than 1 year of age, especially those with
myelomeningocele and “non-postinfectious” hydrocephalus.
In 2012, after conducting several trials, it was clear that infants below
one year of age with congenital aqueductal stenosis would benefit
the most from ETV-CPC.

16. Historical….
In 2014, Warf validated his results from Uganda by conducting ETV-
CPC trials on patients in North American and the results were
consistent with his previous experience.
He also found that ETV-CPC carries a lower risk of postoperative
infection or malfunction compared to shunt procedures, offering a
substantial cost-effectiveness advantage