Selecting patients for endoscopic third ventriculostomy.

ETV using contemporary instrumentation has been used for more than 50 years, but its use has become widespread only in the last 10 to 15 years. Randomized prospective trials comparing ETV with shunts are needed before definitive statements can be made about the role of the former in managing the many forms of hydrocephalus. The absolute and relative contraindications for the use of ETV in the management of hydrocephalus are shown in the Box 1 on this page. It is important not to presume that a specific radiographic or clinical feature would prevent a patient from responding to this rather new procedure without testing the hypothesis. Patients should be given as much information as possible regarding the risks and benefits of ETV so they can participate in the decision-making process. When should the role of ETV in the management of hydrocephalus be discussed with a patient? At the initial diagnosis of hydrocephalus, the patient or family should be informed of this potential alternative to shunting for the management of hydrocephalus. I also believe that patients with working shunts who are being followed chronically should be informed about ETV as a potential treatment option when their shunt fails. Every shunt failure or infection should be viewed as an opportunity to explore the possibility that the patient could become shunt independent.