Reversible Progressive Multiple Cranial Nerve Paresis in the Isolated Fourth Ventricle following Placement of Fourth Ventricle Shunt: Case Report and Review of the Literature

FOURTH VENTRICLE ENTRAPMENT MANAGEMENT AND ITS OUTCOMES: CASE-SERIES FROM A SINGLE NEUROSURGERY CENTER

This case-series aims to report the elaborate management of FVEs in our center and their outcome. Data from 2017 to 2022 were retrospectively collected. We reviewed patient's demography, clinical findings, radiology results, operative procedures, and complications after surgery. Five patients with FVE diagnosis underwent neurosurgical procedures. The procedures include VP shunt, endoscopic cyst fenestration and fourth ventricle peritoneal shunt (FVPS). Out of five patients, 3 had favorable outcomes, 1 deceased, and 1 patient were still hospitalized. The underlying diseases varied from hemorrhage, cyst, infection, congenital, and neoplasm. FVE etiologies range from congenital to intraventricular hemorrhage complications and infection. VPS, FVPS, and endoscopic treatment with stenting or fenestration are surgical options for treating FVE patients. CSF diversion using shunt device is the simplest procedure. Patients with FVE in general have favorable outcome after CSF diversion of any method.

The entity of the trapped fourth ventricle: A review of its history, pathophysiology, and treatment options

An isolated or trapped fourth ventricle is a relatively rare, although serious, adverse effect of hemorrhagic, infectious, or inflammatory processes that involve the central nervous system. This entity usually occurs after successful shunting of the lateral ventricles and may become clinically evident with the development of delayed clinical deterioration. This decline of the neurological status of the patient is evident after an initial period of improvement of the relevant symptoms. Surgical treatment options include cerebrospinal fluid shunting procedures, along with open surgical and endoscopic approaches. Complications related to its management are common and are related with obstruction of the fourth ventricular catheter, along with cranial nerve or brainstem dysfunction. We used the keywords: "isolated fourth ventricle," and "trapped fourth ventricle," in PubMed^® and Web of Science^®. Treatment of the trapped fourth ventricle remains a surgical challenge, although the neurosurgical treatment armamentarium has broadened. However, prompt recognition of the clinical and neurological findings that accompany any individual patient, in conjunction with the relevant imaging findings, is mandatory to organize our treatment plan on an individual basis. The current experience suggests that any individual intervention plan should be mainly based on the underlying pathological substrate of hydrocephalus. This could help us to preserve the patient's life, on an emergent basis, as well as to ensure an uneventful neurological outcome, maintaining at least the preexisting level of neurological function.

Endoscopic aqueductoplasty and stenting in the treatment of isolated fourth ventricle in children: 20-year institutional experience

BACKGROUND

Endoscopic aqueductoplasty with aqueductal stenting is an effective surgical procedure for the treatment of isolated fourth ventricle (IFV). Due to the rarity of the underlying pathology, it can be considered a rare procedure that can be performed with different surgical techniques and approaches.

OBJECTIVES

To assess long-term functioning of permanent aqueductal stents implanted in children affected by hydrocephalus and IFV and to describe some variations of the same procedure.

METHODS

We reviewed retrospectively all the patients presenting at our institution in the years 1999-2019 for symptoms of isolated fourth ventricle who underwent a surgical procedure of endoscopic aqueductoplasty and/or aqueductal stent. Surgical reports, radiological images, and surgical videos were retrospectively analyzed.

RESULTS

Thirty-three patients with symptomatic isolated fourth ventricle (IFV) underwent fifty (50) neuroendoscopic procedures in the period observed. The median age of the patients at the time of first surgery was 7 months, with 22 premature babies. In twenty-nine patients (87.8%), a precoronal approach was performed, while four patients received a suboccipital burr hole. Ten patients were never reoperated since. Twenty-three patients underwent further surgeries: a new aqueductoplasty with aqueductal stent was performed in 13 cases. The remaining 10 patients required a combination of other procedures for management of hydrocephalus. Long-term follow-up showed a permanent stent functioning rate of 87% at 2 years and 73% at 4 years, remaining stable afterwards at very long term (20 years).

CONCLUSION

Endoscopic aqueductoplasty and stenting is a reliable procedure in the long-term management of isolated fourth ventricle.