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. 2024 Mar 18;7(12):CASE23295.
doi: 10.3171/CASE23295. Print 2024 Mar 18.

Endoscopic third ventriculostomy in hydrocephalus patients with functioning ventriculoperitoneal shunts: challenging the dictum that shunts treat all types of hydrocephalus. Patient series

Gersham J Rainone  1 , Cody Woodhouse  2 , Dallas Kramer  2 , Shahed Elhamdani  2 , Jody Leonardo  2
Affiliations

Endoscopic third ventriculostomy in hydrocephalus patients with functioning ventriculoperitoneal shunts: challenging the dictum that shunts treat all types of hydrocephalus. Patient series

Gersham J Rainone et al. J Neurosurg Case Lessons. .

Abstract

Background: Although ventriculoperitoneal shunting is standard for hydrocephalus, shunting may not be ideal for aqueductal stenosis. A cohort of patients with aqueductal stenosis displayed symptoms of over- and underdrainage, despite a patent ventriculoperitoneal shunt (VPS) and optimized valve settings. Endoscopic third ventriculostomies (ETVs) were performed in a subset of these patients with successful treatment of their underlying hydrocephalus, despite a functioning shunt.

Observations: All patients who had undergone ETV with a history of ventriculoperitoneal shunting were retrospectively reviewed. Patients experiencing over- or underdrainage symptoms despite a patent shunt were included. Cerebral aqueduct anatomy and third ventricle bowing were reviewed on preoperative imaging. Seven patients met the study criteria. All showed cerebral aqueductal stenosis and third ventricle bowing. After ETV, all patients demonstrated decreased third ventricle bowing and clinical improvement without the need for secondary cerebrospinal fluid (CSF) diversion.

Lessons: Despite a functioning VPS, patients with aqueductal stenosis may not be adequately treated. The underlying reasons are not clearly understood but suggest abnormal CSF dynamics due to aberrant parenchymal compliance. The authors theorize that ETV can more effectively treat these patients. ETV can be considered a viable treatment option in aqueductal stenosis despite a patent VPS, challenging the traditional teaching that shunts ideally treat all types of hydrocephalus.

Keywords: aqueductal stenosis; endoscopic third ventriculostomy; hydrocephalus; third ventricle floor bowing; ventriculoperitoneal shunt.

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Conflict of interest statement

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

Figures

FIG. 1
FIG. 1
Case 1. Preoperative sagittal CISS (A) and T2 SPACE (B) MRI showing triventriculomegaly with third ventricle floor bowing due to aqueductal stenosis caused by an aqueductal cyst (arrow). Postoperative sagittal CISS (C) and T2 SPACE (D) MRI showing improvement of the triventriculomegaly and resolution of the bowing with a flow void (arrow) through the ETV stoma.
FIG. 2
FIG. 2
Case 7. Preoperative sagittal T1-weighted (A) and T2 SPACE (B) MRI with distal aqueductal stenosis with proximal splaying of the aditus. Postoperative sagittal CISS (C) and T2 SPACE (D) MRI showing a large flow void through the ETV stoma.
See this image and copyright information in PMC

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