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Mulhem A, Alsulaiman AM, Hammersen S, Kantelhardt S. The endoscopic treatment of fourth ventricle outlet obstruction: Report of two children and systematic review. Clin Case Rep 2023; 11:e8234. [PMID: 38033697 PMCID: PMC10683030 DOI: 10.1002/ccr3.8234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 11/01/2023] [Accepted: 11/06/2023] [Indexed: 12/02/2023] Open
Abstract
Fourth ventricle outlet obstruction (FVOO) is a rare cause of hydrocephalus. In the last century, the standard treatment was the suboccipital craniotomy with magendieplasty or ventriculoperitoneal shunt (VP shunt). Since the beginning of the 21st century, the endoscopic third ventriculostomy (ETV) has been considered a less invasive alternative. The medical literature lacks sufficient reports of FVOO cases and strong evidence about ETV's efficacy in treating this condition. We report two cases of FVOO treated with ETV and review published similar cases. Clinical and radiological findings of two FVOO cases with outcomes after ETV were presented. Moreover, we conducted a systematic review after protocol registration in PROSPERO (CRD42021281474). MEDLINE, Embase, Scopus, and Web of Science were searched from inception till December 31, 2022. Studies were included if they reported cases of FVOO treated initially with ETV. Cases with Chiari malformation, Dandy-Walker malformation, tuberous sclerosis, trapped fourth ventricle, or space-occupying lesions were excluded. Two reviewers independently examined title/abstract records in the first stage and full-text publications in the second for eligibility. The primary outcome was the recurrence rate, defined by the need for re-ETV or other invasive treatments (e.g., VP shunt or magendieplasty). Other outcomes included clinical state at follow-up and mortality. Two cases, a 3-year-old male and 3.5-year-old female, with FVOO, were treated with ETV in our department by the same neurosurgeon (SH) in 2013 and 2021. Both cases improved significantly after ETV, and there was no recurrence through the follow-up. Besides the present cases, we found 57 other cases of FVOO treated with ETV reported in 17 studies between 2001 and 2021. The median age was 26 years, with an IQR from 2.4 to 59 years, and 56% of cases were females. The recurrence rate was 32% in the sample (19 out of 59), with a 95% CI from 21% to 46%. The median time to recure was 2 months with IQR from 1.25 to 26. A VP shunt was the treatment for recurrence in 68% and a re-ETV in 32%. At the follow-up (41 ± 29 months), only one case died, and one deteriorated clinically. FVOO is a rare cause of hydrocephalus encountered mainly in the first or sixth decades of life. ETV provides the first reasonable treatment. Despite the moderate recurrence rate, the outcomes are favorable.
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Affiliation(s)
- Ali Mulhem
- Department of NeurosurgeryVivantes Klinikum im FriedrichshainBerlinGermany
- DPhil Program in Evidence‐Based Health Care, Department of Continuing EducationUniversity of OxfordOxfordUK
| | | | - Stefanie Hammersen
- Department of NeurosurgeryVivantes Klinikum im FriedrichshainBerlinGermany
| | - Sven Kantelhardt
- Department of NeurosurgeryVivantes Klinikum im FriedrichshainBerlinGermany
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Rosa MRF, Cruz TZ, Magalhães Junior EV, Nigri F. Tetraventricular noncommunicating hydrocephalus: Case report and literature review. Surg Neurol Int 2021; 12:519. [PMID: 34754569 PMCID: PMC8571210 DOI: 10.25259/sni_635_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 09/03/2021] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Tetraventricular hydrocephalus is a common presentation of communicating hydrocephalus. Conversely, cases with noncommunicating etiology impose a diagnostic challenge and are often neglected and underdiagnosed. Herein, we present a review of literature for clinical, diagnostic, and surgical aspects regarding noncommunicating tetrahydrocephalus caused by primary fourth ventricle outlet obstruction (FVOO), illustrating with a case from our service. METHODS We performed a research on PubMed database crossing the terms "FVOO," "tetraventriculomegaly," and "hydrocephalus" in English. Fifteen articles (a total of 34 cases of primary FVOO) matched our criteria and were, therefore, included in this study besides our own case. RESULTS Most cases presented in adulthood (47%), equally divided between male and female. Clinical presentation was unspecific, commonly including headache, nausea, and dizziness as symptoms (35.29%, 21.57%, and 9.80%, respectively), with ataxic gait (65%) and papilledema (40%) being the most frequent signs. MRI and CT were the imaging modalities of choice (11 patients each), often associated with CSF flow studies, such as cine MRI and CT ventriculogram. Endoscopic third ventriculostomy (ETV) was both the most popular and effective surgical approach (50.85% of cases, with 18.91% of recurrence) followed by ventricle-peritoneal shunt (16.95% of patients, 23.0% of recurrence). CONCLUSION FVOO stands for a poorly understood etiology of noncommunicating tetrahydrocephalus. With the use of ETV, these cases, once hopeless, had its morbimortality and recurrence reduced greatly. Therefore, its suspicion and differentiation from other forms of tetrahydrocephalus can improve its natural course, reinforcing the importance of its acknowledgment.
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Affiliation(s)
- Magno Rocha Freitas Rosa
- Department of Surgical Specialties and Neurosurgery, Pedro Ernesto University Hospital, Rio de Janeiro, Brazil
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Hydrocephalus Caused by Primary Fourth Ventricle Outlet Obstruction: Our Experience and Literature Review. World Neurosurg 2021; 148:e425-e435. [PMID: 33444837 DOI: 10.1016/j.wneu.2021.01.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 01/01/2021] [Accepted: 01/02/2021] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Primary fourth ventricle outlet obstruction (PFVOO) is a rare cause of hydrocephalus with an unclear etiopathogenesis, and thus, consensus regarding the recommended treatment protocol is lacking. This study aims to summarize current knowledge of this condition in the light of our own treatment experience. METHODS Retrospective analysis was carried out of all patients treated for noncommunicating tetraventricular hydrocephalus between 2006 and 2019, from which a subgroup of patients with PFVOO was created. A literature review of PFVOO cases was also carried out. RESULTS A total of 62 patients with PFVOO were discovered, of whom 8 were treated at our institution, representing 3.8% of our patients with noncommunicating hydrocephalus. Patients most commonly presented with headaches, gait disturbance, or symptoms of intracranial hypertension. The mean follow-up duration was 75.4 months among our patients and 29.9 months in the literature. Most patients (54.8%) were treated by endoscopic third ventriculostomy (ETV), with the remainder undergoing suboccipital craniotomy alone (17.7%) or in combination with shunt surgery (9.7%), or endoscopic magendieplasty (12.9%). Treatment failure was noted in 28.6% of ETVs and 9% of craniotomies. No failures were recorded after endoscopic magendieplasty. The risk of treatment failure was found to be significantly higher with ETV compared with other treatment modalities (P < 0.0005). CONCLUSIONS Despite the fact that PFVOO can be defined as an obstructive hydrocephalus, there seems to be a higher risk of ETV failure in such cases. The alternative treatment modalities presented are still recommended. Confirmation of these findings requires a larger multicenter study.
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Kawabata T, Takeuchi K, Nagata Y, Ishikawa T, Choo J, Wakabayashi T. Endoscopic Treatment Strategy for a Disproportionately Large Communicating Fourth Ventricle: Case Series and Literature Review. Neurol Med Chir (Tokyo) 2020; 60:351-359. [PMID: 32536656 PMCID: PMC7358780 DOI: 10.2176/nmc.oa.2019-0299] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
An isolated fourth ventricle (IFV) is characterized by fourth ventricular dilation due to obstruction of its inlet and outlet. A disproportionately large communicating fourth ventricle (DLCFV) is a rare subtype of IFV, characterized by dilation of the fourth ventricle, regardless of the size of the lateral ventricles, with no apparent obstruction of the cerebral aqueduct. To our knowledge, this is the first case series describing endoscopic diagnosis and treatment strategy for DLCFV. We retrospectively reviewed six cases of DLCFV in which endoscopic surgery was performed at our institution and affiliated facilities between June 2013 and March 2017. DLCFV was diagnosed using radiographic imaging and intraoperative endoscopy. We also conducted a PubMed search and included only original studies related to DLCFV treatment written in English in our review of the literature. Endoscopic third ventriculostomy (ETV) was performed in all patients. Additional endoscope-assisted placement of a fourth ventriculoperitoneal (VP) shunt was performed in two patients who could not be managed with ETV alone because of severe adhesion of the interpeduncular cistern due to subarachnoid hemorrhage (SAH). The patients' symptoms and the size of the fourth ventricle improved with surgical treatment, without complications. Endoscopic surgery for DLCFV appears to be a safe and effective treatment. Based on our treatment strategy, ETV is the first-line treatment for DLCFV. Endoscope-assisted placement of the fourth VP shunt can be treatment for severe adhesion of the interpeduncular cistern.
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Affiliation(s)
- Teppei Kawabata
- Department of Neurosurgery, Graduate School of Medicine, Nagoya University
| | - Kazuhito Takeuchi
- Department of Neurosurgery, Graduate School of Medicine, Nagoya University
| | - Yuichi Nagata
- Department of Neurosurgery, Graduate School of Medicine, Nagoya University
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Chowdhury FH, Haque MR, Rumi JUM, Arifin MS. Fourth Ventricular Outflow Obstruction in an Infant with Ileal Atresia and Laryngomalacia: Endoscopic Management. INDIAN JOURNAL OF NEUROSURGERY 2020. [DOI: 10.1055/s-0040-1710104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
AbstractFourth ventricle outflow obstruction (FVOO) is a rare cause of obstructive hydrocephalus. In this study, we described a case of idiopathic FVOO with ileal atresia and laryngomalacia which was managed with endoscopic third ventriculostomy (ETV) and re-endoscopy. We also described the techniques of fenestration of Liliequist membrane and partial removal of arachnoid membrane over dorsum sella (DS) to prevent closure of fenestration and recurrence of hydrocephalus. The patient was a 4-month-old infant presented with progressively increasing head size, feeding difficulty, respiratory distress, and tense fontanel. The infant had a history of laparotomy for ileal atresia. CT scan showed panventriculomegaly due to FVOO. ETV with fenestration of Liliequist membrane was done on emergency basis. After operation, the patient improved clinically and radiologically. Four weeks later, the patient returned with recurrent hydrocephalus. Endoscopic reoperation showed closure of fenestration in arachnoid membrane (Lilieqiest membrane). Endoscopic refenestration with partial excision of arachnoid on DS was done. The patient again recovered radiologically and clinically till last follow-up. In idiopathic FVOO, ETV with wide fenestration of Liliequist membrane, preferably with partial removal of arachnoid on DS, may be very useful in treating hydrocephalus (HCP) and preventing recurrent HCP even in infants.
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Affiliation(s)
- Forhad H. Chowdhury
- Department of Neurosurgery, National Institute of Neurosciences and Hospital, Dhaka, Bangladesh
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Barany L, Baksa G, Patonay L, Racz G, Ganslandt O, Buchfelder M, Kurucz P. Primary Obstruction of the Foramen of Luschka: Anatomy, Histology, and Clinical Significance. World Neurosurg 2018; 112:e288-e297. [PMID: 29339320 DOI: 10.1016/j.wneu.2018.01.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Revised: 01/03/2018] [Accepted: 01/05/2018] [Indexed: 10/18/2022]
Abstract
BACKGROUND The foramen of Luschka is a natural aperture between the fourth ventricle and the subarachnoid space at the cerebellopontine angle. Membranous closure of this foramen is referred to as primary obstruction. Available information about this variant and its role in the development of the cysts of the posterior fossa is contradictory. METHODS The macroscopic and histologic features of the obstructed foramina were examined in 61 formalin-fixed human brains (122 foramina). Three rhomboid lips of various sizes with lateral recess were used for comparison. Five postoperative cases of diverticulum of the foramen of Luschka were included in this study, with 1 case presented in detail to illustrate anatomic and histologic findings. RESULTS Primary obstruction was present in 11 of 122 cases. In 1 case, an enlarged rigid pouch with a thick wall was found. The wall of the membrane in primary obstruction and the rhomboid lip were composed of an inner ependymal, a middle glial, and an outer leptomeningeal layer. CONCLUSIONS The rhomboid lip is a remnant of the roof of the fourth ventricle. Imperforation of the foramen of Luschka results in a pouch in the cerebellopontine angle that contains choroid plexus (Bochdalek's flower basket) and communicates with the fourth ventricle. This pouch has the potential to grow to a diverticulum and cause clinical symptoms. Based on our clinical observations, detailed radiologic and surgical-anatomic criteria were proposed to support the differential diagnosis of a diverticulum of the foramen of Luschka. Treatment strategies were also suggested.
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Affiliation(s)
- Laszlo Barany
- Laboratory for Applied and Clinical Anatomy, Department of Anatomy, Histology and Embryology, Semmelweis University, Budapest, Hungary.
| | - Gabor Baksa
- Laboratory for Applied and Clinical Anatomy, Department of Anatomy, Histology and Embryology, Semmelweis University, Budapest, Hungary
| | - Lajos Patonay
- Laboratory for Applied and Clinical Anatomy, Department of Anatomy, Histology and Embryology, Semmelweis University, Budapest, Hungary
| | - Gergely Racz
- 1(st) Department of Pathology and Experimental Cancer Research, Semmelweis University, Budapest, Hungary
| | - Oliver Ganslandt
- Department of Neurosurgery, Klinikum Stuttgart, Stuttgart, Germany
| | - Michael Buchfelder
- Department of Neurosurgery, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - Peter Kurucz
- Department of Neurosurgery, Klinikum Stuttgart, Stuttgart, Germany; Department of Neurosurgery, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
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Shimoda Y, Murakami K, Narita N, Tominaga T. Fourth Ventricle Outlet Obstruction with Expanding Space on the Surface of Cerebellum. World Neurosurg 2017; 100:711.e1-711.e5. [PMID: 28153613 DOI: 10.1016/j.wneu.2017.01.088] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Revised: 01/19/2017] [Accepted: 01/23/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND Hydrocephalus is classified as noncommunicating and communicating based on whether all ventricular and subarachnoid spaces are communicating. Although the diagnosis between the two different states is crucial, it is difficult in certain conditions. In particular, communicating hydrocephalus and noncommunicating hydrocephalus owing to fourth ventricle outlet obstruction are highly misdiagnosed. We describe a case of fourth ventricle outlet obstruction of unknown origin that was initially misdiagnosed as communicating hydrocephalus. CASE DESCRIPTION A 66-year-old woman with gait disturbance and incontinence caused by hydrocephalus underwent ventriculoperitoneal shunt surgery. After 9 months, her fourth ventricle became enlarged and could not be controlled by lowering the shunt pressure. Magnetic resonance imaging (MRI) demonstrated obstruction at the foramen of Magendie, foramina of Luschka, and the cerebral aqueduct. Endoscopic surgery for aqueduct plasty with third ventriculostomy was planned. Because the aqueduct was observed to open spontaneously, only the standard third ventriculostomy was performed. When MRI findings were reviewed retrospectively, an unnatural space was observed between the lower cranial nerves and cerebellar hemisphere that grew along with the fourth ventricular enlargement. This space was determined by MRI cisternography to be the cystic membrane ballooning out from the foramen of Luschka. The primary hydrocephalus likely resulted from fourth ventricle outlet obstruction. CONCLUSIONS Enlargement of the whole ventricular system with an expanded space between the lower cranial nerves and cerebellar hemisphere can be caused by fourth ventricle outlet obstruction. In such cases, preoperative evaluation of anatomic architecture and cerebrospinal fluid obstruction using MRI cisternography is essential and leads to a successful endoscopic strategy.
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Affiliation(s)
- Yoshiteru Shimoda
- Department of Neurosurgery, Kesen-numa City Hospital, Miyagi, Japan; Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan.
| | - Kensuke Murakami
- Department of Neurosurgery, Sendai Medical Center, Sendai, Japan
| | - Norio Narita
- Department of Neurosurgery, Kesen-numa City Hospital, Miyagi, Japan
| | - Teiji Tominaga
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
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Ishi Y, Asaoka K, Kobayashi H, Motegi H, Sugiyama T, Yokoyama Y, Echizenya S, Itamoto K. Idiopathic fourth ventricle outlet obstruction successfully treated by endoscopic third ventriculostomy: a case report. SPRINGERPLUS 2015; 4:565. [PMID: 26543700 PMCID: PMC4627988 DOI: 10.1186/s40064-015-1368-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Accepted: 09/22/2015] [Indexed: 11/30/2022]
Abstract
Introduction Fourth ventricle outlet obstruction (FVOO) is a rare cause of obstructive hydrocephalus. We describe a case of idiopathic FVOO that was successfully treated with endoscopic third ventriculostomy (ETV). Case report A 3-year old boy without any remarkable medical history presented with a headache and vomiting. Computed tomography (CT) images, which had incidentally been taken 2 years previously due to a minor head injury, showed no abnormality. Magnetic resonance imaging on admission showed tetra-ventricular hydrocephalus associated with the dilatation of the fourth ventricle outlets, without any obstructive lesions. However, CT ventriculography, involving contrast medium injection through a ventricular catheter, suggested mechanical obstruction of the cerebrospinal fluid (CSF) at the fourth ventricle outlets. Thus, the patient was diagnosed with FVOO and ETV was performed; the hydrocephalus was subsequently resolved. Although hydrocephalus recurred 1 year postoperatively, re-ETV for the highly stenosed fenestration successfully resolved this condition. Conclusions ETV should be considered for FVOO treatment, particularly in idiopathic cases without CSF malabsorption.
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Affiliation(s)
- Yukitomo Ishi
- Department of Neurosurgery, Teine Keijinkai Hospital, 1-40, Maeda 1-12, Teine-ku, Sapporo, 006-8555 Japan ; Department of Neurosurgery, Hokkaido University Graduate School of Medicine, North 15 West 7, Kita-ku, Sapporo, 060-8638 Japan
| | - Katsuyuki Asaoka
- Department of Neurosurgery, Teine Keijinkai Hospital, 1-40, Maeda 1-12, Teine-ku, Sapporo, 006-8555 Japan
| | - Hiroyuki Kobayashi
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, North 15 West 7, Kita-ku, Sapporo, 060-8638 Japan
| | - Hiroaki Motegi
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, North 15 West 7, Kita-ku, Sapporo, 060-8638 Japan
| | - Taku Sugiyama
- Department of Neurosurgery, Teine Keijinkai Hospital, 1-40, Maeda 1-12, Teine-ku, Sapporo, 006-8555 Japan
| | - Yuka Yokoyama
- Department of Neurosurgery, Teine Keijinkai Hospital, 1-40, Maeda 1-12, Teine-ku, Sapporo, 006-8555 Japan
| | - Sumire Echizenya
- Department of Neurosurgery, Teine Keijinkai Hospital, 1-40, Maeda 1-12, Teine-ku, Sapporo, 006-8555 Japan
| | - Koji Itamoto
- Department of Neurosurgery, Teine Keijinkai Hospital, 1-40, Maeda 1-12, Teine-ku, Sapporo, 006-8555 Japan
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