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Trapped fourth ventricle—treatment options and the role of open posterior fenestration in the surgical management

  • Original Article - CSF Circulation
  • Published:
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Abstract

Background

Trapped fourth ventricle (TFV) is a rare and difficult to treat condition. Most patients have a past inciting event (infection, IVH, trauma) and history of prior CSF diversion. The symptoms are due to the mass effect on brainstem and cerebellum. Rarely, TFV can also be associated with syrinx formation due to a dissociated craniospinal CSF flow near the fourth ventricle outlets. We present our experience and outcomes of open posterior fenestration in 11 cases, along with an overview of the surgical management of TFV.

Methods

Between 2011 and 2018, 11 patients of TFV were operated by the posterior approach fenestration of the fourth ventricle outlets and arachnoid dissection. The clinical and radiological findings of the patients were retrieved from the hospital database. The surgical technique is described in detail. The patients’ neurological status and imaging findings in the follow-up were recorded and compared.

Results

The average age of the patients was 23.55 years. The most common presenting symptoms were headache (9/11) and gait imbalance (7), with TB meningitis being the commonest etiology. Ten patients had a history of prior CSF diversion with two presenting with shunt malfunction. Mean follow-up duration was 33.33 months. The improvement in neurological status was observed in 9/11 patients, 2 remained status quo. On follow-up imaging, 8/11 (72.72%) patients had a decrease in the size of TFV while syrinx improved in 3/5 (60%).

Conclusion

Multiple surgical approaches have been described for TFV. Endoscopic fourth ventriculostomy with aqueductoplasty is gaining popularity in the past two decades. However, an open posterior fenestration of the midline fourth ventricle outlet (magendieplasty) along with sharp arachnoid dissection (adhesiolysis) along the cerebello-medullary cisterns and paracervical gutters is relatively simple and provides physiological fourth ventricular CSF outflow. This is especially useful in TFV with syrinx as the craniospinal CSF circulation is established.

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References

  1. Cinalli G (2014) Endoscopic aqueductoplasty and placement of a stent in the cerebral aqueduct in the management of isolated fourth ventricle in children. https://doi.org/10.3171/ped.2006.104.1.21

  2. Colpan ME, Savas A, Egemen N, Kanpolat Y (2003) Stereotactically-guided fourth ventriculo-peritoneal shunting for the isolated fourth ventricle. Minim Invasive Neurosurg 46(1):57–60

    Article  CAS  Google Scholar 

  3. Dandy EW (1920) The diagnosis and treatment of hydrocephalus resulting from strictures of the aqueduct of Sylvius. SurgGynecolObstet 31:340–345

    Google Scholar 

  4. Dollo C, Kanner A, Siomin V, Ben-Sira L, Sivan J, Constantini S (2001) Outlet fenestration for isolated fourth ventricle with and without an internal shunt. Childs Nerv Syst 17(8):483–486

    Article  CAS  Google Scholar 

  5. Ferrer E, de Notaris M (2013) Third ventriculostomy and fourth ventricle outlets obstruction. World Neurosurg 79(2):S20.e9–S20.e13

    Article  Google Scholar 

  6. Foltz EL, Shurtleff DB (1966) Conversion of communicating hydrocephalus to stenosis or occlusion of the aqueduct during ventricular shunt. J Neurosurg 24(2):520–529

    Article  CAS  Google Scholar 

  7. Fritsch MJ, Kienke S, Manwaring KH, Mehdorn HM (2004) Endoscopic aqueductoplasty and interventriculostomy for the treatment of isolated fourth ventricle in children. Neurosurgery 55(2):372–377 discussion 377-9

    Article  Google Scholar 

  8. Gallo P, Hermier M, Mottolese C, Ricci-Franchi A-C, Rousselle C, Simon E, Szathmari A (2012) 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 60(3):271

    Article  Google Scholar 

  9. Garber ST, Riva-Cambrin J, Bishop FS, Brockmeyer DL (2013) Comparing fourth ventricle shunt survival after placement via stereotactic transtentorial and suboccipital approaches. J Neurosurg Pediatr 11(6):623–629

    Article  Google Scholar 

  10. Garg RK, Malhotra HS, Gupta R (2015) Spinal cord involvement in tuberculous meningitis. Spinal Cord 53:649–657

    Article  CAS  Google Scholar 

  11. Hall TR, Choi A, Schellinger D, Grant EG (1992) Isolation of the fourth ventricle causing transtentorial herniation: neurosonographic findings in premature infants. Am J Roentgenol 159(4):811–815

    Article  CAS  Google Scholar 

  12. Harter D (2004) Management strategies for treatment of the trapped fourth ventricle. Childs Nerv Syst 20(10):710–716

    PubMed  Google Scholar 

  13. Hawkins JC, Hoffman HJ, Humphreys RP (1978) Isolated fourth ventricle as a complication of ventricular shunting. J Neurosurg 49(6):910–913

    Article  Google Scholar 

  14. Kaynar MY, Koçer N, Gençosmanoğlu BE, Hancı M (2000) Syringomyelia - as a late complication of tuberculous meningitis. Acta Neurochir 142(8):935–939

    Article  CAS  Google Scholar 

  15. Lee M, Leahu D, Weiner HL, Abbott R, Wisoff JH, Epstein FJ (1995) Complications of fourth-ventricular shunts. Pediatr Neurosurg 22(6):309–314

    Article  CAS  Google Scholar 

  16. Longatti P, Fiorindi A, Feletti A, Baratto V (2006) Endoscopic opening of the foramen of Magendie using transaqueductal navigation for membrane obstruction of the fourth ventricle outlets. J Neurosurg 105(6):924–927

    Article  Google Scholar 

  17. Longatti P, Fiorindi A, Martinuzzi A, Feletti A (2009) Primary obstruction of the fourth ventricle outlets. Neurosurgery 65(6):1078–1086

    Article  Google Scholar 

  18. Matula C, Reinprecht A, Roessler K, Tschabitscher M, Koos WT (1996) Endoscopic exploration of the IVth ventricle. Minim Invasive Neurosurg 39(3):86–92

  19. Mohanty A, Manwaring K (2018) Isolated fourth ventricle: to shunt or stent. Oper Neurosurg 14(5):483–493

    Article  Google Scholar 

  20. Montes JL, Clarke DB, Farmer JP (1994) Stereotactic transtentorial hiatus ventriculoperitoneal shunting for the sequestered fourth ventricle. J Neurosurg 80(4):759–761

  21. Orakdogen M, Emon ST, Erdogan B, Somay H (2015) Fourth ventriculostomy in occlusion of the foramen of magendie associated with Chiari Malformation and Syringomyelia. NMC Case Rep J 2(2):72

  22. Raimondi AJ (1987) Pediatric neurosurgery : theoretical principles art of surgical techniques. Springer, New York

    Book  Google Scholar 

  23. Rajshekhar V (2009) Management of hydrocephalus in patients with tuberculous meningitis. Neurol India 57(4):368–374

    Article  Google Scholar 

  24. Teo C, Burson T, Misra S (1999) Endoscopic treatment of the trapped fourth ventricle. Neurosurgery 44(6):1257–1262

    CAS  PubMed  Google Scholar 

  25. Tyagi G, Bhat DI, Devi BI, Shukla D (2019) Multiple remote sequential supratentorial epidural hematomas—an unusual and rare complication after posterior fossa surgery. World Neurosurg 128:83–90

    Article  Google Scholar 

  26. Udayakumaran S, Biyani N, Rosenbaum DP, Ben-Sira L, Constantini S, Beni-Adani L (2011) Posterior fossa craniotomy for trapped fourth ventricle in shunt-treated hydrocephalic children: long-term outcome. J Neurosurg Pediatr 7(1):52–63

    Article  Google Scholar 

  27. Upchurch K, Raifu M, Bergsneider M (2007) Endoscope-assisted placement of a multiperforated shunt catheter into the fourth ventricle via a frontal transventricular approach. Neurosurg Focus 22(4):E8

    Article  Google Scholar 

  28. Villavicencio AT, Wellons JC III, George TM (1998) Avoiding complicated shunt systems by open fenestration of symptomatic fourth ventricular cysts associated with hydrocephalus. Pediatr Neurosurg 29(6):314–319

    Article  CAS  Google Scholar 

  29. Williams B (1990) Paraplegia post-traumatic syringomyelia, an update. ParaplegitJ 28:296–313

    CAS  Google Scholar 

Download references

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Authors and Affiliations

  1. Department of Neurosurgery, II Floor, Faculty Block, National Institute of Mental Health and Neurosciences, Hosur Road, Bengaluru, India

    Gaurav Tyagi, Dhaval Shukla, Nupur Pruthi & Bhagavatula Indira Devi

  2. Department of Neurosurgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India

    Prashant Singh

  3. Department of Neurosurgery, Aster RV Hospital, Bengaluru, India

    Dhanajaya I. Bhat

Authors
  1. Gaurav Tyagi
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  2. Prashant Singh
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  3. Dhanajaya I. Bhat
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  4. Dhaval Shukla
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  5. Nupur Pruthi
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  6. Bhagavatula Indira Devi
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Correspondence to Bhagavatula Indira Devi.

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All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge, or beliefs) in the subject matter or materials discussed in this manuscript.

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Comments

The authors retrospectively review a single-centre case series of 11 patients who underwent surgery for symptomatic trapped fourth ventricle between 2010 and 2018. All underwent an open procedure involving a posterior fossa craniotomy and removal of the posterior arch of C1, with extensive adhesiolysis along the cerebellomedullary fissure, foramen of Magendie and upper cervical spine, and expansile duraplasty. Mean follow up was 33.3 months (all over six months) with clinical improvement in nine patients. The authors conclude that open surgery is an effective and safe method to treat a trapped fourth ventricle. While the surgical risk of an extensive open procedure in a chronically scarred posterior fossa and craniocervical junction may be considered to be higher than in image-guided shunting of the fourth ventricle, this technique allows some restoration of normal anatomy and CSF flow. This study offers further insight into a rare neurosurgical problem and is a valuable contribution to the existing literature.

Kristian Aquilina

London,UK

This article is part of the Topical Collection on CSF Circulation

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Tyagi, G., Singh, P., Bhat, D.I. et al. Trapped fourth ventricle—treatment options and the role of open posterior fenestration in the surgical management. Acta Neurochir 162, 2441–2449 (2020). https://doi.org/10.1007/s00701-020-04352-3

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  • DOI: https://doi.org/10.1007/s00701-020-04352-3

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