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


In terms of immediate and long-term CSF flow through the endoscopically created stoma, all procedures were successful. All patients underwent MR imaging studies of CSF flow that confirmed free pulsatile flow through the created stoma. Only one patient, a 16-year-old girl, underwent ETV as the sole procedure. She had presented with morning headaches, declining school performance, and a large head. Magnetic resonance images showed triventricular hydrocephalus. After ETV her headaches resolved, and 48 hours of ICP monitoring via an implanted external ventricular drain showed normal ICP. Four years after treatment, follow-up data in this patient showed no signs of neurological deficit or increased ICP. She reported difficulty with her short-term memory but demonstrated no change in her school performance. This probably permanent but mild difficulty with short-term memory was the only documented complication among patients in this study. Interestingly, late MR imaging studies revealed free CSF flow through the sylvian aqueduct, which had not been present before the ETV.

There were no deaths, and no complications were revealed by general physical or neurological examinations. Five patients underwent ETV as a first procedure. Post operatively, one of these patients had significantly increased ICP that persisted for 5 days. During hospitalization for this problem, she underwent VP shunt placement despite the free flow of contrast material into the basal cisterns and cortical subarachnoid spaces. Two patients, who had presented with headaches, were symptom free for 18 months and 3 years. Thereafter, they suffered progressively increasing headache disorders refractory to medical management, and they underwent shunting procedures. Despite several admissions for ICP monitoring, headaches remain unrelieved in the three patients who underwent shunting as a salvage procedure.

One patient, who remained symptomatic after a VP shunt had been placed, underwent ETV. Her course was complicated by several infections. The VP shunt was converted to a pleural shunt for failure of the peritoneum to absorb spinal fluid. This patient initially presented with a headache disorder that led to the diagnosis of hydrocephalus and shunt implantation. Her headaches did not respond to adjustment of the programmable shunt valve and documentation of normal ICP during chronic monitoring. The shunt was removed. When her ICP was found to be high after shunt removal, she underwent ETV.[1,29] Her headaches persisted, and the shunt was reinserted at the request of the patient, who believed that the headaches had worsened after the ETV and shunt removal despite a normal ICP. A second patient who was treated for headaches that persisted after an ETV despite normal CSF flow is discussed next.


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