Long-term Control of Hydrocephalus via Endoscopic Third Ventriculostomy in Children with Tectal Plate Gliomas

Neurosurgery ◽  
2002 ◽  
Vol 51 (1) ◽  
pp. 63-68 ◽  
Author(s):  
John C. Wellons ◽  
R. Shane Tubbs ◽  
Jason T. Banks ◽  
Brenda Grabb ◽  
Jeffrey P. Blount ◽  
...  
Keyword(s):  
Endoscopic Third Ventriculostomy ◽  
Third Ventriculostomy ◽  
Primary Therapy ◽  
Ventricular Size ◽  
Imaging Studies ◽  
Successful Treatment Outcome ◽  
Tectal Plate ◽  
Shunt Removal

Abstract OBJECTIVE We report the control of hydrocephalus in children with presumed tectal plate gliomas by the use of endoscopic third ventriculostomy (ETV). METHODS The hospital records, office charts, and imaging studies from children who underwent ETV at the Children's Hospital of Alabama were reviewed. Thirteen children with the diagnosis of tectal plate glioma and hydrocephalus were identified. ETV was the primary therapy instituted for all but one of these children. Successful treatment outcome was defined as shunt freedom, improvement in symptoms, and reduced ventricular size. RESULTS Thirteen children underwent a total of 15 ETVs, and all children were shunt-free at their most recent follow-up examinations. One child underwent successful secondary ETV, one child underwent shunt removal concomitant with the initial ETV, and one child underwent shunt removal concomitant with secondary ETV. Symptoms and signs resolved in all patients. All postoperative cranial imaging studies revealed normal or reduced ventricular size as compared with preoperative cranial imaging scans. The median follow-up period was 31 months. CONCLUSION In our surgical experience, ETV has been uniformly successful in the management of hydrocephalus caused by tectal plate gliomas in children. ETV should be considered the treatment of choice for hydrocephalus in pediatric patients with tectal plate gliomas.

Long-term change in ventricular size following endoscopic third ventriculostomy for hydrocephalus due to tectal plate gliomas

2013 ◽  
Vol 11 (1) ◽  
pp. 20-25 ◽  
Author(s):  
Andrew Romeo ◽  
Robert P. Naftel ◽  
Christoph J. Griessenauer ◽  
Gavin T. Reed ◽  
Richard Martin ◽  
...  
Keyword(s):  
Endoscopic Third Ventriculostomy ◽  
Third Ventriculostomy ◽  
Ventricular Size ◽  
Size Change ◽  
Term Change ◽  
Tectal Plate ◽  
Additional Procedure ◽  
Csf Diversion ◽  
The Mean

Object Endoscopic third ventriculostomy (ETV) is an alternative to shunt placement in children with hydrocephalus due to tectal plate gliomas (TPGs). However, controversy remains regarding the amount of ventricular size reduction that should be expected after ETV. This study investigates ventricular size change after ETV for TPGs. Methods Twenty-two children were identified from a 15-year retrospective database of neuroendoscopic procedures performed at the authors' institution, Children's Hospital of Alabama, in patients with a minimum of 1 year of follow-up. Clinical outcomes, including the need for further CSF diversion and symptom resolution, were recorded. The frontal and occipital horn ratio (FOR) was measured on pre- and postoperative, 1-year, and last follow-up imaging studies. Results In 17 (77%) of 22 children no additional procedure for CSF diversion was required. Of those in whom CSF diversion failed, 4 underwent successful repeat ETV and 1 required shunt replacement. Therefore, in 21 (96%) of 22 patients, CSF diversion was accomplished with ETV. Preoperative and postoperative imaging was available for 18 (82%) of 22 patients. The FOR decreased in 89% of children who underwent ETV. The FOR progressively decreased 1.7%, 11.2%, and 12.7% on the initial postoperative, 1-year, and last follow-up images, respectively. The mean radiological follow-up duration for 18 patients was 5.4 years. When ETV failed, the FOR increased at the time of failure in all patients. Failure occurred 1.6 years after initial ETV on average. The mean clinical follow-up period for all 22 patients was 5.3 years. In all cases clinical improvement was demonstrated at the last follow-up. Conclusions Endoscopic third ventriculostomy successfully treated hydrocephalus in the extended follow-up period of patients with TPGs. The most significant reduction in ventricular size was observed at the the 1-year followup, with only modest reduction thereafter.

Endoscopic Transventricular Transaqueductal Magendie and Luschka Foraminoplasty for Hydrocephalus

Neurosurgery ◽  
2013 ◽  
Vol 74 (4) ◽  
pp. 426-436 ◽  
Author(s):  
Jaime Torres-Corzo ◽  
Juan Sánchez-Rodríguez ◽  
Dominic Cervantes ◽  
Roberto Rodríguez-Della Vecchia ◽  
Fernando Muruato-Araiza ◽  
...  
Keyword(s):  
Pediatric Patients ◽  
Endoscopic Third Ventriculostomy ◽  
Outlet Obstruction ◽  
Third Ventriculostomy ◽  
Alternative Technique ◽  
Vp Shunt ◽  
Long Term Follow Up ◽  
Secondary Causes

ABSTRACT BACKGROUND: Routinely, hydrocephalus related to fourth ventricular outlet obstruction (FVOO) has been managed with ventriculoperitoneal (VP) shunting or endoscopic third ventriculostomy (ETV). Few reports on Magendie foraminoplasty exist, and Luschka foraminoplasty has not been described. OBJECTIVE: To present an alternative technique in the management of FVOO via an endoscopic transventricular transaqueductal Magendie and Luschka foraminoplasty and to discuss the indications, technique, findings, and outcomes. METHODS: Between 1994 and 2011, all patients who underwent endoscopic Magendie and Luschka foraminoplasty were analyzed. RESULTS: A total of 33 Magendie (28) and/or Luschka (5) foraminoplasties were performed in 30 patients. Twenty-three were adult and 7 were pediatric patients. The etiology of the FVOO was divided into primary etiologies (congenital membrane in 5 and atresia in 2) and secondary causes (neurocysticercosis in 14 patients, bacterial meningitis in 9). Fifteen (50%) had previously failed procedures. Intraoperative findings that led to Magendie/Luschka foraminoplasty were ETV not feasible to perform, nonpatent basal subarachnoid space, or primary FVOO. Minor postoperative complications were seen in 3 patients. Only 26 patients had long-term follow-up; 17 (65.3%) of these had clinical improvement and did not require further procedures. Nine (34.7%) did not improve. Eight required another procedure (7 shunts, and 1 endoscopic procedure). One patient died. CONCLUSION: Flexible neuroendoscopic transventricular transforaminal Magendie and Luschka foraminoplasty is feasible and safe. These procedures may prove to be viable alternatives to standard ETV and VP shunt in appropriate patients. Adequate intraoperative assessment of ETV success is necessary to identify patients who will benefit.

Hydrocephalus surveillance following shunt placement or endoscopic third ventriculostomy: a survey of surgeons in the Hydrocephalus Clinical Research Networks

2021 ◽  
pp. 1-8
Author(s):  
David S. Hersh ◽  
Rahul Kumar ◽  
Paul Klimo ◽  
Markus Bookland ◽  
Jonathan E. Martin
Keyword(s):  
Clinical Research ◽  
Endoscopic Third Ventriculostomy ◽  
Research Network ◽  
Third Ventriculostomy ◽  
Imaging Studies ◽  
Shunt Placement ◽  
Late Failure ◽  
Asymptomatic Patients ◽  
Routine Imaging

OBJECTIVE Late failure is a well-documented complication of cerebrospinal fluid shunt placement and, less commonly, endoscopic third ventriculostomy (ETV). However, standards regarding the frequency of clinical and radiological follow-up in these patients have not been defined. Here, the authors report on their survey of surgeons at sites for the Hydrocephalus Clinical Research Network (HCRN) or its implementation/quality improvement arm (HCRNq) to provide a cross-sectional overview of practice patterns. METHODS A 24-question survey was developed using the Research Electronic Data Capture (REDCap) platform and was distributed to the 138 pediatric neurosurgeons across 39 centers who participate in the HCRN or HCRNq. Survey questions were organized into three sections: 1) Demographics (5 questions), 2) Shunt Surveillance (12 questions), and 3) ETV Surveillance (7 questions). RESULTS A total of 122 complete responses were obtained, for an overall response rate of 88%. The majority of respondents have been in practice for more than 10 years (58%) and exclusively treat pediatric patients (79%). Most respondents consider hydrocephalus to have stabilized 1 month (21%) or 3 months (39%) after shunt surgery, and once stability is achieved, 72% then ask patients to return for routine clinical follow-up annually. Overall, 83% recommend lifelong clinical follow-up after shunt placement. Additionally, 75% obtain routine imaging studies in asymptomatic patients, although the specific imaging modality and frequency of imaging vary. The management of an asymptomatic increase in ventricle size or an asymptomatic catheter fracture also varies widely. Many respondents believe that hydrocephalus takes longer to stabilize after ETV than after shunt placement, reporting that they consider hydrocephalus to have stabilized 3 (28%), 6 (33%), or 12 (28%) months after an ETV. Although 68% of respondents have patients return annually for routine clinical follow-up after an ETV, only 56% recommend lifelong follow-up. The proportion of respondents who perform lifelong follow-up increases with greater practice experience (p = 0.01). Overall, 67% of respondents obtain routine imaging studies in asymptomatic patients after an ETV, with “rapid” MRI the study of choice for most respondents. CONCLUSIONS While there is a general consensus among pediatric neurosurgeons across North America that hydrocephalus patients should have long-term follow-up after shunt placement, radiological surveillance is characterized by considerable variety, as is follow-up after an ETV. Future work should focus on evaluating whether any one of these surveillance protocols is associated with improved outcomes.

scholarly journals Endoscopic third ventriculostomy for treatment of adult hydrocephalus: long-term follow-up of 163 patients

2016 ◽  
Vol 41 (3) ◽  
pp. E3 ◽  
Author(s):  
Albert M. Isaacs ◽  
Yarema B. Bezchlibnyk ◽  
Heather Yong ◽  
Dilip Koshy ◽  
Geberth Urbaneja ◽  
...  
Keyword(s):  
Clinical Improvement ◽  
Treatment Modality ◽  
Endoscopic Third Ventriculostomy ◽  
Adult Patients ◽  
Third Ventriculostomy ◽  
Long Term Treatment ◽  
Patient Reported ◽  
Csf Diversion

OBJECTIVE The efficacy of endoscopic third ventriculostomy (ETV) for the treatment of pediatric hydrocephalus has been extensively reported in the literature. However, ETV-related long-term outcome data are lacking for the adult hydrocephalus population. The objective of the present study was to assess the role of ETV as a primary or secondary treatment for hydrocephalus in adults. METHODS The authors performed a retrospective chart review of all adult patients (age ≥ 18 years) with symptomatic hydrocephalus treated with ETV in Calgary, Canada, over a span of 20 years (1994–2014). Patients were dichotomized into a primary or secondary ETV cohort based on whether ETV was the initial treatment modality for the hydrocephalus or if other CSF diversion procedures had been previously attempted respectively. Primary outcomes were subjective patient-reported clinical improvement within 12 weeks of surgery and the need for any CSF diversion procedures after the initial ETV during the span of the study. Categorical and actuarial data analysis was done to compare the outcomes of the primary versus secondary ETV cohorts. RESULTS A total of 163 adult patients with symptomatic hydrocephalus treated with ETV were identified and followed over an average of 98.6 months (range 0.1–230.4 months). All patients presented with signs of intracranial hypertension or other neurological symptoms. The primary ETV group consisted of 112 patients, and the secondary ETV consisted of 51 patients who presented with failed ventriculoperitoneal (VP) shunts. After the initial ETV procedure, clinical improvement was reported more frequently by patients in the primary cohort (87%) relative to those in the secondary ETV cohort (65%, p = 0.001). Additionally, patients in the primary ETV group required fewer reoperations (p < 0.001), with cumulative ETV survival time favoring this primary ETV cohort over the course of the follow-up period (p < 0.001). Fifteen patients required repeat ETV, with all but one experiencing successful relief of symptoms. Patients in the secondary ETV cohort also had a higher incidence of complications, with one occurring in 8 patients (16%) compared with 2 in the primary ETV group (2%; p = 0.010), although most complications were minor. CONCLUSIONS ETV is an effective long-term treatment for selected adult patients with hydrocephalus. The overall ETV success rate when it was the primary treatment modality for adult hydrocephalus was approximately 87%, and 99% of patients experience symptomatic improvement after 2 ETVs. Patients in whom VP shunt surgery fails prior to an ETV have a 22% relative risk of ETV failure and an almost eightfold complication rate, although mostly minor, when compared with patients who undergo a primary ETV. Most ETV failures occur within the first 7 months of surgery in patients treated with primary ETV, but the time to failure is more prolonged in patients who present with failed previous shunts.

scholarly journals Endoscopic third ventriculostomy may have long term efficacy in low birth weight preterm newborns

2013 ◽  
Vol 32 (02) ◽  
pp. 110-113
Author(s):  
Matheus Fernandes de Oliveira ◽  
Koshiro Nishikuni ◽  
José Marcus Rotta
Keyword(s):  
Birth Weight ◽  
Low Birth Weight ◽  
Endoscopic Third Ventriculostomy ◽  
Third Ventriculostomy ◽  
Term Result ◽  
Moebius Syndrome ◽  
Long Term Result ◽  
Preterm Newborns

AbstractEndoscopic third ventriculostomy (ETV) is an established treatment for hydrocephalus and is an alternative method avoiding shunts and its complications. There is still controversy regarding the higher risk of failure in younger infants. NARF was a male preterm newborn of 33 weeks old, with Moebius syndrome and 1,800 grams at birth. Detailed neonatal evaluation revealed hydrocephalus with bilateral ventricular index of 0.6. It was then decided, in spite of prematurity and low birth weight to perform ETV with the age of 25 days, with 1,850 grams. After discharge, follow-up was lost due to family moving to another city. By chance, after seven years child returned to our medical facility and a follow-up magnetic resonance revealed pervious ETV with high flow, demonstrating functionality of ventriculostomy. Patient's age and etiology of hydrocephalus are the most important factors influencing the success rate of ETV. Recently, the age between 6 months and 1 year old became a cutoff below which failure rates are reported to be particularly high and there are dichotomized experience. The results in low birth weight and preterm infants is not widely known and can be poor. Our case illustrates a successful ETV in a both preterm and low birth weight newborn and a satisfactory long term result, reinforcing the security and efficacy of ETV even in newborns.

scholarly journals Long-term follow-up of endoscopic third ventriculostomy performed in the pediatric population

2016 ◽  
Vol 17 (6) ◽  
pp. 734-738 ◽  
Author(s):  
Matthew G. Stovell ◽  
Rasheed Zakaria ◽  
Jonathan R. Ellenbogen ◽  
Mathew J. Gallagher ◽  
Michael D. Jenkinson ◽  
...  
Keyword(s):  
Failure Rate ◽  
Endoscopic Third Ventriculostomy ◽  
Obstructive Hydrocephalus ◽  
Third Ventriculostomy ◽  
Shunt Insertion ◽  
Vp Shunt ◽  
Additional Surgery ◽  
Long Term Follow Up

OBJECTIVE Endoscopic third ventriculostomy (ETV) is an effective treatment for obstructive hydrocephalus and avoids the risk for foreign-body infection associated with ventriculoperitoneal (VP) shunts. The short-term failure rate of ETV strongly depends on the indications for its use but is generally thought to be lower in the long term than that of VP shunts. However, few studies are available with long-term follow-up data of ETV for hydrocephalus in children. The authors reviewed the long-term success of ETV at their institution to investigate the rate of any late failures of this procedure. METHODS Between April 1998 and June 2006, 113 children (including neonates and children up to 16 years old) had primary or secondary ETV for different causes of hydrocephalus. The patients' medical records and the authors' electronic operation database were reviewed for evidence of additional surgery (i.e., repeat ETV or VP shunt insertion). These records were checked at both the pediatric and adult neurosurgical hospitals for those patients who had their care transferred to adult services. RESULTS The median length of follow-up was 8.25 years (range 1 month to 16 years). Long-term follow-up data for 96 patients were available, 47 (49%) of whom had additional ETV or VP shunt insertion for ETV failure. Twenty patients (21%) had a second procedure within 1 month, 17 patients (18%) between 1 and 12 months, 7 patients (7%) between 1 and 5 years, and 3 patients (3%) between 5 and 8 years. CONCLUSIONS In the authors' series, ETV had an initial early failure rate for the treatment of pediatric hydrocephalus as reported previously, and this rate significantly depended on patient age and hydrocephalus etiology. Once stabilized and effective, ETV appeared to be durable but not guaranteed, and some late decline in effectiveness was observed, with some ETV failures occurring many years later. Thus, successful ETV in children cannot be guaranteed for life, and some form of follow-up is recommended long term into adulthood.

LASER-ASSISTED ENDOSCOPIC THIRD VENTRICULOSTOMY

Neurosurgery ◽  
2008 ◽  
Vol 62 (2) ◽  
pp. 437-444 ◽  
Author(s):  
Janneke van Beijnum ◽  
Patrick W. Hanlo ◽  
Kathelijn Fischer ◽  
Mohsen M. Majidpour ◽  
Marlous F. Kortekaas ◽  
...  
Keyword(s):  
Success Rate ◽  
Endoscopic Third Ventriculostomy ◽  
Major Complication ◽  
Aqueductal Stenosis ◽  
Third Ventriculostomy ◽  
Success Rates ◽  
Patients Âgés ◽  
Kaplan Meier

Abstract OBJECTIVE Endoscopic third ventriculostomy is a well-known surgical option in the treatment of noncommunicating hydrocephalus. We studied complications and long-term success in 202 patients to demonstrate the safety and efficacy of laser-assisted endoscopic third ventriculostomy (LA-ETV) using a unique “black” fiber tip/diode laser combination for controlled tissue ablation. METHODS We studied 213 LA-ETVs, which were performed in 202 patients. Patients' ages ranged from 2 days to 83 years (mean age, 27 yr). The mean follow-up period for all patients was 2.7 years (range, 2 d to 12 yr). Hydrocephalus was caused by aqueductal stenosis in 65 patients, tumors in 67 patients, hemorrhages in 24 patients, myelomeningoceles in 20 patients, cysts in 15 patients, and other causes in 11 patients. The long-term effectiveness of LA-ETV was studied with Kaplan-Meier analysis. RESULTS Technically successful LA-ETVs were accomplished in 196 of the 202 patients (97%). The overall success rate for a functional LA-ETV was 68% at the 2-year follow-up evaluation. LA-ETV was more effective in patients aged 1 year and older (70% success rate) than in younger patients (59% success rate). Success rates were greater in patients with aqueductal stenosis or tumors as compared to other etiologies. Complications occurred in 22 procedures (10.3%). Only one patient (0.5%) experienced a major complication. No surgical mortalities or laser-related complications occurred. CONCLUSION This study demonstrates that LA-ETV is a safe and effective procedure that is comparable to other techniques for ETV. LA-ETV is most effective in patients aged 1 year and older and in patients with aqueductal stenosis and tumors, with a low major complication rate.

The role of endoscopic third ventriculostomy in the treatment of hydrocephalus

2013 ◽  
Vol 12 (1) ◽  
pp. 54-61 ◽  
Author(s):  
Timothy W. Vogel ◽  
Biji Bahuleyan ◽  
Shenandoah Robinson ◽  
Alan R. Cohen
Keyword(s):  
Endoscopic Third Ventriculostomy ◽  
Third Ventricle ◽  
Public Health Problem ◽  
High Rate ◽  
Third Ventriculostomy ◽  
Major Public Health Problem ◽  
Shunt System

Object Hydrocephalus remains a major public health problem. Conventional treatment has relied on extracranial shunting of CSF to another systemic site, but this approach is associated with a high rate of complications. Endoscopic third ventriculostomy (ETV) is a novel treatment for select forms of hydrocephalus that can eliminate the need for implantation of a lifelong ventricular shunt system. However, the indications for ETV are contested and its long-term effectiveness is not well established. Methods The authors selected 100 consecutive patients who underwent ETV for hydrocephalus beginning in 1994. Patients were enrolled and treated at a single institution by a single surgeon. The primary outcome was success of ETV, with success defined as no need for subsequent surgery for hydrocephalus. Results Ninety-five patients satisfied the inclusion criteria. The mean follow-up period was 5.1 years (median 4.7 years) with follow-up data available for as long as 17 years. Patients commonly presented with headache (85%), ataxia (34%), emesis (29%), and changes in vision (27%). The success rate for ETV was 75%. Twenty-one patients (22%) in the series had malfunctioning shunts preoperatively and 13 (62%) were successfully treated with ETV. Preoperative inferior bowing of the third ventricle floor on MRI was significantly associated with ETV success (p < 0.05). Conclusions Endoscopic third ventriculostomy is an effective and durable treatment for select patients with hydrocephalus. When successful, the procedure eliminates the lifelong complications associated with implanted ventricular shunts.

Long-term Reliability of Endoscopic Third Ventriculostomy

Neurosurgery ◽  
2005 ◽  
Vol 56 (6) ◽  
pp. 1271-1278 ◽  
Author(s):  
David Kadrian ◽  
James van Gelder ◽  
Danielle Florida ◽  
Robert Jones ◽  
Marianne Vonau ◽  
...  
Keyword(s):  
Endoscopic Third Ventriculostomy ◽  
Third Ventriculostomy ◽  
Aqueduct Stenosis ◽  
Previous Infection ◽  
Long Term Follow Up ◽  
The Mean ◽  
The Individual ◽  
Operating Surgeon

Abstract OBJECTIVE: To describe the short-term operative success and the long-term reliability of endoscopic third ventriculostomy (ETV) for treatment of hydrocephalus and to examine the influence of diagnosis, age, and previous shunt history on these outcomes. METHODS: We retrospectively analyzed 203 consecutive patients from a single institution who had ETV as long as 22.6 years earlier. Patients with hydrocephalus from aqueduct stenosis, myelomeningocele, tumors, arachnoid cysts, previous infection, or hemorrhage were included. RESULTS: The overall probability of successfully performing an ETV was 89% (84–93%). There was support for an association between the surgical success and the individual operating surgeon (odds ratios for success, 0.44–1.47 relative to the mean of 1.0, P = 0.08). We observed infections in 4.9%, transient major complications in 7.2%, and major and permanent complications in 1.1% of 203 procedures. Age was strongly associated with long-term reliability. The longest observed reliability for the 13 patients 0 to 1 month old was 3.5 years. The statistical model predicted the following reliability at 1 year after insertion: at 0 to 1 month of age, 31% (14–53%); at 1 to 6 months of age, 50% (32–68%); at 6 to 24 months of age, 71% (55–85%); and more than 24 months of age, 84% (79–89%). There was no support for an association between reliability and the diagnostic group (n = 181, P = 0.168) or a previous shunt. Sixteen patients had ETV repeated, but only 9 were repeated after at least 6 months. Of these, 4 procedures failed within a few weeks, and 2 patients were available for long-term follow-up. CONCLUSION: Age was the only factor statistically associated with the long-term reliability of ETV. Patients less than 6 months old had poor reliability.

scholarly journals Endoscopic third ventriculostomy for hydrocephalus associated with tectal gliomas

2005 ◽  
Vol 18 (6) ◽  
pp. 1-4 ◽  
Author(s):  
Khan W. Li ◽  
Chanland Roonprapunt ◽  
Herman C. Lawson ◽  
I. Rick Abbott ◽  
Jeffrey Wisoff ◽  
...  
Keyword(s):  
Initial Treatment ◽  
Endoscopic Third Ventriculostomy ◽  
Obstructive Hydrocephalus ◽  
Third Ventriculostomy ◽  
Success Rates ◽  
Shunt Placement ◽  
Initial Procedure ◽  
History Of

Object Tectal gliomas are a distinct form of pediatric brainstem tumor that present in patients with symptoms related to increased intracranial pressure due to obstructive hydrocephalus. The natural history of these lesions is often uniquely indolent. Thus, initial surgical therapies are directed at treatment of hydrocephalus, usually with ventricular shunt placement. Recently, third ventriculostomy has been used in patients with tectal gliomas, both as an initial procedure and after shunt failures. In this report the authors review their experience with the treatment of hydrocephalus in patients with tectal gliomas. Methods The authors reviewed 31 consecutive cases of tectal gliomas and compared the success rates of ventricular shunt placement with the success rates of endoscopic third ventriculostomy (ETV). Shunt placement procedures were associated with a significant number of malfunctions, and most patients required shunt revisions. The ETV procedure was attempted both as an initial treatment and after shunt malfunction. Overall, ETV was attempted in 18 patients and was performed successfully in all cases. At the time of follow-up evaluation, 16 patients (89%) were shunt free. Conclusions The authors found that ETV could be performed with good long-term success both as an initial treatment and after shunt failure. Overall, ETV was found to be superior to ventricular shunt placement in the management of hydrocephalus associated with tectal gliomas.

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