Successful combination chemotherapy (cisplatinum, vinblastine, and bleomycin) against peritoneal dissemination of intracranial germ cell tumor

We found combination chemotherapy with cisplatinum, vinblastine, and bleomycin (PVB therapy) effective in the treatment of a patient with a pineal germ cell tumor with peritoneal dissemination. The metastatic complication may have been attributable to the ventriculoperitoneal shunt tube. After the first course of PVB therapy, the disseminated tumors were decreased in size; no residual tumors were detected after the third course by laparoscopic examination, computed tomographic scanning, or echogram. Our results suggest that combined PVB therapy is effective in the treatment of extraneural metastasis from intracranial germ cell tumors.     

The risks of metastases from shunting in children with primary central nervous system tumors

The authors reviewed the hospital charts of 415 pediatric patients treated for benign or malignant primary brain tumors over the past 20 years at the Children's Hospital Medical Center, Seattle. Patients' ages ranged from the neonatal period to 18 years. A shunt was placed in 152 patients (37%), 45 before and 94 after surgery. Confirmation of extraneural metastases was based on clinical and diagnostic examination. Factors analyzed as possibly influencing the occurrence of extraneural metastases were: 1) the shunt: type, valve, location, filter, and revisions; 2) extent of resection; 3) pathology; and 4) treatment regimen. Eight of the 415 patients developed extraneural metastases during life. All eight patients had a medulloblastoma (cerebellar primitive neuroectodermal tumor). These eight patients were separated into Group A (without a shunt) and Group B (with a shunt). In Group A (five patients), the mean interval from primary diagnosis to metastasis was 15 months. Two children had gross total resection of the tumor. The predominant location of metastases in Group A was: bone (two cases); cervical lymph nodes (one); lung/bone (one); and retroperitoneal pelvic mass (one). Three Group A patients had a simultaneous central nervous system (CNS) recurrence. Of the three Group B patients, two had a ventriculoperitoneal (VP) shunt and one a ventriculoatrial (VA) shunt; all were placed postoperatively. One Group B patient had a simultaneous CNS recurrence. No shunt revisions were performed in these three patients. The mean time from primary diagnosis to metastasis was 25 months. One patient had a total tumor resection. The predominant location of metastases was bone (one case), retroperitoneal pelvic mass (one), and abdominal cavity with ascites (one case). Only one patient in the entire series had a filter placed; this resulted in shunt obstruction and was removed 1 month following placement. It is concluded that cerebrospinal fluid shunts, regardless of type, location, revision rate, or filter insertion, do not predispose pediatric patients with brain tumors to develop extraneural metastases. A diagnosis of shunt-related metastases should be based on the development of intra-abdominal (VP shunt) or pulmonary (VA shunt) dissemination primarily with or without additional sites. The diagnosis of medulloblastoma is an important factor related to metastasis occurrence while the extent of resection and postoperative therapy are not influential.     

Comparison of clinical outcomes of intraventricular hematoma between neuroendoscopic removal and extraventricular drainage

The efficacy of treatment for intraventricular hematoma by neuroendoscopic surgery and extraventricular drainage was compared in 10 patients with intraventricular hematoma and hydrocephalus who underwent neuroendoscopic surgery (endoscopic group), and eight patients with intraventricular hematoma and hydrocephalus treated with extraventricular drainage (EVD group). The outcomes in each group were assessed retrospectively using the Graeb scores on the pre- and postoperative computed tomography (CT), duration of extraventricular drainage, requirement for a shunt operation, and modified Rankin scale score at 12 months. The Graeb scores on the preoperative CT were not significantly different between the two groups, but the duration of catheter placement was significantly shorter (69.3%) in the endoscopic group (2.7 days) than in the EVD group (8.8 days). None of the patients in either group required a shunt procedure for communicating hydrocephalus 12 months after surgery. Neuroendoscopic removal is a safe and effective procedure for intraventricular hematoma. Advantages include rapid removal of hematoma in the ventricular systems and reliable improvement of non-communicating hydrocephalus in the acute phase. The procedure resulted in faster removal of the catheter in the postoperative period and earlier patient ambulation.     

Clinical value of percutaneous needle trephination (PNT)

Summary In 56 neurosurgical patients 70 percutaneous needle trephinations were performed. This method was mostly used in patients with acute increase of ICP due to occlusive hydrocephalus of various aetiologies. Thanks to the accuracy and exhaustiveness of CT information, and thanks to the simplicity and safety of percutaneous needle trephination, this latter could be more and more used in daily clinical practice as a diagnostic and therapeutic procedure, for example for the study of adult hydrocephalus, for provisional external ventricular drainage, for treatment of CSF infections, and for ventricular bleedings (also in newborns and premature infants). No serious complication was seen even after prolonged CSF drainage over a period of 41 days. The method of PNT, as described in detail, can be used under sterile conditions at the bedside, on the stretcher in the emergency room, or in the CT or X-ray laboratory. It fulfils the criteria for clinical acceptance: simplicity, low risk, reliability, exactness, and effectiveness.     

Perioperative external ventricular drainage in obstructive hydrocephalus secondary to infratentorial brain tumours

Summary Of 148 patients with infratentorial brain tumours which were operated upon during a 5 year period, 59 patients had associated obstructive hydrocephalus, as evidenced by preoperative CT scan. External ventricular drainage was performed in these cases at time of surgery. CSF drainage was continued in the postoperative period for a mean of 2.3 (± 1.6) days. Only 6 of these 59 patients (10%) required a subsequent indwelling shunt. The infection rate was 10% and the total mortality was 8%. Perioperative ventricular drainage during and following the removal of posterior fossa tumours causing hydrocephalus provides an effective alternative to the preoperative placement of an indwelling shunt. Problems of shunt dysfunction, tumour seeding and upward herniation are thereby avoided. Post-operative ICP monitoring and drainage of blood and debris laden CSF is performed, increasing the safety of the postoperative period and possibly reducing the incidence of aspetic meningitis and post-operative shunt requirement.     

Hydrocephalus: comparison of clipping and embolization in aneurysm treatment

OBJECT: In this retrospective study conducted at Atkinson Morley's Hospital and Middlesbrough General Hospital, the authors analyzed 100 matched patients who had suffered subarachnoid hemorrhage (SAH) to determine whether the technical procedure by which aneurysms are treated affects the development of chronic hydrocephalus. METHODS: Four hundred seventy-five patients presented with SAH between 1995 and 1998. Exclusion criteria included posterior circulation aneurysms, multiple aneurysms, electively clipped or embolized aneurysms, angiographically undetected SAH, patients who died within 1 month of neurosurgical intervention, and patients with the same aneurysm location but a different Fisher grade. The authors matched 50 patients who underwent embolization of their aneurysms with another 50 who had similar Fisher grades and aneurysm types and underwent clipping of their aneurysms. The maximum incidence of ruptured aneurysms occurred in patients who were between 41 and 60 years of age, with women preponderant in both study groups. In each group, 27 patients had anterior communicating artery aneurysm, 13 had posterior communicating artery aneurysm, seven had middle cerebral artery aneurysm, and three had internal carotid artery aneurysm. The lesions in three patients in each group were Fisher Grade I, in 23 patients they were Fisher Grade II, in 14 they were Fisher Grade III, and 10 patients had Fisher Grade IV SAH. Nine patients among those with clipped aneurysms and eight of the patients who underwent embolization had hydrocephalus for which they needed intervention. These interventions included lumbar puncture, ventricular drainage, and ventriculoperitoneal (VP) shunt placement; three patients in each group needed VP shunt placement. CONCLUSIONS: The technical procedure used to treat aneurysms, whether clipping or embolization, does not significantly affect the development of chronic hydrocephalus. However, a larger sample of patients is needed for accurate comparisons and stronger conclusions.     

Ventricular diverticula in obstructive hydrocephalus secondary to tumor growth

OBJECTIVE: The association of ventricular diverticula with intra- and paraventricular tumors causing obstructive hydrocephalus has rarely been reported. METHODS: Records and imaging findings for 57 patients with obstructive hydrocephalus caused by tumors who were treated at our institution were reviewed for the presence of ventricular diverticula. For the anatomic study of ventricular diverticula, data were collected from five cadaveric heads. RESULTS: Ventricular diverticula were identified on magnetic resonance imaging scans in five cases. Diverticula were similarly located in the quadrigeminal cistern but originated from the medial wall of the atrium of the lateral ventricle in three cases and from the superior portion of the fourth ventricle in two cases. Regression of diverticula occurred in all cases after either insertion of a shunt or removal of the obstructing tumor. The cadaveric study suggested that the choroidal fissure and the rostral portion of the superior medullary velum might be the origins of diverticula from the atrium and from the superior portion of the fourth ventricle, respectively. CONCLUSION: Ventricular diverticula should be distinguished from other cystic lesions in the quadrigeminal region. Detection of an ostium of a diverticulum or communication between the cyst and the ventricular system is important for diagnosis.     

Neuroendoscopic stent procedure in obstructive hydrocephalus due to both foramina of monro occluding craniopharyngioma: technical note

BACKGROUND: The development of various neuroendoscopic surgical instruments has offered more options for endoscopic procedures in the treatment of intraventricular tumors. Not only tumor biopsy or tumor resection but also restoration of an obstructed cerebral spinal fluid (CSF) pathway can be performed using the same approach. METHOD: A 76-year-old woman with a cardiac pacemaker for an underlying heart disease was diagnosed with obstructive hydrocephalus because of a third ventricular tumor 8 years ago. The patient had been treated with ventriculo-peritoneal shunt placement. At admission she presented with a subcutaneous infection of the shunt catheter and an abdominal mass of unknown etiology. Neuroendoscopic stenting between lateral and third ventricle was performed to restore the obstructed CSF pathway, and the infected shunt system was removed in the same setting. RESULT: The postoperative course was uneventful. Contrast ventriculography demonstrated a restored CSF pathway between the lateral and third ventricle. Histologic examination of the intraventricular tumor revealed a craniopharyngioma, and the abdominal mass was diagnosed as a gastrointestinal adenocarcinoma. CONCLUSION: The neuroendoscopic foraminoplasty technique should be considered as an alternative treatment for patients who present with an obstructive hydrocephalus caused by a tumor that occludes both foramina of Monro when shunt placement or endoscopic third ventriculostomy is not feasible.     

Case of spontaneous ventriculocisternostomy: with special reference to a CT finding

Spontaneous ventriculocisternostomy rarely occurs in obstructive hydrocephalus. The authors experienced a case of spontaneous ventriculocisternostomy diagnosed by CT scan with metrizamide and Conray. Patient was 23-year-old male who had been in good health until one month before admission, when he began to have headache and tinnitus. He noticed bilateral visual acuity was decreased about one week before admission and vomiting appeared two days before admission. He was admitted to our hospital because of bilateral papilledema and remarkable hydrocephalus diagnosed by CT scan. On admission, no abnormal neurological signs except for bilateral papilledema were noted. Immediately, right ventricular drainage was performed. Pressure of the ventricle was over 300 mmH2O and CSF was clear. PVG and PEG disclosed an another cavity behind the third ventricle, which was communicated with the third ventricle, and occlusion of aqueduct of Sylvius. Metrizamide CT scan and Conray CT scan showed a communication between this cavity and quadrigeminal and supracerebellar cisterns. On these neuroradiological findings, the diagnosis of obstructive hydrocephalus due to benign aqueduct stenosis accompanied with spontaneous ventriculocisternostomy was obtained. Spontaneous ventriculocisternostomy was noticed to produce arrest of hydrocephalus, but with our case, spontaneous regression of such symptoms did not appeared. In the literature, arrest of hydrocephalus was noted in 50 per cent of 14 cases of obstructive hydrocephalus with spontaneous ventriculocisternostomy. By surgical ventriculocisternostomy (method by Torkildsen, Dandy, or Scarff), arrest of hydrocephalus was seen in about 50 to 70 per cent, which was the same results as those of spontaneous ventriculocisternostomy. It is concluded that VP shunt or VA shunt is thought to be better treatment of obstructive hydrocephalus than the various kinds of surgical ventriculocisternostomy.     

Temporary ventricular drainage and emergency radiotherapy in the management of hydrocephalus associated with germinoma

OBJECT: The authors used an alternative strategy to avoid shunt placement for hydrocephalus associated with germinoma, and the ensuing complications. METHODS: Between 1998 and 2000, five patients presenting with germinomas of the pineal area and symptomatic obstructive hydrocephalus were treated with a novel strategy. On arrival, they underwent ventriculostomy placement and one of several surgical procedures to obtain tissue for diagnosis. Within several days of the initial diagnosis, stereotactically guided fractionated radiotherapy was started. All patients experienced rapid tumor shrinkage and resolution of hydrocephalus, allowing discontinuation of external ventricular drainage without the need for permanent shunting of cerebrospinal fluid. To date, follow up reveals 100% radiographically and clinically confirmed tumor control. CONCLUSIONS: Prompt resolution of hydrocephalus and absence of complications make this a potentially valuable therapy for control of germinomas and their symptoms.     

Delayed endoscopic intraventricular hemorrhage (IVH) removal and endoscopic third ventriculostomy may not prevent consecutive communicating hydrocephalus if IVH removal was insufficient.

OBJECT: The aim of this study was to investigate whether delayed endoscopic treatment of intraventricular hemorrhage (IVH) can prevent consecutive communicating hydrocephalus. METHODS: A retrospective series of 9 patients with IVH caused by intracerebral hemorrhage (ICH) who were treated with external ventricular drainage (EVD) or endoscopic IVH removal and endoscopic third ventriculostomy (ETV) was studied in our institute. Five of these patients who had previously been treated a year before in our institute with the installation of a flexible endoscope, were treated with EVD alone on admission. Of the other patients, three received endoscopic removal of IVH and ETV and, after a one week, EVD placement, and the final patient underwent endoscopic IVH removal and ETV one day after onset. RESULTS: Three of the patients treated with EVD alone were fitted with the EVD for 8, 11 and 16 days, and 2 patients were fitted with the EVD until they died. No patients treated with EVD alone required shunt placement. In contrast, of the 4 patients treated endoscopically, EVD was placed totally for 0, 6, 9, and 22 days for each patient, among whom 2 patients required shunt placement. CONCLUSIONS: Delayed endoscopic IVH removal and ETV might not prevent consecutive communicating hydrocephalus if IVH removal was insufficient.     

Extracorporeal ventriculoatrial shunt with the use of one-way ball valve

We developed a simple system of an "extracorporeal" ventriculoatrial (VA) shunt using a one-way ball valve (Acty valve II, Kaneka Medix) to release the patient from postoperative constraint during the ventricular drainage. The system is constructed in such a way that the ventricular drainage tube is connected to the central venous catheter via a one-way valve. The CSF is regulated by using the valve and is diverted into the systemic circulation as in the conventional ventriculoatrial shunt. After 2 or 3 weeks of CSF diversion through the extracorporeal VA shunt, a ventriculoperitoneal shunt is placed if hydrocephalus is apparent by temporary occlusion of the system. We applied this system to 4 patients with hydrocephalus, and we found it useful and free from adverse effects. The patient was freed from physical constraint involved in conventional ventricular drainage and an effective program of early rehabilitation was able to be started.     

Extraneural metastasis of malignant glioma through a ventriculo-peritoneal shunt: growth in peritoneal cavity as ascitic form

This is the first report of extraneural metastasis of malignant glioma through V-P shunt tube and growth in peritoneal cavity as ascitic form. The patient was a 43-year-old man who was admitted to our hospital with occipital headache. CT scan showed enhanced cystic tumor mass at left temporal lobe. Craniotomy and partial excision of the tumor was done and the histology of tumor tissue showed a malignant astrocytoma. Following this treatment, the patient received the adjuvant therapies of radiation, chemotherapy and immunotherapy with interferon, and also recraniotomy three times. In the mean time, a ventriculo-peritoneal shunt was set up for internal hydrocephalus. One month later, abdominal bulging appeared and yellowish ascites could be obtained with peritoneal tap. In the ascite, tumor cells with glial fibrillary acidic protein were observed at the concentration of 5-10 x 10(4) cells/ml. The patient died three months after extraneural metastasis to the abdominal cavity as ascitic form. At autopsy, solid metastatic mass lesion was not found in extraneural region include abdomen.     

Ventriculoperitoneal shunt for hydrocephalus secondary to tuberculous meningitis: a case report

A case of hydrocephalus secondary to tuberculous meningitis is reported. A 6-month-old baby was admitted to our hospital with a 10-day history of high fever. Neurological examination revealed no abnormal findings other than neck stiffness. Cerebrospinal fluid findings suggested tuberculous meningitis, because of pleocytosis (608/mm3, 100% lymphocytes) and reduced sugar content (19 mg/dl). Mycobacterium tuberculosis was found in cerebrospinal fluid culture. Although anti-tuberculous therapy was administered for 2 weeks, deterioration of consciousness and papilledema appeared. CT scan demonstrated enlargement of the entire ventricular system, indicating communicating hydrocephalus. After a ventricular drainage was performed, consciousness disturbance improved, but the high fever persisted. Judging by cerebrospinal fluid findings, the meningitis seemed to be in the active stage. Therefore an Ommaya reservoir was installed instead of a cerebrospinal fluid shunt for fear of disseminating the tuberculous infection through the shunt tube. However, the hydrocephalus was not well controlled. Consequently, a ventriculoperitoneal shunt was placed, despite the fact that the disease was still active. The fever then gradually subsided, and cerebrospinal fluid findings normalized. The patient was discharged without any neurological deficits one month after emplacement of the ventriculoperitoneal shunt. The antituberculous therapy has been continued, and there is no sign of infection propagated through the shunt 13 months following discharge from the hospital. The result suggests that a cerebrospinal fluid shunt can be placed for hydrocephalus even in the active stage of tuberculous meningitis under antituberculous therapy.     

Laparoscopic-assisted lumboperitoneal shunt: a simplified technique.

OBJECTIVES: Lumboperitoneal shunt has been advocated as a better alternative to ventriculoperitoneal shunt in communicating hydrocephalus. To minimize the morbidity of subcutaneous tunneling or an open abdominal wound, we developed a simplified technique for laparoscopy-assisted placement of lumboperitoneal shunts. METHODS: Patients deemed candidates for lumboperitoneal shunts underwent laparoscopy-assisted lumboperitoneal shunt placement. Using a Tuohy needle, the neurosurgeon obtains access to the lumbar subthecal space. Simultaneously, the laparoscopist obtains access to the peritoneal cavity with two 5-mm ports for the take down of the descending colon, clearing the way for the passage of the shunt passer from the back into the peritoneal cavity. RESULTS: Over the last 5 years, 45 patients have undergone laparoscopy-assisted lumboperitoneal shunt placement. Patients have been followed with neuropsychiatric examinations, imaging studies, and repeated neurological examinations. No complications related to the laparoscopy have occurred. Neurosurgical complications included postural headaches caused by overdrainage in 4 patients requiring laparoscopic modification of the shunt slit and in 1 patient with acquired Arnold-Chiari I malformation. CONCLUSION: Laparoscopy-assisted lumboperitoneal shunt offers many advantages over percutaneous ventriculoperitoneal or laparoscopic transabdominal lumboperitoneal shunts. The procedure can be performed in less than 30 minutes by any practicing laparoscopist.     

Role of endoscopic third ventriculostomy in patients with communicating hydrocephalus: an evaluation by MR ventriculography

Post-tubercular meningitic hydrocephalus (TBMH) and post-traumatic hydrocephalus (PTH) is often considered a contraindication for endoscopic third ventriculostomy (ETV), as it is mostly of communicating type in these cases. The aim of the present study was to define the role of ETV in patients with communicating hydrocephalus. Ten consecutive patients of TBMH, PTH and postneurocysticercus (NCC) hydrocephalus were formed the study group. Diagnosis of communicating hydrocephalus was made using magnetic resonance ventriculography (MRV). If contrast was seen coming out from the ventricular system into the basal cisterns, it was considered as communicating hydrocephalus. Patients with clinical and imaging evidence of raised intracranial pressure and failed medical treatment were taken up for ETV. All patients were studied by preoperative and postoperative MRV. Success of the procedure was assessed by the improvement in clinical and imaging parameters on postprocedure follow-up in all these cases. Technically successful ETV was performed in all 10 patients. Overall success rate of ETV in communicating hydrocephalus was 70% (n = 7). The shunt surgery was performed in the remaining three patients with ETV failure. One patient developed complication following postoperative MRV and was managed conservatively. We conclude that ETV is effective in post-TBM, post-traumatic communicating and post-NCC communicating hydrocephalus and should be considered as initial surgical option for cerebrospinal fluid diversion in these patients. MRV is a relatively safe technique to ascertain the patency of subarachnoid space as well as ETV stoma.     

Endoscopic hematoma evacuation for hypertensive cerebellar hemorrhage.

OBJECT: The management of spontaneous cerebral hemorrhage remains controversial, particularly the surgical indications. Endoscopic surgery was evaluated for the treatment of spontaneous cerebellar hemorrhage. METHODS: The records of 69 patients with hypertensive cerebral hemorrhage were retrospectively reviewed. Patients treated by endoscopic surgery (n = 10) were compared with patients treated by conventional surgical hematoma evacuation (n = 10) under the same surgical indications. RESULTS: The surgical procedure time, duration of ventricular drainage, extent of hematoma evacuation, necessity for cerebrospinal fluid (CSF) shunt, surgical complications, and outcome at discharge and at 3 months after onset were compared. The extent of hematoma evacuation was greater in the endoscopic group (95.2 %) than in the craniectomy group (90.6 %) but without significant difference. The endoscopic technique (64.5 min) took significantly less time than the craniectomy method (230.6 min, p < 0.0001). The period of ventricular drainage was significantly shorter in the endoscopic group (2.6 days) compared to the craniectomy group (12.3 days, p < 0.01). CSF shunt surgery was required in no patient in the endoscopic group compared to three in the craniectomy group. CONCLUSION: Endoscopic hematoma evacuation is a rapid, effective, and safe technique for the removal of hypertensive cerebellar hemorrhage. Reduction of the mass effect can be accomplished with low risk of recurrent hemorrhage. Release of obstructive hydrocephalus in the early stage may improve the patient's outcome and decrease the requirement for permanent shunt emplacement.     

Atypical presentation of delayed communicating hydrocephalus after supratentorial glioma resection with opening of the ventricles

We report four cases of communicating hydrocephalus, requiring shunt placement, in the subset of patients whose ventricles were breached at the time of glioma resection (a total 97 cases over 3 years). The hydrocephalus in these cases presented without ventricular dilatation on computed tomography (CT) scanning, and in 3 cases without headache. Failure to progress, visual deterioration or cerebrospinal fluid (CSF) leak in the post-operative patient after tumour resection with ventricular opening should alert clinicians to the possibility of hydrocephalus, despite the absence of headache or ventriculomegaly, and lumbar puncture should be performed without delay.     

Stenosis of the aqueduct of Sylvius. Etiology and treatment

Etiology, mechanism and treatment remain controversial in aqueductal stenosis. The review of 114 cases operated on between 1975 and 1982 in the Service of Pediatric Neurosurgery of "Les Enfants-Malades" in Paris was undertaken with the hope of improving our understanding of these problems. Toxoplasmosis was in our series the most frequent etiology, accounting for 15% of the cases; 74% of the aqueductal stenoses in this series were of unknown origin. In two cases, a small arachnoid cyst, developed in contact with the ambient cistern, was the cause of the aqueductal stenosis. In about half of the 32 pneumoencephalograms performed, a rounded, dilated ambient cistern was found. No such dilatation was observed in 35 pneumoencephalograms performed in cases of communicating hydrocephalus. It is likely that some cases of aqueductal stenoses are the consequence of a compression of the brain stem by an overpressurized ambient cistern, whether communicating or not with the subarachnoid spaces. Although the ventricular volume is less reduced after percutaneous ventriculostomy than after shunting, the long term results of the two treatments are comparable. The risk of infection is lower with ventriculostomies, but the rate of failures is higher. Since ventriculocisternostomy is a safe procedure when patients are properly selected, it can be tested first, a shunt being inserted at a later time in case of failure.     

Ventriculoperitoneal shunt malfunction due to pregnancy

A 27-year-old female was admitted to our department due to gait disturbance and disorientation. Computed tomography (CT) scan revealed symmetrical ventricular dilatation. She was pregnant at 25 weeks of gestation. At the age of 16 years, she had received a ventriculo-peritoneal (VP) shunt for hydrocephalus, induced by a cerebellar medulloblastoma. Neurological examination at the current admission showed that she was disoriented with ataxic gait and convergence nystagmus. Analysis of the cerebrospinal fluid showed normal cell composition. Magnetic resonance images (MRI) and Thalium-single photon emission tomography (CI-SPECT) revealed no recurrence of the tumor. The radio-isotope shunt flow study showed there was no obstruction of the shunt tube or retardation of intraabdominal diffusion. The patient was diagnosed as having shunt malfunction without obstruction of the shunt tube. We performed pumping of a flushing device for the shunt system. As a result her symptom was gradually improved. The follow-up MRI, 20 days after the using, showed complete disappearance of hydrocephalus. She was discharged from our hospital 1 month later. She continued pumping of the flushing device by herself at home. Three months later, she delivered a healthy infant by vaginal labor. She has not need to do pumping after that. And MRI showed no sign of hydrocephalus.