Endoscopic third ventriculostomy with choroid plexus cauterization for hydrocephalus treatment: The Brazilian Experience

INTRODUCTION The combination of endoscopic third ventriculostomy (ETV) with bilateral lateral ventricle choroid plexus cauterization (CPC) addresses the challenges of shunt dependence in the treatment of infant hydrocephalus, a condition with a significant incidence in Brazil (3–4 per 1,000 live births), primarily treated with ventriculoperitoneal shunt (VPS) surgeries. ETV/CPC can eliminate the need for shunts in over half of all patients, regardless of etiology, and is associated with a lower infection rate (Figures 1 and 2). However, its long-term efficacy as a primary treatment has not been extensively studied in Brazil. OBJECTIVES This study aimed to compare the outcomes of ETV/CPC and VPS placement, assessing their effectiveness in preventing further surgeries and identifying preoperative factors that may predict the need for additional operations or shunt insertion post-ETV/CPC. A retrospective analysis was conducted in two pediatric neurosurgery centers in Brazil. METHODS A retrospective analysis was performed over a 22-month period at Santa Casa de São Paulo and Belém, Brazil, from October 2022 to March 2024. Inclusion criteria were patients with hydrocephalus and favorable anatomy, as determined by preoperative brain magnetic resonance imaging (MRI), who were younger than two years of age and treated via ETV/CPC using a flexible ventriculoscope (FV). Preoperative clinical data and hydrocephalus metrics were collected, along with operative details. Follow-up data included postoperative hydrocephalus metrics. ETV failure and reoperations were documented. Data were presented as medians. RESULTS Over the 22-month period, a total of 65 children were considered for hydrocephalus treatment via ETV/CPC. Of these, 12 (18.5%) had unfavorable anatomy upon FV exploration. The remaining 53 patients underwent endoscopic hydrocephalus treatment (51 ETV/CPC; 2 ETV) and were included in the determination of absolute ETV/CPC success rates. The median (mean) age at treatment was 5.3 months (9.7 mo), with a mean head circumference of 46 cm. Among the 51 patients treated via ETV/CPC, 41 (80.4%) remained shunt-free at the time of last follow-up (median: 7.1 months). A total of 14 (27.4%) patients experienced ETV/CPC failure at a median time-to-failure of 1.5 months. Of these, 10 underwent VPS placement, while 4 underwent redo ETVs (Graphic 1). No patient experience death within 30 days of surgery or at any time due to progressive hydrocephalus. CONCLUSION In this dual center study — the first of its kind in Brazil — ETV/CPC for the treatment of infant hydrocephalus was shown to be feasible and safe. Furthermore, the ETV/CPC success rate of 81.1%, suggests that this technique may be the preferred method for hydrocephalus treatment in young children in Brazil. Larger, multicenter studies with longer follow-up periods are needed to corroborate these findings.