Sudden death secondary to delayed closure of endoscopic third ventriculostomy

An 11-year-old boy who underwent an initially successful endoscopic third ventriculostomy (ETV) died 4 months later secondary to acute hydrocephalus. This is the first report of sudden death caused by delayed closure of ETV. Guidelines to patients, parents and primary caregivers should include the possibility of ETV failure and encourage early neurosurgical consultation when symptoms of raised intracranial pressure occur.     

Successful aqueductal plasty and stenting for tectal plate tumor after failed third ventriculostomy: a case report

BACKGROUND: Tectal region tumors can lead to hydrocephalus secondary to aqueductal compression. Surgical options for these patients include extracranial cerebrospinal fluid (CSF) shunts, third ventriculostomy, and/or aqueductal plasty. In cases of third ventriculostomy failure, the accepted alternative is an extracranial CSF shunt. We report a patient in whom a repeat third ventriculostomy with aqueductal plasty and stenting was successful after a failed initial third ventriculostomy. CASE PRESENTATION: A 12-year-old patient with hydrocephalus secondary to a tectal tumor presented with headaches and blurry vision. She had no focal neurologic findings. She underwent a third ventriculostomy. Five months after the procedure she had recurrence of her symptoms. Therefore, she underwent a secondary third ventriculostomy with aqueductal plasty and stenting. She has been symptom-free for 1 year. CONCLUSION: Aqueductal plasty with stenting may be an alternative to CSF shunts in some patients with hydrocephalus because of aqueductal compression resulting from tectal tumors.     

Endoscopic third ventriculostomy in obstructive hydrocephalus due to giant basilar artery aneurysm

OBSTRUCTIVE: hydrocephalus due to giant basilar artery (BA) aneurysm is a rare finding, and endoscopic treatment has not been reported. Here the authors present their experience with endoscopic third ventriculostomy (ETV) in obstructive hydrocephalus due to giant BA aneurysm. Between December 2000 and March 2007, 3 patients (2 men and 1 woman; age range 32-80 years) underwent an ETV for the treatment of obstructive hydrocephalus caused by a giant BA aneurysm. All 3 patients presented with cephalgia, nausea, vomiting, and a variable decrease in consciousness. An obstructive hydrocephalus caused by a giant BA aneurysm was found in each case as the underlying pathological entity. Intraoperatively, a narrowing of the third ventricle by upward displacement of the tegmentum was found in all 3 patients. A standard ETV was performed and included an inspection of the prepontine cisterns. The endoscopic treatment was successful in all patients with respect to clinical signs and radiological ventricular enlargement. No complications were observed. In all, the endoscopic ventriculostomy was proven to be a successful treatment option in obstructive hydrocephalus even if it is caused by untreated giant BA aneurysm.     

Endoscopic treatment of hydrocephalus in children: a controlled study using newly developed Yamadori-type ventriculoscopes.

Although cerebrospinal fluid (CSF) shunting is the most common neurosurgical treatment for hydrocephalus, the long-term results have still been unsatisfactory because of a wide variety of shunt complications. We have recently developed flexible ventriculoscopes (Yamadori-type) which have excellent image quality, maneuverability, and capabilities for endoscopic operation. Here we report the efficacy of the new treatment in 88 children with hydrocephalus who initially underwent either ventriculoscopic operation or shunting surgery. The primary outcome measures were the rate of shunt independency and/or shunt complications with a follow-up of 2 years in each group. We performed endoscopic third ventriculostomy in cases of aqueductal stenosis, cyst fenestration, and choroid plexus coagulation in limited cases of communicating hydrocephalus. Overall, thirty-three (75%) of the 44 children initially treated endoscopically did not require ventriculoperitoneal (VP) shunts. The endoscopic procedures were repeated in the remaining 11 children (25%) mostly less than 1-year-old who ultimately required endoscope-guided VP shunting. Even in such patients, there was virtually no need for shunt revisions and no major complications such as slit-like ventricle, meningitis, and intraventricular hemorrhage. These results were statistically highly significant (p < 0.0001) compared to a control group of 44 patients treated initially by VP shunting. Our data demonstrate that therapeutic ventriculoscopy is safe and clinically effective as the first-line treatment of hydrocephalus in children.     

Intratumoral hemorrhage in choriocarcinoma during neuroendoscopic third ventriculostomy: case report

The authors report a case of intratumoral hemorrhage in a pineal region choriocarcinoma during neuroendoscopic third ventriculostomy. A 12-year-old boy who presented with headache and vomiting had precocious puberty. Neuroimagings revealed a pineal region tumor with obstructive hydrocephalus and his serum HCG level was 4,280 mIU/ml. He was diagnosed as having choriocarcinoma and underwent neuroendoscopic third ventriculostomy for obstructive hydrocephalus. There were many tumor vessels observed on the tumor surface, some of which bled subcapsularly. Postoperative CT scan showed the tumor increased in size with the intratumoral hemorrhage. After irradiation and chemotherapy, the tumor disappeared with normalization of serum HCG level. His symptoms improved and no additional neurological deficit was observed in his clinical course. We might infer from this case that the intratumoral hemorrhage was induced by the intracranial pressure change during neuroendoscopic surgery. Perioperative management is very important for avoiding fetal intratumoral hemorrhage.     

Endoscopic third ventriculostomy is the treatment of choice for obstructive hydrocephalus due to pediatric pineal tumors.

Pineal lesions in the pediatric patient are often complicated by the development of hydrocephalus due to obstruction of the aqueduct or the third ventricle by tumor masses. In such cases, hydrocephalus treatment has the highest priority and should be performed prior to any surgical treatment of the pineal tumor itself. The golden standard in obstructive hydrocephalus treatment remains placement of a temporary or permanent cerebrospinal fluid shunt, although there are many long-term complications associated with a shunt system. To avoid these and to render the patients independent from a failure-prone shunt system, we employed endoscopic third ventriculostomy for permanent relief of elevated intracranial pressure prior to surgical removal of the pineal lesions. The present study summarizes the results of this approach in 7 pediatric patients with obstructive hydrocephalus. No complications of the endoscopic procedure were encountered, and the ventriculostomy remained patent in all cases, as confirmed by motion sensitive MRI. The advantages of endoscopic third ventriculostomy as compared with other techniques are discussed, and its increasing role in the management of children with space occupying lesions of the pineal region is defined.     

Neuroendoscopic third ventriculostomy for failed shunts

BACKGROUND: Neuroendoscopic third ventriculostomy has increased in frequency for the management of hydrocephalus. The objective of this paper is to study the outcome in patients with hydrocephalus whose shunt subsequently failed and who were treated with neuroendoscopic third ventriculostomy (NTV). METHOD: The departmental prospectively acquired database, kept since 1994, was researched to identify those patients who underwent NTV, having presented with a failed shunt. Subsequent failure of the NTV occurs when further treatment for the hydrocephalus is required. RESULTS: There were 88 patients identified, 45(51%) male and 43(49%) female. Median age at time of NTV was 14 years (range 1 day to 69 years). Median time from last shunt to NTV was 8 years (1 week to 35 years). Follow-up was for a median of 3 years (1 month to 6 years) after their NTV. Overall 42 (48%) failed and 46 (52%) were successful. In those with noncommunicating causes the success rate was 73%. Median time to failure was 1 month (immediate to 5 years) Median age of failed patients at time of NTV was 7 years. Serious complications occurred in 5 (5.6%). CONCLUSION: NTV in patients having previously been shunted for their hydrocephalus is safe and as successful as in primary NTV. Failure can be expected to occur with greater frequency in communicating than noncommunicating types of hydrocephalus. The fact that they have a malfunctioning shunt in situ is not a contraindication to this procedure. In cases of infected shunts it is a useful adjunct to the treatment of the infection.     

Transoral migration of the inferior end of a ventriculoperitoneal shunt: A case report with literature review

Ventriculoperitoneal (VP) shunt surgery is the most widely used technique for the treatment of hydrocephalus. However, it can incur certain complications. Beside frequent complications (infection, obstruction), migration of the peritoneal catheter is a rare but dangerous complication. This report presents the case of a 4-year-old boy who had undergone VP shunt for hydrocephalus. One month later, the patient presented with protrusion of the peritoneal catheter through his mouth. He underwent another procedure to remove the peritoneal catheter, retaining the original ventricular catheter and valve chamber. Progression was favorable. To the best of our knowledge, only 7 cases of VP shunt transoral extrusion were reported, but many risk factors were identified. Bowel perforation is a serious complication of VP shunt surgery, sometimes leading to fatal outcome.     

Hématome extradural précoce après dérivation interne du liquide céphalorachidien pour hydrocéphalie non communicante

We present the first case of early epidural hematoma after CSF shunt probably caused by defective material. A 26-year-old man was treated for obstructive hydrocephalus associated with a tonsillar herniation, revealed by headaches and papillary edema. Ventriculoperitoneal shunt was preferred to endoscopic ventriculostomy. Three hours after the operation, the patient fell into a coma, developing a voluminous bifrontal epidural hematoma that was evacuated immediately. The patient completely recovered neurologically. One month later, to treat persistent hydrocephalus, endoscopic ventriculostomy was performed without incident. Then the shunt was removed and an opening threshold close to zero was discovered. Distant MRI showed a reduction in ventricular size, normalization of the tonsils’ position and a tumor of the tectal plate. To our knowledge, this is the only case of early epidural hematoma after ventriculoperitoneal shunt. We discuss the choice of treatments for obstructive hydrocephalus and its risks and complications.     

Death after late failure of endoscopic third ventriculostomy: a potential solution

OBJECTIVE: Late failure after successful third ventriculostomy is rare, and death caused by failure of a previously successful third ventriculostomy has been reported on four occasions. We describe a simple innovation that adds little morbidity and has the potential to reduce the advent of death after late failure of endoscopic third ventriculostomy. METHODS: After endoscopic fenestration of the floor of the third ventricle, a ventricular catheter and subcutaneous reservoir are placed via the endoscope path. With acute blockage and neurological deterioration, cerebrospinal fluid can be removed via needle puncture of the reservoir until consultation with a neurosurgeon. RESULTS: From 1979 to 2003, more than 240 endoscopic third ventriculostomies have been performed at our institution, with one death after late failure. The revised technique was devised after this death and has been performed on 21 patients to date. CONCLUSION: The addition of a reservoir adds little time and morbidity to the procedure and offers the potential to sample cerebrospinal fluid, measure intracranial pressure, and reduce mortality associated with late failure of endoscopic third ventriculostomy.     

Stereotactic third ventriculostomy in patients with nontumoral adolescent/adult onset aqueductal stenosis and symptomatic hydrocephalus

Sixteen consecutive patients with obstructive hydrocephalus due to nontumoral aqueductal stenosis of adolescent or adult onset underwent computerized tomography-guided stereotactic third ventriculostomy. Computer-assisted angiographic target-point cross-registration was used in surgical planning to reduce morbidity. The procedure was used as primary treatment in five previously unshunted patients and in 11 patients who had previously received shunts and who presented when their shunts became obstructed (five patients), became infected (five patients), or required multiple revisions (one patient). At the time of third ventriculostomy, shunt hardware was removed in patients with infected shunts and the distal element of the shunt was ligated in all patients with obstructed shunts except one, who later required repeat third ventriculostomy; the distal shunt was ligated at that time. Follow-up data (range 1 to 5 years, mean 3 1/2 years, after surgery) showed that only one of the 16 patients had undergone a shunting procedure after the third ventriculostomy. The other 15 patients are asymptomatic and shunt-independent. In previously shunt-dependent patients, the peripheral subarachnoid space and cerebrospinal fluid absorption mechanism remained patent in spite of shunts placed earlier. Therefore, in patients with obstructive hydrocephalus due to aqueductal stenosis of adolescent or adult onset, stereotactic third ventriculostomy should be seriously considered as primary surgical management in previously unshunted patients and in shunt-dependent patients with obstructed or infected shunts.     

Endoscopic third ventriculostomy in patients with cerebrospinal fluid infection and/or hemorrhage

OBJECT: In this study the authors evaluate the safety, efficacy, and indications for endoscopic third ventriculostomy (ETV) in patients with a history of subarachnoid hemorrhage or intraventricular hemorrhage (IVH) and/or cerebrospinal fluid (CSF) infection. METHODS: The charts of 101 patients from seven international medical centers were retrospectively reviewed; 46 patients had a history of hemorrhage, 42 had a history of CSF infection, and 13 had a history of both disorders. All patients experienced third ventricular hydrocephalus before endoscopy. The success rate for treatment in these three groups was 60.9, 64.3, and 23.1%, respectively. The follow-up period in successfully treated patients ranged from 0.6 to 10 years. Relatively minor complications were observed in 15 patients (14.9%), and there were no deaths. A higher rate of treatment failure was associated with three factors: classification in the combined infection/hemorrhage group, premature birth in the posthemorrhage group, and younger age in the postinfection group. A higher success rate was associated with a history of ventriculoperitoneal (VP) shunt placement before ETV in the posthemorrhage group, even among those who had been born prematurely, who were otherwise more prone to treatment failure. The 13 premature infants who had suffered an IVH and who had undergone VP shunt placement before ETV had a 100% success rate. The procedure was also successful in nine of 10 patients with primary aqueductal stenosis. CONCLUSIONS: Patients with obstructive hydrocephalus and a history of either hemorrhage or infection may be good candidates for ETV, with safety and success rates comparable with those in more general series of patients. Patients who have sustained both hemorrhage and infection are poor candidates for ETV, except in selected cases and as a treatment of last resort. In patients who have previously undergone shunt placement posthemorrhage, ETV is highly successful. It is also highly successful in patients with primary aqueductal stenosis, even in those with a history of hemorrhage or CSF infection.     

Neuroendoscopy: one year of experience--personal results, observations and limits.

After reading reports of successful neuroendoscopic treatment of hydrocephalus, colloid cysts and arachnoid cysts as well as tumor biopsy, we started using endoscopic procedures in our Department, one year ago. One surgeon (E.S.) skilled in the Decq Endoscope, performed a series of sixteen procedures, from January 2001 to March 2002 (in patients aged 28 to 69 years). The most common pathology was obstructive hydrocephalus (14 cases), one was colloid cyst, and the last case was tumor biopsy. The surgical treatment consisted of third ventriculostomy, cyst opening and shrinking and tumor biopsy. In fourteen patients treated for hydrocephalus with third ventriculostomy (ETV), one required a definitive shunt. Complication occurred in one case with chronic subdural collection. We further report one case of aqueductal restoration after third ventriculostomy. Our results, with no neurological deficits or deaths, confirmed our opinion that neuroendoscopy is a safe surgical technique in well-selected patients and we believe it is the ideal treatment in obstructive hydrocephalus.     

Rational management of transient obstructive hydrocephalus secondary to a cerebellar infarct.

INTRODUCTION: Cerebrovascular disease is a common occurrence in adults with immediate as well as long-term neurological effects. Sequelae are disabling for patients and lead to a greater demand for healthcare infrastructure and search for treatment options. The acute phase in a cerebellar infarction may become complicated with transient obstructive hydrocephalus, subsequent intracranial hypertension, and the need for surgical management. Although many patients respond well to medical treatment, clinical findings and neuroimaging methods must be considered to determine whether the hydrocephalus can be surgically treated in a timely fashion. A series of cases is presented and a proposal is made for adding endoscopic third ventriculostomy to the available treatment armamentarium. CLINICAL CASES: Fourteen patients with cerebellar strokes and their clinical course are reported. Six required surgery for hydrocephalus management. Three of the cases had an endoscopic third ventriculostomy without complications, the rest were managed conservatively. As an average, patency was re-established in the aqueduct three months post ictus. CONCLUSIONS: Management of obstructive hydrocephalus in the acute phase of a cerebellar stroke must be individualized. In cases with transient obstructive hydrocephalus, endoscopic third ventriculostomy is a good surgical treatment option that avoids the risks of a long-term ventricular shunt.     

Limitations of Neuroendoscopic Treatment for Pediatric Hydrocephalus and Considerations from Future Perspectives

Neuroendoscopy has become common in the field of pediatric neurosurgery. As an alternative procedure to cerebrospinal fluid shunt, endoscopic third ventriculostomy has been the routine surgical treatment for obstructive hydrocephalus. However, the indication is still debatable in infantile periods. The predictors of late failure and how to manage are still unknown. Recently, the remarkable results of endoscopic choroid plexus coagulation in combination with third ventriculostomy, reported from experiences in Africa, present puzzling complexity. The current data on the role of neuroendoscopic surgery for pediatric hydrocephalus is reported with discussion of its limitations and future perspectives, in this review.     

Re-ventriculostomy for treatment of obstructive hydrocephalus in cases of stoma dysfunction.

In this article, 12 re-ventriculostomies in the treatment for obstructive hydrocephalus are described. The etiology of the hydrocephalus was a benign aqueductal stenosis in 9 patients, a tumor around the aqueduct in 2 patients and intraventricular bleeding in one patient. In all cases the initial ventriculostomy was successful, but after a time interval of 2 weeks to 6 years the patients developed similar clinical symptoms as preoperatively. In all except one case the radiological findings spoke in favour of stoma closure. Intraoperatively the stoma was completely closed in 9 patients and in 3 patients a subtotal closure was observed. In all cases a re-ventriculostomy was performed bluntly with a Fogarty catheter in loco typico at the floor of the third ventricle. Of the 12 patients 6 had an excellent outcome postoperatively, one patient improved and one had a benefit from the re-ventriculostomy although he died of cardiac problems. In the remaining 4 patients the re-ventriculostomy was not successful and the patients needed a shunt operation. In conclusion, after initially successful endoscopic third ventriculostomy, re-ventriculostomy should be considered as a sufficient treatment option in case of suspected stoma dysfunction.     

Chronic subdural hematoma as a complication of endoscopic third ventriculostomy

BACKGROUND: Endoscopic third ventriculostomy has become a popular alternative to ventricular shunts for noncommunicating hydrocephalus. Although endoscopic third ventriculostomy is a safe procedure, several complications related to this procedure have been reported in the literature. The authors present a rare case of symptomatic bilateral subdural hematomas after an uneventful endoscopic third ventriculostomy. CASE DESCRIPTION: A 51-year-old male patient presented with symptoms of obstructive hydrocephalus, headaches and memory disturbance. Magnetic resonance imaging demonstrated hydrocephalus secondary to aqueductal stenosis. An endoscopic third ventriculostomy was performed. The patient was discharged home in several days without complication. He then presented with headaches 3 weeks following surgery. A computed tomography study demonstrated bilateral subdural hematomas. These were treated with burr hole evacuation and drainage. Postoperatively, his headaches improved. At last follow-up he remains symptom-free and has radiographic evidence of a patent ventriculostomy. CONCLUSION: This case confirms chronic subdural hematoma formation is a possible complication following third ventriculostomy. Patients should be followed closely for possible subdural hematoma formation.     

Management of hydrocephalus in pediatric patients with posterior fossa tumors: the role of endoscopic third ventriculostomy.

OBJECT: The authors undertook a study to evaluate the effectiveness of endoscopic third ventriculostomy in the management of hydrocephalus before and after surgical intervention for posterior fossa tumors in children. METHODS: Between October 1, 1993, and December 31, 1997, a total of 206 consecutive children with posterior fossa tumors underwent surgery at H?pital Necker-Enfants Malades in Paris. Excluded were 10 patients in whom shunts had been placed at the referring hospital. The medical records and neuroimaging studies of the remaining 196 patients were reviewed and categorized into three groups: Group A, 67 patients with hydrocephalus present on admission in whom endoscopic third ventriculostomy was performed prior to tumor removal; Group B, 82 patients with hydrocephalus who did not undergo preliminary third ventriculostomy but instead received conventional treatment; and Group C, 47 patients in whom no ventricular dilation was present on admission. There were no significant differences between patients in Group A or B with respect to the following variables: age at presentation, evidence of metastatic disease, extent of tumor resection, or follow-up duration. In patients in Group A, however, more severe hydrocephalus was demonstrated (p < 0.01): the patients in Group C were in this respect different from those in the other two groups. Ultimately, there were only four patients (6%) in Group A compared with 22 patients (26.8%) in Group B (p = 0.001) in whom progressive hydrocephalus required treatment following removal of the posterior fossa tumor. Sixteen patients (20%) in Group B underwent insertion of a ventriculoperitoneal shunt, which is similar to the incidence reported in the literature and significantly different from that demonstrated in Group A (p < 0.016). The other six patients (7.3%) were treated by endoscopic third ventriculostomy after tumor resection. In Group C, two patients (4.3%) with postoperative hydrocephalus underwent endoscopic third ventriculostomy. In three patients who required placement of CSF shunts several episodes of shunt malfunction occurred that were ultimately managed by endoscopic third ventriculostomy and definitive removal of the shunt. There were no deaths; however, there were four cases of transient morbidity associated with third ventriculostomy. CONCLUSIONS: Third ventriculostomy is feasible even in the presence of posterior fossa tumors (including brainstem tumors). When performed prior to posterior fossa surgery, it significantly reduces the incidence of postoperative hydrocephalus. The procedure provides a valid alternative to placement of a permanent shunt in cases in which hydrocephalus develops following posterior fossa surgery, and it may negate the need for the shunt in cases in which the shunt malfunctions. Furthermore, in patients in whom CSF has caused spread of the tumor at presentation, third ventriculostomy allows chemotherapy to be undertaken prior to tumor excision by controlling hydrocephalus. Although the authors acknowledge that the routine application of third ventriculostomy in selected patients results in a proportion of patients undergoing an "unnecessary" procedure, they believe that because patients' postoperative courses are less complicated and because the incidence of morbidity is low and the success rate is high in those patients with severe hydrocephalus that further investigation of this protocol is warranted.     

Obstetrical anesthesia for a parturient with a ventriculoperitoneal shunt and third ventriculostomy

PURPOSE: To describe the anesthetic considerations for a primiparous woman whose history included four neurosurgeries: ventriculoperitoneal (VP) shunt insertion, evacuation of a subdural hematoma, shunt revision, and third ventriculostomy for hydrocephalus secondary to aqueductal stenosis. CLINICAL FEATURES: A 37-yr-old GI, P0 woman with a VP shunt and third ventriculostomy was assessed in the Obstetrical Anesthesia Clinic at 36 wk. gestation to consider analgesic options for labour and delivery and review anesthetic management in the event that an operative delivery was required. A third ventriculostomy had been performed when increased intracranial pressure and neurological symptoms reappeared despite the previous VP shunt. Pregnancy was uneventful and vaginal delivery was anticipated. She presented in spontaneous labour at 40 wk. gestation. She declined analgesia throughout her four and a half hour labour A mediolateral episiotomy was performed to facilitate spontaneous delivery of a 4,182 g female infant. Mother and baby were discharged home without incident after two days. She denied any problems, including headaches, on follow up at two and four weeks. CONCLUSION: A review of the literature concerning pregnant patients with shunts found that both regional and general anesthesia has been used with no reports of complications directly related to anesthesia. No published cases describing labour analgesia for patients with third ventriculostomy were found. Two neurosurgeons advised that regional anesthesia was not contraindicated in such patients and that analgesia should be based on obstetrical considerations and the neurological status of the patient.     

Endoscopic removal of a third ventricular cysticercal cyst

We report the case of a young man who presented with acute obstructive hydrocephalus previously treated with bilateral ventriculo-peritoneal shunts. Previous magnetic resonance imaging studies were consistent with aqueduct stenosis; no intraventricular pathology was identified. Neuroendoscopy was performed in order the third ventricle and perform a third ventriculostomy. This revealed a cysticercal lesion of the third ventricle which was removed endoscopically. In addition, a third ventriculostomy was performed and both shunt systems removed. Following a course of albendazole the patient went on to make a full recovery, and currently remains shunt independent.