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Although the use of newly developed procedures such as endoscopic third ventriculostomy or coagulation of the choroid plexus has gradually expanded, ventriculoperitoneal(VP)shunts are still not obsolete. They are the most commonly performed surgery for treating pediatric hydrocephalus. Young neurosurgeons may frequently encounter this CSF diversion procedure in clinical practice. However, the VP shunt remains a failure-prone procedure, as exemplified by obstruction, infection, mechanical shunt failure, over drainage, and distal catheter site-specific failures. Therefore, surgery requires exquisite techniques, especially in the pediatric population, to meet the needs of the child's growth. This article sheds light on the refined methodology for pediatric VP shunting with meticulous details of the surgical technique. Neurosurgeons must always remember that appropriate ICP control has a major impact on patient development and that a stably functioning VP shunt can deliver the full potential of children with hydrocephalus.

Certain congenital or developmental anomalies of adult-onset hydrocephalus often share clinical symptoms with idiopathic normal pressure hydrocephalus(iNPH). These anomalies include long-standing overt ventriculomegaly in adults(LOVA), persistent Break's pouch cyst(PBC)and panventriculomegaly(PaVM). Certain patients with adult-onset hydrocephalus might have congenital or secondary etiologies, such as late-onset idiopathic aqueductal stenosis(LIAS), and syndrome of hydrocephalus in young and middle-aged adults(SHYMA). Some of these conditions have unknown etiologies, and the definitions of LOVA differ between Japan and overseas. Adult-onset hydrocephalus usually presents with chronic onset, with younger patients tending to have headaches and older patients tending to have iNPH symptoms. In cases where the third ventricle floor bulging, endoscopic third ventriculostomy(ETV)is often performed. However, the arachnoid membrane of the pontine cistern might be strong, and the brain stem might be shifted to the clivus due to the enlarged fourth ventricle. For treating such patients, experienced hands might be needed. At present, it is necessary to carefully examine the cerebrospinal fluid dynamics in each patient and select the best test and treatment.

Endoscopic third ventriculostomy(ETV)is the first-line treatment for fourth ventricle outlet obstruction(FVOO)-associated hydrocephalus. However, because FVOO is difficult to diagnose in the acute stage, ventriculoperitoneal shunt(VPS)is also used. Herein, we report two cases of shunted FVOO resulting in overdrainage or slit ventricle syndrome(SVS)that were treated successfully with the shunt-clamp system. In addition, we discuss the efficacy of the shunt-clamp system for FVOO-associated hydrocephalus. CASE 1:A 79-year-old man complained of severe postural headaches. One year earlier, he underwent VPS for secondary hydrocephalus associated with hemorrhagic cerebellar infarction. CT revealed that the ventricle had become slit-like. Although the shunt valve adjusted the maximum pressure, his complaint and the ventricle shape did not improve. After the on-off valve was inserted in the shunt system and clamped, his symptoms were resolved and the ventricle size was normalized. CASE 2:A 21-year-old man who complained of drowsiness, diplopia, and severe intermittent retroocular pain was admitted to our hospital. One year earlier, he underwent VPS with the shunt-clamp system for a secondary hydrocephalus after surgery for medulloblastoma. CT on admission revealed ventricle dilatation;however, the shape of the ventricle became slit-like 3 days after admission. We made a diagnosis of SVS and planned ETV. Owing to the difficulty in approaching the lateral ventricle, the shunt system was clamped 8 hours before the operation. After confirming ventricle dilatation, ETV was successfully performed. After the operation, the symptoms were resolved, and magnetic resonance imaging confirmed that the ventricle size was normalized.

Introduction: Glioblastoma multiforme (GBM) is a very rare type of tumor involving the pineal region. No case of pineal region GBM with tumoral hemorrhage has ever been reported. Here, we present the first such case report., Case Report: A 65-year-old man presented with sudden-onset disturbance of consciousness. CT revealed intraventricular hemorrhage and acute hydrocephalus. The patient was treated by an emergent operation for ventricular drainage. MRI with contrast media showed a heterogeneous enhanced area in the pineal region. The patient underwent endoscopic biopsy surgery and a third ventriculostomy for non-communicating hydrocephalus. The pathological diagnosis was high-grade glioma, indicating the need for tumor removal via the occipital transtentorial approach. The tumor was removed subtotally and radiation and chemotherapy courses were then started., Conclusion: Pineal GBM with tumoral hemorrhage has never been reported before. Endoscopic operations are useful for rapid decision making prior to radical surgery.

A 57 year-old man developed broad-based unsteady gait and memory loss over a period of one year. On admission, bradykinesia and impairment of postural reflex were evident. Mini-mental state examination scored 27/ 30. Urinary control was normal. MRI revealed symmetric dilatation of lateral and 3rd ventricles, but the 4th ventricle appeared normal. Partial obstruction of the aqueduct with a membranous structure was disclosed by fast imaging employing steady state acquisition (FIESTA), and the diagnosis of late-onset aqueductal membranous occlusion (LAMO) was made. The symptoms were ameliorated shortly after endoscopic aqueductoplasty (EAP) and endoscopic third ventriculostomy (ETV). Membranous occlusion of the aqueduct can be detected by FIESTA and it can be cured by neuro-endoscopic measures.

A 25-year-old man presented with headache and consciousness disturbance. MRI revealed well enhanced mass lesions using gadolinium at bilateral thalamus and right para lateral ventricle with mild perifocal edema. Obstructive hydrocephalus was observed. On neuroendoscopic observation, the tumor was not appeared on the surface of the ventricle, therefore biopsy of the lesion was not sufficient to make a definitive pathological diagnosis. Third ventriculostomy was successful and the patient's consciousness improved. One week later, a stereotactic biopsy for right para lateral ventricle lesion made possible the histological diagnosis of typical germinoma. Post operative course was uneventful. Chemotherapy (CDDP and etoposide) following 30 Gy whole ventricle irradiation resulted in the complete response of the lesion. Four years later, he has no neurological deficit except for mild disturbance in his eye movement. Our experience suggests that a synchronous lesion at thalamus and para lateral ventricle seems to be due to subependymal infiltration other than CSF dissemination.

The authors present a case of aqueductal stenosis (AS) with acute progressive symptoms during pregnancy. A 39-year-old pregnant woman in 19th gestation week was admitted with headache, nausea and deterioration of consciousness. On admission, computed tomography (CT) scan showed acute hydrocephalus. Ventricular drainage was performed on emergency and her symptoms were resolved in a few days. Postoperative T2-weighted MR images showed enlargement of the lateral and third ventricles with membranous occlusion of the aqueduct. Endoscopic third ventriculostomy was performed uneventfully. A healthy baby was delivered by Cesarean section in 36th gestation week considering her previous extirpation of hysteromyoma. In this case of pregnant woman, increase of total body water, cardiac output, and central venous pressure, and decrease in plasma osmotic pressure might contribute to development and sudden worsing of symptoms of pre-existed hydrocephalus due to aqueductal stenosis. Endoscopic third ventriculostomy, especially in the pregnant case, should be recommended in hydrocephalus due to aqueductal stenosis to avoid shunt malfunction caused by increasing intraabdominal pressure and shunt infecton during Cesarean section.

Among the patients with idiopathic cardiomyopathy, those with dilated cardiomyopathy were surgically treated. Initial 18 patients were treated with partial left ventriculectomy(PLV) and thereafter PLV in 26 patients, septal exclusion technique (EVCPP) in 5 patients, or solo-valvular surgery in 12 patients were applied according to the findings of the intraoperative cardiac echogram. The postoperative morbidity and mortality decreased after the selection of the operative procedures. Conclusively, left ventriculoplasty with PLV or EVCPP is a hope for the patients with dilated cardiomyopathy.

A total of 21 neonates with intraventricular hemorrhage (IVH) were studied; 12 (57.1%) survived, and 7 (58.3%) of these 12 cases suffered from hydrocephalus. Hydrocephalus occurred only in patients with IVH of grades III and IV on Papile's classification, and its occurrence rate was 87.5% as the sum total for the two groups. Destructive hydrocephalus (DHC) occurred in 5 cases of grade III and grade IV, and its occurrence rate was 62.5% as the sum total for the two groups. It could be conjectured that the prognosis of the IVH depends upon the extent of the primary hemorrhagic lesions. However, in cases with DHC, the resistance of the cerebral parenchyma to the hydrodynamic force is decreased, so that secondary cerebral destruction yielding rapid and intense ventricular dilatation, which is responsible for the development of neurological disorders, might occur more easily than in cases with IVH of grades III and IV, and to the secondary parenchymal destruction that may arise in association with hydrocephalus. It is essential that a shunt operation should be performed as soon as possible after the diagnosis of DHC has been established so as to allow repair of the primary lesion and to minimize the secondary brain damage.

Since the introduction of the CT scan in 1976, we have experienced 6 cases of the isolated fourth ventricle among 244 hydrocephalic patients (2.5%). Age at diagnosis of the isolated fourth ventricle ranged from 1 year 8 months to 13 years (mean age, 8 years, 6 months). The time interval between the first shunting procedure and the diagnosis of the isolated fourth ventricle varied from 1 year 5 months to 7 years 4 months (mean interval, 4 years 1 months). The prior hydrocephalus were due to intraventricular hemorrhage in two patients, meningomyelocele in a patient and brain tumor in three patients. Two patients had history of cerebrospinal fluid (CSF) infection and five cases underwent multiple shunt revisions. Posterior fossa signs were evident in all cases. It was quite easy to make a diagnosis of the isolated fourth ventricle with CT scan, which demonstrated a large rounded or pear-shaped midline cyst in the posterior fossa. Slit-like lateral ventricles were noted in three cases, while the remaining three had enlarged lateral ventricles. Ventriculography confirmed the isolation of the fourth ventricle in 5 cases. Metrizamide which had been injected into the fourth ventricle was diluted when CT scan was performed 48 hours later, and contrast medium disappeared since then. Magnetic resonance imaging (MRI) well showed the characteristic findings of the isolated fourth ventricle: cystic dilatation of the fourth ventricle, compression and distortion of the brain stem, upward tentorial herniation, occlusion of the aqueduct, downward displacement of the occipital lobe, septum formation of the fourth ventricle and accompanied anomalies such as, Chiari malformation or syringomyelia.(ABSTRACT TRUNCATED AT 250 WORDS)