Traffic light alarming signs are indispensable prerequisites for fruitful endoscopic third ventriculostomy

Abstract Background Endoscopic third ventriculostomy (ETV) is a satisfying neuro-endoscopic journey in candidates with preoperatively predicted higher success rates. Alarming cases require extra care to avoid serious complications, predict/identify failure and offer reasonable intra-/postoperative decisions. Purpose To create easily interpretable traffic light alarming signs to increase the awareness level for neurosurgeons regarding ETV difficulty/failure. Methods A 3-year-retrospective study of postoperative ETV infants of both sexes with obstructive hydrocephalus and preoperative ETV success score ≤ 70, age ≤ 12 months, and follow-up for ≥ 6 months with a postoperative radiological evaluation of the ETV patency and cerebrospinal fluid dynamics. The ETV difficulty scale (ETV-DS) was designed as an intraoperative monitor for surgical/anatomical difficulties. And the ETV failure threshold (ETV-FT) was offered for postoperative evaluation to identify cases that are mistakenly interpreted as failure. Results Among our 159 case series, 54 infants were involved. Patients’ demographics, age: ≤ 28 days, > 28 days to 6 months, and >6 to 12 months, were 5.5%, 70.3%, and 24.2%, respectively. Postoperatively, the outcome based on ETV-FT color scale was dark green (ETV-FT=0), light green (ETV-FT=1), yellow (ETV-FT=2), orange (ETV-FT=3), red (ETV-FT=4) in 29%, 14%, 20%, 10.3%, and 26.7%, respectively. Actual failure is identified as ETV-FT=4 based on clinical/radiological data. The failure rate was significantly attributed to inadequate communication with the basal cistern due to difficult/unsafe perforation of the thick/dense Liliequist membrane (87%) ( P = 0.001). Conclusion The traffic light alarming signs (ETV-DS and ETV-FT) can warn neurosurgeons to recognize critical cases that necessitate ultra-precautions to navigate safely through landmines for worthy outcomes.