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We demonstrate a case report of triventricular hydrocephalus due to an aqueductal web and stenosis which presented itself clinically solely with bilateral hand tremors in an adolescent male. The patient underwent Endoscopic third ventriculostomy (ETV) and the subsequent improvement in cerebrospinal fluid (CSF) flow resulted in complete resolution of his tremor. We propose a mechanism involving compression of the rubrospinal tract (or stretching of the frontal premotor area) and advise cranial imaging in cases of hand tremor to exclude this as a potential cause. Neurosurgical review and potential CSF diversion if triventriclar hydrocephalus is established should be considered as positive clinical outcome can be achieved.

Background and Importance: Acquired lesions within the aqueduct of Sylvius are rare and their surgical management is challenging. Open transcranial approaches require dissection and manipulation of surrounding eloquent structures. Use of an endoscope can avoid potential morbidity from traversing and handling eloquent structures during open approaches whilst providing better visualisation of an intraventricular lesion., Clinical Presentation: A 62-year-old female presented with insidious onset short-term memory loss, unsteady gait, urinary incontinence and left-sided dysaesthesia. Magnetic resonance imaging (MRI) revealed hydrocephalus from an obstructive haemorrhagic lesion consistent with a cavernoma at the central midbrain within the aqueduct of Sylvius. An endoscopic approach was selected to provide optimal visualisation of the lesion. As only a single instrument could be accommodated, rotational movements were employed to tease out the lesion. Gross total resection was achieved. Her symptoms improved immediately postoperatively and she made a complete recovery by 2 months. Post-operative MRI showed resolution of hydrocephalus and no evidence of residual/recurrence of the lesion. Unfortunately, she developed hydrocephalus 3 months post-op and required placement of a ventriculoperitoneal shunt., Conclusions: Endoscopic resection is safe and feasible for selected periaqueductal lesions as it provides direct access while minimising disruption of the surrounding anatomical structures. The limitation of only having a single instrument can be overcome by employing rotational movements.

Introduction: Aqueductal webs are a rare cause of obstructive hydrocephalus. Accurate diagnosis and intervention can prevent neurological complications., Case Presentation: Herein, we describe a case of a child presenting with headaches and vomiting. Magnetic resonance imaging (MRI) revealed obstructive tri-ventricular hydrocephalus caused by an aqueductal web. Endoscopic third ventriculostomy (ETV) was successfully performed to restore cerebrospinal fluid (CSF) flow., Conclusion: This case underscores the importance of phase-contrast and T2-weighted cinematic magnetic resonance imaging of cerebrospinal fluid flow for diagnosis of aqueductal webs. These modalities provide valuable insights into CSF dynamics and guidance of appropriate neurosurgical intervention., Competing Interests: Declarations. Ethics approval: A written informed consent was obtained from the patient’s parents for publication of the details of their medical case and any accompanying images. Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)

Congenital aqueduct stenosis AS is a significant cause of fetal obstructive hydrocephalus, characterized by the obliteration of the cerebral aqueduct, leading to cerebrospinal fluid (CSF) accumulation in the ventricular system and secondary brain damage and cerebral maldevelopment. This review explores the progression from basic science to clinical applications of antenatal surgical interventions for AS, emphasizing historical efforts, current research, and translational studies. Despite advances in prenatal imaging and genetic screening, challenges remain in achieving appropriate fetal candidates, consistent ventricular decompression, and standardized surgical protocols. This review highlights the need for further research and innovation to improve prenatal treatment and outcomes for AS-affected fetuses., Competing Interests: Declaration of competing interest The authors report no proprietary or commercial interest in any product mentioned or concept discussed in this article., (Copyright © 2024. Published by Elsevier Ltd.)

Background and Importance: While navigating the ventricles with a rigid endoscope provides excellent visualization and the ability to use endoscopic instruments for complex surgery, these endoscopes are often too large to navigate tight areas. We present a surgical video showing the technique of mother-daughter endoscopy, which consists of the introduction of a flexible 1-mm fiberoptic endoscope through the channel of a large rigid endoscope to allow visualization across small spaces or channels, in this case, the cerebral aqueduct. This combination of superior visualization and handling of rigid endoscopes and flexibility and small size of fiberoptic endoscopes enhances safety and broadens possibilities in ventricular surgery., Clinical Presentation: A 64-year-old woman with prior endoscopic aqueductoplasty for triventricular hydrocephalus and a failed endoscopic third ventriculostomy presented with focal restenosis of the aqueduct. A repeat endoscopic aqueductoplasty with stent placement were performed. Mother-daughter endoscopy was used to explore the occluded aqueduct for improved safety before fenestration and to ensure proper stent placement after fenestration., Conclusion: Mother-daughter endoscopy can add safety to complex or high-risk endoscopic procedures, particularly those with tight spaces that the large mother endoscope cannot visualize., (Copyright © Congress of Neurological Surgeons 2024. All rights reserved.)

Purpose: Endoscopic transaqueductal stenting has become a well-accepted treatment option for a selected small subset of aqueductal stenosis-related obstructive hydrocephalus. However, transaqueductal stenting poses unique challenges and risks which requires critical consideration. This report discusses the clinical experiences with transaqueductal stenting for periaqueductal tumor-related aqueductal stenosis focusing on pediatric patients., Methods: A retrospective analysis of all patients undergoing endoscopic TAS from 01/1993 to 01/2022 in the author's departments was performed. Demographic, clinical, radiological, and intraoperative endoscopic data were evaluated. All patients with AS-related occlusive hydrocephalus that was treated with TAS were analyzed and prospectively followed. Special attention has been given to providing insights into indications, surgical technique, and limitations., Results: Out of 28 endoscopic transaqueductal endoscopis stenting procedures, five procedures were performed on periaqueductal tumor-related obstructive hydrocephalus, two children and three adult patients. CSF pathway was obstructed by tumor located in the aqueduct in 2, by tumor in the thalamus/mesencephalon in 1, by a tumor within the third ventricle in 1, and by a tumor of the lamina tecti in 1. Simultaneously with transaqueductal stenting, 2 endoscopic third ventriculostomies (ETV), 3 tumor biopsies, and 1 tumor resection were performed. Postoperative complications included the following: CSF fistula (1 case), and asymptomatic fornix contusion (1 case). A working aqueductal stent was achieved in all cases based on clinical follow-up evaluation. Postoperatively, all patients showed improvement or resolution of their symptoms. The mean follow-up period was 25.2 months (range, 1-108 months). One patient died due to tumor progression during early follow-up. No stent migration was seen., Conclusion: Endoscopic third ventriculostomy remains the gold standard for treatment of CSF circulation obstructions with lesions in the posterior third ventricle and aqueduct. Transaqueductal stenting for periaqueductal tumor-related aqueductal compression is technically feasible. However, because of the potential high risks and subtle advantages compared with ETV transaqueductal stenting, it might be indicated in a small subset of well-selected patients if alternative treatment options are not at hand., (© 2023. The Author(s).)

Background: Spontaneous third ventriculostomy (STV) is a rare occurrence in cases of obstructive hydrocephalus where the walls of the third ventricle rupture, communicating the ventricular system, and the subarachnoid space leading to arrest of active hydrocephalus. We aim to review our series of STVs while reviewing previous reports., Methods: A retrospective review of cases undergoing cine phase-contrast magnetic resonance imaging (PC-MRI) from 2015 to 2022 of any age with imaging evidence of arrested obstructive hydrocephalus was performed. Patients in which aqueductal stenosis was radiologically evident and the presence of third ventriculostomy through which cerebrospinal fluid flow was detectable were included. Patients who previously underwent endoscopic third ventriculostomy were excluded. Data on patient demographics, presentation, and imaging details of STV and aqueductal stenosis were collected. We searched the PubMed database using the following keyword combination: ((("spontaneous ventriculostomy") OR ("spontaneous third ventriculostomy")) OR ("spontaneous ventriculocisternostomy")) including English reports of STV published between 2010 and 2022., Results: Fourteen cases were included (7 adults, 7 pediatrics), all with history of hydrocephalus. STV occurred in the floor of the third ventricle in 57.1% of the cases, at the lamina terminalis in 35.7%, and at both sites in 1 case. Eleven publications reporting 38 cases of STV were identified from 2009 to date. Minimum follow-up period was 10 months and maximum follow-up is 77 months., Conclusions: In cases of chronic obstructive hydrocephalus, neurosurgeons should be minded with the possibility of the presence of an STV on cine phase-contrast magnetic resonance imaging leading to arrested hydrocephalus. The delayed flow at the aqueduct of Sylvius might not be the only determinant of the necessity of cerebrospinal fluid diversion and the presence of an STV should be factored into the neurosurgeon's decision considering the patient's clinical picture., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Isolated fourth ventricle (IFV) is a challenging entity to manage. In recent years, endoscopic treatment for aqueductoplasty has been on the rise. However, in patients with complex hydrocephalus and distorted ventricular system, its implementation can be complex., Methods: We present a 3-year-old patient with myelomeningocele and postnatal hydrocephalus treated by ventriculoperitoneal shunt. In follow-up, a progressive IFV and isolated lateral ventricle with symptoms of the posterior fossa developed. An endoscopic aqueductoplasty (EA) with panventricular stent plus septostomy guided with neuronavigation was decided due to the complexity of the ventricular system., Conclusion: In IFV associated with complex hydrocephalus with distortion of the ventricular system, navigation can be of great help for planning and as a guide for performing EA., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Austria, part of Springer Nature.)

Background: The anatomy of the roof of the fourth ventricle has been illustrated in many laboratory investigations, but in vivo reports of the roof anatomy and its variants are still lacking., Objective: To describe the topographical anatomy of the roof of the fourth ventricle explored through a transaqueductal approach that overcomes cerebrospinal fluid depletion, displaying in vivo anatomic images possibly quite close to normal physiological conditions., Methods: We critically reviewed the intraoperative video recordings of our 838 neuroendoscopic procedures, selecting 27 cases of transaqueductal navigation that provided good quality image details of the anatomy of the roof of the fourth ventricle. Twenty-six patients affected by different forms of hydrocephalus were therefore categorized into three groups: Group A: blockage of the aqueduct-aqueductoplasty, Group B: communicating hydrocephalus, and Group C: tetraventricular obstructive hydrocephalus., Results: Group A has shown what the roof of a normal fourth ventricle really looks like albeit the structures seemed overcrowded because of the narrow space. Images from groups B and C paradoxically allowed a more distinct identification of the roof structures flattened by ventricular dilation, making them more comparable with the topography traced on the laboratory microsurgical studies., Conclusion: Endoscopic in vivo videos and images provided a novel anatomic view and an in vivo redefinition of the real topography of the roof of the fourth ventricle. The relevant role of cerebrospinal fluid was defined and outlined, as well as the effects of hydrocephalic dilation on some structures on the roof of the fourth ventricle., (Copyright © Congress of Neurological Surgeons 2023. All rights reserved.)

Benign cysts within the pure aqueductal region are a rare entity. Their critical location within the ventricular system presents a risk of potentially catastrophic outcomes. We present a case of a 68-year-old female who was transferred to our unit with an acute obstructive triventricular hydrocephalus caused by a benign cyst within the cerebral aqueduct. She became unconscious and had an urgent endoscopic third ventriculostomy (ETV). Post-operatively, the patient was recovering well but then developed a sudden onset severe headache accompanied by vomiting. Imaging revealed intracystic haemorrhage with expansion of lesion but there was no obstructive hydrocephalus due to CSF diversion performed 9 d prior. She was treated conservatively and continued to improve.

Background: Tetraventricular Hydrocephalus (TetHCP) is a heterogeneous group of cerebrospinal fluid (CSF) flow disorders having varying success rates with Endoscopic third ventriculostomy (ETV). This is report on the efficacy and rationale of ETV in a specific subset of primary TetHCP with aqueductal CSF flow voids., Methods: Patients of primary acquired TetHCP presenting with increasing head size and/or headache having aqueductal CSF flow void on sagittal Magnetic Resonance Imaging (MRI) were included in this study. All of them underwent ETV. All patients were evaluated for clinical improvement & MRI at 3 months, and need for any additional procedure, in contrast to those without CSF flow void. The pathophysiology of hyperdynamic CSF circulation and its correlation to ETV was further reviewed., Results: Eleven patients had tetraventricular hydrocephalus and aqueductal flow void, with age ranging from 10 months to 59 years. Two patients who could undergo quantitative flow study confirmed the hyperdynamic flow across the aqueduct. Following ETV, all showed clinical improvement. MRI at 3 months showed CSF flow void across the third ventricular stoma in addition to across the aqueduct. None of these patients required any redo procedures for a mean follow-up of 39.2 months. In contrast, there was 30% failure rate after ETV among 10 patients of tetraventricular hydrocephalus without aqueductal flow void., Conclusion: Tetraventricular hydrocephalus with aqueductal CSF flow void may be a unique entity with hyperdynamic CSF circulation and relative resistance at fourth ventricular outlets. ETV is highly efficacious in these patients, resulting in consistent clinico-radiological improvement.

A trapped fourth ventricle is a clinic-radiological entity characterised by progressive neurological symptoms due to an enlargement of the fourth ventricle secondary to obstruction to its outflow. This condition is most commonly observed in ex-preterm patients shunted for a post-haemorrhagic or post-infective hydrocephalus. Until the introduction of endoscopic aqueductoplasty and stent placement, through a supratentorial or an infratentorial approach, treatment of trapped fourth ventricle entailed high rates of complications, repeated procedures and consequent morbidity. We describe the first case of successful treatment of trapped fourth ventricle by fenestration of superior medullary velum through an infratentorial approach in a 20-month-old child with a functional supratentorial ventriculoperitoneal shunt and an aqueductal anatomy not favourable for stenting. To the best of our knowledge, this is the first reported case of utilisation of this technique in a patient with a trapped fourth ventricle, and we wish to highlight this new alternative approach in cases where conventional aqueductoplasty and stenting may not be feasible., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Arachnoid cysts of the fourth ventricle are rarely reported. Management options include CSF diversion, cyst fenestration, or cyst excision. Fenestration can be done via open microsurgical technique or endoscopically with or without simultaneous third ventriculostomy; and both rigid and flexible endoscopy have been used successfully. However, application of this treatment modality in pediatric patients is not well described. Therefore, to their knowledge, the authors report the first successful treatment of a fourth ventricular arachnoid cyst with a single frontal burr hole entry point for third ventriculostomy and fourth ventricular arachnoid cyst fenestration performed using flexible neuroendoscopy. The patient was a 13-month-old boy presenting with progressive macrocephaly. The authors review their technique, discuss special considerations when using this approach, and include an annotated intraoperative video for demonstration to help instruct and guide management. The authors demonstrate with an example that a single frontal burr hole entry point for flexible endoscopic third ventriculostomy and navigation through a dilated cerebral aqueduct for fourth ventricular arachnoid cyst fenestration is a viable treatment for symptomatic fourth ventricular arachnoid cysts in children.

Aim: To show the normal anatomy of the cerebral aqueduct, and the feasibility of the extreme anterior interhemispheric transcallosal approach to remove tumors within the aqueduct., Material and Methods: This human cadaveric brain research was composed of ten formalin-fixed human brains and one injected head. The dissection was performed under an operative microscope with 6x to 40x magnification. The cerebral aqueduct anatomy was delineated along with the relationship to nearby structures in the extreme anterior interhemispheric transcallosal approach., Results: We described the anatomy of the cerebral aqueduct within the brain and showed that, with the proper angle for the extreme anterior interhemispheric transcallosal approach, lesions in the cerebral aqueduct can be reached in a single session without damaging periventricular structures., Conclusion: The extreme anterior interhemispheric transcallosal approach provides a direct corridor to the cerebral aqueduct and, thus, is feasible for resecting pure aqueduct tumors in an already dilated intraventricular foramen.

Background: Hydrocephalus is one of the most common presentations of occipital encephaloceles and usually develops within the first year of life. This case report presents a rare case of late-onset obstructive hydrocephalus associated with occipital encephalocele with an extraordinarily large occipital skull defect., Case Report: At birth, a newborn girl presented with an absence of a vast amount of occipital cranium and skin and was diagnosed with occipital hydroencephalomeningocele. Under meticulous sterile management, the affected area was successfully epithelialized, and the patient was discharged without infectious complication. Despite an obstructed cerebral aqueduct, she grew without any signs of hydrocephalus until the age of 7 years. Her gait gradually worsened, and imaging tests at the age of 8 years revealed markedly enlarged lateral and third ventricles but not the fourth ventricle. Endoscopic third ventriculostomy successfully relieved her symptoms with improvement of hydrocephalus., Conclusion: This is the first case of late-onset obstructive hydrocephalus associated with an occipital encephalocele characterized by large-scale cranial bony defects. Although further investigation is required to elucidate the mechanism of hydrocephalus, this rare phenomenon should be noted during neurological and radiological follow-up., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Trapped fourth ventricle is a clinic-radiological entity characterised by progressive neurological symptoms due to enlargement and dilatation of fourth ventricle secondary to obstruction to its outflow. There are several causative mechanisms for the development of trapped fourth ventricle, including previous haemorrhage, infection or inflammatory processes. However, this condition is most commonly observed in ex preterm paediatric patients shunted for a post-haemorrhagic or post-infective hydrocephalus. Until the introduction of endoscopic aqueductoplasty and stent placement, treatment of trapped fourth ventricle was associated with high rates of reoperation and complications resulting in morbidity. With the advent of new endoscopic techniques, supratentorial and infratentorial approaches for aqueductoplasty and stent insertion have revolutionised the treatment of trapped fourth ventricle. Fourth ventricular fenestration and direct shunting remain viable options in cases where aqueduct anatomy and length of obstruction is not surgically favourable for endoscopic approaches. In this book chapter, we explore the background, historical developments,$ and surgical treatment strategies in the management of this challenging condition., (© 2023. The Author(s), under exclusive license to Springer Nature Switzerland AG.)

Aqueduct stenosis is a recognized cause of obstructive hydrocephalus in children and can be treated effectively with endoscopic third ventriculostomy. Preoperative magnetic resonance imaging is often diagnostic of the cause of aqueduct stenosis. We describe 2 pediatric cases with obstructive hydrocephalus secondary to a working diagnosis of idiopathic aqueduct stenosis. Following successful endoscopic third ventriculostomy, repeat magnetic resonance brain imaging revealed tectal plate glioma as the primary cause of obstruction. We believe these 2 reported cases demonstrate a previously unreported phenomenon whereby concealed tectal gliomas presenting with hydrocephalus are only unmasked following relief of hydrocephalus and decompression and normalization of the ventricular system. We aim to raise awareness about this unusual phenomenon and recommend routine postoperative interval imaging following endoscopic third ventriculostomy to avoid missing underlying pathology masquerading as aqueduct stenosis., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Agenesis of the internal carotid artery (aICA) is a rare congenital vascular condition that can affect one or both sides of the patient. Most patients remain asymptomatic, but ischemic/hemorrhagic stroke, intracranial aneurysm, and other neurologic findings can occur. CT scan can demonstrate the absence of the bony carotid canal and helps to differentiate a complete aICA from aplasia or hypoplasia. The association of aICA and aqueductal stenosis (AS) has never been reported in the literature. We report the case of a 9-year-old with agenesis of the right ICA associated with AS and hydrocephalus, which was treated successfully with an endoscopic third ventriculostomy (ETV). We review the literature looking for the association of the clinical findings and the evolution of the patient., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Neonatal hydrocephalus represents an important pathological condition with significant impact on medical care and neurocognitive development. This condition requires early recognition, appropriate medical and surgical management, and long-term surveillance by clinicians and pediatric neurosurgeons. Common etiologies of neonatal and infant hydrocephalus include intraventricular hemorrhage related to prematurity with subsequent post-hemorrhagic hydrocephalus, myelomeningocele, and obstructive hydrocephalus due to aqueductal stenosis. Clinical markers of elevated intracranial pressure include rapid increases in head circumference across percentiles, elevation and firmness of the anterior fontanelle, splitting or splaying of cranial sutures, upgaze palsy, lethargy, frequent emesis, or episodic bradycardia (unrelated to other comorbidities). Complementing these clinical markers, imaging modalities used for the diagnosis of neonatal hydrocephalus include head ultrasonography, brain magnetic resonance imaging, and head computed tomography in urgent or emergent situations. Following diagnosis, temporizing measures may be employed prior to definitive treatment and include ventricular access device or ventriculo-subgaleal shunt insertion. Definitive surgical management involves permanent cerebrospinal fluid (CSF) diversion via CSF shunt insertion, or endoscopic third ventriculostomy with or without choroid plexus cauterization. Surgical decision-making and approaches vary based on patient age, hydrocephalus etiology, neuroanatomy, imaging findings, and medical comorbidities. Indications, surgical techniques, and clinical outcomes of these procedures continue to evolve and elicit significant attention in the research environment. In this review we describe the epidemiology, pathophysiology, clinical markers, imaging findings, early management, definitive surgical management, and clinical outcomes of pediatric patients with neonatal hydrocephalus., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Obstructive hydrocephalus in adulthood can be caused by stenosis in the aqueductal area. Chronic changes lead to a dilatation of the lateral ventricles and ballooning of infratentorial recesses. In rare cases a rupture of the floor of the third ventricle (so-called spontaneous ventriculostomy) has been described in the literature.Case presentation: We present two cases of chronic obstructive hydrocephalus due to aqueductal stenosis in adult patients. Magnetic resonance imaging included phase-contrast-imaging and revealed significant flow through the floor of the third ventricle in keeping with spontaneous ventriculostomy. In addition to other typical changes associated with chronic hydrocephalus, a distinct flattening of the tectal plate could be identified in one case., Conclusion: We present two cases of spontaneous ventriculostomy in patients with chronic hydrocephalus. To our knowledge, flattening of the tectal plate has not yet been described in the literature and may be caused by continuous cerebrospinal fluid-pulsation.

Background: Although various motor manifestations can be seen in patients with cerebrospinal fluid (CSF) disorders, such as hydrocephalus or intracranial hypotension, the clinical presentation with parkinsonism is not clearly elucidated., Methods: We searched the literature for studies describing the occurrence of parkinsonism in subjects with normal pressure hydrocephalus (NPH), obstructive hydrocephalus, and intracranial hypotension. We analyzed the clinical presentation (particularly with respect to bradykinesia, rigidity, rest tremor, and gait disturbance/postural instability) as well as the response to treatment., Results: Parkinsonism was most commonly reported in NPH patients. Although gait disturbance/postural instability is a well-known motor symptom of NPH, other cardinal signs include upper limb involvement or asymmetric presentation. As for obstructive hydrocephalus, parkinsonism was mainly observed in subjects with aqueductal stenosis and more often after shunt surgery. Patients with NPH or obstructive hydrocephalus rarely improved with levodopa therapy, while most subjects only improved with shunt surgery. Although the mechanism is still controversial, a functional involvement of nigrostriatal pathway has been hypothesized based on imaging studies and case reports. Brain imaging is also helpful for atypical cases of intracranial hypotension presenting with parkinsonism. Parkinsonism improved after treatment in such cases as well., Conclusions: Studies exploring the relationship between CSF disorders and parkinsonism are mainly descriptive and their quality is generally poor. However, considering that these disorders can be treated, clinicians' awareness of the differential diagnosis is important and future studies better exploring the underlying pathophysiological mechanisms are warranted. This article is part of the Special Issue "Parkinsonism across the spectrum of movement disorders and beyond" edited by Joseph Jankovic, Daniel D. Truong and Matteo Bologna., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Purely aqueductal tumors represent a rare but distinct entity of neoplasms with characteristic morphology and clinical presentation. This study aims to describe the extreme anterior interhemispheric transcallosal approach as a surgical option for purely aqueductal tumors in the upper part of the cerebral aqueduct and present the surgical results. Prospectively collected data of 4 patients undergoing the extreme anterior interhemispheric transcallosal approach for purely aqueductal tumors in the upper cerebral aqueduct was analyzed. The technique is a variation of the anterior interhemispheric transcallosal approach. The callosotomy is placed at the transition between the body and genu of the corpus callosum, allowing an approach steep enough to reach through the foramen of Monro to the upper cerebral aqueduct without opening the choroidal fissure. All patients had preoperative, and intraoperative or immediate postoperative 3-T magnetic resonance imaging, and underwent examination at admission, after surgery, at discharge, and 3 months postoperatively. Patient data are reported according to common descriptive statistics. All patients harbored low-grade gliomas causing hydrocephalus. Complete resection was achieved without mortality or morbidity. All patients recovered and presented neurologically intact at the 3-month postoperative follow-up. None had recurrence or needed adjuvant therapy. The extreme anterior interhemispheric transcallosal approach proved to be effective and safe. This approach does not require manipulation of the choroidal fissure or disrupt healthy brain parenchyma (except for a small callosotomy). We propose it as an option for removing a purely aqueductal tumor in the upper cerebral aqueduct with associated hydrocephalus., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: Longstanding overt ventriculomegaly in adults (LOVA) represents a form of chronic adulthood hydrocephalus with symptomatic manifestation in late adulthood. Based on the patency of the aqueduct, two different subcohorts of LOVA can be distinguished. Surgical treatments of this condition are also debated. Therefore, we analyzed preoperative characteristics and clinical outcome after different surgical treatments in a subgroup of LOVA patients with a patent aqueduct., Methods: Eighteen LOVA patients with a patent aqueduct consecutively treated at our institution between July 2013 and December 2019 were analyzed for this study. Median age was 70 years. Preoperative radiological and clinical features, surgical procedures (ventriculo-peritoneal shunt or endoscopic third ventriculostomy), and outcomes were collected. Successful outcome was qualitatively defined as an improvement or a halt of progression of the presenting symptoms at follow-up, and quantitatively by changes in mRS and iNPHGS scales., Results: Twelve patients underwent an ETV as a primary treatment, while 6 underwent VPS. A total of 22.2% of them were lost to follow-up. Median follow-up time was 38 months. Six patients (66.7%) in the ETV cohort achieved a successful outcome after treatment, with a complication rate of 11.1%. Two patients underwent rescue VPS after ETV failure with a good outcome. Four patients (100%) underwent primary VPS and achieved a satisfactory outcome after treatment, with a reported complications rate of 25%., Conclusion: LOVA with patent aqueduct represents, in our opinion, a distinct clinical form of chronic hydrocephalus. For this subgroup, as well as for other forms of LOVA, ETV remains an acceptable first-line treatment option considering the good results, and the low complication rate, obtained in those patients and the hypothesis that hydrocephalus is due to an "intracisternal" obstruction., (© 2021. The Author(s).)

Objective: Although evidence and descriptions of the central canal (CC) along the medulla oblongata and the spinal cord have been provided by several anatomical and radiological studies, a clear picture and assessment of the opening of the CC, or apertura canalis centralis (ACC), into the fourth ventricle is lacking, due to its submillimetric size and hidden position in the calamus scriptorius., Methods: The authors reviewed all of their cases in which patients underwent ventricular transaqueductal flexible endoscopic procedures and selected 44 cases in which an inspection of the region of the calamus scriptorius had been performed and was suitable for study inclusion. Patients were divided into different groups, based on the presence or absence of a chronic pathological process involving the fourth ventricle. In each case, the visual appearance of the opening of the CC of the ACC was classified as no evidence (A0), indirect evidence (A1), or clear evidence (A2). Morphometric measurements were inferred from surrounding structures and the size of surgical tools visible in the field., Results: The opening of the CC could be clearly observed in all cases (A1 4.5%, A2 95.5%). In normal cases, a lanceolate shape along the median sulcus was most frequently found, with an average size of 600 × 250 µm that became rounded and smaller in size in cases of hydrocephalus. The distance between the caudal margin of the ACC and the obex was about 1.8 mm in normal cases, 2.1 mm in cases of obstructive hydrocephalus, and 1 mm in cases of normal pressure hydrocephalus. The two wings of the area postrema, variable in size and shape, were sited just caudal to the opening., Conclusions: A flexible scope inserted through the cerebral aqueduct can approach the hidden calamus scriptorius like a pen fits into an inkpot. With this privileged viewpoint, the authors provide for the first time, to their knowledge, a clear and novel vision of the opening of the CC in the fourth ventricle, along with the precise location of this tiny structure compared to other anatomical landmarks in the inferior triangle.

Background: Although flexible endoscopy is effective for intraventricular lesions, it is less frequently used for hemorrhagic cases. In some hemorrhagic strokes, blood clots may plunge into the cerebral aqueduct and cause acute obstructive hydrocephalus. A flexible endoscope can aspirate clots and prevent acute hydrocephalus., Methods: Here, we report four cases of hemorrhage: one of intracerebral hemorrhage and three of subarachnoid hemorrhages., Results: In all cases, acute hydrocephalus was not apparent upon admission. Sudden comatose occurred; computed tomography revealed acute obstructive hydrocephalus with a strangulated clot in the cerebral aqueduct. We performed aspiration of the strangulated clot using a flexible endoscope. Consciousness improved in all cases, and acute hydrocephalus was prevented in all cases., Conclusion: The use of simple flexible endoscopic aspiration for clots might be a beneficial and less-invasive procedure for acute obstructive hydrocephalus caused by a small clot with hemorrhagic stroke., (© 2020. Springer-Verlag GmbH Germany, part of Springer Nature.)

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.

Purpose: Evidence supporting the effectiveness of endoscopic aqueductoplasty (EA) for the treatment of isolated fourth ventricle (IFV) is limited to small surgical series of cases. Additionally, studies adopted different radiological outcome criteria, which makes it difficult to compare outcomes accurately. Thus, we aimed to develop a radiological score (RS) as an alternative assessment method for EA., Methods: The cases of 20 consecutive pediatric patients harboring IFV and treated by EA were retrospectively reviewed. Clinical data and pre- and 1-year postoperative brain images were analyzed. The RS was based on the enlargement of the fourth ventricle and deformation of the cerebellum and brainstem. After randomization, three experts, blinded to patient outcomes, analyzed the brain images and established a consensus for the values of the score. Outcomes were validated by comparing the maximum anteroposterior distance of the fourth ventricle using the RS, pediatric functional status score, and clinical symptoms., Results: The RS was strongly correlated with the anteroposterior distance of the fourth ventricle (Pearson's coefficient = 0.78), and the mean RS dropped from 6.15 to 3.90 (p < 0.001) 1 year after EA. Upward extension (p = 0.021) and brainstem deformation (p = 0.010) were the most significant improved features. There was agreement among RS and symptom improvement in 16 children (80%) and the pediatric functional status score in 14 children (70%)., Conclusion: In this study, the proposed radiological score proved to be an accurate tool for the evaluation of IFV treatment with EA.

Hydrocephalus may cause Parinaud's syndrome which consists of vertical gaze palsy, convergence palsy, lid retraction and pupil light-near dissociation. We are aware of only two prior reports of hydrocephalus presenting with bilateral ptosis. Both were cured by ventriculoperitoneal shunts. We report a 28-month-old girl who presented acute bilateral ptosis but full eye movements both sides. Neuroimages revealed chronic hydrocephalus and aqueductal stenosis. The bilateral ptosis resolved quickly after endoscopic third ventriculostomy (ETV).

Object: The purpose of this study was to evaluate whether endoscopic third ventriculostomy (ETV) and endoscopic cyst fenestration are effective minimally invasive alternatives to a craniotomy with cyst resection for the treatment of symptomatic pineal cyst-associated aqueductal stenosis., Methods: Sixteen patients with symptomatic pineal cysts were operatively managed endoscopically and these cases were retrospectively reviewed. There were 12 females and 4 males. The median age at the time of surgery was 31 years (range 3 to 62 years)., Results: All patients presented with symptoms and imaging consistent with elevated intracranial pressure. The median maximum cyst diameter was 15 mm (range 10 mm to 27 mm). In all cases, there was mass effect on the tectum that resulted in effacement of the cerebral aqueduct and ventriculomegaly was present in 38% of cases. ETV was performed in 15 patients. Cyst fenestration was performed in 2 patients, one of which also had an ETV. Resolution of symptoms was achieved in 81% of patients with a median follow-up of 13 months., Conclusion: This study showed that ETV is effective for symptomatic pineal cyst-associated aqueductal stenosis. Patients can be symptomatic without overt ventriculomegaly and normal ventricular volume does not preclude safe endoscopic management. Endoscopic cyst fenestration is recommended if a Perinaud syndrome is present or if ETV is not feasible.

Preoperative judgement of which children is likely to benefit from endoscopic third ventriculostomy (ETV) is still the most difficult challenge. This study aimed to compare the efficiency of third ventricular floor bowing (TVFB) and ETV success score (ETVSS) in selecting ETV candidates and achieve a better preoperative patient selection method for ETV based on our institutional experience. Children (≤ 16 years old) with newly diagnosed hydrocephalus treated with ETV between January 2013 and June 2018 were included in this prospective study. Patients with TVFB will receive ETV procedure in the pediatric subgroup of our department. ETVSS was calculated in every patient. The ETVSS predicted ETV success rate and the actual ETV success rate in our institution were compared and further analyzed. One hundred twenty-nine children with TVFB were enrolled in our study. The mean age at ETV was 5.84 ± 5.17 years (range, 0.04-16). Brain tumors, aqueductal stenosis, and inflammatory are the most common hydrocephalus etiologies. The most common complication was noninfectious fever (3.1%). During the average follow-up of 19.5 ± 14.95 months, twenty-five patients had depicted ETV failure. The actual ETV success rate (81%) in our study was higher than the success rate (69%) predicted by ETVSS. TVFB is a pragmatic, efficient, and simple model to predict the ETV outcome. We suggest that for hydrocephalic patients with preoperative third ventricular floor bowing, ETV should be the first-treatment choice regardless of the ETV success score. And for patients without such sign, ETVSS should be applied to select ETV candidates.

Developmental venous anomalies (DVAs), previously also known as venous angiomas, are variations of normal trans-medullary veins draining from white and gray matter. DVAs are usually asymptomatic and mostly discovered incidentally on brain imaging. However, some studies have reported symptomatic cases associated with DVAs. In this report, we report an extremely rare case of a 14-month-old boy with obstructive hydrocephalus following aqueductal stenosis caused by developmental venous anomalies. At the age of 14 months, his head circumference exceeded + 2SD significantly. Brain magnetic resonance imaging (MRI) showed triventriculomegaly and dilated collector vein coursing through the Sylvian aqueduct, causing aqueductal stenosis. Endoscopic third ventriculostomy (ETV) was successfully performed. During the procedure, a dilated collector vein was confirmed obstructing the Sylvian aqueduct. Postoperative cine MRI showed good flow signal through the opening and improvement of hydrocephalus was noted. Obstructive hydrocephalus following aqueductal stenosis caused by DVAs is very rare; nonetheless, it can be considered as a causal differential diagnosis for hydrocephalus. Whether ETV should be chosen, as the technique for diversion of cerebrospinal fluid (CSF) flow, remains controversial. This case report showed that ETV was effective and safe.

Background: Late-onset aqueductal membranous occlusion (LAMO) is 1 of the few causes of noncommunicating hydrocephalus. Here, we report a case of LAMO and review the associated literature., Case Description: A 36-year-old man had complained of headache and loss of consciousness. Conventional magnetic resonance imaging (MRI) showed dilatation of the lateral and third ventricles but not of the fourth ventricle. Phase-contrast cine MRI confirmed cessation of cerebrospinal fluid (CSF) flow in the aqueduct of Sylvius. Sagittal and coronal turbo spin echo T2-weighted imaging with 3-dimensional driven equilibrium pulse (3D-DRIVE) revealed a membranous occlusion at the aqueduct of Sylvius and LAMO was diagnosed. The patient underwent endoscopic third ventriculostomy. Occlusion of the aqueduct of Sylvius by a thin membrane was observed and endoscopic aqueductoplasty was also conducted. The patient's symptoms were ameliorated shortly after the operation. Postoperative phase-contrast cine and 3D-DRIVE MRI showed restored CSF flow in the aqueduct of Sylvius and at the bottom of the third ventricle., Conclusions: We treated a case of LAMO, which usually presents with headache as an initial symptom. 3D-DRIVE MRI is useful for detecting membranous occlusions and for evaluating pre- and postoperative CSF flow. LAMO can be cured by endoscopic third ventriculostomy and/or endoscopic aqueductoplasty., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: To technically review and explore long-term follow-up results of aqueductoplasty and stenting under flexible neuroendoscopy in infantile obstructive hydrocephalus., Methods: The clinical data, surgical techniques, and long-term effects in 14 infants with obstructive hydrocephalus treated by flexible neuroendoscopic aqueductoplasty and stenting between 2008 and 2010 were analyzed retrospectively., Results: The 14 infants had a mean age of 5.71 ± 3.10 months (range, 2-11 months) and a mean duration of follow-up of 62.64 ± 34.52 months (range, 9-121 months). Subdural effusion was observed in 4 infants (28.6%) after surgery. There were no deaths or serious complications related to intracranial stent placement. Three infants (21.4%) failed, 2 due to proximal aqueduct occlusion from a short stent length and 1 due to intraluminal ependymal adhesion obstruction. One case was abandoned when a second surgical adjustment stent was unsuccessful, and the other 2 cases went to shunt surgery., Conclusions: Aqueductoplasty with stenting is a feasible and safe surgical procedure for treating infants with midbrain aqueduct stenosis or occlusion. However, the optimal stent material and definitive outcomes after this procedure require additional long-term follow-up studies in large numbers of infants., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: During surgery in the posterior fossa in the prone position, blood can sometimes fill the surgical field, due both to the less efficient venous drainage compared to the sitting position and the horizontally positioned surgical field itself. In some cases, blood clots can wedge into the cerebral aqueduct and the third ventricle, and potentially cause acute hydrocephalus during the postoperative course., Objective: To illustrate a technique that can be used in these cases: the use of a flexible scope introduced through the opened roof of the fourth ventricle with a freehand technique allows the navigation of the fourth ventricle, the cerebral aqueduct, and the third ventricle in order to explore the cerebrospinal fluid pathways and eventually aspirate blood clots and surgical debris., Methods: We report on one patient affected by an ependymoma of the fourth ventricle, for whom we used a flexible neuroendoscope to explore and clear blood clots from the cerebral aqueduct and the third ventricle after the resection of the tumor in the prone position. Blood is aspirated with a syringe using the working channel of the scope as a sucker., Results: A large blood clot that was lying on the roof of the third ventricle was aspirated, setting the ventricle completely free. Other clots were aspirated from the right foramen of Monro and from the optic recess., Conclusion: We describe this novel technique, which represents a safe and efficient way to clear the surgical field at the end of posterior fossa surgery in the prone position. The unusual endoscopic visual perspective and instrument maneuvers are easily handled with proper neuroendoscopic training., (Copyright © 2018 by the Congress of Neurological Surgeons.)

Background: Tumors protruding into the cerebral aqueduct are rare, and tumors arising from within the cerebral aqueduct are rarer still., Case Description: In this report, we discuss the presentation and clinical outcome of a 65-year-old man who presented to us with symptoms of hydrocephalus. Prior imaging had revealed a small enhancing nodule within the cerebral aqueduct. In the 6 months between initial imaging and our seeing the patient, the tumor demonstrated substantial interval growth, so the patient was offered resection. The tumor was accessed using a sitting, supracerebellar, intracollicular approach, which allowed for gross total resection of the mass without complication. Histopathology later revealed the lesion to be a hemangioblastoma. Two years after surgery, the patient was doing well with no neurologic deficits., Conclusions: We report the first case of an aqueductal hemangioblastoma and describe our use of a sitting, supracerebellar, intracollicular approach to access tumors occupying this cerebrospinal fluid space., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Poor sanitation, poor hygiene, and archaic cooking practices have led to neurocysticercosis (NCC) being endemic in India. Apart from a cortical location that leads to seizures, intraventricular NCC can present with hydrocephalus and sudden deterioration in sensorium. Consequently, endoscopic excision plays an important role in its treatment because a dilated ventricle offers a minimally invasive and less traumatic route to the pathology., Methods: All endoscopically excised intraventricular NCC cases operated were retrospectively analyzed from 2014 to 2017, discussing surgical nuances and postoperative outcome., Results: Twelve such cases were found (mean age, 21.9 ± 8.36 years; 9 men and 3 women). The mean follow-up period was 21.17 ± 13.96 months (range, 2-40 months). The most common site was the aqueduct and fourth ventricle., Conclusions: An endoscopic approach is a feasible and safe tool for treating this disease. Technical nuances such as entry point and trajectory of endoscope need to be kept in mind while operating., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Opening the Sylvian fissure is an important technique in neurosurgery. Despite providing excellent anatomic fidelity, cadaveric and synthetic models lack real-time hemodynamics and coagulation physiology. We introduce a live rat aortoiliac model to practice the basic skills of Sylvian fissure splitting based on its arachnoidal microanatomy. Cadaveric dissections were carried out to assess the microanatomical relationships between the Sylvian fissure arachnoid and its contents, namely arteries (A), veins (V), and brain (B). Rat surgeries were performed to assess the similarities between separating aortoiliac arteries from adjacent veins and the various technical aspects of dissecting the Sylvian fissure. The Sylvian fissure could be divided into 3 compartments regarding the progressive steps of its dissection: (1) superficial opercular, (2) deep opercular, and (3) cisternal. The major arachnoidal connections that required division during dissection of each Sylvian compartment were as follows: B-V and V-V types in the superficial opercular; B-B and A-B types in the deep opercular; and A-B and A-A types in the cisternal compartments. Dissection techniques in the rat aortoiliac model correlated with key techniques in Sylvian fissure dissection. Despite lacking brain tissue, the rat aortoiliac arteries offer a model in which the arteries and veins with their investing connective tissues mimic the arachnoid-vessel interconnections in the Sylvian fissure. Therefore, using this model simulates the essential sub-techniques of splitting the Sylvian fissure. The rat model may be used to provide trainees with an opportunity to practice under the duress of the real-time hemodynamics and coagulation physiology., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

It is presented case report of extremely rare pathology - protoplasmic astrocytoma of sylvian aqueduct involving posterior section of the third ventricle. The main principles of treatment were considered. Dynamics of neurological status was demonstrated. An effectiveness of treatment strategy was assessed.

Background: Endocrine abnormalities are well-recognized consequences of intracranial pathology such as pituitary tumours. Less commonly, hydrocephalus may lead to dysfunction of the endocrine system, presenting as amenorrhoea or precocious puberty. We present a case report and literature review of hydrocephalus causing endocrine abnormalities including reversible infertility., Case Description: A 34 year-old female presented with amenorrhoea and infertility. MRI showed a third ventricular mass and hydrocephalus. The amenorrhoea resolved within weeks of endoscopic third ventriculostomy and tumour biopsy; pregnancy ensued within 6 months. Thirty-two cases of hydrocephalus-related amenorrhoea were reported between 1915 and 2007. All patients who underwent modern hydrocephalus treatment experienced partial or complete resolution of endocrine dysfunction. Successful pregnancy was reported in three patients, as in our case presentation. While mechanisms of dysfunction have not been completely elucidated, studies point toward loss of GnRH pulsatility due to compression of the medio-basal hypothalamic structures., Conclusion: Hydrocephalus can cause endocrine dysfunction, including amenorrhoea, which may reverse with CSF diversion. Therefore, cranial imaging is an important component in the evaluation of such endocrine abnormalities.

OBJECTIVE It has been suggested that the treatment of infant hydrocephalus results in different craniometric changes depending upon whether ventriculoperitoneal shunt (VPS) placement or endoscopic third ventriculostomy with choroid plexus cauterization (ETV/CPC) is performed. Without an objective and quantitative description of expected changes to the infant cranium and ventricles following ETV/CPC, asserting successful treatment of hydrocephalus is difficult. By comparing infants successfully treated via ETV/CPC or VPS surgery, the authors of this study aimed to define the expected postoperative cranial and ventricular alterations at the time of clinical follow-up. METHODS Patients who underwent successful treatment of hydrocephalus at 4 institutions with either VPS placement or ETV/CPC were matched in a 3:1 ratio on the basis of age and etiology. Commonly used cranial parameters (including head circumference [HC], HC z-score, fontanelle status, and frontooccipital horn ratio [FOHR]) were compared pre- and postoperatively between treatment cohorts. First, baseline preoperative values were compared to ensure cohort equivalence. Next, postoperative metrics, including the relative change in metrics, were compared between treatment groups using multivariate linear regression. RESULTS Across 4 institutions, 18 ETV/CPC-treated and 54 VPS-treated infants with hydrocephalus were matched and compared at 6 months postoperatively. The most common etiologies of hydrocephalus were myelomeningocele (61%), followed by congenital communicating hydrocephalus (17%), aqueductal stenosis (11%), and intraventricular hemorrhage (6%). The mean age at the time of CSF diversion was similar between ETV/CPC- and VPS-treated patients (3.4 vs 2.9 months; p = 0.69), as were all preoperative cranial hydrocephalus metrics (p > 0.05). Postoperatively, the ventricle size FOHR decreased significantly more following VPS surgery (-0.15) than following ETV/CPC (-0.02) (p < 0.001), yielding a lower postoperative FOHR in the VPS arm (0.42 vs 0.51; p = 0.01). The HC percentile was greater in the ETV/CPC cohort than in the VPS-treated patients (76th vs 54th percentile; p = 0.046). A significant difference in the postoperative z-score was not observed. With both treatment modalities, a bulging fontanelle reliably normalized at last follow-up. CONCLUSIONS Clinical and radiographic parameters following successful treatment of hydrocephalus in infants differed between ETV/CPC and VPS treatment. At 6 months post-ETV/CPC, ventricle size remained unchanged, whereas VPS-treated ventricles decreased to a near-normal FOHR. The HC growth control between the procedures was similar, although the final HC percentile may be lower after VPS. The fontanelle remained a reliable indicator of success for both treatments. This study establishes expected cranial and ventricular parameters following ETV/CPC, which may be used to guide preoperative counseling and postoperative decision making.

Background: Flexible endoscopes have both a wide range of movement and a wide field of view and are therefore widely used for endoscopic third ventriculostomy and biopsy. However, tumor resection around the aqueduct of Sylvius using flexible endoscopes has scarcely been reported., Case Description: We report 2 cases of tumor resection around the aqueduct of Sylvius. The first case is a 38-year-old man presenting with progressive headache, nausea, and diplopia. Magnetic resonance imaging (MRI) revealed a 1.4 cm nonenhancing mass at the entry of the aqueduct of Sylvius and occlusive hydrocephalus. We performed tumor resection and endoscopic third ventriculostomy (ETV) simultaneously. His symptoms disappeared after the operation. Final pathologic diagnosis was ancient schwannoma. The second case is a 78-year-old woman presenting with progressive disturbance of consciousness (coma). MRI showed 0.7 cm nonenhancing mass at the entry of the aqueduct of Sylvius and occlusive hydrocephalus. We performed tumor resection and ETV similarly. Her consciousness improved after the operation. Final tumor diagnosis was cavernous malformation. In both cases there was no additional neurologic deficit after the surgery., Conclusions: By using a flexible endoscope for tumor dissection, resection of a tumor without a neck, which cannot be removed through aspiration alone, becomes possible. To our knowledge, the presented cases are the first to describe the effectiveness of complete resection of a tumor in the third ventricle using flexible endoscopy., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Purpose: Correct placement of the ventricle catheter directly influences the function of cerebral shunt systems. The incidence of proximal catheter misplacement reaches up to 45%. To avoid misplacements and revisions a new intra-catheter endoscope for precise ventricle catheter placement in children was evaluated., Methods: The semi-rigid ShuntScope (Karl Storz GmbH & Co.KG, Tuttlingen, Germany) with an outer diameter of 1.0 mm and an image resolution of 10,000 pixels was used in a series of 27 children and adolescents (18 males, 9 females, age range 2 months-18 years). Indications included catheter placement in aqueductal stenting (n = 4), first time shunt placement (n = 5), burr hole reservoir insertion (n = 4), catheter placement after endoscopic procedures (n = 7) and revision surgery of the ventricle catheter (n = 7)., Results: ShuntScope guided precise catheter placement was achieved in 26 of 27 patients. In one case of aqueductal stenting, the procedure had to be abandoned. One single wound healing problem was noted as a complications. Intraventricular image quality was always sufficient to recognize the anatomical structures. In case of catheter removal, it was helpful to identify adherent vessels or membranes. Penetration of small adhesions or thin membranes was feasible. Postoperative imaging studies demonstrated catheter tip placements analogous to the intraoperative findings., Conclusions: Misplacements of shunt catheters are completely avoidable with the presented intra-catheter technique including slit ventricles or even aqueductal stenting. Potential complications can be avoided during revision surgery. The implementation of the ShuntScope is recommended in pediatric neurosurgery., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Objective: Increasing experience with intraventricular neuroendoscopic procedures shows good results in the combination of endoscopic third ventriculostomy (ETV) and tumor biopsy. Other possible combinations are mainly presented in subgroups in the literature. Here, we present our experience with combined intraventricular procedures within 1 setting over the last 2 decades., Methods: This study retrospectively analyzes data from neuroendoscopic intraventricular procedures between 1993 and 2015 in 3 different departments of neurosurgery. Inclusion criteria were a combination of at least 2 intraventricular endoscopic procedures (e.g. third ventriculostomy, cyst fenestration, tumor surgery or aqueductoplasty) within 1 setting., Results: One-hundred and thirty cases with more than 300 procedures fulfilled the inclusion criteria. The most frequent combinations were ETV and tumor biopsy (n = 36), ETV and aqueductoplasty/stenting (n = 30), and ETV and cyst fenestration (n = 18). The complication rate was 16.9% with an overall morbidity of 1.6% and mortality of 0.8%. Fornix contusion was one of the most frequent intraoperative complications (16.4%). Shunt independency was achieved in 82.9% of cases with hydrocephalic symptoms., Conclusions: A combination of different intraventricular endoscopic procedures is safe and reliable, bearing similar risks of morbidities and mortality to single neuroendoscopic procedures. This study is one of the largest series in the literature and has similar low complication rates to others. Fornix contusion is the most frequent intraoperative complication in these patients. However, obvious clinical correlation is rare., (Copyright © 2017. Published by Elsevier Inc.)

Introduction: Posterior third ventricle ependymomas with intraaqueductal extension are relatively infrequent lesions. Its surgical management represents a formidable technical challenge and includes a wide variety of approaches. Minimally invasive surgery including the endoscopic management can play a crucial role to obtain an optimal clinical outcome., Patients and Methods: We report the clinical outcome of an 11-year-old female patient with a 6-year history of recurrent episodes of headache and vomiting. On brain MRI a posterior third ventricle lesion with extension to the aqueduct of Sylvius and fourth ventricle, and associated hydrocephalus was observed., Results: Our management of the lesion included a two-step endoscopic surgery: first an anterior third ventriculostomy and biopsy of the lesion that was reported to be a low-grade ependymoma, and posteriorly an endoscopic-assisted resection of the lesion. Clinical outcome was optimal without neurological sequelae. The postoperative MRI showed a thickened ependymal area on the tumor base of implantation. It was considered to be a remnant of the lesion and subsequently treated with radiotherapy., Conclusion: Posterior third ventricle ependymomas with intraaqueductal extension can be endoscopically managed to obtain a successful outcome.