ETV/CPC Procedure

Benjamin Warf, MD, Hydrocephalus and Spina Bifida Chair at Boston Children's Hospital and director of Neonatal and Congenital Anomaly Neurosurgery, has pioneered a treatment for hydrocephalus in infants that combines two procedures: endoscopic third ventriculostomy (ETV) and choroid plexus cauterization procedure (CPC). Combined, this procedure is called ETV/CPC.

Before shunts came into use, a few neurosurgeons had treated some cases of hydrocephalus with CPC alone, but the technique had largely been abandoned until Warf began combining it with ETV and found this combined procedure was superior to ETV alone in infants.

ETV is a minimally invasive procedure that creates an opening in the floor of the third ventricle in the brain. This allows cerebrospinal fluid (CSF) trapped within the brain's ventricles to escape into its normal pathway.

CPC is a procedure that reduces the choroid plexus (tissue that produces CSF) in two of the four ventricles inside the brain. This decreases the amount of fluid produced and may also reduce the strength of pulses that can cause the ventricles to enlarge. This makes the ETV procedure more likely to succeed in a child's brain.

During the ETV/CPC procedure, the neurosurgeon:

• Makes a small incision in the scalp at the edge of the baby's soft spot (fontanel)
• Opens the lining over the brain (dura), which will be closed after the operation
• Inserts a miniature, flexible endoscope to see inside the brain’s fluid spaces (ventricles) and to work within the ventricles using tiny instruments
• Performs the ETV by making an opening in the floor of the third ventricle
• Finds the choroid plexus in the first and second ventricles and uses a tiny wire with low electrical current to burn the tissue so it produces less fluid

Using the combined ETV/CPC procedure reduces the production of CSF in the first and second ventricles, while eliminating blockages between the third and fourth ventricles.

Our team has found the combined ETV/CPC procedure is more effective in treating infants under age 1 than ETV alone. ETV/CPC is also a successful treatment for most infants who have both hydrocephalus and spina bifida.

Research has shown that ETV/CPC can prevent the need for a shunt in most infants with hydrocephalus caused by a range of conditions, including post-hemorrhageic hydrocephalus, prematurity, congenital aqueduct stenosis, Dady-Walker malformation, spina bifida, encephalocele, infection within the ventricles, and cases where there is no clear cause for the hydrocephalus (congenital idiopathic hydrocephalus).