Efficacy of simultaneous single-trajectory endoscopic tumor biopsy and endoscopic cerebrospinal fluid diversion procedures in intra- and paraventricular tumors

Pineal Apoplexy: Highlighting the Causes, Treatment, and Outcome

BACKGROUND

 Pineal apoplexy, alternatively referred to as pineal hemorrhage or pineal gland hemorrhagic stroke, is an infrequent pathologic condition characterized by bleeding within the pineal gland. In this review, we encompass the primary factors contributing to this uncommon ailment.

METHODS

 The retrieval of pertinent research, including patients with pineal apoplexy, was conducted through PubMed, Google Scholar, and Scopus databases. This study exclusively incorporated comprehensive articles written in the English language. The search encompassed the MeSH terms "pineal apoplexy" and "pineal hemorrhage."

RESULTS

 A total of 41 articles were identified, encompassing a collective sample size of 57 patients. The median age of the patients in the study was 30 years, with a range spanning from 1 to 73 years. There were 27 males, representing 47.4% of the participants. The study identified the most often reported symptoms as headache (49; 86%), nausea/vomiting (19; 33.3%), and Parinaud's syndrome (16; 28.1%). The treatment options encompass several approaches, including open resection, shunting, ventriculostomy, endoscopic aspiration, and conservative care. In the conducted study, a notable number of patients, amounting to 45 cases (78.9%), indicated an amelioration of their symptoms upon their discharge.

CONCLUSION

 Data from a cohort of 57 cases provide insights into symptoms, lesions, treatments, and outcomes. Management approaches range from conservative measures to surgical interventions, with prognosis hinged on timely intervention. This investigation serves as a valuable resource for clinicians and researchers, underscoring the need for early diagnosis before permanent neurologic dysfunction happens and tailored treatments for optimal outcomes in pineal apoplexy cases.

Endoscopic extended transforaminal approach (medial subchoroid) as an alternative to the classical transchoroidal approach: Technical note

The extended transforaminal endoscopic approaches allows visualization and manipulation of the middle and posterior third of the III ventricle. In selected cases where the venous anatomy is favorable, the medial subchoroidal approach can be performed as an alternative to the classic transchoroidal approach (via trans-taenia fornicis) with increased protection over the fornix and without the need to sacrifice the septal vein. We present a 14-year-old male with history of Neurofibromatosis type 1 referred for two weeks of clinical evolution with headache, dizziness, gait instability and appearance of a right VI nerve palsy. Magnetic resonance imaging showed obstructive tri-ventricular hydrocephalus due to stenosis of the aqueduct of Sylvius with suspicion of an underlying tumor. An endoscopic surgical procedure was performed through a single approach with III cisternostomy and resection of the tissue that produced the stenosis. The anatomopathological diagnosis showed reactive glial tissue with no signs of malignancy. In conclusion, the medial subchoroidal approach is a plausible alternative in the endoscopic approach to the III ventricle structures in a safe and comfortable manner.

Tumor-related hydrocephalus in infants: a narrative review

Primary brain tumors diagnosed during infancy present several challenges for the pediatric neurosurgeon including the management of tumor-related hydrocephalus. Infant tumor-related hydrocephalus (iTRH) is present in over 70% of new diagnoses overall and in over 90% of infants with infratentorial neoplasms. iTRH may be related to direct obstruction of cerebrospinal fluid (CSF) pathways, shedding of protein and/or cells leading to dysfunctional subarachnoid, tumor-related CSF production, or, most frequently, a combination of these mechanisms. Treatment plans must consider the acuity of presentation, the mechanism of iTRH, and the additional neoadjuvant or adjuvant therapies required to treat the neoplasm. This narrative review provides a broad reference on the epidemiology, pathophysiology, and treatment of iTRH.

Endoscopic Third Ventriculostomy and Simultaneous Tumor Biopsy in Pineal Region Tumors using the "Single Burr Hole" Technique: An Analysis of 34 Cases

Background

Pineal region tumors often present with hydrocephalus. Endoscopic third ventriculostomy (ETV) and simultaneous tumor biopsy remain a minimally invasive procedure offering both diagnostic and therapeutic advantages in the management of these tumors. However, different operative techniques have been described in the literature.

Aim

The aim is to study the ETV success rate, diagnostic rate of simultaneous tumor biopsy, complications, and follow-up of patients of pineal region tumors managed with ETV and simultaneous tumor biopsy using the single burr hole technique.

Methods

The study was performed by retrospectively reviewing the records of patients of pineal region tumors managed by simultaneous ETV and tumor biopsy using a "single burr hole" technique from January 2012 to December 2019.

Results

Thirty-four patients (22 males and 12 females) with a mean age of 28.7 years were analyzed. ETV was successful in relieving hydrocephalus in 29 (87.8%) patients. Three patients needed a ventriculoperitoneal shunt, and one required Ommaya reservoir placement for persistent hydrocephalus. Histological diagnosis was successfully established in 26 (78.8%) patients. There were two procedure-related mortalities. Two patients underwent craniotomy and tumor excision subsequently. Radiotherapy was given to 11 patients, and 9 patients were managed by observation alone. The mean follow-up of our study was 15.8 months.

Conclusions

Simultaneous ETV and tumor biopsy using a single burr hole technique is a safe, minimally invasive procedure for the management of pineal region tumors.

Role of endoscopic surgical biopsy in diagnoses of intraventricular/periventricular tumors: review of literature including a monocentric case series

The intra- and periventricular location tumor (IPVT) of a brain remains a hard challenge for the neurosurgeon because of the deep location and eloquent anatomic associations. Due to this high risk of iatrogenic injury, many surgeons elect to perform biopsies of such lesions to establish a diagnosis. On the one hand, stereotaxic needle biopsy (SNB) is a minimally invasive procedure but with a significant risk of complications and a high risk of lack of tissue for molecular analyses for this region [Fukushima in Neurosurgery 2:110-113 (1978)]; on the other hand, the use of endoscopic intraventricular biopsy (EIB) allows for diagnosis with minimal surgical intervention [Iwamoto et al. in Ann Neurol 64(suppl. 6):628-634 (2008)]. IPVTs and related CSF pathway obstructions can be safely and effectively treated with endoscopic techniques. It is not possible to compare EIB with diagnoses made by any other method or with the established treatment. We aim to analyze the accuracy of EIB results by comparing them with results of biopsies performed later, in other methods and thereby evaluating the treatment evolution considering our personal experience. The difficulties and complications encountered are presented and compared with those reported in the literature to obtain the best review possible for this topic. A systematic review of literature was done using MEDLINE, the NIH Library, PubMed, and Google Scholar yielded 1.951 cases for EIB and 1912 for SNB, according to standard systemic review techniques. Review was conducted on 50 studies describing surgical procedures for lesions intra- and para-ventricular. The primary outcome measure was a diagnostic success. We also consider 20 patients with IPVT treated in our department. Clinical characteristics and surgical outcome were evaluated and a systematic review of the literature was performed. Overall, all our biopsies were diagnostic, with a positive histologic sample in 100% of our patients. 8 patients underwent a concurrent endoscopic third ventriculostomy. 4 patients underwent a concurrent ventriculostomy combined with septostomy. For 1 patient was necessary the only septostomy combined with biopsy. Every case has obtained a histological diagnosis. The percentage of complications was very low with only 1 case of post-operative infection and 1 case of hemorrhage. It was impossible to create a specific comparison from literature data of IPVTs between a stereotactic and endoscopic procedure, it presents only the collection of pineal gland tumor [Kelly in Neurosurgery 25(02):185-194 (1989); Quick-Weller in World Neurosurgery 96:124-128 (2016)] or unknown location of the lesion in major review [Marenco-Hillembrand et al. in Front Oncol 8:558 (2018)]. The present study aims to report our experience with the surgical management of IPVTs. The EIB sample yields an accurate histologic diagnosis tumor, with a positive histologic sample in 87, 95% of patients. The choice of the appropriate procedure should consider not only the preference and the experience of the neurosurgeon but also the several other variables as the location. While some periventricular lesions are better approached by endoscopic techniques, others are more suited for stereotactic-guided approaches. The ability to perform an EIB and relieve tumor-associated hydrocephalus by neuroendoscopy is considered to be a benefit of this procedure since this is less invasive than other treatments.

Neurocognitive Complications after Ventricular Neuroendoscopy: A Systematic Review

In recent years, neuroendoscopic treatment of hydrocephalus and various ventricular pathologies has become increasingly popular. It is considered by many as the first-choice treatment for the majority of these cases. However, neurocognitive complications following ventricular neuroendoscopic procedures may occur leading mostly to amnesia, which might have a grave effect on the patient's quality of life. Studies assessing neurocognitive complications after ventricular neuroendoscopic procedures are sparse. Therefore, we conducted a systematic review assessing the available literature of neurocognitive complications and outcome after ventricular neuroendoscopy. Of 1216 articles screened, 46 were included in this systematic review. Transient and permanent neurocognitive complications in 2804 ventricular neuroendoscopic procedures occurred in 2.0% (n = 55) and 1.04% (n = 28) of the patients, respectively. Most complications described are memory impairment, followed by psychiatric symptoms (psychosyndrome), cognitive impairment not further specified, declined executive function, and confusion. However, only in 20% of the series describing neurocognitive complications or outcome (n = 40) was neurocognition assessed by a trained neuropsychologist in a systematic manner. While in most of these series only a part of the included patients underwent neuropsychological testing, neurocognitive assessment was seldom done pre- and postoperatively, long-term follow up was rare, and patient's cohorts were small. A paucity of studies analyzing neurocognitive complications and outcome, through systematic neuropsychological testing, and the correlation with intraoperative lesions of neuronal structures (e.g., fornix) exists in the literature. Therefore, the neurocognitive and emotional morbidity after ventricular neuroendoscopic procedures might be underestimated and warrants further research.

Ventriculostomy and endoscopic biopsy of pineal mass with hydrocephalus and unexpected definitive diagnosis

A 72-year-old female with no relevant medical history consulted in the emergency room for a two-week history of headache, vomiting and gait disturbance. Head CT scan revealed obstructive hydrocephalus secondary to a pineal mass with compression of the third ventricle. Magnetic Resonance showed another mass located in the right Lushcka foramen. Endoscopic third-ventriculostomy and biopsy of pineal mass were performed. Pathological analysis was consistent with metastasis of carcinoma. Full-body CT scan showed a lung mass related to primary carcinoma. The patient received systemic treatment for metastatic lung cancer. She died two months after diagnosis.

Flexible Neuroendoscopic Diagnosis and Management of Ventricular Tumors: A Retrospective Cohort Study

BACKGROUND

Ventricular tumors (VTs) represent approximately 10% of intracranial lesions and are associated with hydrocephalus in 73.9%-100% of patients. We present our experience using flexible neuroendoscopy as a diagnostic and hydrocephalus-related treatment strategy for paraventricular and intraventricular tumors.

METHODS

This retrospective cohort included 27 pediatric and 21 adult patients with paraventricular or intraventricular tumors treated with flexible neuroendoscopy. Terminally ill patients and patients with incomplete data were excluded.

RESULTS

Male and female patients comprised 52% and 48% of the population, respectively. Mean patient age was 20.45 years (±18.65 SD). The most common tumor location was the thalamic and pineal region. Conclusive pathologic diagnosis was obtained in 40 patients (83.3%); the most common type of tumor was astrocytoma. Hydrocephalus was present in 38 (79.1%) patients, who were treated successfully with endoscopic procedures. There were no major complications.

CONCLUSIONS

Flexible neuroendoscopy is a strategic tool for diagnosis of VTs, especially in patients with associated hydrocephalus and VTs unreachable by other means. Flexible neuroendoscopy has a high rate of definitive diagnosis with low associated complications. More studies evaluating the long-term efficacy of flexible neuroendoscopy for hydrocephalus associated with VTs are needed.

Endoscopic biopsy of intra- and paraventricular brain tumors

Introduction

Selection of the optimal treatment method of intra- and paraventricular tumors often requires histopathological verification that can be obtained by endoscopic biopsy.

Aim

To discuss the usefulness of the method in their own experience.

Material and methods

The results of 32 biopsies carried out during a 15-year period were reviewed retrospectively. All tumors were located supratentorially, 25 of them were intraventricular and 7 paraventricular. In 18 patients the tumor was accompanied by internal hydrocephalus. If the ventricular system was narrow, the biopsy was supported by a neuronavigation system. A rigid neuroendoscope was used. The obtained material was subjected to intraoperative and final histopathological examination.

Results

Viable diagnostic material was obtained from all patients. In 11 patients with tumor of the posterior portion of the third ventricle, cerebrospinal fluid was collected additionally for diagnostic tests. In 9 patients with obstructive hydrocephalus concomitant third ventriculostomy was performed. In 4 patients with tumor of the interventricular foramen, the tumor mass was reduced and in 2 cases septostomy was performed. In 3 (9.4%) cases the histopathological diagnosis was descriptive and did not explain the nature of the lesion. Four biopsies resulted in persistent bleeding, in 3 patients transient memory impairments were observed, and in 1 patient an epileptic seizure occurred. Five patients needed ventriculoperitoneal shunt placement.

Conclusions

Endoscopic biopsy is a safe method to verify the histopathological nature of intra- and paraventricular lesions. It enables sampling of cerebrospinal fluid, reduction of tumor size, and in cases of coexisting obstructive hydrocephalus also third ventriculostomy or septostomy.

Pitfalls of Neuroendoscopic Biopsy of Intraventricular Germ Cell Tumors

OBJECTIVE

A neuroendoscopic biopsy has become common for the diagnosis of ventricular tumors. However, its utility in patients with germ cell tumors (GCTs) has not been well discussed. We examined the usefulness and pitfalls of neuroendoscopic biopsies of intraventricular GCTs at a single institution.

METHODS

We retrospectively studied 21 consecutive patients diagnosed with GCTs by a neuroendoscopic biopsy of the ventricular region via the lateral ventricle. We examined the localization of tumors, histologic diagnoses using biopsies, surgical complications, and consistency of the diagnosis at the latest follow-up.

RESULTS

Tumor specimens were obtained from a pineal lesion (n = 20), neurohypophysial lesion (n = 5), and lateral ventricular wall lesion (n = 2). In 5 patients, the specimens were obtained from multiple areas. The initial diagnoses were pure germinoma (n = 16), immature teratoma (n = 1), yolk sac tumor (n = 1), and mixed GCT (n = 3). Six of 21 patients needed a second transcranial removal of enhanced residual lesions in the course of the treatment. A discrepancy in the histologic diagnosis between 2 surgeries occurred in 3 patients: All 3 patients had a new diagnosis of teratoma component following transcranial surgery. No postoperative mortality or permanent morbidity related to the neuroendoscopic procedures was noted.

CONCLUSION

Neuroendoscopic biopsies are safe and useful for obtaining reliable histologic diagnoses in the management of GCTs. However, for GCTs with mixed histology, biopsies are susceptible to diagnostic errors, especially missing detecting a component of teratoma.

Neuroendoscopic stent placement for cerebrospinal fluid pathway obstructions in adults

OBJECTIVE Since its revival in the early 1990s, neuroendoscopy has become an integral component of modern neurosurgery. Endoscopic stent placement for treatment of CSF pathway obstruction is a rarely used and underestimated procedure. The authors present the first series of neuroendoscopic intracranial stenting for CSF pathway obstruction in adults with associated results and complications spanning a long-term follow-up of 20 years. METHODS The authors retrospectively reviewed a prospectively maintained clinical database for endoscopic stent placement performed in adults between 1993 and 2013. RESULTS Of 526 endoscopic intraventricular procedures, stents were placed for treatment of CSF disorders in 25 cases (4.8%). The technique was used in the management of arachnoid cysts (ACs; n = 8), tumor-related CSF disorders (n = 13), and hydrocephalus due to stenosis of the foramen of Monro (n = 2) or aqueduct (n = 2). The mean follow-up was 87.1 months. No deaths or infections occurred that were related to endoscopic placement of intracranial stents. Late stent dislocation or migration was observed in 3 patients (12%). CONCLUSIONS Endoscopic intracranial stent placement in adults is rarely required but is a safe and helpful technique in select cases. It is indicated when reliable and long-lasting restoration of CSF pathway obstructions cannot be achieved with standard endoscopic techniques. In the treatment of tumor-related hydrocephalus, it is a good option to avoid reclosure of the restored CSF pathway by tumor growth. Currently, routine stent placement after endoscopic fenestration of ACs is not recommended. Stent placement for treatment of CSF disorders due to tumor is a good option for avoiding CSF shunting. To avoid stent migration and dislocation, and to allow for easy removal if needed, the device should be fixed to a bur hole reservoir.

Resection of Intraventricular Tumors in Children by Purely Endoscopic Means

OBJECTIVE

Neuroendoscopy is increasingly being used in the management of intraventricular brain tumors. The role of endoscopy in diagnostic biopsy is well established. Expansion of these techniques may allow for definitive resection of intraventricular tumors. We report the feasibility and outcomes of endoscopic resection of select intraventricular tumors in children.

METHODS

The clinical characteristics of 11 children with solid intraventricular tumors who underwent tumor resection were reviewed. Twelve procedures were performed.

RESULTS

Gross-total resection was achieved in 11 of 12 cases (92%). Maximal tumor diameter ranged from 9 to 26 mm (mean, 16.6 mm). Pathologic results included subependymal giant cell astrocytomas, ependymomas, nongerminomatous germ cell tumors, and pilocytic astrocytomas. Mean follow-up was 35 months (range, 10-109 months). All patients returned to their neurologic baselines after surgery. Local tumor recurrence occurred in 1 patient and distant recurrence in another. In 1 patient, a transitory intraoperative increase of intracranial pressure without clinical implications occurred. There was no permanent morbidity or mortality in this series. Hydrocephalus was present preoperatively in 5 cases and was treated either with tumor removal alone or with an additional endoscopic third ventriculostomy. No patient required a ventriculoperitoneal shunt.

CONCLUSIONS

Neuroendoscopic gross-total resection of solid intraventricular tumors is a safe and efficacious procedure in carefully selected pediatric patients.

Endoscopic third ventriculostomy for obstructive hydrocephalus: Outcome analysis of 120 consecutively treated patients from a developing country

OBJECTIVES

Endoscopic third ventriculostomy (ETV) for the treatment of obstructive hydrocephalus is a relatively new concept amongst neurosurgeons of the developing world. Therefore, this study was conducted to report our experience, patient selection, success rates and complications of ETV and compare our results with the literature from the developed countries.

METHODS

We performed ETV on 120 patients at our centre and prospectively collected their clinical data on pre designed questionnaires. Success was defined as clinical improvement on 3rd month post operative clinic visit. The data was analyzed using SPSS version 20.

RESULTS

There were 79 male and 41 female patients. The mean age was 36.1 ± 14.3 years. Overall, ETV was successful in 107 (89.2%) of patients. 4 patients had intra operative bleeding, 4 patients developed CSF leaks while 1 patient had a transient gaze palsy. There was no mortality.

CONCLUSION

ETV is a very effective treatment modality for treating obstructive hydrocephalus in well selected patients and can be successfully practiced by neurosurgeons in the developing countries.

Neuroendoscopic biopsy of brain lesions: accuracy and complications

OBJECT

The authors conducted a study to analyze the accuracy of neuroendoscopic biopsies of ventricular and periventricular lesions and record any difficulties or complications of the neuroendoscopic biopsy procedure.

METHODS

A total of 50 patients with different diseases consecutively underwent endoscopic biopsy procedures. The biopsy result was considered diagnostic if the pathologist reported any specific finding on which clinicians could base decisions about treatment or observation. The biopsy result was referred to as accurate if the results matched results of a sample obtained later or if the treatment response and disease evolution were compatible with the diagnosis. The biopsy result was considered inaccurate if results showed any relevant differences from those of the later sample or if the patient's disease did not evolve as expected. Complications were recorded and compared with those found in a literature review.

RESULTS

For 2 patients, the procedure had to be terminated. The biopsy diagnostic rate was 89.6%, and the accuracy rate was 86%. Complications associated with the procedure were 3 hemorrhages (6%), 2 infections (4%), and 1 death (2%); no reoperations were needed.

CONCLUSIONS

Endoscopic biopsy seems to be an accurate procedure with acceptable morbidity and mortality rates.

Endoscopic biopsy of brain tumors: Does the technique matter?

Background:

Endoscopic biopsy of brain tumors is an important part of the armamentarium of management of intra- and periventricular tumors that is generally considered an acceptable and, in some situations, a preferred method for tissue sampling. The diagnostic yield of the procedure has been variably reported. Technical aspects of the procedure should undoubtedly reflect on its success rate and accuracy. Such impact on diagnostic yield of endoscopic brain biopsy is infrequently discussed in the literature.

Methods:

A search of the medical literature was conducted for publications on endoscopic brain biopsy. These reports were analyzed regarding the various technical aspects.

Results:

In the 43 publications analyzed, lenscopes were exclusively used in 22 reports and a tissue diagnosis was possible in 362 out of 387 endoscopic biopsies with a diagnostic yield of 93.54%. Only fiberscopes were used in 8 reports and a tissue diagnosis was possible in 100 out of 132 endoscopic biopsies with a diagnostic yield of 75.76%. The diagnostic yield in the mixed and unspecified groups was 88.95 and 88.04%, respectively. Very few details on the histopathological methods and tumor molecular genetics could be found.

Conclusion:

Endoscopic biopsy of brain tumors has a higher diagnostic yield when lenscopes are used. Neuronavigation seems to add to the diagnostic accuracy of the procedure. Studies detailing molecular genetic features of biopsied tumors are necessary in the future.

An overview of the current surgical options for pineal region tumors

BACKGROUND

The list of pineal region tumors comprises an extensive array of pathological entities originating within one of the most complex areas of the intracranial cavity. With the exception of germ cell tumors, microsurgical excision is still nowadays the mainstay of management for most pineal region tumors.

METHODS

A search of the medical literature was conducted for publications addressing surgical options for management of pineal region tumors.

RESULTS

The infratentorial supracerebellar and the occipital transtentorial approaches are currently the most frequently used approaches for pineal region tumors. Endoscopic tumor biopsy with simultaneous endoscopic third ventriculostomy has emerged as a minimally invasive and highly effective strategy for initial management since it addresses the issue of tissue diagnosis and offers a solution for the associated hydrocephalus frequently encountered in these patients. Endoscope-assisted microsurgery and purely endoscopic excision have been reported in few reports and are likely to be more utilized in the future.

CONCLUSION

Preoperative planning is very crucial and should most importantly be individualized according to the anatomical features of the lesion and structures encountered during the procedure.

Initial experience with endoscopic side cutting aspiration system in pure neuroendoscopic excision of large intraventricular tumors

OBJECTIVE

Conventionally, neuroendoscopic excision of intraventricular tumors has been difficult and time consuming because of lack of an effective decompression system that can be used through the working channel of the endoscope.

METHODS

The authors report their initial experience in purely endoscopic excision of large intraventricular tumors with the minimally invasive NICO Myriad system. The NICO Myriad is a side cutting soft tissue aspiration system that uses an inner reciprocating cannula and an outer stationary sheath with a side port. During decompression, applied suction approximates the tumor into the lumen of the outer sheath, with the inner cannula excising the tissue by oscillation of the cutting edge. The tumor is then removed by aspiration through the inner sheath.

RESULTS

Three patients with large intraventricular tumors were operated by a purely endoscopic approach using a GAAB rigid endoscope and the NICO Myriad system. Of these, two had intraventricular craniopharyngiomas and one had a lateral ventricular subependymoma. The tumor size varied between 1.9 and 4.5 cm in the largest diameter. A relatively firm and solid tumor was encountered in two and a multicystic tumor with thick adherent walls in one. The tumor could be subtotally removed in one and near totally in two. There were no long-term complications.

CONCLUSION

The NICO Myriad is a highly effective tumor decompression system that can be effectively used in a purely endoscopic approach to intraventricular lesions.

Endoscopic third ventriculostomy

Endoscopic third ventriculostomy (ETV) is considered as a treatment of choice for obstructive hydrocephalus. It is indicated in hydrocephalus secondary to congenital aqueductal stenosis, posterior third ventricle tumor, cerebellar infarct, Dandy-Walker malformation, vein of Galen aneurism, syringomyelia with or without Chiari malformation type I, intraventricular hematoma, post infective, normal pressure hydrocephalus, myelomeningocele, multiloculated hydrocephalus, encephalocele, posterior fossa tumor and craniosynostosis. It is also indicated in block shunt or slit ventricle syndrome. Proper Pre-operative imaging for detailed assessment of the posterior communicating arteries distance from mid line, presence or absence of Liliequist membrane or other membranes, located in the prepontine cistern is useful. Measurement of lumbar elastance and resistance can predict patency of cranial subarachnoid space and complex hydrocephalus, which decides an ultimate outcome. Water jet dissection is an effective technique of ETV in thick floor. Ultrasonic contact probe can be useful in selected patients. Intra-operative ventriculo-stomography could help in confirming the adequacy of endoscopic procedure, thereby facilitating the need for shunt. Intraoperative observations of the patent aqueduct and prepontine cistern scarring are predictors of the risk of ETV failure. Such patients may be considered for shunt surgery. Magnetic resonance ventriculography and cine phase contrast magnetic resonance imaging are effective in assessing subarachnoid space and stoma patency after ETV. Proper case selection, post-operative care including monitoring of ICP and need for external ventricular drain, repeated lumbar puncture and CSF drainage, Ommaya reservoir in selected patients could help to increase success rate and reduce complications. Most of the complications develop in an early post-operative, but fatal complications can develop late which indicate an importance of long term follow up.