Longstanding Overt Ventriculomegaly in Adults: Pitfalls in Treatment With Endoscopic Third Ventriculostomy

Harold L. Rekate, M.D.


Neurosurg Focus. 2007;22(4):E6 

In This Article

Clinical Material and Methods

Between 1992 and 2006, six patients (two males and four females) were identified as having LOVA and underwent ETV as part of their treatment ( Table 1 ). The patients ranged from 16 to 55 years old (mean age 34 years) on first presentation. All patients had clearly macrocephalic head circumferences and longstanding triventricular hydrocephalus. The large head implied that the process leading to the hydrocephalus began before closure of the sutures and most likely began before the age of 2 years. No patient had a history that suggested an initial cause of the hydrocephalus, such as brain tumor, intracranial hemorrhage, or meningitis.

Four patients underwent their first imaging study given the sole symptom of headaches. One patient presented at the age of 55 years with severe headaches, gait disturbance, and urinary frequency. In the sixth patient headaches played a role in her presentation, but her course was complicated by an unexpected decline in cognitive performance in high school. Only one patient exhibited the signs and symptoms usually associated with NPH, including gait disturbance and urinary incontinence.[11]

Five of the six patients underwent ETV at my institution; one was referred after symptoms failed to improve after an ETV performed elsewhere. Five patients underwent ETV as their first procedure. One patient underwent ETV for persistent severe headaches and multiple shunt complications, including infection and failure of the abdomen to absorb CSF. In all patients MR imaging studies showed flow through the stoma. After injecting iodinated myelographic dye into the ventricles through a tapping reservoir, it was apparent in five patients that flow through the stoma was unimpeded: CSF flowed into the basal cisterns and over the convexities (Fig. 1). None of these patients underwent ICP monitoring as part of the workup for hydrocephalus therapy before the first treatment with either ETV (five patients) or ventriculoperitoneal shunt (one patient).

Cisternogram demonstrating CSF flow through the stoma created by the ETV.


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