There are no effective medicines for hydrocephalus, and most children require surgery. The goal is to lessen the pressure in the brain by providing another pathway for cerebrospinal fluid (CSF) to be drained and absorbed away from the brain.
Some children with non-communicating hydrocephalus (the build-up of pressure from CSF when a blockage occurs within the brain) can have surgery called an endoscopic third ventriculostomy (ETV). This surgery creates an opening to allow CSF to flow in and around the brain as it should. Sometimes, an ETV is done in combination with a procedure called choroid plexus cauterization (CPC). The choroid plexus is a network of blood vessels and cells, located in the ventricles that create CSF. A CPC can help reduce the amount of CSF that the brain produces.
Endoscopic third ventriculostomy (ETV) surgery
An endoscopic third ventriculostomy (ETV) is one of the types of surgery done on some children who have hydrocephalus. Your child’s neurosurgeon will tell you if this surgery is possible for your child.
During an ETV, the neurosurgeon makes an opening in the floor of the ventricle at the base of the brain to divert the fluid and create an alternate pathway. The CSF is then no longer blocked inside the ventricle. It can now flow in and around the brain as it should.
Preparing for the procedure
Most parents and children are more comfortable with their visit to the hospital if they know what will happen when they arrive. Please see Coming for surgery to find out how you can prepare your child for their ETV surgery.
If you have any specific questions about your child’s procedure before their surgery, contact your child’s neurosurgery team.
During the ETV operation
Your child will be brought down to the operating room and go to sleep under general anesthesia. Your child will not feel any pain during the operation.
An incision will be made on your child’s head. A special scope with a camera on it will be passed into the ventricle. The neurosurgeon uses the camera to see the part of the ventricle that needs to be opened up. Once the opening is made, the neurosurgeon will be able to see if the CSF is flowing outside of the ventricle.
The operation will take between one and two hours.
If the neurosurgeon is not able to safely do the ETV, a shunt may be inserted instead. The incisions are then closed using staples or stitches. For more information about shunts, see Treatment for hydrocephalus: Shunt.
After the ETV operation
- Your child will wake up soon after the operation. You will be able to see your child after they wake up.
- Your child will have a bandage on their head.
- A nurse will check on your child often. They will also be checking to see how easily your child wakes up, even at night.
- Your child will have an intravenous (IV) line after surgery until they able to drink well.
- Your child may have a computed tomography (CT) or MRI scan after surgery to make sure the ventricles have decreased in size and that the ETV is working.
Pain after the operation
After the operation, your child may have pain at the operative sites. A nurse will give your child medicine as needed to control the pain. If it does not control the pain, speak to your child's health-care team.
Your child may also learn other ways to control pain, such as blowing bubbles or relaxation breathing. Ask your child’s health-care team to help you and your child learn how to do this.
Your child's health-care team will tell you when your child can start normal activity, such as sitting up and walking. After your child has recovered from the surgery, they can go home.
Following up after the operation
Your child’s neurosurgeon will need to see your child for a follow-up clinic visit about six weeks after you go home. The appointment may be made for you when your child leaves the hospital. If one has not been made, call the neurosurgery clinic to make an appointment when you get home.
Any medical questions you may have after the procedure can be answered by your child’s health-care team at their follow-up appointment. Be sure to write down your questions beforehand.
Removing staples or stitches
How your child's staples or stitches are taken out depends on the type of staple or stitch that was used. Your child’s health-care team will tell you whether staples or stitches were used.
- If your child has staples or stitches that need to be taken out, this can often be done by their primary health-care provider. The stitches should be taken out about seven to 10 days after the operation. Staples should be removed about 10 days after the operation. Your child’s health-care team will confirm when they need to come out.
- If staples were used, you will be given a special remover to take to your child’s primary health-care provider.
- If your child has the kind of stitches that dissolve on their own, you can see your child’s primary health-care provider to have the incision line checked; but the stitches will not need to be removed.
Longer-term: as your child grows to adulthood
A child with hydrocephalus needs to see the neurosurgery team often to make sure the ETV is working properly and that the pressure does not begin to build up again. Several members of the team will help and guide you as your child grows and develops. You should encourage your child to become involved in this ongoing process.
An ETV does not guarantee your child's hydrocephalus will never come back. If your child's ETV is not working properly, the pressure will return to the brain. It is very important to watch your child for signs that the pressure is building up again, as it is possible that the ETV could “fail”. This means that the opening made during surgery has closed/is blocked. If any signs of pressure come back, it is very important to call your child’s health-care team right away so that your child can be checked.
When to seek medical attention
If you notice any signs that the ETV is not working properly or hydrocephalus symptoms coming back, it is very important to seek medical attention right away. Call 911 or go to the closest Emergency Department right away. Failed/blocked ETVs that are not treated promptly and appropriately can lead to serious consequences.
Possible signs that the ETV is not working
In babies, the following signs and symptoms may occur:
- poor feeding
- vomiting (throwing up)
- sleepy (hard to wake up) or not as awake or alert as usual
- large head (your child’s health-care provider can measure this)
- bulging soft spot (fontanelle) on the top of the head
- seeming irritable (cries easily or without reason)
- seizures
- very noticeable scalp veins
- slowness at reaching milestones (for example, slow to roll over, slow to sit) or loss of milestones (for example, was sitting or walking and now unable)
- "sunset" eyes, when the eyes appear to be always looking down and are not able to look up
In older children, the following signs and symptoms may occur:
- headaches
- nausea and vomiting
- tired (sleeping more than usual, difficult to wake up, does not want to play as usual)
- seeming irritable
- changes in personality, behaviour or school performance
- loss of coordination
- seizures
- changes in vision
At SickKids
The Neurosurgery unit is located on 5C, 5th floor of the Atrium.
The Neurosurgery clinic is located on 6C, 6th floor of the Atrium. Phone: 416-813-5222