Establishing successful cerebrospinal fluid flow for radioimmunotherapy

Successful delivery of intraventricular radioimmunotherapy is contingent on adequate CSF flow. The authors present a patient with medulloblastoma in whom obstructed CSF flow was causing hydrocephalus, which was initially corrected by implantation of a programmable shunting device. While managing the hydrocephalus, an endoscopic third ventriculostomy (ETV) needed to be performed in a collapsed ventricular system to ensure adequate radioimmunotherapy distribution. This 18-month-old patient with medulloblastoma involving leptomeningeal dissemination presented for intraventricular radioimmunotherapy. A CSF (111)In-DTPA scintigraphy study obtained through the existing programmable ventriculoperitoneal shunt demonstrated activity in the lateral and third ventricles, but no activity over the cerebral convexities or spinal canal, consistent with obstruction at the level of the cerebral aqueduct. By maximization of ventricular size in a controlled setting, the patient was able to undergo a trial of ETV through very small ventricles. A postoperative CINE MR imaging study confirmed patent ETV. The pressure settings on the shunt were kept at the highest opening pressure (200 mm H(2)O) to maximize flow through the stoma and improve the distribution of CSF throughout the subarachnoid space. The CSF flow scintigraphy study was again performed, this time with tracer activity demonstrated down the thecal sac at 3 hours, and symmetrically over the cerebral convexities at 24 hours. The patient began weekly intraventricular administration of (131)I-3F8 therapy. Successful rerouting of CSF flow for the purpose of therapeutic radioisotope administration is possible. Endoscopic third ventriculostomy can be considered in patients with programmable shunting devices; normal or slit ventricles do not preclude successful ETV.     

Endoscopic third ventriculostomy in prepontine-suprasellar tuberculoma with tuberculous meningitis hydrocephalus: a case report

We present a case of prepontine-suprasellar tuberculoma involving the premamillary region of the third ventricular floor, a site suitable to perform an endoscopic third ventriculostomy (ETV) stoma, managed endoscopically, and discuss our findings. A 5-year-old male child was admitted in an unconscious state with a history of gradually progressive symptoms of raised intracranial pressure and low-grade fever for the last 3 months. Head computed tomography showed thick enhancing basal exudates, a prepontine-suprasellar ring-enhancing lesion with consequent obstructive hydrocephalus. The child was subjected to urgent endoscopy which revealed multiple ependymal tubercles along with prepontine-suprasellar tuberculoma involving the premamillary region of the third ventricular floor. The tuberculoma was decompressed using a 5-french catheter, and ETV was performed. Postoperatively, the child improved clinicoradiologically on antitubercular chemotherapy and needed no further cerebrospinal fluid diversion surgery; he is under regular follow-up. We conclude that ETV may be attempted even in the presence of thick basal exudates and/or prepontine-suprasellar tuberculoma.     

Endoscopic third ventriculostomy for hydrocephalus secondary to central nervous system infection or intraventricular hemorrhage in children

OBJECTIVE: We review our experience of endoscopic third ventriculocisternostomy (ETV) in children with hydrocephalus from central nervous system (CNS) infection or intraventricular hemorrhage to better elucidate success rates and predictors of success in these children. METHODS: We performed a retrospective review of 12 children less than 21 years of age with ETV treated from 1999 to 2002 with a minimum follow-up of 12 months. Children selected for surgery had been diagnosed with hydrocephalus from perinatal germinal matrix hemorrhage or CNS infection and had neuroimaging consistent with obstruction of the aqueduct, fourth ventricular outlets or both at the time of ETV. Charts and imaging studies were reviewed to determine clinical outcomes and predictors of successful ETV. An ETV was deemed successful if the child did not require placement or replacement of a ventriculoperitoneal shunt. RESULTS: Thirteen ETV were performed in 12 patients (7 boys and 5 girls; mean age 9.2 years, range 3.8-21 years), with an overall success rate of 60% for those with CNS infections and 71% for those with perinatal intraventricular hemorrhage at initial presentation. There were no significant complications from the procedure. CONCLUSIONS: ETV is a safe procedure, which in carefully selected children with etiologies of hydrocephalus thought to be 'communicating' in nature carries a satisfyingly high success rate. Further application and study of this modality in larger groups of patients with these causes of hydrocephalus is warranted.     

Giant syringobulbia associated with cerebellopontine angle arachnoid cyst and hydrocephalus

The aim in reporting this case was to discuss the pathophysiology and treatment issues in an infant with a giant syringobulbia associated with a right cerebellopontine angle (CPA) arachnoid cyst causing noncommunicating hydrocephalus. This 7-month-old infant presented to the hospital with a history of delayed milestones and an abnormal increase in head circumference. Magnetic resonance images and CT scans of the brain showed a large CSF cavity involving the entire brainstem and a right CPA arachnoid cyst causing obstruction of the fourth ventricle and dilation of the lateral and third ventricles. Cerebrospinal fluid diversion was performed by direct communication from the syringobulbia cavity to the left lateral ventricle and from the left lateral ventricle through another ventricular catheter; external ventricular drainage was performed temporarily for 5 days. Communication between the syrinx and arachnoid cyst was confirmed. Clinically, there was a reduction in head circumference, and serial MR imaging of the brain showed a decrease in the size of the syrinx cavity and the ventricle along with opening of the normal CSF pathways. The postoperative course was uneventful, and no further intervention was necessary. On follow-up of the child at 3 years, his developmental milestones were normal. Surgical intervention for this condition is mandatory. The appropriate type of surgery should be performed on the basis of the pathophysiology of the developing syringobulbia.     

Acute obstructive hydrocephalus due to a large posterior third ventricle choroid plexus cyst

We present the case of a child in whom acute hydrocephalus developed secondary to obstruction of the foramen of Monro by a choroid plexus cyst. The patient was seen in the emergency department with fevers, acute onset of headaches, and lethargy. Computed tomography demonstrated dilated lateral and third ventricles with a relatively normal-sized fourth ventricle. An external ventricular drain was placed. Despite decompression of the lateral ventricles, follow-up magnetic resonance imaging demonstrated a dilated third ventricle with a possible thin-walled mass extending from the foramen of Monro into the posterior portion of the third ventricle. The patient subsequently underwent endoscopic fenestration of the cyst with endoscopic third ventriculostomy. Although two other cases of symptomatic choroid plexus cysts of the third ventricle have been previously reported in children, our paper highlights the possibility of endoscopic cyst fenestration together with a third ventriculostomy as a treatment option in cases where the cyst extends into the posterior third ventricle. Despite adequate decompression, we were concerned that due to CSF pulsations the remnant cyst wall could result in acute aqueduct obstruction and subsequent hydrocephalus.     

Chronologic changes of cerebral ventricular size in a transgenic model of hydrocephalus

We have maintained a transgenic mouse model of hydrocephalus created to overproduce the cytokine, transforming growth factor-beta1 (TGF-beta1) in the central nervous system (CNS). The aim of the present study was to estimate the embryonic period when the transgenic mice would develop hydrocephalus, by investigating the chronological developmental changes of the cerebral ventricles. Qualitative analysis of ventricular size was performed on sections cut in the coronal plane of embryos at the 15th (E15) and 18th (E18) embryonic days, and postnatal mice aged 4 days (P4). The presence of the TGF-beta1 transgene was determined by performing polymerase chain reaction (PCR) analysis. We have examined 24 embryos and 14 postnatal mice. By performing PCR analysis, the TGF-beta1 transgene was determined to be present in 16 (42.1%). Five of 16 embryos at E15 carried the transgene, and showed a slight enlargement of the lateral ventricles. Three of 8 embryos at E18 carried the transgene, and had remarkable enlargement of the lateral ventricles. Eight of 14 pups at P4 carried the transgene, and 7 of 8 pups with the transgene developed hydrocephalus. In pups that were positive for the transgene, massive enlargement of the lateral ventricles was observed and there was an associated thinning of the overlying cerebral cortex. These results suggest that congenital hydrocephalus may develop at an important embryonic time period, which coincides with the stage of neural stem cell proliferation and differentiation in the CNS.     

Specific enlargement of the fourth ventricle after ventriculo-peritoneal shunt for post-haemorrhagic hydrocephalus.

Disproportionate enlargement or isolation of the fourth ventricle are rare complications of ventriculo-peritoneal shunt for post-haemorrhagic hydrocephalus. Obvious features such as ataxia may indicate raised intracranial pressure in the posterior fossa. The child may, however, present with less specific signs of vomiting, anorexia, and lethargy and these symptoms may be misinterpreted as secondary to dilation of the lateral ventricular system due to malfunction of the ventriculo-peritoneal shunt. Two children with disproportionate enlargement of the fourth ventricle and two children with isolation of the fourth ventricle are described to illustrate the wide variations in clinical presentation. These rare complications can be diagnosed by real time ultrasound examination of the brain or computed tomography of the head. They should be considered in the differential diagnosis of a child who deteriorates after lateral ventriculo-peritoneal shunting for post-haemorrhagic hydrocephalus, and dealt with specifically to avoid the risk of upward herniation of the enlarged fourth ventricle.     

Failure to treat obstructive hydrocephalus with endoscopic third ventriculostomy in a patient with neurodegenerative Langerhans cell histiocytosis

The second most frequent central nervous system involvement pattern in Langerhans cell histiocytosis (LCH) is a rare condition documented in a number of reports called "neurodegenerative LCH" (ND-LCH). Magnetic resonance images confirming the presence of the disease usually demonstrate striking symmetric bilateral hyperintensities predominantly in the cerebellum, basal ganglia, pons, and/or cerebral white matter. The authors here describe for the first time in the literature a patient with ND-LCH and concomitant hydrocephalus initially treated using endoscopic third ventriculostomy (ETV). This 9-year-old boy, who had undergone chemotherapy for skin and lung LCH without central nervous system involvement at the age of 10 months, presented with acute ataxia, headaches, and paraparesis and a 1-year history of gradually increasing clumsiness. Magnetic resonance images showed obstructive hydrocephalus at the level of the aqueduct of Sylvius and signs of ND-LCH. After registering high intracranial pressure (ICP) spikes with an intraparenchymal pressure monitor, an ETV was performed. A second ETV was required months later because of ostomy occlusion, and finally a ventriculoperitoneal shunt was placed because of ostomy reocclusion. Endoscopic third ventriculostomy was initially considered the treatment of choice to divert cerebrospinal fluid without leaving a ventriculoperitoneal shunt and to obtain biopsy specimens from the periinfundibular recess area. The third ventriculostomy occluded twice, and an endoscopic aqueduct fenestration was unsuccessful. The authors hypothesized that an inflammatory process related to late ND disease was responsible for the occlusions. Biopsy specimens from the infundibular recess and fornix column did not show histopathogical abnormalities. Increased ICP symptoms resolved with cerebrospinal fluid diversion. This case is the first instance of ND-LCH with hydrocephalus reported in the literature to date. Shunt placement rather than ETV seems to be the favorable choice in relieving elevated ICP.     

The impact of endoscopic third ventriculostomy on the management of newly diagnosed hydrocephalus in infants

OBJECTIVES: To evaluate the role of endoscopic third ventriculostomy (ETV) as a primary treatment for hydrocephalus in children less than 1 year old and to determine its impact as a whole on the reduction of shunts necessary in a new population of hydrocephalic infants. METHODS: Data were collected prospectively on 47 infants with newly diagnosed hydrocephalus of all aetiologies who were referred between 1st April 1998 and 30th September 2000. Twenty-one patients (median age 6 weeks, range 34 weeks of gestation to 10 months) underwent ETV, while the remaining 26 patients had insertion of a ventriculoperitoneal shunt. Anatomical criteria and demonstration of third ventricle outflow obstruction on preoperative magnetic resonance imaging were used to select patients for ETV. RESULTS: There was no mortality or major morbidity following ETV. The median follow-up period was 18 (range 8-36) months. During the follow-up period, the ETV remained patent in 7 (33%) of the 21 patients. Of the 14 patients with failed ETV, 11 had insertion of a ventriculoperitoneal shunt, while 3 have undergone successful redo ETV. Therefore, in total 10 patients (48%) of the ETV group remain shunt independent. The best results were obtained in patients with congenital aqueduct stenosis with 71% (5 of 7 patients) success rate, while patients with posthaemorrhagic hydrocephalus did particularly badly with only 1 of 10 patients having a successful ETV. Overall, 10 of 47 (21%) infants with newly diagnosed hydrocephalus have avoided a shunt. CONCLUSIONS: Our results suggest that the selective use of ETV as the primary treatment in infants with hydrocephalus is safe and can lead to a reduction in the shunted population of all newly diagnosed hydrocephalic infants by up to 21%. Success of ETV is aetiology, not age dependent.     

Difference between left and right lateral ventricular sizes in neonates

The objective of this study is to determine the causes of asymmetry of the lateral ventricles in neonates. We also studied the effect of head position and the relationship of body weight at birth in regard to lateral ventricular size. Eligible for inclusion in this study were 60 neonatal infants whose gestational age was 33.1+/-3.5 weeks and whose birth weight was 1793+/-613 g. Ultrasonographic examinations were performed at the first and the second weeks after birth. In parasagittal and coronal scans through the posterior horn of the lateral ventricle, the lateral ventricle was traced and its area was measured. We found no significant variation of ventricular size in relation to body weight at birth. The left ventricular size was larger than the right one. The difference of the left and right ventricular sizes was partially effected by head position. The ratio of left to right lateral ventricular sizes showed a very wide distribution. We considered that ventricular asymmetry is not pathological, but due to individual differences.     

Acute and subacute hydrocephalus in a rat neonatal model: correlation with functional injury of neurotransmitter systems

OBJECT: The evolution and severity of hydrocephalus in animal models varies in the species and mode of induction. This makes comparisons of the physiological system under investigation difficult between models. We noted that injection of kaolin into neonatal rats results in a dichotomous outcome into either an acute or subacute form. We investigated the clinical and functional transmitter system changes to compare these two types of hydrocephalus evolution. METHODS: Hydrocephalus was induced in Wistar neonatal rats (within a week after their birth) by intracisternal injection of 0.02 ml volume of 25% kaolin solution under microscopic guidance. The same volume of sterile saline was injected into 12 neonatal rats as control group. The animals were assigned to either the acute or subacute group according to their head size, and sacrificed at 2, 4 and 8 weeks after injection. Biparietal diameter, ventricular size, cholinergic interneurons in the neostriatum and dopaminergic projection neurons in the substantia nigra were analyzed at each stage. RESULTS: Animals affected with the acute type of hydrocephalus had obvious head enlargement, rapid ventricular enlargement, and all died at about 4 weeks. Animals with subacute type had slowly progressive ventricular enlargement, and all survived until 8 weeks. There appeared to be more kaolin ventral to the brainstem in the acute type. The number of cholinergic neostriatal neurons was significantly reduced at 2 and 4 weeks in the acute type, but only at 8 weeks in the subacute type. The number of dopaminergic nigral neurons was decreased at 4 weeks in the acute type, but unaffected in the subacute type. CONCLUSIONS: The severity of onset of hydrocephalus in this animal model also correlates with the clinical outcome and changes in functional transmitter systems.     

婴幼儿阻塞性脑积水两种手术方式的疗效比较

目的 回顾性分析2005年以来上海交通大学医学院附属新华医院收治的2岁以下阻塞性脑积水患儿的临床资料,比较神经内镜下第三脑室底造瘘术（ETV）与传统的脑室腹腔分流术（VP shunt）治疗婴儿阻塞性脑积水的疗效.方法 2005年以来作者收治36例阻塞性脑积水患儿,均为单纯导水管狭窄,根据手术方式分为ETV治疗组和VP shunt治疗组,比较两组围手术期情况、影像学检查结果以及临床症状,并进行统计学分析.结果 36例中,ETV治疗组20例;VP shunt治疗组16例.均手术顺利,无术中并发症.ETV组有2例术后当天出现癫痫,考虑为间脑发作,经药物治疗后未再复发;1例出现脑室内出血,1例出现硬膜下出血,均予药物治疗后吸收;1例术后第10天出现伤口渗液、脑脊液漏,改行VP shunt治疗后痊愈;ETV组成功率95%,再手术率5%,近期并发症发生率25%,无远期并发症.VP shunt组16例中,1例术后第10天出现头端伤口感染,予抗感染治疗后好转,2个月后出现颅内感染,行拔管术,抗感染治疗好转后重新置管;1例术后5个月后复发脑积水,行ETV后好转;1例转流功能障碍,行再次VP shunt后好转;1例分流管头端脱出,行再次VP shunt后好转,手术总成功率75%,再手术率25%,近期并发症发生率6.25%,远期并发症发生率18.75%.结论 2岁以下婴幼儿阻塞性脑积水ETV与分流治疗对比,ETV近期并发症的发生率高于VP shunt,长期随访未出现新的神经功能障碍,远期并发症明显少于VP shunt,具有推广价值.     

精神分裂症患儿颅脑结构异常与认知功能的关系

目的调查精神分裂症患儿颅脑结构异常和认知功能的关系。方法选择55例首发精神分裂症患儿和39名健康儿童为研究对象,利用MRI进行颅脑结构测量,用《中国修订韦氏儿童智力量表手册》(C-WISC)评估其认知功能。结果 1.精神分裂症患儿第三脑室横径、侧脑室前脚间距、左右颞角宽度、左右外侧裂脑沟根部宽、额叶和顶叶脑沟宽均高于健康对照组(Pa<0.05),胼胝体厚低于健康对照组(P<0.05);2.精神分裂症患儿第三脑室横径与常识、领悟、算术、数字广度、言语总分、言语智商(VIQ)、全量表分及全量表智商(FIQ)均呈负相关(Pa<0.05),第三脑室侧壁至左右脑岛面距、侧脑室前脚间距、侧脑室体最大距与常识均呈负相关(Pa<0.05),左右颞角宽度与常识、算术、言语总分、VIQ、全量表分及FIQ均呈负相关(Pa<0.05),左右外侧裂脑沟根部宽与常识、算术、数字广度、言语总分、VIQ、全量表分及FIQ均呈负相关(Pa<0.05),额叶脑沟宽与算术、言语总分及VIQ均呈负相关(Pa<0.05),顶叶脑沟宽与常识、算术、言语总分及VIQ均呈负相关(Pa<0.05),胼胝体厚与常识呈正相关(P<0.05)。结论精神分裂症患儿存在显著的脑室扩大和脑结构异常,脑室扩大和脑结构异常与认知损害存在相关关系,脑室扩大和脑结构异常越明显,认知损害越严重。     

Reference ranges for the linear dimensions of the intracranial ventricles in preterm neonates

AIMS: To establish normal ranges, in preterm infants < 33 weeks' gestation, for measurements of the lateral, third, and fourth ventricles and to assess intra-observer and inter-observer reliability. To assess the effect of head position during scanning on lateral ventricle size. To determine whether sex influences ventricle size. METHODS: A prospective study involving infants < 33 weeks' gestational age (GA) at birth. Cranial ultrasound scans were done during the first 3 days of life. Linear dimensions of the anterior horn width and thalamo-occipital distance of the lateral ventricles, the width of the third ventricle, and the width and length of the fourth ventricle were measured. Measurements were plotted against GA and reference ranges produced. All measurements were tested for intra-observer and inter-observer reliability. Head position and sex differences were studied. RESULTS: 120 infants with known GA (23(+1) to 32(+6) weeks) had their intracranial ventricles measured. Reference ranges obtained were-anterior horn width: 0-2.9 mm; thalamo-occipital distance: 8.7-24.7 mm; third ventricle width: 0-2.6 mm; fourth ventricle width: 3.3-7.4 mm; fourth ventricle length: 2.6-6.9 mm. Dependent and non-dependent lateral ventricles did not differ significantly in size. There was no clinically significant difference in ventricular size between sexes. CONCLUSIONS: Reference ranges for the measurement of the intracranial ventricles in preterm infants from 23 to 33 weeks' GA are provided and can be used in the diagnosis and assessment of ventricular enlargement in preterm infants. All measurements have good intra-observer and inter-observer reliability. Head position at the time of scanning does not influence the asymmetry of the lateral ventricular measurements. The infant's sex does not influence ventricular size.     

Longitudinal comparison of diffusion tensor imaging parameters and neuropsychological measures following endoscopic third ventriculostomy for hydrocephalus

The authors report the case of a 25-month-old boy who underwent endoscopic third ventriculostomy (ETV) for hydrocephalus resulting from aqueductal stenosis. The patient's recovery was monitored longitudinally and prospectively using MR diffusion tensor imaging (DTI) and formal neuropsychological testing. Despite minimal change in ventricle size, improvement in the DTI characteristics and neurodevelopmental trajectory was observed following ETV. These data support the use of DTI as a biomarker to assess therapeutic response in children undergoing surgical treatment for hydrocephalus. In the patient featured in this report, DTI appeared to provide more information regarding postoperative neurodevelopmental outcome than ventricle size alone.     

Failed endoscopic third ventriculostomy in children: management options

Endoscopic third ventriculostomy (ETV) for obstructive hydrocephalus has a failure rate of 20-50% in various series. The present study analyzes ETV failures in 72 patients over a 2-year period and attempts to outline a management plan. Of the 72 patients who underwent ETV, it failed in 13. Seven of these failures occurred within 1 month, and in 5 others, ETV failed after 1-2 months. Another patient had a delayed failure 2 years after the initial surgery. Upon clinical failure, MRI scans were performed in all patients using either T2 fast spin echo or two-dimensional phase contrast MRI techniques. Of these, no flow could be demonstrated in 12 patients, whereas in 1 patient, good flow was observed. Endoscopic exploration was undertaken in the 12 patients in whom flow could not be demonstrated. Of the 12 who underwent endoscopic exploration, a patent stoma was observed in 7, necessitating insertion of a ventriculoperitoneal shunt (VPS). In the other 5, the stoma had closed by gliosis and a repeat ETV was performed. In 3 of these patients, in addition to the ETV, a VPS was also inserted in accordance with the family's wishes. VPS insertion was carried out in the patient with suggestion of good flow through the stoma. In failed ETV, MRI with flow studies is essential to identify the possible cause of failure. Endoscopic exploration is indicated for patients with no evidence of flow. A repeat ETV is indicated in patients with a closed stoma. Patients with a patent stoma could require insertion of a cerebrospinal fluid shunt.     

Third ventricular ependymal cyst presenting with acute hydrocephalus

Ependymal cysts are generally located in the cerebral parenchyma but rarely found in the third ventricle. A 4-year-old boy presented with headache, vomiting, and upward gaze palsy. His consciousness gradually deteriorated in the course of 6 h. A magnetic resonance imaging study disclosed dilation of the lateral ventricle and a cystic mass in the third ventricle. We performed an endoscopic resection of the cyst wall. The cyst originated on the lateral wall of the third ventricle and obstructed the aqueduct. Histological examination confirmed a diagnosis of ependymal cyst. The patient recovered quickly and his headache and nausea disappeared. Third ventricular ependymal cysts are a rare cause of acute hydrocephalus but an important differential diagnosis. Their neuroendoscopic resection can resolve disturbances in cerebrospinal fluid circulation, is useful for cyst wall removal, and appears to be superior to shunt placement.     

Intracranial metastasis of Wilms' tumor involving the tectal plate without pulmonary involvement. Case report.

Intracranial metastasis without pulmonary involvement of Wilms' tumor is very rare, and most previously reported metastatic sites have been in the cerebral parenchyma. We experienced a rare case of metastasis of Wilms' tumor in the tectal plate without pulmonary involvement. A 3-month-old boy was admitted to our hospital due to hydrocephalus. After insertion of a ventriculoperitoneal shunt, there were no neurological deficits. Five months after the operation, a mass 5 cm in diameter extending from the tectal plate into the third ventricle was found. A mass 10 cm in diameter within the retroperitoneal space, which occupied the right kidney, was also found. Both tumors were resected and diagnosed histologically as Wilms' tumor. Despite every effort including chemotherapy and radiotherapy, the patient died at 14 months old. The majority of children with hydrocephalus showing thickening of the tectal plate would most likely have tectal glioma; however, this unusual case report reminds us that metastasis of Wilms' tumor can occur in the tectal plate causing hydrocephalus.     

The application of controlled intracranial hypertension in slit ventricle syndrome patients with obstructive hydrocephalus and shunt malfunction.

When a shunted patient with slit-ventricle syndrome (SVS) presents with a shunt malfunction or infection, the third ventricle may not be of sufficient caliber, despite the shunt malfunction, to allow atraumatic passage of an endoscope to the floor of the third ventricle. We describe four slit ventricle syndrome patients with respectively 24, 12, 18 and 2 prior shunt revisions who presented with shunt infection. In each patient the shunt was externalized and controlled intracranial hypertension (CIH) was applied over an average of 5.8 days by raising the height of the external ventricular drain (EVD) bag to a mean height of 18.8 cm above EAM. This increased the mean transverse third ventricular diameter from an average of 0.28 cm on admission to 1.13 cm after application of CIH. Endoscopic third ventriculocisternostomy (ETV) was satisfactorily performed in three of the four patients who remain shunt free after a mean follow-up of 21.3 months. CIH followed by ETV is an option in selected SVS patients who present with shunt malfunction or infection.     

Lateral ventricular diverticulum extending into supracerebellar cistern from unilateral obstruction of the foramen of monro in a neonate

A ventricular diverticulum is usually found in patients with long-standing severe obstructive hydrocephalus that may extend into the supracerebellar cistern. The route involved in the supracerebellar extension of the ventricular diverticulum is believed to originate through the tela choroidea of the temporal choroid plexus or of the antral choroid plexus. The authors report a 4-week-old girl with hydrocephalus as a result of unilateral obstruction of the foramen of Monro, which dilated the right ventricle and displaced the midline to the left side, collapsing the contralateral lateral ventricle. The dilated lateral ventricular diverticulum herniated to the supracerebellar cistern in the posterior fossa that compressed the cerebellum inferiorly. She was treated successfully by a ventriculoperitoneal shunt, resulting in a marked reduction of the ventricle and diverticulum on the follow-up computed tomography and magnetic resonance imaging. We reviewed the literature for the supracerebellar extension route of ventricular diverticulum and suggest that the medial choroidal fissure in the antrum and the velum interpositum may be important anatomical structures for the extension of the lateral ventricular diverticulum into the supracerebellar cistern.