Endoscopic Third Ventriculostomy With “Rescue” Fourth Ventriculocisternostomy: 2-Dimensional Operative Video

Abstract This case of endoscopic third ventriculostomy (ETV) and flexible endoscopy for lysis of fourth ventricle adhesions for obstructive hydrocephalus illustrates a key anatomical variant (anastomosis of posterior communicating arteries) that increases the difficulty of ETV and should be recognized preoperatively. The video further demonstrates flexible endoscopy for lysis of a fourth ventricular web and excellent third and fourth ventricular anatomy. This patient presented with normal pressure hydrocephalus-like symptoms and magnetic resonance imaging suggestive of a fourth ventricular outflow obstruction. An ETV would be an ideal intervention with a high chance of success1 and avoiding a ventriculoperitoneal shunt or a more invasive suboccipital craniectomy for fourth ventricle exploration; however, variant anatomy and resultant medialization of the bilateral posterior communicating arteries put their location directly beneath the tuber cinereum. After discussing the risks and benefits of the proposed procedure, the patient consented to proceeding with the surgery. Patient is not identifiable either by clinical vignette or through this operative video, which is entirely intraventricular. The care rendered was standard (nonexperimental). The patient did sign consent for filming and production of the educational video submitted. Here, we present operative video from our ETV, demonstrating an inability to confirm adequate fenestration and subsequent flexible endoscopy for fourth ventriculocisternostomy.

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Fourth Ventricle Outlet Obstruction and Diverticular Enlargement of Luschka Foramina in a Child with Down Syndrome

Pediatric Neurosurgery ◽

10.1159/000511088 ◽

2020 ◽

pp. 1-4

Author(s):

Valentina Orlando ◽

Pietro Spennato ◽

Maria De Liso ◽

Vincenzo Trischitta ◽

Alessia Imperato ◽

...

Keyword(s):

Down Syndrome ◽

Fourth Ventricle ◽

Endoscopic Third Ventriculostomy ◽

Obstructive Hydrocephalus ◽

Radiological Finding ◽

Outlet Obstruction ◽

Third Ventriculostomy ◽

Viable Option ◽

Case Presentation

Introduction: Hydrocephalus is not usually part of Down syndrome (DS). Fourth ventricle outlet obstruction is a rare cause of obstructive hydrocephalus, difficult to diagnose, because tetraventricular dilatation may suggest a communicant/nonobstructive hydrocephalus. Case Presentation: We describe the case of a 6-year-old boy with obstructive tetraventricular hydrocephalus, caused by Luschka and Magendie foramina obstruction and diverticular enlargement of Luschka foramina (the so-called fourth ventricle outlet obstruction) associated with DS. He was treated with endoscopic third ventriculostomy (ETV) without complications, and a follow-up MRI revealed reduction of the ventricles, disappearance of the diverticula, and patency of the ventriculostomy. Conclusion: Diverticular enlargement of Luschka foramina is an important radiological finding for obstructive tetraventricular hydrocephalus. ETV is a viable option in tetraventricular obstructive hydrocephalus in DS.

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Endoscopic Third Ventriculostomy in Previously Shunted Children

Minimally Invasive Surgery ◽

10.1155/2013/584567 ◽

2013 ◽

Vol 2013 ◽

pp. 1-4 ◽

Cited By ~ 6

Author(s):

Eva Brichtova ◽

Martin Chlachula ◽

Tomas Hrbac ◽

Radim Lipina

Keyword(s):

Success Rate ◽

Fourth Ventricle ◽

Pediatric Patients ◽

Endoscopic Third Ventriculostomy ◽

Obstructive Hydrocephalus ◽

Surgical Revision ◽

Clinical State ◽

Third Ventriculostomy ◽

Safe Procedure ◽

Shunt Implantation

Endoscopic third ventriculostomy (ETV) is a routine and safe procedure for therapy of obstructive hydrocephalus. The aim of our study is to evaluate ETV success rate in therapy of obstructive hydrocephalus in pediatric patients formerly treated by ventriculoperitoneal (V-P) shunt implantation. From 2001 till 2011, ETV was performed in 42 patients with former V-P drainage implantation. In all patients, the obstruction in aqueduct or outflow parts of the fourth ventricle was proved by MRI. During the surgery, V-P shunt was clipped and ETV was performed. In case of favourable clinical state and MRI functional stoma, the V-P shunt has been removed 3 months after ETV. These patients with V-P shunt possible removing were evaluated as successful. In our group of 42 patients we were successful in 29 patients (69%). There were two serious complications (4.7%)—one patient died 2.5 years and one patient died 1 year after surgery in consequence of delayed ETV failure. ETV is the method of choice in obstructive hydrocephalus even in patients with former V-P shunt implantation. In case of acute or scheduled V-P shunt surgical revision, MRI is feasible, and if ventricular system obstruction is diagnosed, the hydrocephalus may be solved endoscopically.

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Endoscopic opening of the foramen of Magendie using transaqueductal navigation for membrane obstruction of the fourth ventricle outlets

Journal of Neurosurgery ◽

10.3171/jns.2006.105.6.924 ◽

2006 ◽

Vol 105 (6) ◽

pp. 924-927 ◽

Cited By ~ 38

Author(s):

Pierluigi Longatti ◽

Alessandro Fiorindi ◽

Alberto Feletti ◽

Vittorio Baratto

Keyword(s):

Posterior Fossa ◽

Fourth Ventricle ◽

Endoscopic Third Ventriculostomy ◽

Clinical Symptoms ◽

Therapeutic Option ◽

Surgical Approaches ◽

Third Ventriculostomy ◽

Prepontine Cistern ◽

Suboccipital Craniectomy ◽

Rhomboid Fossa

✓A membrane obstruction of the foramina of Magendie and Luschka is an uncommon origin of hydrocephalus characterized by unusual clinical symptoms of rhomboid fossa hypertension. Various surgical approaches have been proposed to alleviate this obstruction, including opening the obstructed foramen of Magendie using suboccipital craniectomy, shunting procedures, and more recently, endoscopic third ventriculostomy (ETV). In some cases, however, reshaping of the posterior fossa due to the collapse of the prepontine cistern could make ETV difficult for the surgeon and dangerous to the patient. In these cases, endoscopic opening of the foramen of Magendie by transaqueductal navigation of the fourth ventricle is a suitable and feasible therapeutic option.

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Upward transtentorial herniation: A new role for endoscopic third ventriculostomy

Surgical Neurology International ◽

10.25259/sni_140_2021 ◽

2021 ◽

Vol 12 ◽

pp. 334

Author(s):

Júlia Moscardini-Martelli ◽

Juan Antonio Ponce-Gomez ◽

Victor Alcocer-Barradas ◽

Samuel Romano-Feinholz ◽

Pilar Padilla-Quiroz ◽

...

Keyword(s):

Endoscopic Third Ventriculostomy ◽

Obstructive Hydrocephalus ◽

External Ventricular Drainage ◽

Hemorrhagic Transformation ◽

Third Ventriculostomy ◽

Safe Procedure ◽

Cerebellar Stroke ◽

Transtentorial Herniation ◽

Suboccipital Craniectomy ◽

Upward Herniation

Background: The placement of external ventricular drainage (EVD) to treat hydrocephalus secondary to a cerebellar stroke is controversial because it has been associated to upward transtentorial herniation (UTH). This case illustrates the effectiveness of endoscopic third ventriculostomy (ETV) after the ascending herniation has occurred. Case Description: A 50-year-old man had a cerebellar stroke with hemorrhagic transformation, tonsillar herniation, and non-communicating obstructive hydrocephalus. Considering that the patient was anticoagulated and thrombocytopenic, an EVD was placed initially, followed by clinical deterioration and UTH. We performed a suboccipital craniectomy immediately after clinical worsening, but the patient did not show clinical or radiological improvement. On the 5th day, we did an ETV, which reverses the upward herniation and hydrocephalus. The patient improved progressively with good neurological recovery. Conclusion: ETV is an effective and safe procedure for obstructive hydrocephalus. The successful resolution of the patient’s upward herniation after the ETV offers a potential option to treat UTH and advocates further research in this area.

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Combined rigid and flexible endoscopy for tumors in the posterior third ventricle

Journal of Neurosurgery ◽

10.3171/2014.9.jns141397 ◽

2015 ◽

Vol 122 (6) ◽

pp. 1341-1346 ◽

Cited By ~ 30

Author(s):

Jonathan Roth ◽

Shlomi Constantini

Keyword(s):

Endoscopic Third Ventriculostomy ◽

Obstructive Hydrocephalus ◽

Third Ventricle ◽

Choroid Plexus Papilloma ◽

Flexible Endoscopy ◽

Endoscopic Biopsy ◽

Third Ventriculostomy ◽

Low Grade ◽

Rigid Endoscope ◽

Ventricular Tumors

OBJECT Tumors leading to occlusion of the sylvian aqueduct include those of pineal, thalamic, and tectal origins. These tumors cause obstructive hydrocephalus and thus necessitate a CSF diversion procedure such as an endoscopic third ventriculostomy (ETV), often coupled with an endoscopic biopsy (EBX). Lesions located posterior to the massa intermedia pose a technical challenge, as the use of a rigid endoscope for performing both an ETV and EBX is limited. The authors describe their experience using a combined rigid and flexible endoscopic procedure through a single bur hole for both procedures in patients with posterior third ventricular tumors. METHODS Since January 2012, patients with posterior third ventricular tumors causing hydrocephalus underwent dual ETV and EBX procedures using the combined rigid-flexible endoscopic technique. Following institutional review board approval, data from clinical, radiological, surgical, and pathological records were retrospectively collected. RESULTS Six patients 3.5–53 years of age were included. Lesion locations included pineal (n = 3), fourth ventricle (n = 1), aqueduct (n = 1), and tectum (n = 1). The ETV and EBX were successful in all cases. Pathologies included pilocytic astrocytoma, pineoblastoma, ependymoma Grade II, germinoma, low-grade glioneural tumor, and atypical choroid plexus papilloma. One patient experienced an immediate postoperative intraventricular hemorrhage necessitating evacuation of the clots and resection of the tumor, eventually leading to the patient's death. CONCLUSIONS The authors recommend using a combined rigid-flexible endoscope for endoscopic third ventriculostomy and biopsy to approach posterior third ventricular tumors (behind the massa intermedia). This technique overcomes the limitations of using a rigid endoscope by reaching 2 distant regions.

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GCT-53. CASE OF INTRACRANIAL GROWING TERATOMA SYNDROME WITH DIFFICULTY IN TIMING OF RESECTION

Neuro-Oncology ◽

10.1093/neuonc/noaa222.271 ◽

2020 ◽

Vol 22 (Supplement_3) ◽

pp. iii339-iii339

Author(s):

Hidenobu Yoshitake ◽

Hideo Nakamura ◽

Yuta Hamamoto ◽

Yusuke Otsu ◽

Jin Kikuchi ◽

...

Keyword(s):

Radiation Therapy ◽

Endoscopic Third Ventriculostomy ◽

Obstructive Hydrocephalus ◽

Mature Teratoma ◽

Timing Of Surgery ◽

Optimal Timing ◽

Third Ventriculostomy ◽

Mixed Tumor ◽

Gland Tumor ◽

Growing Teratoma Syndrome

Abstract BACKGROUND Intracranial Growing teratoma syndrome(iGTS) is a phenomenon in which a tumor with a teratoma component grows during treatment, and its pathological tissue is often a mature teratoma. Here we report a case of iGTS in which the timing of surgery was determined by tumor markers and changes in tumor size on MRI images. CASE-REPORT: 11-year-old boy with a short stature. He developed a headache and we found a pineal gland tumor on MRI. Due to obstructive hydrocephalus, an endoscopic third ventriculostomy and biopsy were performed. The pathological diagnosis was mature teratoma, but AFP was elevated at 104.2 ng/mL. Considering NGGCT, we started chemoradiation immediately. Despite the declining AFP, it gradually increased, at which point we suspected iGTS. Resection was considered, but at some point tumor growth had stopped, so radiation therapy and a second course of ICE therapy preceded the resection. Thereafter, the tumor was completely removed, and a third course of ICE therapy was performed. DISCUSSION The onset mechanism of iGTS has not been elucidated, and its prediction is difficult. Early resection of the tumor is required, but discontinuation of radiation therapy and side effects of chemotherapy also need to be considered. In our case, resection was performed after normalization of AFP and recovery of myelosuppression. The patient followed an uneventful course, but the timing of resection was controversial. CONCLUSION We experienced a case of iGTS in NGGCT, a mixed tumor with mature teratoma. The optimal timing of the resection was discussed and literature was reviewed.

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Endoscopic third ventriculostomy for obstructive hydrocephalus in children younger than 6 months of age: is it a first-choice method?

Child s Nervous System ◽

10.1007/s00381-008-0616-6 ◽

2008 ◽

Vol 24 (9) ◽

pp. 1021-1027 ◽

Cited By ~ 28

Author(s):

Radim Lipina ◽

Štefan Reguli ◽

Viera Doležilová ◽

Marie Kunčíková ◽

Hana Podešvová

Keyword(s):

Endoscopic Third Ventriculostomy ◽

Obstructive Hydrocephalus ◽

Third Ventriculostomy ◽

First Choice ◽

Choice Method

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Endoscopic Third Ventriculostomy in Infants Less than One Year of Age: A Short Series of 14 Cases

Pediatric Neurosurgery ◽

10.1159/000513359 ◽

2021 ◽

Vol 56 (2) ◽

pp. 105-109

Author(s):

Sarita Chowdhary ◽

Shyamendra Pratap Sharma ◽

Pranaya Panigrahi ◽

Manoj Kumar Yadav ◽

Shiv Prasad Sharma

Keyword(s):

Endoscopic Third Ventriculostomy ◽

Obstructive Hydrocephalus ◽

Aqueductal Stenosis ◽

Csf Shunt ◽

Third Ventriculostomy ◽

Occipital Encephalocele ◽

Shunt Implantation ◽

Permanent Morbidity ◽

One Year

Background: Endoscopic third ventriculostomy (ETV) is currently considered as an alternative to cerebrospinal fluid (CSF) shunt systems in the treatment of obstructive hydrocephalus. This procedure allows the CSF to drain in the basal cisterns and reabsorbed by arachnoid granulations, and avoiding implantation of exogenous material. Aims and Objectives: The purpose of this study was to assess the success rate of ETV in infants less than 1 year of age with congenital noncommunicating hydrocephalus. Material and Methods: This study was a 2-year prospective study from August 2017 to July 2019. ETVs were performed in 14 patients younger than 1 year with diagnosis of noncommunicating hydrocephalous. A failure was defined as the need for shunt implantation after ETV. Phase-contrast MRI of the brain was done after 6 months to see patency of ETV fenestration and CSF flow through ventriculostomy. Results: ETV was tried in 18 patients and successfully performed in 14 patients. Out of the 14 patients, shunt implantation after ETV was performed in 3 patients (failed ETV). In the successful cases, etiology was idiopathic aqueductal stenosis in 8, shunt complications in 2, and 1 case was a follow-up case of occipital encephalocele; the mean age was 7.7 months (range 3–12). In the 3 failed cases, etiology was aqueductal stenosis, mean age was 7.6 months (range 3–11). In all ETVs, failed patients MPVP shunting was done. Follow-up of nonshunted patients was done from 6 to 24 months (mean 15 months). There was no mortality or permanent morbidity noted following ETV. Conclusion: ETV is a good surgical procedure for less than 1-year-old children.

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