Case Prep: Pediatric Endoscopic Third Ventriculostomy (± Choroid Plexus Cauterization)

Case / Approach Snapshot

• Anatomy at risk: age-specific skull/soft tissue, developing brain and tracts, CSF pathways, brainstem/lower cranial nerves, tumor or congenital lesion relationships, and blood-volume constraints.
• Operative steps: adapt positioning/anesthesia to age, confirm imaging and goals with family, expose gently, preserve neurovascular/CSF pathways, reconstruct durably for growth, and plan ICU/endocrine/rehab surveillance; use the detailed operative sequence and approach notes below as the step-by-step source.
• Rescue plans: blood loss, hypothermia, swelling, hydrocephalus, airway/swallowing issues, endocrine/electrolyte shifts, infection, and staged therapy with oncology or rehab teams.
• Figures: review Figures, Imaging & Video and the Curated Image Set; embedded local figures should remain open-access, public-domain, or otherwise reusable with attribution.
• Papers: review High-Yield Literature for seminal sources, modern reviews, and outcome data specific to this page.

One-Liner

[Age — months/years] [M/F] child with obstructive hydrocephalus due to [aqueductal stenosis / posterior fossa tumor / other] planned for endoscopic third ventriculostomy [with choroid plexus cauterization (ETV/CPC)].

Figures, Imaging & Video

🎥 Operative video — search operative video on YouTube ▸ · The Neurosurgical Atlas ▸

Neurosurgical Atlas · Radiopaedia · PubMed Central — operative figures © linked; see media-sources.md

High-Yield Literature

• Paediatric hydrocephalus — Kahle KT. Nature reviews. Disease primers 2024. PubMed
• Endoscopic third ventriculostomy versus shunt for pediatric hydrocephalus: a systematic literature review and meta-analysis — Texakalidis P. Child’s nervous system : ChNS : official journal of the International Society for Pediatric Neurosurgery 2019. PubMed
• Endoscopic third ventriculostomy for shunt malfunction in the pediatric population: a systematic review, meta-analysis, and meta-regression analysis — Lee KS. Journal of neurosurgery. Pediatrics 2023. PubMed
• Predicting endoscopic third ventriculostomy success in pediatric shunt dysfunction: a monocentric retrospective case series of 70 consecutive children, systematic review, and meta-analysis — Guida L. Journal of neurosurgery. Pediatrics 2023. PubMed
• Endoscopic third ventriculostomy versus ventriculoperitoneal shunt in pediatric and adult population: a systematic review and meta-analysis — Pande A. Neurosurgical review 2021. PubMed
• Endoscopic third ventriculostomy versus ventriculoperitoneal shunt for treating pediatric tuberculous meningitis hydrocephalus: a systematic review and meta-analysis — Fagundes W. Journal of neurosurgery. Pediatrics 2025. PubMed
• Endoscopic third ventriculostomy for pediatric tumor-associated hydrocephalus — Sherrod BA. Neurosurgical focus 2020. PubMed
• Infant Hydrocephalus — Lu VM. Pediatrics in review 2024. PubMed
• The Global Rise of Endoscopic Third Ventriculostomy with Choroid Plexus Cauterization in Pediatric Hydrocephalus — Dewan MC. Pediatric neurosurgery 2017. PubMed
• Endoscopic third ventriculostomy in the treatment of hydrocephalus in pediatric patients — Di Rocco C. Advances and technical standards in neurosurgery 2006. PubMed

Curated Image Set

Open-access figures are embedded from PubMed Central articles and kept unique to this guide.

Figure 2. Source: Re-endoscopic third ventriculostomy versus ventriculoperitoneal shunting in failed endoscopic third ventriculostomy in pediatric patients with hydrocephalus: A systematic review — Surg Neurol Int. 2025 May 30;16:205. doi: 10.25259/SNI_1111_2024; CC BY-NC-SA.

Figure 3. Source: Re-endoscopic third ventriculostomy versus ventriculoperitoneal shunting in failed endoscopic third ventriculostomy in pediatric patients with hydrocephalus: A systematic review — Surg Neurol Int. 2025 May 30;16:205. doi: 10.25259/SNI_1111_2024; CC BY-NC-SA.

Figure 4. Source: Re-endoscopic third ventriculostomy versus ventriculoperitoneal shunting in failed endoscopic third ventriculostomy in pediatric patients with hydrocephalus: A systematic review — Surg Neurol Int. 2025 May 30;16:205. doi: 10.25259/SNI_1111_2024; CC BY-NC-SA.

Figure 5. Source: Re-endoscopic third ventriculostomy versus ventriculoperitoneal shunting in failed endoscopic third ventriculostomy in pediatric patients with hydrocephalus: A systematic review — Surg Neurol Int. 2025 May 30;16:205. doi: 10.25259/SNI_1111_2024; CC BY-NC-SA.

Figure 6. Source: Re-endoscopic third ventriculostomy versus ventriculoperitoneal shunting in failed endoscopic third ventriculostomy in pediatric patients with hydrocephalus: A systematic review — Surg Neurol Int. 2025 May 30;16:205. doi: 10.25259/SNI_1111_2024; CC BY-NC-SA.

Figure 7. Source: Re-endoscopic third ventriculostomy versus ventriculoperitoneal shunting in failed endoscopic third ventriculostomy in pediatric patients with hydrocephalus: A systematic review — Surg Neurol Int. 2025 May 30;16:205. doi: 10.25259/SNI_1111_2024; CC BY-NC-SA.

Fig. 1. Preoperative axial a, b, and sagittal c MR images showing tri-ventricular occlusive hydrocephalus due to compression of the aqueduct by a tectal lesion, suspected for low-grade tumor Source: Endoscopic transaqueductal stent placement for tumor-related aqueductal compression in pediatric patients: surgical consideration, technique, and results — Child’s Nervous System 2023; CC BY.

Fig. 2. Intraoperative endoscopic view on the occluded aqueduct above the posterior commissure a, b. After an endoscopic biopsy c, the transaqueductal stent is inserted via the aqueduct into the… Source: Endoscopic transaqueductal stent placement for tumor-related aqueductal compression in pediatric patients: surgical consideration, technique, and results — Child’s Nervous System 2023; CC BY.

Fig. 3. Postoperative obtained axial computed tomogram a axial and sagittal MR images b, c, d showing the optimal positioning of the transaqueductal stents. Additionally, the obvious reduction… Source: Endoscopic transaqueductal stent placement for tumor-related aqueductal compression in pediatric patients: surgical consideration, technique, and results — Child’s Nervous System 2023; CC BY.

History of Present Illness

• Chief complaint: Macrocephaly, bulging fontanelle, sunsetting eyes, irritability, vomiting, developmental delay (infants); headache/vomiting (older)
• Etiology: aqueductal stenosis, tumor (tectal/pineal/posterior fossa), post-hemorrhagic, post-infectious
• ETV Success Score (age, etiology, prior shunt) — younger infants and post-infectious have lower success; ETV+CPC improves success in infants (Warf technique, esp. < 1-2 years)

Past Medical History

• Prematurity, IVH (post-hemorrhagic hydrocephalus), prior infection (post-infectious), prior shunt
• Birth/developmental history

Imaging Review

MRI (sagittal, T2, CISS, cine flow)

• Triventricular hydrocephalus (obstructive pattern), aqueduct (stenosis/tumor)
• Third ventricle floor — thinned, bowed; prepontine cistern space (adequate between floor and basilar/clivus)
• Basilar artery position, anatomy (massa intermedia, infundibular recess, mammillary bodies)
• Etiology (tumor, septations)

Labs

• CBC, BMP, Coags, pediatric pre-op

Examination

• Head circumference (plot), fontanelle, eye movements (sunsetting, CN VI), developmental status

Surgical Planning

Case Logistics, OR Needs & Orders

• OR setup: pediatric anesthesia/equipment, warming, weight-based implants/antibiotics, navigation/endoscope/microscope as needed, blood availability for tumor/myelomeningocele cases, and family-centered postop handoff.
• Special needs: weight-based fluids/meds, latex allergy precautions for myelomeningocele, steroid/endocrine/DI plan when sellar/posterior fossa risk exists, EVD/CSF diversion plan, and age-appropriate neuro baseline.
• Immediate postop orders: PICU/step-down neuro checks, airway/swallow monitoring when relevant, CT/MRI timing, drain/EVD/shunt orders, antibiotics/steroid taper, pain control, wound/skin precautions, and PT/OT/rehab planning.

Diagnosis & Indication

• Indication: Obstructive hydrocephalus; ETV avoids shunt dependence; ETV+CPC for infants to improve success (cauterize choroid plexus to reduce CSF production)
• Cautions: very young infants (lower ETV success alone → add CPC), prepontine scarring (post-infectious), narrow cistern, distorted anatomy

ETV Success Read

• Favor ETV when hydrocephalus is obstructive with a defined block (aqueductal stenosis, tectal/pineal/posterior fossa obstruction) and a navigable third-ventricle floor/prepontine cistern.
• Lower success is expected in very young infants, postinfectious/posthemorrhagic hydrocephalus, thick opaque floor, scarred prepontine cistern, small ventricles, or prior failed ETV with closed/scarred stoma.
• ETV+CPC is most relevant in infants and selected shunt-avoidance scenarios; the added value depends on age, etiology, anatomy, and ability to safely reach/cauterize the plexus.
• A shunt is still the safer answer when the anatomy is hostile, the floor landmarks are not trustworthy, or the child cannot tolerate an uncertain ETV failure risk.

Imaging Checklist

• MRI sagittal CISS/FIESTA or equivalent: third-ventricle floor thickness, basilar position, clival/dorsum relationship, prepontine cistern size, Liliequist membrane, and any interpeduncular scarring.
• Coronal/axial planning: foramen of Monro size, venous anatomy, septations, mass trajectory constraints, and whether a flexible scope is needed for CPC.
• Review prior shunt history, infection/hemorrhage, and whether ventricles are large enough for safe endoscopic working room.

Position

• Supine, head neutral/slightly flexed, age-appropriate fixation/padding
• Right frontal entry (modified Kocher trajectory to foramen of Monro)

Key Surgical Steps

1. Right frontal burr hole (or fontanelle-based in infants), trajectory to foramen of Monro
2. Introduce rigid (or flexible) neuroendoscope via peel-away sheath into the lateral ventricle
3. Identify foramen of Monro landmarks (choroid plexus, septal/thalamostriate veins, fornix)
4. Enter third ventricle; identify floor landmarks — mammillary bodies (posterior), infundibular recess (anterior), tuber cinereum (between)
5. Fenestrate the floor in the midline anterior to the mammillary bodies, behind the dorsum sellae (through tuber cinereum) — blunt perforation (not cautery near basilar), dilate with Fogarty balloon
6. Open the membrane of Liliequist; confirm patency into the prepontine cistern; visualize and avoid the basilar artery and perforators
7. ETV+CPC (if performed): with flexible scope, cauterize the choroid plexus bilaterally in the lateral ventricles (and septostomy as needed)
8. Confirm flow (floor pulsation), hemostasis, withdraw scope, closure

Critical Anatomy & Structures at Risk

1. Basilar artery and perforators — directly below the floor; injury catastrophic
2. Fornix (foramen of Monro) — memory
3. Hypothalamus (floor) — endocrine/autonomic
4. Choroid plexus vessels (CPC — bleeding), septal/thalamostriate veins

Equipment

• Rigid neuroendoscope (ETV) ± flexible scope (for CPC), working channel
• Fogarty/ETV balloon, blunt fenestration probe, bipolar/cautery (CPC)
• Warm irrigation (LR), EVD kit (backup), pediatric setup

Monitoring

• Standard; watch bradycardia (floor manipulation)

Anesthesia

• Pediatric general; warm irrigation (thermoregulation), watch bradycardia/asystole during floor manipulation (stop, irrigate), careful fluid balance

Potential Complications

1. Basilar artery injury (rare, catastrophic), bradycardia/arrest (floor)
2. Fornix/hypothalamic injury, CN III palsy
3. ETV failure (esp. infants/post-infectious) → may need repeat or shunt; delayed closure possible (counsel re: warning signs)
4. CSF leak, intraventricular hemorrhage (CPC), infection

Rescue and Failure Logic

• Bradycardia/asystole during floor work: stop manipulation, irrigate warm fluid, let anesthesia restore hemodynamics, and resume only if landmarks remain clear and the child is stable.
• Basilar/perforator seen too close or floor opaque: do not force the stoma; adjust trajectory only if safe, otherwise abort to shunt/alternate diversion.
• Bleeding during CPC: irrigate patiently, lower irrigation pressure once visibility returns, use focal bipolar only on plexus, and avoid chasing blood into the foramen/veins.
• No visible prepontine flow after fenestration: open Liliequist membrane, inspect for a second membrane, confirm the basilar/perforator corridor, and consider leaving an EVD or converting if patency remains doubtful.
• Early clinical failure: do not rely on ventricular size alone; evaluate symptoms, fontanelle/OFC, wound, infection, cine flow when useful, and have a low threshold for shunt in an unstable infant.
• Late failure: treat recurrent headache/vomiting/lethargy/sunsetting as urgent hydrocephalus until proven otherwise, even years after a successful ETV.

Operative Note Template

Preoperative Diagnosis: Obstructive hydrocephalus ([aqueductal stenosis / tumor / post-hemorrhagic])

Postoperative Diagnosis: Same

Procedure: Endoscopic third ventriculostomy [with choroid plexus cauterization (ETV/CPC)]

Surgeon / Assistant: Anesthesia: Pediatric general endotracheal EBL / Fluids: Minimal Adjuncts: Rigid [± flexible] neuroendoscope, Fogarty/ETV balloon, [bipolar for CPC], warm irrigation Complications: None Note: Watch for bradycardia during floor manipulation

Indications: [Age — months/years] child with obstructive hydrocephalus and favorable floor anatomy; [ETV+CPC chosen to improve success in the infant]. Risks (basilar injury, bradycardia, ETV failure) discussed with family.

Description of Procedure: After consent and time-out, pediatric general anesthesia was induced (warm irrigation). A right frontal entry was made along a trajectory to the foramen of Monro and the endoscope introduced. The foramen of Monro landmarks were identified and the third ventricle entered; the floor landmarks (mammillary bodies, infundibular recess, tuber cinereum) were defined. The floor was bluntly fenestrated in the midline anterior to the mammillary bodies and dilated with a Fogarty balloon, the membrane of Liliequist opened, and patency confirmed with the basilar artery visualized and avoided. [With a flexible scope, the choroid plexus was cauterized bilaterally (CPC).] Floor pulsation confirmed flow.

The endoscope was withdrawn and closure performed. The infant/child was transferred with head-circumference/fontanelle monitoring and family education on ETV-failure signs.

Postoperative Plan

• Floor/PICU per age, neuro checks, head circumference/fontanelle
• CT/MRI postop (ventricles may not shrink immediately; cine flow shows stoma patency)
• Monitor for ETV failure (recurrent hydrocephalus — bulging fontanelle, increasing OFC, vomiting, sunsetting — can be early or delayed → shunt)
• Educate family on warning signs of failure
• Follow-up MRI, developmental surveillance, neurosurgery follow-up

Chief-Level Case Review

Use these as the senior-level mental model for Pediatric Endoscopic Third Ventriculostomy (± Choroid Plexus Cauterization):

• Decision point: The setup is age-specific: blood volume, warming, positioning pressure, airway, latex risk, family counseling, and ICU/PICU handoff differ from adults.
• Technical lever: Preserve future options: growth, shunt dependence, cranioplasty/bone healing, endocrine/neurocognitive trajectory, and adjuvant therapy influence today’s choices.
• Bailout: Have a complication script: blood loss, CSF leak, hydrocephalus, wound breakdown, posterior fossa mutism, infection, and airway/swallow risk should be anticipated.
• Postop watch: Postop communication matters: family expectations, neurologic baseline, therapy needs, school/developmental supports, and surveillance imaging/labs should be clear.

Common Pimp Questions

Use these to pressure-test preparation for Pediatric Endoscopic Third Ventriculostomy (± Choroid Plexus Cauterization):

1. What age-specific anatomy, blood volume, temperature, and positioning issue changes the plan?
2. What is the neurologic, developmental, or syndromic baseline?
3. What skin, wound, CSF, or infection risk is highest in this child?
4. What family-facing expectation should be clarified before surgery?
5. What postop bed, feeding, pain, imaging, and activity plan is safest?

Attending Preference Variables

Items that commonly vary by surgeon or institution:

• Blood availability threshold, warming strategy, antibiotic dosing, and Foley/drain use: [attending-specific]
• Positioning aids, pinning versus horseshoe, and skin-prep preference: [attending-specific]
• Family update cadence and expected ICU/floor disposition: [attending-specific]
• Postop feeding, pain regimen, wound care, and activity restrictions: [attending-specific]