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ORIGINAL ARTICLE
Year : 2012  |  Volume : 60  |  Issue : 3  |  Page : 271-277

The endoscopic trans-fourth ventricle aqueductoplasty and stent placement for the treatment of trapped fourth ventricle: Long-term results in a series of 18 consecutive patients


1 Department of Neurological Surgery, University Hospital, Verona, Italy
2 Department of Pediatric Neurosurgery, Hopital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Lyon, France

Date of Submission28-Feb-2012
Date of Decision05-Apr-2012
Date of Acceptance11-May-2012
Date of Web Publication14-Jul-2012

Correspondence Address:
Pasquale Gallo
Service of Pediatric Neurosurgery, University Hospital of Verona, Piazzale A. Stefani, 137126 Verona
Italy
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DOI: 10.4103/0028-3886.98507

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 » Abstract 

Background: Different surgical approaches have been described in the past to treat a trapped fourth ventricle (TFV) but, unfortunately, these techniques showed a high rate of dysfunction and complications. During the last 10 years the development of neuroendoscopy has dramatically changed the outcome of these patients. Materials and Methods: We conducted a retrospective evaluation of the safety, effectiveness, and long-term outcome of endoscopic aqueductoplasty and stent placement, performed in 18 consecutive patients with symptomatic TFV through a trans-fourth ventricle approach between 1994 and 2010. Thirteen patients underwent endoscopic aqueductoplasty and stent placement and 5 patients underwent aqueductoplasty alone using a tailored suboccipital approach through the foramen of Magendie in prone or sitting position. Results: The mean age of the patients at the time of surgery was 15.2 years. All patients but 3 had a supratentorial ventriculoperitoneal shunt. Fifteen patients presented with slit supratentorial ventricles. At a mean followup of 90.8 months all patients experienced a stable clinical improvement. Only two complications were observed: A transient diplopia due to dysconjugate eye movements in one patient and a transient trochlear palsy in another one. Conclusions: Our experience and the literature review suggest that endoscopic trans-fourth ventricle aqueductoplasty and stent placement is a minimally invasive, safe, and effective technique for the treatment of TFV and should be strongly recommended, especially in patients with supratentorial slit ventricles.


Keywords: Aqueductoplasty, endoscopy, hydrocephalus, stent placement, trapped fourth ventricle


How to cite this article:
Gallo P, Szathmari A, Simon E, Ricci-Franchi AC, Rousselle C, Hermier M, Mottolese C. The endoscopic trans-fourth ventricle aqueductoplasty and stent placement for the treatment of trapped fourth ventricle: Long-term results in a series of 18 consecutive patients. Neurol India 2012;60:271-7

How to cite this URL:
Gallo P, Szathmari A, Simon E, Ricci-Franchi AC, Rousselle C, Hermier M, Mottolese C. The endoscopic trans-fourth ventricle aqueductoplasty and stent placement for the treatment of trapped fourth ventricle: Long-term results in a series of 18 consecutive patients. Neurol India [serial online] 2012 [cited 2014 Dec 20];60:271-7. Available from: http://www.neurologyindia.com/text.asp?2012/60/3/271/98507



 » Introduction Top


The trapped fourth ventricle (TFV) is an uncommon sequela usually observed in patients with ventricular shunt placed to treat a posthemorrhagic or postmeniningitic hydrocephalus. [1],[2] After successful treatment, the entire ventricular system gets decompressed and the aqueductal walls may adhere in the presence of ependymal surface inflammation. [3],[4] Under anatomic circumstances, cerebrospinal fluid (CSF) exits the fourth ventricle via the  Foramina of Luschka More Details and Magendie. If these outlets are not patent and the cerebral aqueduct is blocked, the CSF produced by the choroid plexus results in a progressive dilatation of the fourth ventricle. [5] Clinical presentation of the fourth ventricle enlargement is similar to posterior fossa mass lesions. [6],[7],[8] Surgical management of TFV can be demanding and often results in multiple surgeries. [9] Particularly, fourth ventricle shunts, the most commonly used procedures, are associated with a high rate of dysfunction and complications mainly related to the insertion of the catheter within the fourth ventricle. [10],[11] The development of endoscopic techniques has really changed the therapy of trapped fourth ventricle. Endoscopic reopening of the aqueduct, from above, through a classical precoronal approach, or from below, through a suboccipital approach, depending on the anatomic situation, is the ideal and most physiologic therapy of TFV. This leads to communication between the isolated fourth ventricle and the supratentorial compartment equating intraventricular pressure gradients and allowing a single supratentorial shunt to control hydrocephalus. [12],[13],[14] In this study, we report our experience of 18 patients with TFV who underwent endoscopic aqueductoplasty, with or without stent placement by using a tailored suboccipital approach through the foramen of Magendie to access the trapped fourth ventricle.


 » Materials and Methods Top


Patients

Between January 1994 and December 2009 at the Department of Pediatric Neurosurgery, Hopital Neurologique, Lyon, France, 18 patients, that is, 13 children and 5 adults, with symptomatic TFV underwent endoscopic aqueductoplasty alone (adult patients) or accompanied by stent placement (children). The mean age of the patients at the time of surgery was 15.2 years (range, 10 months to 66 years). Pediatric patients had a history of posthemorrhagic hydrocephalus in 5, postmeningitic hydrocephalus in 3, hydrocephalus postremoval of a posterior fossa tumor in 3, and hydrocephalus associated with myelomeningocele in 2. In adult patients the etiology of hydrocephalus was posthemorrhagic in 2, postremoval of posterior fossa tumor in 3 (1 hemangioblastoma and 2 ependymomas), and in 1 case due to brain stem compression caused by giant coiled basilar tip aneurysm. All patients but 3 adults had undergone supratentorial ventriculoperitoneal shunt for hydrocephalus and 2 underwent also endoscopic third ventriculostomy. Only 3 children had their shunt previously revised for malfunction. TFV developed at different times in patients with shunts, the median time was 4.5 years (range, 2-15 years). Clinical presentation included headache, vomiting, ataxia, vertigo, diplopia, swallowing trouble, and impaired consciousness [Table 1]. All the patients underwent preoperative computed tomography (CT) scan or magnetic resonance imaging (MRI) and postoperative MRI and further followup studies at an interval of 3 or 6 months. Preoperative radiologic examinations showed a slit supratentorial ventricular system in 15 (83%) patients.
Table 1: Characteristics of the patients in our series

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Surgical technique

The procedures were performed in a sitting position in the first 2 patients, and in a prone position in the remaining patients. The head was fixed in a 3-point headholder in patients older than 2 years of age; younger children were positioned prone in a padded horseshoe. The amount of neck flexion needed to align the Silvius aqueduct and the foramen magnum was identified by carefully reviewing the MRI [Figure 1]a and b. A 4 cm craniocervical midline skin incision was made so that the midpoint of the incision represents the projection on the skin of the imaginary aqueduct-foramen magnum line. A small amount of bone was removed from the suboccipital bone with a rongeur to give a wider range of motion to the endoscope during the intraventricular step. The atlanto-occipital membrane was opened and partially removed exposing the underlying dura [Figure 2]. A 1 cm opening of the dura mater was done exposing the arachnoid of the cisterna magna and the cerebellar tonsils. The arachnoid was opened under endoscope view [Figure 3]a-c. A 0° or 30° rigid endoscope was advanced in between the cerebellar tonsils, through the foramen of Magendie (sometimes in TFV covered by a thin membrane that is easily opened) into the large fourth ventricle [Figure 3]d. After we identified the principal landmarks inside the ventricle (the lateral recessus with their choroid plexus and the structures of the fourth ventricle floor) the endoscope was moved toward the caudal end of the aqueduct and a Lapras tube with double wings (Codman Johnson & Johnson, Saint Priest-Cedex, France), redesigned and adapted to endoscopic use, was pushed forward until the superior wing reached the third ventricle. The inferior wing of the tube remained into the fourth ventricle [Figure 4]a-d. If a thin membrane was visualized, we tried to break it using a gentle irrigation or a smooth dissection with the catheter's tip before stenting the aqueduct. In cases we could reopen the aqueduct in this way, and the opening was larger than the diameter of the stent at the wing's level, we did not put the catheter into the aqueduct. The right position and the functioning of the catheter are tested by gently irrigating a Ringer solution inside the distal end of the tube and observing the dripping of the liquid into the fourth ventricle [Figure 4]e and f. The endoscope was then withdrawn and the dura mater was closed in a watertight fashion. In case of unusual or distorted anatomy we used neuronavigation to better identify the inlet of the aqueduct and thus the entry point. All patients underwent postoperative clinical and imaging evaluation. CT scans were obtained within 48 h after surgery mainly to check the stent position.
Figure 1(a-b): Patient in prone position: The amount of neck flexion needed to align the Silvius aqueduct and the foramen magnum is identified by reviewing carefully the inclination of the aqueduct on magnetic resonance imaging

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Figure 2: A small amount of bone is removed from the suboccipital bone and the atlanto-occipital membrane is opened and partially removed exposing the underlying dura

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Figure 3: The arachnoid is opened under endoscope view (a,b). A 30° rigid endoscope is advanced in between the cerebellar tonsils, through the foramen of Magendie (c) into the large fourth ventricle (d)

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Figure 4: Surgical steps of the cannulation of the Silvius aqueduct by using a double wings Lapras stent. After we have identified the principal landmarks inside the ventricle (the lateral recessus with their choroid plexus and the structures of the fourth ventricle floor) the endoscope is moved toward the caudal end of the aqueduct and a Lapras tube with double wings (Codman) is pushed forward, keeping in mind the orientation of the aqueduct, until the superior wing reaches the third ventricle (a-c). The inferior wing of the tube remains into the fourth ventricle and the distal end of the catheter is cut (d). The right position and the functioning of the catheter were tested by gently irrigating a Ringer solution inside the distal end of the tube and observing the dripping of the liquid into the fourth ventricle (e,f)

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 » Results Top


All pediatric patients underwent aqueductoplasty and stent placement while the 5 adults underwent aqueductoplasty alone. Postoperatively, clinical signs of intracranial pressure disappeared in the patients. At a mean followup of 90.8 months, all the patients experienced a stable clinical improvement and of the 6 patients who developed cerebellar signs postoperatively, 4 patients recovered completely and 2 patients had mild persistent cerebellar sings in the right arm. Four patients had preoperative oculomotor deficits; 2 patients showed a significant improvement within 10 months after the operation and 2 patients showed a complete recovery. Patients with swallowing difficulty completely recovered within 2 months.

Two patients had postoperative complications related to the cannulation of the aqueduct, both the complications completely resolved within 2 months; a transient diplopia due to dysconjugate eye movements in 1 patient and a transient trochlear palsy in another one. There were no infectious or hemorrhagic complications and no patient had any sort of postoperative complication related to the posterior fossa approach.

All patients are regularly followedup as outpatients and no patient was lost at the followup. During the followup period, 5 patients had their supratentorial shunt revised for malfunction. No patient developed restenosis in the group of aqueductoplasty alone and in no case there was a necessity to revise the stent in the group in which a catheter was placed. From a radiologic point of view, the volume of the fourth ventricle dramatically decreased in size in 76% of cases, in the others it remained quite large [Figure 5]a-e.
Figure 5: Preoperative magnetic resonance imaging (MRI) view of the trapped fourth ventricle (a,b). Note the slit-like supratentorial ventricles (c). Postoperative MRI view with the stent inserted (d,e)

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 » Discussion Top


Although TFV is a rare complication, trapped fourth ventricle is a well-known pathologic entity with several surgical strategies of treatment approaches. [15] Among these therapeutic options, the placement of a fourth ventricle shunt has been the most widely used therapy. [16],[17] Shunt procedures can be effective but they present a high rate of malfunction [10] and complications mainly related to the risk of potential lesions to the floor of the fourth ventricle during the positioning of the catheter or, later, following a reduction in the size of the fourth ventricle. [11] Some authors proposed to introduce the catheter parallel to the fourth ventricle floor through a supra-transtentorial approach under stereotactic guidance. [18] However, in our opinion, this approach poses some dangers due to the risk of injury of the venous structures displaced on the superolateral wall of the trapped fourth ventricle. Aqueductal stent therapy through a posterior fossa approach is not a new concept. Dandy in 1920 reported 2 patients with aqueductal stenosis treated by this approach. He used a rubber catheter that was inserted in the aqueduct only to shape its lumen and then was withdrawn 2-3 weeks after the operation. One patient survived the procedure. [19] Since Dandy, only few neurosurgeons tried this approach because of the associated high mortality and morbidity rate. [20],[21],[22],[23],[24],[25],[26] Lapras, who developed the catheter that bears his name, reported the largest series in the literature (77 patients) of the cannulation of the aqueduct through a posterior fossa approach. In this series the mortality rate was 5% and the morbidity rate (mainly related to the complication of an invasive posterior fossa approach) was 30%. [27],[28],[29] The advent of shunt surgery and subsequent development of the technique of third ventriculostomy under endoscopic guidance made obsolete the cannulation of the Silvius aqueduct through a posterior approach in the treatment of obstructive hydrocephalus. In 1996, Matula et al. [30] and then in 1999 Teo et al. [31] described the endoscopic infratentorial approach through a small suboccipital craniectomy to treat patients with trapped fourth ventricle when the third ventricle was too narrow to admit the endoscope. Both of them showed feasibility and low morbidity rate of endoscopic technique compared with multiple extracranial ventricular shunt catheters. Schroeder et al. demonstrated on cine phase contrast MRI that aqueductal CSF flow after endoscopic aqueductoplasty is similar to aqueductal CSF flow in healthy volunteers and showed that aqueductoplasty restores the physiologic CSF pathways and equalizes ventricular pressure across the tentorium in patients with obstructive hydrocephalus. [32] Nevertheless, we are skeptical that this procedure is more effective and safer than ETV as treatment for hydrocephalus in aqueductal stenosis (or, probably, it could be beneficial in cases of aqueductal stenosis due to the presence of a thin caudal end membrane). On the other hand, we are convinced it is the ideal treatment in case of TFV where the fourth ventricle is large and the length of the aqueductal stenosis is minimal. [33],[34]

A review of the literature of the surgical series reporting the endoscopic treatment of TFV found 13 studies with 64 patients. [12],[13],[14],[30],[31],[35],[36],[37],[38],[39],[40],[41] The majority of the papers reported the experience with a single case or few cases; a suboccipital approach was selected only in 17 patients [Table 2]. Although the choice of the approach is dictated mainly by the size of the supratentorial ventricular system, slit-like lateral and third ventricle with a large fourth ventricle are by far the most frequent situations encountered in case of TFV and from our perspective, a suboccipital trans-Magendie approach appears to be the most logical, less traumatic, and less risky approach to solve the problem. Concerning the position of the patient during the procedure we think it mainly depends on the experience of the surgeon and anesthesiologist preference. The sitting position presents the problem of air embolism and postoperative pneumocephalus but makes the cannulation easier. On the other hand, prone position presents the inconvenience of the accumulation of CSF and blood at the top of the ventricular cavity around the inferior aqueductal entry and so could be responsible for a longer duration of the procedure [Figure 6]a-c. Literature review suggests that aqueductal stent placement, although has the disadvantage of leaving additional foreign material within the ventricular system, is strongly recommended especially in patients with a history of intraventricular hemorrhage or infection; no restenosis occurred in patients who underwent aqueductal stent placement against 53% of restenosis rate reported in patients who underwent aqueductoplasty alone. [12],[13],[14],[30],[31],[35],[36],[37],[38],[39],[40],[41] On the basis of our experience, we recommend stent placement in all cases in which the restoration of the stenosis achieved with aqueductoplasty alone is smaller than the diameter of the stent. In our series long-term radiologic reduction of the fourth ventricle size was observed in 76% of cases, while the ventricle remained quite large in the remaining cases. As all the patients clinically improved, in our opinion the postoperative ventricular size is not so predictive of good outcome.
Figure 6: Note the inconvenience of the accumulation of cerebrospinal fluid and blood at the top of the ventricular cavity around the inferior aqueductal entry when patient is in prone position (a). The need to draw the liquid to improve the surgeon's view could be responsible for a longer duration of the procedure (b). Endoscopic view after the successful cannulation of the aqueduct (c)

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Table 2: Literature review of 64 trapped fourth ventricle treated with an endoscopic approach

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Transient ophthalmoparesis is the most common complication reported in the literature after endoscopic aqueductoplasty with or without stent placement (10.9% in patients treated for a TFV). The anatomic substrates for these problems are trochlear nuclei, medial longitudinal fasciculus, tectum, dorsal longitudinal fasciculus, and periaqueductal central gray area. [31] In our experience this complication occurred only in 2 patients and completely resolved within 2 months. During stent placement, in case of distorted anatomy, there is a real risk of injury to the periaqueductal structures; in these circumstances we found the use of neuronavigation very beneficial to identify the right entry point into the aqueduct. The criticism by some authors that stent placement increases the risk of infection [42] has not been document till date, and further supported by our experience. We use a Lapras tube with double wings redesigned and adapted to endoscopic use (Codman) as aqueductal stent and no infection, hemorrhage, stent migration, or periaqueductal structures injury occurred using this type of catheter.

Our experience combined with the literature evidence suggests that endoscopic approach should be the first therapeutic line in patients presenting with TFV. Among the endoscopic options, in our opinion, aqueductoplasty with stent placement by using a suboccipital approach through the foramen of Magendie appears to be the most logical, atraumatic, and effective procedure to solve this challenging condition.

 
 » References Top

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

  [Table 1], [Table 2]

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