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Idiopathic fourth ventricle outlet obstruction successfully treated by endoscopic third ventriculostomy: a case report.

Ishi Y, Asaoka K, Kobayashi H, Motegi H, Sugiyama T, Yokoyama Y, Echizenya S, Itamoto K - Springerplus (2015)

Bottom Line: Magnetic resonance imaging on admission showed tetra-ventricular hydrocephalus associated with the dilatation of the fourth ventricle outlets, without any obstructive lesions.Although hydrocephalus recurred 1 year postoperatively, re-ETV for the highly stenosed fenestration successfully resolved this condition.ETV should be considered for FVOO treatment, particularly in idiopathic cases without CSF malabsorption.

View Article: PubMed Central - PubMed

Affiliation: 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.

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.

No MeSH data available.


Related in: MedlinePlus

Computed tomography images after the injection of contrast medium through the ventricular catheter (a 1 h after injection, b 3 h after injection). Both images show delayed diffusion of contrast medium to the pre-pontine cistern
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Fig2: Computed tomography images after the injection of contrast medium through the ventricular catheter (a 1 h after injection, b 3 h after injection). Both images show delayed diffusion of contrast medium to the pre-pontine cistern

Mentions: A 3-year-old boy without any medical history presented with a headache and vomiting and was referred to our institute. Computed tomography (CT) images, which had incidentally been taken 2 years before at a local neurosurgical clinic for the assessment of a minor head injury, were available and showed no significant abnormality (Fig. 1a). The patient had no neurological deficit on admission. Magnetic resonance imaging (MRI) showed enlargement of all ventricular systems associated with the dilatation of the foramina of Magendie and Luschka, with no obstructive organic lesions (such as brain tumors) on contrast enhanced MRI (Fig. 1b–f). The patient underwent emergent ventricular drainage through the anterior horn of the right lateral ventricle to relieve his symptoms. We had initially considered this case might be a communicating hydrocephalus because the fourth ventricle outlets appeared to be patent on MRI. However, the highly expanded fourth ventricle and its outlets were inconsistent with communicating hydrocephalus. We thus conducted CT ventriculo-cisternography on the fifth day post-surgery by injecting contrast medium (Isovist®) via a ventricular catheter (Fig. 2). On serial CT images, contrast medium was accumulated in the foramina of Magendie and Luschka 1 h after injection, with limited diffusion to the adjacent cisterns at 3 h after injection. These findings suggested a mechanical obstruction at the outlets of the fourth ventricle. We therefore diagnosed the patient with FVOO and chose to perform an ETV using a flexible neuro-endoscope (VEF-V, Olympus, Tokyo, Japan). The endoscope was inserted into the fourth ventricle through the dilated cerebral aqueduct and encountered the suspected cause of obstructive hydrocephalus—a thickened, arachnoid, membranous structure that enveloped the foramina of Magendie and Luschka (Fig. 3). A standard third ventriculostomy in the tuber cinereum was performed without any additional surgical intervention to the membranous structures in the fourth ventricle outlets. On endoscopic observation of the lateral ventricle and pre-pontine cistern, no abnormalities suggestive of previous meningitis or intraventricular hemorrhage were found. The patient’s postoperative course was uneventful with no signs of neurological deficit. MR images obtained 1 month post-surgery revealed significant resolution of the hydrocephalus (Fig. 4a). However, after 1 year, the patient again presented with vomiting, and it was noted that the hydrocephalus had recurred (Fig. 4b). Re-exploration with the endoscope revealed severe stenosis of the fenestration site from the first surgical procedure and a second ETV was subsequently performed. Postoperative MRI confirmed that the hydrocephalus was resolved (Fig. 4c). The patient has remained in good condition without recurrence of hydrocephalus, as identified by MRI, since undergoing the second ETV for 20 months.Fig. 1


Idiopathic fourth ventricle outlet obstruction successfully treated by endoscopic third ventriculostomy: a case report.

Ishi Y, Asaoka K, Kobayashi H, Motegi H, Sugiyama T, Yokoyama Y, Echizenya S, Itamoto K - Springerplus (2015)

Computed tomography images after the injection of contrast medium through the ventricular catheter (a 1 h after injection, b 3 h after injection). Both images show delayed diffusion of contrast medium to the pre-pontine cistern
© Copyright Policy - OpenAccess
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4627988&req=5

Fig2: Computed tomography images after the injection of contrast medium through the ventricular catheter (a 1 h after injection, b 3 h after injection). Both images show delayed diffusion of contrast medium to the pre-pontine cistern
Mentions: A 3-year-old boy without any medical history presented with a headache and vomiting and was referred to our institute. Computed tomography (CT) images, which had incidentally been taken 2 years before at a local neurosurgical clinic for the assessment of a minor head injury, were available and showed no significant abnormality (Fig. 1a). The patient had no neurological deficit on admission. Magnetic resonance imaging (MRI) showed enlargement of all ventricular systems associated with the dilatation of the foramina of Magendie and Luschka, with no obstructive organic lesions (such as brain tumors) on contrast enhanced MRI (Fig. 1b–f). The patient underwent emergent ventricular drainage through the anterior horn of the right lateral ventricle to relieve his symptoms. We had initially considered this case might be a communicating hydrocephalus because the fourth ventricle outlets appeared to be patent on MRI. However, the highly expanded fourth ventricle and its outlets were inconsistent with communicating hydrocephalus. We thus conducted CT ventriculo-cisternography on the fifth day post-surgery by injecting contrast medium (Isovist®) via a ventricular catheter (Fig. 2). On serial CT images, contrast medium was accumulated in the foramina of Magendie and Luschka 1 h after injection, with limited diffusion to the adjacent cisterns at 3 h after injection. These findings suggested a mechanical obstruction at the outlets of the fourth ventricle. We therefore diagnosed the patient with FVOO and chose to perform an ETV using a flexible neuro-endoscope (VEF-V, Olympus, Tokyo, Japan). The endoscope was inserted into the fourth ventricle through the dilated cerebral aqueduct and encountered the suspected cause of obstructive hydrocephalus—a thickened, arachnoid, membranous structure that enveloped the foramina of Magendie and Luschka (Fig. 3). A standard third ventriculostomy in the tuber cinereum was performed without any additional surgical intervention to the membranous structures in the fourth ventricle outlets. On endoscopic observation of the lateral ventricle and pre-pontine cistern, no abnormalities suggestive of previous meningitis or intraventricular hemorrhage were found. The patient’s postoperative course was uneventful with no signs of neurological deficit. MR images obtained 1 month post-surgery revealed significant resolution of the hydrocephalus (Fig. 4a). However, after 1 year, the patient again presented with vomiting, and it was noted that the hydrocephalus had recurred (Fig. 4b). Re-exploration with the endoscope revealed severe stenosis of the fenestration site from the first surgical procedure and a second ETV was subsequently performed. Postoperative MRI confirmed that the hydrocephalus was resolved (Fig. 4c). The patient has remained in good condition without recurrence of hydrocephalus, as identified by MRI, since undergoing the second ETV for 20 months.Fig. 1

Bottom Line: Magnetic resonance imaging on admission showed tetra-ventricular hydrocephalus associated with the dilatation of the fourth ventricle outlets, without any obstructive lesions.Although hydrocephalus recurred 1 year postoperatively, re-ETV for the highly stenosed fenestration successfully resolved this condition.ETV should be considered for FVOO treatment, particularly in idiopathic cases without CSF malabsorption.

View Article: PubMed Central - PubMed

Affiliation: 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.

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.

No MeSH data available.


Related in: MedlinePlus