Background Hydrocephalus (HC) is a common pediatric neurosurgical condition characterized by the accumulation of cerebrospinal fluid (CSF) and elevated intracranial pressure. Without treatment, HC causes substantial neurological morbidity and mortality. The gold-standard treatment for HC, CSF shunting, is associated with high rates of shunt infection, obstruction, and malfunction and requires lifelong access to prompt neurosurgical care. Endoscopic third ventriculostomy with choroid plexus cauterization (ETV-CPC) was thus developed as an alternative to CSF shunting in low and middle-income countries (LMICs); however, the impact of this treatment on neurological function or brain development remains unclear.

Methods The current study details the technical development of an experimental, large animal model of ETV-CPC to examine the neurobiological and neurobehavioral effects of ETV-CPC versus CSF shunting.

Results Hydrocephalus was induced in juvenile pigs by cisternal injection of 25% kaolin and confirmed with high-resolution MRI after 10-14 days post-induction. For surgical treatment of HC, frameless stereotactic Stealth neuronavigation was registered to the animal's head and an orthogonal trajectory to the foramen of Monro was planned with entry 1 cm lateral to midline. After incision, a burr hole was fashioned, the dura cauterized, and a ventricular catheter was passed into the right lateral ventricle. After the collection of ~1 ml of CSF for later analyses, the catheter was removed and a flexible ventriculoscope was inserted along the track. The endoscope was navigated through the foramen of Monro and into the 3rd ventricle, where a flexible Bugbee wire was used to make an ETV in the lamina terminalis. After completion of the ETV, the endoscope was withdrawn into the right lateral ventricule, and the choroid plexus was cauterized, beginning at the foramen of Monro and moving toward the atrium/glomus, and then into the temporal horn to the temporal tip. In most cases, the septum pellucidum was incompetent, and the same procedure was used to cauterize the entirety of the choroid plexus in the left lateral ventricle. After the ETV-CPC, the endoscope was removed and a ventricular catheter was affixed to a ventricular reservoir, inserted into the right lateral ventricle, and secured in place with pericranial sutures. The wound was irrigated and closed.

Conclusion This experimental juvenile porcine model of ETV-CPC offers the opportunity to study the neurobiological and neurobehavioral effects of ETV-CPC and CSF shunting in a novel way. Understanding the long-term effects of these treatments is paramount in identifying the optimal treatment for children with HC.