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Endoscopic third ventriculostomy for hydrocephalus after perimesencephalic subarachnoid hemorrhage: initial experience in three patients

  • Clinical Article
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Abstract

Background

To review the outcome after endoscopic third ventriculostomy (ETV) for symptomatic, persistent hydrocephalus in three patients with perimesencephalic angiographically negative subarachnoid hemorrhage (PNH) who were dependent on an external ventricular drain (EVD).

Methods

All patients initially presented with severe headache, nuchal rigidity, confusion and lethargy (Hunt-Hess Grade II or III), and persistent, EVD-dependent hydrocephalus. Cranial CT images in each revealed acute hydrocephalus and perimesencephalic hemorrhage pattern with a heavy clot burden (Fisher grade 3). A 3D-CT angiogram on admission and two four-vessel cerebral angiograms failed to demonstrate a bleeding source. All three patients failed trial EVD clamping, with clinical deterioration and elevated intracranial pressure (ICP). ETV was performed with a 0-degree endoscope in a 4.6-mm irrigating sheath using an endoscopic-coring/“cookie-cut” technique. An EVD was left in place for postoperative ICP monitoring but was clamped.

Results

ETV was accomplished in all patients. In one case, a tiny basilar tip aneurysm was seen during the endoscopic procedure. Intraoperatively, the prepontine cistern revealed dense, degraded blood products. Postprocedure ICP measurements were reduced to normal range. Clinical improvement, normal ICP readings, and/or radiographic evidence of resolution of hydrocephalus allowed uneventful removal of the EVD within 36–48 h post-ETV in all patients. All remained headache-free, with a normal neurological examination, during a follow-up period of 10, 11, and 12 months, respectively.

Conclusion

To our knowledge, this is the first report of ETV for PNH with hydrocephalus and the first report of a basilar tip microaneurysm seen intraoperatively during ETV. ETV is a viable treatment option for refractory hydrocephalus secondary to a perimesencephalic pattern of subarachnoid hemorrhage (SAH). Its early application can avoid placement of a ventriculoperitoneal shunt, curtail the extended use of an EVD, and reduce the associated infection risks. Despite thorough angiographic investigation for an aneurysmal cause of SAH, a “microaneurysm” of the basilar artery was found at ETV. No complication or rebleeding was encountered.

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Abbreviations

CSF:

cerebrospinal fluid

CT:

computed tomographic

ETV:

endoscopic third ventriculostomy

EVD:

external ventricular drain

ICP:

intracranial pressure

PNH:

perimesencephalic angiographically negative subarachnoid hemorrhage

SAH:

subarachnoid hemorrhage

VP:

ventriculoperitoneal

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Acknowledgements

The authors thank Paul H. Dressel, BFA, for preparation of the illustrations and Debra J. Zimmer, AAS CMA-A, for editorial assistance.

Funding of/support for this study

None

Conflicts of interest

None.

Disclosure

Aesculap has provided educational grants to support the annual brain endoscopy courses held in Buffalo, NY, for which Dr. Grand and Dr. Leonardo are the course director and co-director, respectively. Dr. Snyder has received research support from Toshiba. Dr. Chamczuk reports no relationships.

Author contributions to the study and manuscript preparation include the following:

Conception and design: Grand. Acquisition of data: Grand, Chamczuk, Leonardo. Analysis and interpretation of data: Grand, Leonardo, Snyder. Drafting the manuscript: Grand, Chamczuk. Critically revising the article: all authors. Reviewing the final version of the manuscript and approving it for submission: all authors. Study supervision: Grand.

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Authors and Affiliations

  1. Department of Neurosurgery, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA

    Walter Grand, Andrea J. Chamczuk, Jody Leonardo & Kenneth V. Snyder

  2. Department of Neurosurgery, Millard Fillmore Gates Hospital and Buffalo General Hospital, Kaleida Health System, Buffalo, NY, USA

    Walter Grand, Andrea J. Chamczuk, Jody Leonardo & Kenneth V. Snyder

  3. University at Buffalo Neurosurgery, 3 Gates Circle, Buffalo, NY, 14209, USA

    Walter Grand

Authors
  1. Walter Grand
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  2. Andrea J. Chamczuk
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  3. Jody Leonardo
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  4. Kenneth V. Snyder
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Corresponding author

Correspondence to Walter Grand.

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Comment

The authors present a three case series with literature review of treating perimesencephalic non-aneurysmal subarachnoid hemorrhage-associated hydrocephalus with endoscopic third ventriculostomy (ETV).

Patients with non-aneurysmal perimesencephalic subarachnoid hemorrhage (NPMSAH) represent approximately 5% of subarachnoid hemorrhages. Although the development of hydrocephalus is uncommon, it is rare that permanent CSF diversion is required (i.e., VPS). The authors demonstrate the feasibility of performing an endoscopic third ventriculostomy to treat these patients. ETV is a well-accepted technique for treating obstructive hydrocephalus, commonly due to aqueductal stenosis. Intuitively, the role of ETV in treating communicating hydrocephalus is less obvious; however, it has been used successfully. The exact reason, as the authors allude to, is poorly understood.

The results cannot be disputed. The patients clearly had hydrocephalus, with elevated intracranial pressures. After failing to remove the EVD, the patients underwent an ETV. The ventricular size and intracranial pressures responded favorably, and the patients were spared the placement of a VPS. Although follow-up is short, ≈1 year, the patients have done well, and no evidence of hydrocephalus exists. It is of interest whether the ETV has remained patent. I commend the authors for their contribution.

Michael W. Weaver

Christopher M. Loftus

Philadelphia, PA

Financial relationships and/or potential conflicts of interest are as follows: Aesculap has provided educational grants to support the annual brain endoscopy courses held in Buffalo New York, for which Dr. Grand and Dr. Leonardo are the course director and co-director respectively. Dr. Snyder has received research support from Toshiba. Dr. Chamczuk has no financial relationships to disclose.

Previous presentation

Presented partially in abstract form at The Neurosurgical Society of America meeting at Pebble Beach, California, October 14, 2010

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Grand, W., Chamczuk, A.J., Leonardo, J. et al. Endoscopic third ventriculostomy for hydrocephalus after perimesencephalic subarachnoid hemorrhage: initial experience in three patients. Acta Neurochir 153, 2049–2056 (2011). https://doi.org/10.1007/s00701-011-1106-2

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