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Purpose: Endoscopic third ventriculostomy (ETV) is an effective treatment for obstructive hydrocephalus. Secondary stoma closure may be life threatening and is the most common reason for late ETV failure, mostly secondary to local scarring. Local stents intended to maintain patency are rarely used. In this study, we summarize our experience using stented ETV (sETV), efficacy, and safety., Material and Methods: Data was retrospectively collected from all consecutive patients who underwent ETV with stenting at four centers. Collected data included indications for using sETV, hydrocephalic history, surgical technique, outcomes, and complications., Results: Sixty-seven cases were included. Forty had a primary sETV, and 27 had a secondary sETV (following a prior shunt, ETV, or both). The average age during surgery was 22 years. Main indications for sETV included an adjacent tumor (n = 15), thick or redundant tuber cinereum (n = 24), and prior ETV failure (n = 16). Fifty-nine patients (88%) had a successful sETV. Eight patients failed 11 ± 8 months following surgery. Reasons for failure included obstruction of the stent, reabsorption insufficiency, and CSF leak (n = 2 each), and massive hygroma and tumor spread (n = 1 each). Complications included subdural hygroma (n = 4), CSF leak (n = 2), and stent malposition (n = 1). There were no complications associated with two stent removals., Conclusion: Stented ETV appears to be feasible and safe. It may be indicated in selected cases such as patients with prior ETV failure, or as a primary treatment in cases with anatomical alterations caused by tumors or thickened tuber cinereum. Future investigations are needed to further elucidate its role in non-communicating hydrocephalus., (© 2024. The Author(s).)

Purpose: Endoscopic transaqueductal stenting has become a well-accepted treatment option for a selected small subset of aqueductal stenosis-related obstructive hydrocephalus. However, transaqueductal stenting poses unique challenges and risks which requires critical consideration. This report discusses the clinical experiences with transaqueductal stenting for periaqueductal tumor-related aqueductal stenosis focusing on pediatric patients., Methods: A retrospective analysis of all patients undergoing endoscopic TAS from 01/1993 to 01/2022 in the author's departments was performed. Demographic, clinical, radiological, and intraoperative endoscopic data were evaluated. All patients with AS-related occlusive hydrocephalus that was treated with TAS were analyzed and prospectively followed. Special attention has been given to providing insights into indications, surgical technique, and limitations., Results: Out of 28 endoscopic transaqueductal endoscopis stenting procedures, five procedures were performed on periaqueductal tumor-related obstructive hydrocephalus, two children and three adult patients. CSF pathway was obstructed by tumor located in the aqueduct in 2, by tumor in the thalamus/mesencephalon in 1, by a tumor within the third ventricle in 1, and by a tumor of the lamina tecti in 1. Simultaneously with transaqueductal stenting, 2 endoscopic third ventriculostomies (ETV), 3 tumor biopsies, and 1 tumor resection were performed. Postoperative complications included the following: CSF fistula (1 case), and asymptomatic fornix contusion (1 case). A working aqueductal stent was achieved in all cases based on clinical follow-up evaluation. Postoperatively, all patients showed improvement or resolution of their symptoms. The mean follow-up period was 25.2 months (range, 1-108 months). One patient died due to tumor progression during early follow-up. No stent migration was seen., Conclusion: Endoscopic third ventriculostomy remains the gold standard for treatment of CSF circulation obstructions with lesions in the posterior third ventricle and aqueduct. Transaqueductal stenting for periaqueductal tumor-related aqueductal compression is technically feasible. However, because of the potential high risks and subtle advantages compared with ETV transaqueductal stenting, it might be indicated in a small subset of well-selected patients if alternative treatment options are not at hand., (© 2023. The Author(s).)

Introduction: Endoscopy was first employed in the surgical treatment of neurosurgical diseases early in the twentieth century, but did not become an established practice for a long time, mainly because of poor technology and clinical results. After a slow re-appearance in the 1980s, the 1990s saw an explosion of techniques and instrumentation. Continuing technological improvement has led to further expansion of surgical techniques and indications for use of neuroendoscopy., Discussion: The expansion of ventricular endoscopy has led to significant understanding of CSF disorders. Aqueduct stenosis as cause of hydrocephalus and arachnoid cysts are an example of pathologies, the concept and understanding of which now is considerably enhanced, due to the application of neuroendoscopy in their treatment. Management of loculated hydrocephalus has been facilitated considerably with the use of the endoscope. The concepts of aqueductoplasty, septostomy, and foraminoplasty of the foramina of Monro and Magendie emerged, which were previously unknown. Skull base surgery, especially surgery for craniopharyngioma, has seen dramatic improvement in results with the use of the endoscope. Coupling of the endoscope with neuronavigation has expanded technical capabilities even further. Overall, we can do a lot more with the endoscope now in comparison to 30 years ago., Conclusion: We should always remember that the endoscope is only a tool. Its use has indications and limitations related to its design and our ability to extract the maximum, in the context of its shortcomings. Further technological advances will push surgical frontiers even more in years to come., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objective: Hydrocephalus is the most common brain disorder in children and is more common in low- and middle-income countries. Research output on hydrocephalus remains sparse and of lower quality in low- and middle-income countries compared with high-income countries. Most studies addressing hydrocephalus epidemiology are retrospective registry studies entailing their inherent limitations and biases. This study aimed to investigate child-related, parental, and socioeconomic risk factors of congenital hydrocephalus (CH) in a lower-middle-income country., Methods: An investigator-administered questionnaire was used to query parents of patients with CH and controls who visited the authors' institution from 2017 until 2021. Patients with secondary hydrocephalus and children older than 2 years of age at diagnosis were excluded. Uni- and multivariable logistic regression was performed to identify the factors affecting CH development., Results: Seven hundred forty-one respondents (312 cases and 429 controls) were included in this study. The authors showed that maternal diseases during pregnancy (OR 3.12, 95% CI 1.96-5.03), a lack of periconceptional folic acid intake (OR 1.92, 95% CI 1.32-2.81), being a housewife (OR 2.66, 95% CI 1.51-4.87), paternal illiteracy (OR 1.65, 95% CI 1.02-2.69), parental consanguinity (OR 3.67, 95% CI 2.40-5.69), a history of other CNS conditions in the family (OR 2.93, 95% CI 1.24-7.34), conceiving a child via assisted fertilization techniques (OR 3.93, 95% CI 1.57-10.52), and the presence of other congenital anomalies (OR 2.57, 95% CI 1.38-4.87) were associated with an independent higher odds of a child having CH. Conversely, maternal hypertension (OR 0.22, 95% CI 0.09-0.48), older maternal age at delivery (OR 0.93, 95% CI 0.89-0.97), and having more abortions (OR 0.80, 95% CI 0.67-0.95) were negatively correlated with CH., Conclusions: Multiple parental, socioeconomic, and child-related factors were associated with higher odds for developing CH. These results can be utilized to guide parental counseling and management, and direct social education and prevention programs.

Indications for surgery of pineal cysts without ventriculomegaly are still under debate. In view of the limited data for pineal cyst resection in the absence of hydrocephalus, and the potential risk of this approach, we have analyzed our patient cohort focusing on strategies to avoid complications according to our experience in a series of 73 pineal cyst patients. From 2003 to 2015, we reviewed our database retrospectively for all patients operated on a pineal cyst. Furthermore, we prospectively collected patients from 2016 to 2020. In summary, 73 patients with a pineal cyst were treated surgically between 2003 and 2020. All patients were operated on via a microscopic supracerebellar-infratentorial (SCIT) approach. The mean follow-up period was 26.6 months (range: 6-139 months). Seventy-three patients underwent surgery for a pineal cyst. An absence of enlarged ventricles was documented in 62 patients (51 female, 11 male, mean age 28.1 (range 4-59) years). Main presenting symptoms included headache, visual disturbances, dizziness/vertigo, nausea/emesis, and sleep disturbances. Complete cyst resection was achieved in 59/62 patients. Fifty-five of 62 (89%) patients improved after surgery with good or even excellent results according to the Chicago Chiari Outcome Scale, with complete or partial resolution of the leading symptoms. Pineal cysts resection might be an indication in certain patients for surgery even in the absence of ventriculomegaly. The high percentage of postoperative resolution of quality-of-life impairing symptoms in our series seems to justify surgery. Preoperatively, other causes of the leading symptoms have to be excluded., (© 2022. The Author(s).)

Background: A paradigm shift toward less radicality in the treatment of craniopharyngioma (CP) has increasingly gained recognition. In selected patients, a less invasive approach aiming at cyst decompression may be suitable., Objective: To present our experience with the endoscopic transcortical-transventricular approach (ETTA) for the treatment of CP located in the third ventricle, describe our surgical technique, and explore the results reported in the literature., Methods: Data for third ventricular CPs treated using ETTA in 2 tertiary medical centers between 2006 and 2020 were retrospectively reviewed. Cystic, mixed lesion, new, and recurrent cases were included. ETTA aimed at cyst fenestration, subtotal or partial tumor resection, managing the hydrocephalus, or a combination of these modalities. Fractionated radiotherapy (RT) was performed (54 Gy in 30 fractions)., Results: The described approach was performed in 13 patients with a mean age of 30.2 years. Tumor excision was attempted in 10 patients. Cystic fenestration alone was conducted in 3 patients, followed by intracystic catheter implantation in 2 patients. Permanent diabetes insipidus developed in 3 patients, and 1 patient experienced a surgical site infection. The recurrence rate for ETTA + RT (pre-ETTA in 33.3%) was 2/9 (22.2%) after a mean follow-up of 21.3 months. Four patients did not undergo RT after ETTA, and all these patients experienced recurrences after a mean follow-up of 15.5 months. Hydrocephalus resolved in all 6 patients who presented with accompanying hydrocephalus., Conclusion: ETTA combined with adjuvant RT is a safe and effective option in the management of cystic or predominantly cystic CP extending into the third ventricle. This procedure also effectively treats the accompanying hydrocephalus., (Copyright © Congress of Neurological Surgeons 2022. All rights reserved.)

Purpose: Age and etiology play a crucial role in success of endoscopic third ventriculostomy (ETV) as a treatment of obstructive hydrocephalus. Outcome is worse in infants, and controversies still exist whether ETV is superior to shunt placement. We retrospectively analyzed 70 patients below 2 years from 4 different centers treated with ETV and assessed success., Methods: Children < 2 years who received an ETV within 1994-2018 were included. Patients were classified according to age and etiology; < 3, 4-12, and 13-24 months, etiologically; aqueductal stenosis, post-hemorrhagic-hydrocephalus (PHH), tumor-related, fourth ventricle outflow obstruction, with Chiari-type II and following CSF infection. We investigated statistically the predictors for ETV success through computing Kaplan-Meier estimates using patient's follow-up time and time to ETV failure., Results: We collected 70 patients. ETV success rate was 41.4%. The highest rate was in tumor-related hydrocephalus and fourth ventricle outlet obstruction (62.5%, 60%) and the lowest rate was in Chiari-type II and following infection (16.7%, 0%). The below 3 months age group showed relatively lower success rate (33.3%) in comparison to older groups which showed similar results (46.4%, 46.6%). Statistically, a previous VP shunt was a predictor for failure (p value < 0.05)., Conclusion: Factors suggesting a high possibility of failure were age < 3 months and etiology such as Chiari-type II or following infection. Altered CSF dynamics in patients with PHH and under-developed arachnoid villi may play a role in ETV failure. We do not recommend ETV as first line in children < 3 months of age or in case of Chiari II or following infection.

Background: During the 1990s, endoscopic aqueductoplasty (AP) was considered to be a valuable alternative to endoscopic third ventriculostomy (ETV) in treating hydrocephalus related to idiopathic aqueductal stenosis (iAS), with promising short-term outcomes., Objective: To evaluate the long-term outcome of AP in the treatment of iAS., Methods: Long-term follow-up clinical examinations and magnetic resonance (MR) imaging were performed for patients treated by an AP for iAS in our department., Results: Twenty patients (14 female, 6 male, mean age 41.7 yr, range 0.5-67 yr) were treated between 1996 and 2002. Two patients were lost to long-term follow-up. One patient died 6 mo after AP, but death was not related to the procedure. The mean follow-up for the remaining 17 patients was 120 mo. Clinically relevant aqueductal reclosure was observed in 11/17 patients after a mean follow-up of 53.4 mo. These 11 patients underwent ETV, which has been successful during further follow-up. Four of the six remaining patients presented with no clinical symptoms, although aqueductal restenosis was observed on MR imaging. Thus, the overall failure rate of AP was 88.2%. The failures were homogeneously distributed over the entire follow-up period., Conclusion: AP has a high risk of failure during long-term follow-up and is not recommended as the first choice of treatment in hydrocephalus caused by iAS. ETV should be done instead. AP may be reserved for a limited number of patients in whom ETV is not feasible but should be combined with stenting to avoid reclosure of the aqueduct., (Copyright © 2018 by the Congress of Neurological Surgeons.)

Objectives:  Ventriculoperitoneal (VP) shunting is commonly used to treat pediatric hydrocephalus, but failure rates are high. VP shunt failure in children is mostly caused by infection and/or proximal/distal shunt obstruction. However, to our knowledge, no previous reviews have discussed this topic using only clinical studies when age-related data could be obtained. This systematic review aimed at reevaluating what is already known as the most common causes of shunt failure and to determine the incidence and causes of VP shunt failure during the first 2 years of life as a step to establish solid evidence-based guidelines to avoid VP shunt failure in infants., Methods:  We performed a search using the search terms "Cerebrospinal Fluid Shunts" (Medical Subject Headings [MeSH]) AND failure [All Fields] AND ("humans" [MeSH] AND English [lang] AND "infant" [MeSH]). Only articles that specifically discussed VP shunt complications in children < 2 years were included., Results:  We found that the most common causes of VP shunt failure in children < 2 years were shunt obstruction and infection, both observed in a range., Conclusion:  VP shunt failure is very common in infants, mostly resulting from obstruction and infection. Future studies should focus on methods designed to avoid these complications or on alternative treatments for hydrocephalus., Competing Interests: None., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: Ventriculoperitoneal (VP) shunting is the most commonly performed procedure in the treatment of hydrocephalus. VP shunt migration can occur at different sites. The aim of the study was to present different sites of abnormal distal shunt location, pathophysiology, and the management in each situation., Methods: Between 2014 and 2017, all patients with hydrocephalus in the Department of Neurosurgery, Cairo University, were gathered prospectively. All pediatric patients below the age of 12 years with shunt migration of the distal end of the VP shunt were identified., Results: Of 1092 patients operated on by the VP shunt between 2014 and 2017, 15 presented with shunt dysfunction because of distal shunt migration (6 anal, 3 scrotal, 1 colon, 1 peroral, 1 upper lumbar extrusion, 1 paraspinal, 1 penile, and 1 umbilical). Especially upper lumbar extrusion and paraspinal shunt location are extremely rare. All the 15 patients were treated successfully with VP shunts and prospectively followed until they presented with complications on different occasions., Conclusions: Peritoneal complications are among the most common causes of VP failure. We present a rare complication where the shunt migrates outside the peritoneal cavity elsewhere with ambiguous pathogenesis. Special considerations have to be appointed during the shunt revision surgeries of these cases., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: There is paucity of information about the frequency of hydrocephalus prior to and after posterior fossa tumor surgery in adult patients and about the best way it should be managed. The present study was conducted to determine the frequency of hydrocephalus prior to and after posterior fossa tumor surgery in adult patients as well as the value of an endoscopic third ventriculostomy (ETV) prior to posterior fossa tumor surgery with regard to the rate of perioperative complications and persistent hydrocephalus., Methods: A single-institution retrospective chart review of all posterior fossa tumor surgeries of our department in a 10-year period (2005 to 2014) has been done., Results: Fifty-two of 243 adult patients with posterior fossa tumors presented with hydrocephalus at the time of admission prior to tumor surgery. 39/52 received early tumor surgery, 11/52 an ETV prior to tumor surgery and in 2/52 an external ventricular drainage (EVD) was inserted prior to tumor surgery. 3/52 patients required a permanent cerebrospinal fluid (CSF) diverting procedure for persistent hydrocephalus after tumor removal. One hundred ninety-one patients did not demonstrate a hydrocephalus before surgical treatment and four of them developed a post-resection hydrocephalus., Conclusion: The frequency of hydrocephalus prior to posterior fossa tumor surgery in adult patients is 21.4% and therefore much lower than in respective reports of pediatric patients. The risk of persistent hydrocephalus and newly developed hydrocephalus after tumor surgery was very low, too (5.7 and 2.1%, respectively). An ETV is not justified in every adult patient prior to posterior fossa tumor surgery.

Objective:  Obstructive hydrocephalus in patients with posterior fossa tumors is frequently seen. Treatment options include immediate tumor removal or prior cerebrospinal fluid (CSF) diversion procedures. The necessity and feasibility of an ETV in these situations has not yet been proven in adult patients., Methods:  We retrospectively reviewed our prospectively maintained database for ETVs before surgery of posterior fossa tumors in adults. The primary focus of data analyses was the question of whether the ETV was suitable to treat the acute situation of hydrocephalus without an increased rate of complications due to the special anatomical situation with a posterior fossa tumor. We also analyzed whether any further CSF diverting procedures were necessary., Results:  A total of 40 adult patients who underwent an ETV before posterior fossa tumor surgery were analyzed. Overall, 33 patients (82.5%) had clinical signs of hydrocephalus, and all of them improved in their clinical course after ETV. Seven patients (17.5%) did not demonstrate clinical signs of hydrocephalus, but ETV was performed with prophylactic or palliative intent in six patients and one patient, respectively. No complications were observed due to ETV itself. No permanent shunting procedure was necessary in a mean follow-up of 76.5 months. Early additional CSF diverting procedures (redo ETV, external ventricular drain) were performed in five patients (12.5%)., Conclusion:  The present series confirms the feasibility and safety of ETV before posterior fossa tumor surgery in adult patients. If patients had symptomatic hydrocephalus before tumor surgery, an ETV can be performed, followed by early elective tumor surgery. A prophylactic ETV in asymptomatic patients is not advised. Early elective tumor surgery should be performed in these patients., Competing Interests: Henry W. S. Schroeder and Michael R. Gaab are consultants for Karl Storz GmbH & Co. KG, Tuttlingen, Germany., (Georg Thieme Verlag KG Stuttgart · New York.)