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Purpose: This Hydrocephalus Clinical Research Network (HCRN) study had two aims: (1) to compare the predictive performance of the original ETV Success Score (ETVSS) using logistic regression modeling with other newer machine learning models and (2) to assess whether inclusion of imaging variables improves prediction performance using machine learning models., Methods: We identified children undergoing first-time ETV for hydrocephalus that were enrolled prospectively at HCRN sites between 200 and 2020. The primary outcome was ETV success 6 months after index surgery. The cohort was randomly divided into training (70%) and testing (30%) datasets. The classic ETVSS variables were used for logistic regression and machine learning models. Predictive performance of each model was evaluated on the testing dataset using area under the receiver operating characteristic curve (AUROC)., Results: There were 752 patients that underwent first time ETV, of which 185 patients (24.6%) experienced ETV failure within 6 months. For aim 1, using the classic ETVSS variables, machine learning models did not outperform logistic regression with AUROC 0.60 (95% CI: 0.52-0.69) for Naïve Bayes (highest machine learning model performance) and 0.68 (95% CI: 0.60-0.76) for logistic regression. After inclusion of imaging features (aim 2), machine learning model prediction improved but remained no better than the above logistic regression with the highest AUROC of 0.67 (95% CI: 0.59-0.75) attained using Naïve Bayes architecture compared to 0.68 (95% CI: 0.59-0.76) for logistic regression., Conclusions: This contemporary multicenter observational cohort study demonstrated that machine learning modeling strategies did not improve performance of the ETVSS model over logistic regression., Competing Interests: Declarations. Competing interests: The authors declare no competing interests., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: Myelomeningocele (MMC) is a prevalent neural tube closure defect often associated with hydrocephalus, necessitating surgical intervention in a significant proportion of cases. While ventriculoperitoneal shunting (VPS) has been a standard treatment approach, endoscopic third ventriculostomy (ETV) has emerged as a promising alternative. However, factors influencing the success of ETV in MMC patients remain uncertain. This retrospective observational study aimed to identify clinical and radiological factors correlating with a higher success rate of ETV in MMC patients., Methods: Medical records of MMC patients who underwent ETV at a tertiary care center between 2015 and 2021 were reviewed. Demographic, clinical, and radiological data were analyzed. ETV success was defined as the absence of further hydrocephalus treatment during follow-up., Results: Of 131 MMC patients, 21 met inclusion criteria and underwent ETV. The overall success rate of ETV was 57.1%, with a six-month success rate of 61.9%. Age ≤ 6 months was significantly associated with lower ETV success (25%) compared to older patients (76.9%) (OR: 0.1; 95% CI 0.005-2.006; p = 0.019). Radiological factors, including posterior fossa dimensions and linear indices, did not exhibit statistically significant associations with ETV success., Conclusion: Age emerged as a significant factor affecting ETV success in MMC patients, with younger patients exhibiting lower success rates. Radiological variables did not significantly influence ETV outcomes in this study. Identifying predictors of ETV success in MMC patients is crucial for optimizing treatment strategies and improving patient outcomes., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objective: Endoscopic management of pediatric hydrocephalus is always challenging because of the different anatomical structure of the ventricles. The aim of this study is to document the endoscopic anatomy of the ventricular system and to show the variations and deformations., Methods: The study included 84 children who underwent endoscopic surgery for the treatment of hydrocephalus in the department of neurosurgery between 2017 and 2022. All preoperative and postoperative radiological images and intraoperative video recordings were retrospectively analyzed. Anatomy of the lateral ventricles and the third ventricle, variations, and deformations were detected and evaluated in detail., Results: The mean age of the patients was 7.6 months. Myelomeningocele-encephalocele-associated hydrocephalus was the most common cause of hydrocephalus (38%), followed by postventriculitis in 21%, posthemorrhagic in 21%, and obstructive causes in 20% of cases, respectively. Endoscopic anomaly/variation or deformation was detected in 83% of all cases. Based on the preoperative radiological images, septum pellucidum anomaly/variation or deformation was the most common radiological finding in 64% of the cases. Lateral ventricle anomaly/variation or deformation was noted in 62% of the cases, and third ventricle anomaly/variation or deformation was observed as a radiological finding in 27% of the cases., Conclusions: The compliance of the brain deteriorates with increasing intracranial pressure in pediatric hydrocephalus and the intraventricular anatomical structures differ from the normal anatomy. Developmental anomalies of the ventricle are also significant and since all these variations are often unpredictable on preoperative imaging, awareness of endoscopic anatomy, variations, and deformations will improve operative safety in children., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: Surgery of lesions in the posterior wall of the third ventricle requires great expertise due to its deep location and important surrounding structures. This region has been traditionally reached through a supracerebellar infratentorial approach, but new options have emerged, especially with the development of neuroendoscopy., Methods: One formalin-fixed cadaver human head was dissected. Five different endoscopic approaches were performed: interhemispheric transcallosal transchoroidal, frontal transforaminal transchoroidal, supraorbital subfrontal translamina terminalis, expanded endonasal, and supracerebellar infratentorial. An anatomical description of the different approaches was conducted and quantitative measurements (craniocaudal and latero-lateral distances) were taken using the StealthStation ® workstation after performing a CT scan of the specimen., Results: The interhemispheric transcallosal transchoroidal, frontal transforaminal transchoroidal, and supraorbital subfrontal translamina terminalis approaches provided great view of all the structures of the posterior wall of the third ventricle. Maximum craniocaudal distance was obtained through the supraorbital subfrontal translamina terminalis approach (10.6 mm), with great difference from the expanded endonasal approach (5.2 mm). The widest latero-lateral distance from inside the third ventricle was achieved through the interhemispheric transcallosal transchoroidal approach (4.6 mm), similar to the expanded endonasal (4.1 mm), and differing from the supraorbital subfrontal translamina terminalis (2.4 mm)., Conclusions: The endoscopic approaches provided an adequate alternative to more traditional microsurgical approaches to the posterior wall of the third ventricle, with a great view of all its structures. The selection of the approach must be taken under consideration in each case., Competing Interests: Declarations of interest None., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

Background and Purpose: In fetuses with lateral ventriculomegaly and normal posterior fossa cerebrospinal spaces, third ventricle distention is a compelling clue that supports a diagnosis of aqueductal stenosis. However, this association assumes normal ventricular anatomy. Structural constraints can impair pressure-induced compliance. We aimed to determine how thalamic massa intermedia size alterations may impact the size of the third ventricle in the setting of congenital aqueductal stenosis., Materials and Methods: This retrospective study was performed at a single academic pediatric hospital after institutional review board approval. We searched our brain MRI reports for all examinations describing aqueductal stenosis and included all the patients who had both fetal and postnatal examinations. Patients with interhypothalamic adhesions and hydrocephalus unrelated to congenital aqueductal stenosis were excluded from this study. We evaluated all the MRIs for the presence of thalamic massa intermedia and documented third ventricle diameters (supraoptic recess, central and suprapineal recesses) and the thalamic massa intermedia circumference. The Spearman correlation was used to identify the potential relationship between the thalamic massa intermedia circumference and third ventricle size in fetal and postnatal MRIs. Patients were also stratified into 2 groups based on the presence or absence of thalamic massa intermedia. Mann-Whitney U tests were used to compare third ventricle diameters between these groups., Results: The study included both fetal and postnatal studies from 59 patients. The overall third ventricle diameter was inversely proportional to the circumference of the thalamic massa intermedia in both groups (fetal: P = .001, ρ = -0.422; [95% CI, -0.628 to -0.181]; postnatal: P < .001, ρ = -0.653; [95% CI, -0.782 to -0.479]). Nonetheless, dilation of anterior and posterior recesses still occurred when the mid third ventricle was nondilated or less severely dilated in patients with an enlarged thalamic massa intermedia. Third ventricle dilation was most severe in patients lacking a thalamic massa intermedia compared with patients with a thalamic massa intermedia ( P < .001)., Conclusions: In patients with suspected congenital aqueductal stenosis, lack of marked third ventriculomegaly as conventionally measured can sometimes be explained by thickening of the thalamic massa intermedia. In this circumstance, it is important to evaluate the extreme recesses of the third ventricle for evidence of dilation on fetal MRI., (© 2024 by American Journal of Neuroradiology.)

Objective: Determining the long-term success of endoscopic third ventriculostomy (ETV) remains challenging. This study aimed to investigate the impact of clinical and radiological factors on ETV success in pediatric patients with hydrocephalus., Methods: The study included patients < 18 years old with hydrocephalus who underwent ETV between March 2014 and May 2021. Data including patient age, gender, history of previous shunt surgery, previous external ventricular drain placement, intraventricular hemorrhage history, and postoperative meningitis were extracted from medical records. Imaging features such as aqueductal stenosis, third ventricle floor bowing, displaced lamina terminalis, pulsatility index (PI), and maximum diameter of the cortical subarachnoid space (CSAS) were recorded for each patient using preoperative CT scans. Two independent neurosurgeons measured the CSAS maximum diameter and the PI. CSAS measurements were obtained on axial slices of the preoperative CT scans, whereas the PI was based on intraoperative third ventricle pulsatility. Patients were followed up for 1 year after surgery, with failure defined as the need for ventriculoperitoneal shunt (VPS) placement or death attributable to hydrocephalus., Results: Ninety-eight children with a mean age of 16.39 ± 19.07 months underwent ETV for hydrocephalus. No deaths were recorded, but over 6 months and 1 year of follow-up, 12.2% and 22.4% of patients, respectively, experienced documented ETV failure requiring VPS placement. At the 6-month follow-up, a smaller maximum diameter of the CSAS was significantly associated with ETV failure; multivariate analysis revealed that CSAS maximum diameter was a predictor of 6-month ETV failure. At the 1-year follow-up, a lower PI was significantly associated with ETV failure, and multivariate analysis confirmed the PI as a significant predictor of ETV failure within 1 year after surgery. CSAS and PI measurements were repeated to assess interrater reliability: the intraclass correlation coefficients were 0.897 and 0.669 for CSAS and PI, respectively., Conclusions: This study found that the CSAS maximum diameter and the PI are predictors of ETV failure at 6 months and 1 year, respectively. These findings highlight the importance of considering specific factors such as the CSAS and PI when assessing the likelihood of ETV success in pediatric patients with hydrocephalus. Further research and consideration of these factors may help optimize patient selection and improve outcomes for those undergoing ETV as a treatment for hydrocephalus.

Objective: Endoscopic third ventriculostomy (ETV) is a treatment option for obstructive hydrocephalus; reported success rates vary. We investigated immediate postoperative magnetic resonance imaging to evaluate the role of imaging parameters associated with outcomes., Methods: Retrospective chart review was performed on patients undergoing initial ETV between 2005 and 2019. Patients with preoperative and postoperative magnetic resonance imaging with follow-up>one year were included. The following were noted: changes in subarachnoid cerebrospinal fluid, third ventricle diameter, bowing of the third ventricle floor, and postoperative flow void. Kaplan-Meier survival methods were used to assess ETV success and univariable and multivariable Cox proportional-hazards models were fitted to assess factors contributing to ETV success., Results: Fifty-eight subjects were included. Nineteen (32.8%) experienced failure within one year; individually, no single imaging parameter predicted success. However, all cases of failure had no identifiable flow void. Any postoperative radiological change was not consistently associated with decreased odds of failure. Obstructive hydrocephalus treated with ETV demonstrated significantly better ETV success than patients treated with nonobstructive hydrocephalus. Interobserver reliability was moderate for 2 of the radiological variables and substantial for 1 of the radiological variables., Conclusions: Individually, none of the qualitative radiologic parameters measured in our study predicted ETV success. Absence of a flow void predicted ETV failure, but additional studies are needed to determine its true negative predictive value. Inability to clarify which specific parameter predicts success reflects the limited role of immediate postoperative imaging in influencing clinical management., (Copyright © 2024. Published by Elsevier Inc.)

Objective: Hydrocephalus is one of the neurological risks occurring in patients with achondroplasia. Ventriculoperitoneal shunt (VPS) insertion is the most common treatment. However, reports of successful endoscopic third ventriculostomy (ETV) suggest that ETV may be a good alternative to VPS insertion in achondroplasia. However, it has been stated that ETV in achondroplasia patients is technically demanding to perform. The current study examined the anatomical variations of the third ventricle and the brainstem in achondroplasia patients and correlated the findings with the difficulty of performing ETV., Methods: A retrospective analysis of 51 patients with achondroplasia and 138 hydrocephalus patients without achondroplasia (48 patients had tumor-related hydrocephalus and 90 patients had hydrocephalus of nontumorous origin) who have visited the authors' institution since 2012 was performed. Preoperative T2-weighted sagittal MR images were used to measure α (steepness of the third ventricle floor), β (endoscopic angle of incidence), d1 (vertical distance between the dorsum sellae and basilar bifurcation), and d2 (horizontal distance between the dorsum sellae and basilar artery). Each value was compared using the Tukey multicomparison test., Results: Achondroplasia patients showed significantly smaller α (p < 0.001) and β (p < 0.001) angles, while there were no significant differences between the control groups (p = 0.947 for α, p = 0.836 for β). The d1 value was significantly larger in achondroplasia patients (p < 0.001), and d2 was smaller (p < 0.001). The control groups showed similar d1 and d2 values (p = 0.415 for d1, p = 0.154 for d2). Smaller α and β values meant that in achondroplasia patients the third ventricle floor stood more vertically than in other patients with hydrocephalus, and the endoscopic contact angles were small, increasing the risk of ventriculostomy devices slipping down into the infundibular recess. Additionally, a large d1 meant that the basilar artery was shifted upward and a small d2 indicated that the basilar artery was located closer to the dorsum sellae, potentially increasing the risk of basilar artery damage., Conclusions: Achondroplasia patients' skull and brain anatomies were significantly different from those of other hydrocephalus patients, with steeper third ventricle floors and basilar arteries closer to the dorsum sellae. Because these anatomical differences lead to difficulties in performing ETVs in achondroplasia patients, such differences should be considered when ETV is planned for the patients.

Objective: Hydrocephalus is a challenging neurosurgical condition due to nonspecific symptoms and complex brain-fluid pressure dynamics. Typically, the assessment of hydrocephalus in children requires radiographic or invasive pressure monitoring. There is usually a qualitative focus on the ventricular spaces even though stress and shear forces extend across the brain. Here, the authors present an MRI-based vector approach for voxelwise brain and ventricular deformation visualization and analysis., Methods: Twenty pediatric patients (mean age 7.7 years, range 6 months-18 years; 14 males) with acute, newly diagnosed hydrocephalus requiring surgical intervention for symptomatic relief were randomly identified after retrospective chart review. Selection criteria included acquisition of both pre- and posttherapy paired 3D T1-weighted volumetric MRI (3D T1-MRI) performed on 3T MRI systems. Both pre- and posttherapy 3D T1-MRI pairs were aligned using image registration, and subsequently, voxelwise nonlinear transformations were performed to derive two exemplary visualizations of compliance: 1) a whole-brain vector map projecting the resulting deformation field on baseline axial imaging; and 2) a 3D heat map projecting the volumetric changes along ventricular boundaries and the brain periphery., Results: The patients underwent the following interventions for treatment of hydrocephalus: endoscopic third ventriculostomy (n = 6); external ventricular drain placement and/or tumor resection (n = 10); or ventriculoperitoneal shunt placement (n = 4). The mean time between pre- and postoperative imaging was 36.5 days. Following intervention, the ventricular volumes decreased significantly (mean pre- and posttherapy volumes of 151.9 cm3 and 82.0 cm3, respectively; p < 0.001, paired t-test). The largest degree of deformation vector changes occurred along the lateral ventricular spaces, relative to the genu and splenium. There was a significant correlation between change in deformation vector magnitudes within the cortical layer and age (p = 0.011, Pearson), as well as between the ventricle size and age (p = 0.014, Pearson), suggesting higher compliance among infants and younger children., Conclusions: This study highlights an approach for deformation analysis and vector mapping that may serve as a topographic visualizer for therapeutic interventions in patients with hydrocephalus. A future study that correlates the degree of cerebroventricular deformation or compliance with intracranial pressures could clarify the potential role of this technique in noninvasive pressure monitoring or in cases of noncompliant ventricles.

Objective: Transcranial sonography (TCS) is a noninvasive neuroimaging technique, visualizing deep brain structures and the ventricular system. Although widely employed in diagnosing various movement disorders, such as Parkinson's disease and dystonia, by detecting disease-specific abnormalities, the specific characteristics of the TCS in cerebellar ataxia remain inconclusive. We aimed to assess the potential value of TCS in patients with cerebellar ataxias for disease diagnosis and severity assessment., Methods: TCS on patients with genetic and acquired cerebellar ataxia, including 94 with spinocerebellar ataxias (SCAs) containing 10 asymptomatic carriers, 95 with cerebellar subtype of multiple system atrophy (MSA-C), and 100 healthy controls (HC), was conducted. Assessments included third ventricle width, substantia nigra (SN) and lentiform nucleus (LN) echogenicity, along with comprehensive clinical evaluations and genetic testing., Results: The study revealed significant TCS abnormalities in patients with cerebellar ataxia, such as enlarged third ventricle widths and elevated rates of hyperechogenic SN and LN. TCS showed high accuracy in distinguishing patients with SCA or MSA-C from HC, with an AUC of 0.870 and 0.931, respectively. TCS abnormalities aided in identifying asymptomatic SCA carriers, effectively differentiating them from HC, with an AUC of 0.725. Furthermore, third ventricle width was significantly correlated with SARA and ICARS scores in patients with SCA3 and SCOPA-AUT scores in patients with MSA-C. The SN area and SARA or ICARS scores in patients with SCA3 were also positively correlated., Interpretation: Our findings illustrate remarkable TCS abnormalities in patients with cerebellar ataxia, serving as potential biomarkers for clinical diagnosis and progression assessment., (© 2024 The Author(s). Annals of Clinical and Translational Neurology published by Wiley Periodicals LLC on behalf of American Neurological Association.)

Background: This research discusses colloid cyst surgical concerns, with an emphasis on the value of a novel surgical classification based on anatomical sites. In the study, 59 patients who underwent surgical intervention between 2009 and 2022 and were diagnosed with colloid cysts via computed tomography scan and magnetic resonance imaging participated., Methods: There were more male cases than female ones (57.6%). The majority of patients presented with headache (79%), followed by abnormal gait (12%), visual blurring (5%), and seizures (4%)., Results: In this study, we present a new surgical classification based on anatomical locations, distinguishing 4 types: open Monro type (50.84%), closed Monro type (23.72%), retroforaminal type (13.55%), and interforniceal type (11.86%)., Conclusions: In summary, the surgical classification that has been suggested provides significant insights into the varied anatomical sites where colloid cysts might be found. Microneurosurgeons significantly need to be oriented about the possible sites of colloid cysts through this classification to achieve complete and curative resection and reduce the likelihood of recurrence., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: A ventricle-to-brain index (VBI) >0.35 is associated with low scores on the Bayley Scales of Infant and Toddler Development, Third Edition (BSID-III) in preterm infants with birth weight <1,250 g. However, VBI obtained at the third ventricle has only moderate interobserver reliability. The objective of this study was to test (1) reliability of VBI measured at the foramen of Monro on the latest ultrasonogram (US) before discharge using the intraclass correlation coefficient (ICC) and (2) the relationship between VBI and BSID-III scores at ≥18 months corrected age., Study Design: The present study is a single-center retrospective cohort study., Results: The study included 270 preterm infants born at 23 0/7 to 28 6/7 weeks of gestational age. The ICC of VBI between independent measurements by two study radiologists on the first 50 patients was 0.934. Factors associated with the value of VBI included severe intraventricular hemorrhage, bronchopulmonary dysplasia, and systemic steroid administration for BPD but not postmenstrual age. In multivariate analysis, VBI was negatively and independently associated with cognitive ( p  = 0.002), language ( p  = 0.004), and motor ( p  < 0.001) BSID-III scores. The association between VBI and BSID-III scores was observed even in infants in whom the latest US was obtained before term equivalent age. The association between VBI and BSID-III scores was also observed after excluding those with severe intraventricular hemorrhage., Conclusion: In this very preterm cohort the measurement of VBI had excellent reliability. Moreover, VBI measurements were negatively associated with motor, language, and cognitive BSID-III scores., Key Points: · Mean values of VBI are stable with postmenstrual age.. · Values at the foramen of Monro are reliable and reproducible.. · VBI is negatively associated with Bayley scores.. · The association is observed even before term age.., Competing Interests: None declared, (Thieme. All rights reserved.)

Introduction: Differentiating Progressive Supranuclear Palsy (PSP) from Parkinson's Disease (PD) may be clinically challenging. In this study, we explored the performance of machine learning models based on MR imaging and blood molecular biomarkers in distinguishing between these two neurodegenerative diseases., Methods: Twenty-eight PSP patients, 46 PD patients and 60 control subjects (HC) were consecutively enrolled in the study. Serum concentration of neurofilament light chain protein (Nf-L) was assessed by single molecule array (SIMOA), while an automatic segmentation algorithm was employed for T1-weighted measurements of third ventricle width/intracranial diameter ratio (3 rd V/ID). Machine learning (ML) models with Logistic Regression (LR), Random Forest (RF), and XGBoost algorithms based on 3 rd V/ID and serum Nf-L levels were tested in distinguishing among PSP, PD and HC., Results: PSP patients showed higher serum Nf-L levels and larger 3 rd V/ID ratio in comparison with both PD and HC groups (p < 0.005). All ML algorithms (LR, RF and XGBoost) showed that the combination of MRI and blood biomarkers had excellent classification performances in differentiating PSP from PD (AUC ≥0.92), outperforming each biomarker used alone (AUC: 0.85-0.90). Among the different algorithms, XGBoost was slightly more powerful than LR and RF in distinguishing PSP from PD patients, reaching AUC of 0.94 ± 0.04., Conclusion: Our findings highlight the usefulness of combining blood and simple linear MRI biomarkers to accurately distinguish between PSP and PD patients. This multimodal approach may play a pivotal role in patient management and clinical decision-making, paving the way for more effective and timely interventions in these neurodegenerative diseases., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Background: Traditional microsurgical approaches for addressing intraventricular craniopharyngioma provide limited access to the retrochiasmatic area and tumors with significant lateral or rostrocaudal extensions. Extended endoscopic endonasal approaches can effectively overcome many of limitations, yet they require a favorable working angle between the optic chiasm and pituitary gland, as well as the involvement of the third ventricle floor by the tumor., Methods: Herein, the authors describe the surgical nuances of a keyhole technique for resecting third ventricle craniopharyngiomas via a fully endoscopic minimally invasive trans-eyebrow supraorbital translaminar approach (ESOTLA). A case description detailing the key surgical steps and application of the approach is provided, along with a series of cadaveric photographs to highlight the relevant anatomy and step-by-step dissection process., Results: The patient is a 44-year-old man who presented with polyuria, low urine specific gravity, and panhypopituitarism. Brain magnetic resonance imaging revealed a solid-cystic heterogeneous-enhanced retrochiasmatic mass within the third ventricle, consistent with craniopharyngioma. A 1-stage ESOTLA was indicated based on the narrow pituitary-chiasm angle and the high functional status of the patient. Near-total resection was achieved, and no new postoperative neurologic or endocrine change was observed. Targeted therapy was implemented based on the histologic result, and the most recent surveillance magnetic resonance imaging showed no evidence of the residual tumor., Conclusions: By combining a keyhole approach with variable-angle endoscopic visualization through a smaller bony and soft tissue exposure, ESOTLA can provide enhanced illumination within the third ventricle, potentially addressing cosmetic concerns and limited exposure area/angle of freedom associated with its conventional microsurgical counterpart., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Purpose: Basal duct-like recess (DR) sign serves as a specific marker of papillary craniopharyngiomas (PCPs) of the strictly third-ventricular (3 V) topography. Origins of this sign are poorly understood with limited validation in external cohorts., Methods: In this retrospective study, MRIs of pathologically proven PCPs were reviewed and evaluated for tumor topography, DR sign prevalence, and morphological subtypes., Results: Twenty-three cases with 24 MRIs satisfied our inclusion criteria. Median age was 44.5 years with a predominant male distribution (M/F ratio 4.7:1). Overall, strictly 3 V was the commonest tumor topography (8/24, 33.3%), and tumors were most commonly solid-cystic (10/24, 41.7%). The prevalence of DR sign was 21.7% (5/23 cases), all with strictly 3 V topography and with a predominantly solid consistency. The sensitivity, specificity and positive and negative predictive value of the DR sign for strict 3 V topography was 62.5%, 100%, 100% and 84.2% respectively. New pertinent findings associated with the DR sign were observed in our cohort. This included development of the cleft-like variant of DR sign after a 9-year follow-up initially absent at baseline imaging. Additionally, cystic dilatation of the basal tumor cleft at the pituitary stalk-tumor junction and presence of a vascular structure overlapping the DR sign were noted. Relevant mechanisms, hypotheses, and implications were explored., Conclusion: We confirm the DR sign as a highly specific marker of the strictly 3 V topography in PCPs. While embryological and molecular factors remain pertinent in understanding origins of the DR sign, non-embryological mechanisms may play a role in development of the cleft-like variant., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Idiopathic intracranial hypertension in children often presents with non-specific symptoms found in conditions such as hydrocephalus. For definite diagnosis, invasive intracranial pressure measurement is usually required. Ultrasound (US) of the optic nerve sheath diameter provides a non-invasive method to assess intracranial pressure. Transtemporal US allows imaging of the third ventricle and thus assessment for hydrocephalus., Objective: To investigate whether the combination of US optic nerve sheath and third ventricle diameter can be used as a screening tool in pediatric idiopathic intracranial hypertension to indicate elevated intracranial pressure and exclude hydrocephalus as an underlying pathology. Further, to analyze whether both parameters can be used to monitor treatment outcome., Materials and Methods: We prospectively included 36 children with idiopathic intracranial hypertension and 32 controls. Using a 12-Mhz linear transducer and a 1-4-Mhz phased-array transducer, respectively, optic nerve sheath and third ventricle diameters were determined initially and during the course of treatment., Results: In patients, the mean optic nerve sheath diameter was significantly larger (6.45±0.65 mm, controls: 4.96±0.32 mm) and the mean third ventricle diameter (1.69±0.65 mm, controls: 2.99±1.31 mm) was significantly smaller compared to the control group, P<0.001. Optimal cut-off values were 5.55 mm for the optic nerve sheath and 1.83 mm for the third ventricle diameter., Conclusions: The combined use of US optic nerve sheath and third ventricle diameter is an ideal non-invasive screening tool in pediatric idiopathic intracranial hypertension to indicate elevated intracranial pressure while ruling out hydrocephalus. Treatment can effectively be monitored by repeated US, which also reliably indicates relapse., (© 2024. The Author(s).)

Background: The selection of patients in whom endoscopic third ventriculostomy (ETV) can be effective remains poorly defined. The ETV success score (ETVSS) and the presence of bowing of the third ventricle have been identified as independent factors for predicting success, each with limitations. The objective of this study is to elaborate a combined predictive model to predict ETV success in a mixed cohort of patients., Methods: Demographic, intraoperative, postoperative, and radiologic variables were analyzed in all ventriculostomies performed consecutively at a single institution from December 2004 to December 2022. Qualitative and quantitative measurements of preoperative, immediate, and late postoperative magnetic resonance imaging were conducted. Univariate analysis and logistic regression models were performed., Results: 118 ETVs were performed in the selected period. Of these procedures, 106 met the inclusion criteria. The overall success rate was 71.7%, with a median follow-up of 3.64 years (interquartile range, 1.06-5.62). The median age was 36.1 years (interquartile range, 11.7-53.5). 35.84% were children (median, 7.81 years). Among the 80 patients with third ventricle bowing, the success rate was 88.8% (P < 0.001). Larger third ventricle dimensions on preoperative mid-sagittal magnetic resonance imaging were associated with increased ETV success. The model with the best receiver operating characteristic curves, with an area under the curve of 0.918 (95% confidence interval, 0.856-0.979) includes sex, ETVSS, presence of complications, and third ventricle bowing., Conclusions: The presence of bowing of the third ventricle is strongly associated with a higher ETV success rate. However, a combined predictive model that integrates it with the ETVSS is the most appropriate approach for selecting patients for ETV., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: To use third ventricle morphometric variables as a tool for the selection of patients with idiopathic normal pressure hydrocephalus (iNPH) who are candidates for ventriculoperitoneal shunts (VPS)., Material and Methods: Retrospective study enrolling patients with iNPH. Katzman infusion test was performed and a Rout > 12 mmHg/mL/min was considered a positive result. The transverse diameter and the volume of the third ventricle were measured in the preoperative MRI. Postoperative improvement was assessed with the NPH score. The results were analysed with SPSS software., Results: 52 patients with a mean age of 76 years were analysed. There was no difference in the diameter of the third ventricle among patients with a positive result and those with a negative result in the infusion test (12.28 vs 11.68 mm; p = 0.14). Neither were difference detected in the ventricle volume of both groups (3.6 vs 3.5cc; p = 0.66). Those patients who improved after VPS had a smaller third ventricle compared to those who did not respond after surgery (11.85 mm vs. 12.96 mm; p = 0.009). Diameter and volume of third ventricle present a significant strong correlation (Pearson correlation coefficient = 0.72; p < 0.0001)., Conclusion: Morphometric variables of third ventricle may be useful in predicting a good response to VPS in patients with idiopathic normal pressure hydrocephalus., (Copyright © 2023 Sociedad Española de Neurocirugía. Published by Elsevier España, S.L.U. All rights reserved.)

Object: One of the critical steps for the success of intraventricular neuroendoscopic procedures is the entry into the third ventricle and passage of the endoscopy system through the foramen of Monro (FM). A diameter larger than that of the instrument used is considered a prerequisite for safely performing the technique, as damage to this structure can lead to alterations in the fornix and vascular structures. When the foramen diameter is narrow and there is no obstruction/stenosis, the role of foraminoplasty in reducing the risk of complications has not been adequately assessed in the literature., Methods: A review of endoscopic procedures conducted at our center since 2018 was undertaken. Cases in which preoperative imaging indicated a FM diameter < 6 mm and foraminoplasty technique was applied were examined to determine the technical and functional success of the procedure. The technical success was determined by completing the neuroendoscopic procedure with the absence of macroscopic lesions in the various structures comprising the foramen and without complications in the follow-up imaging tests. Functional success was defined as the absence of cognitive/memory alterations during the 3-month postoperative follow-up. Additionally, a review of the various forms of foraminoplasty described in the literature is conducted., Results: In our cohort, six patients were identified with a preoperative FM diameter < 6 mm without obstruction or stenosis. Foraminoplasty was planned for these cases to facilitate various intraventricular neuroendoscopic procedures. In all instances, the technique was successfully performed without causing macroscopic damage to the structures comprising the foramen. Follow-up visits included various cognitive tests to assess potential sequelae related to microscopic damage to the fornix. None of the patients exhibited anomalies., Conclusion: Foraminoplasty in patients with a narrow FM without signs of stenosis/obstruction is a useful technique to reduce the risk of complications during the passage of the endoscopy system through this structure, enabling the safe performance of neuroendoscopic procedures., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Austria, part of Springer Nature.)

Purpose: The purpose of this study was to compare outcomes of endoscopic third ventriculostomy (ETV) and ventriculoperitoneal shunt (VPS) in children with symptomatic triventricular hydrocephalus due to primary aqueductal stenosis., Method: This is a retrospective analytical study. Patients who underwent either ETV or VPS as the first procedure for hydrocephalus due to primary aqueductal stenosis were included in the study., Result: A total of 89 children were included in the study for analysis. The mean age was 8.4 years. Forty-four (49.4%) had their first surgery as ETV and 45 (50.6%) had their first surgery as VPS. Overall, 34 (38.2%) patients required a second surgery (either ETV or VPS) for persistent or recurrent hydrocephalus. The mean follow-up duration was 832.9 days. The overall complication rate was 13.5%. The mean timing of the second surgery after index surgery was 601.35 days. Factors associated with a second surgery were the presence of complications, high protein in cerebrospinal fluid, the relative change of frontal-occipital horn ratio (FOHR) and Evans' index. The survival of the first surgery was superior in ETV (751.55 days) compared to VPS (454.49 days), p = 0.013. The relative change of fronto-occipital horn index ratio (FOIR) was high in the VPS (mean 7.28%) group compared to the ETV (mean 4.40%), p = 0.001 group., Conclusion: Overall procedural survival was better after ETV than VPS for hydrocephalus due to aqueductal stenosis. VPS causes more reduction in linear indices of ventricles as compared to ETV, however, is not associated with the success or complication of the procedure., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background:  Suprasellar and third ventricle cavernous malformations (CMs) are uncommon. Conventional approaches such as interhemispheric and translamina terminalis approaches are often used to resect these lesions. Here we demonstrate the use of the endoscopic endonasal approach for a third ventricle CM., Case Description:  A 31-year-old man presented with progressive symptoms of headache and visual disturbance as well as short-term memory deficit over a 6-month period. Neurologic examination revealed bitemporal hemianopsia. Radiologic images showed a suprasellar lesion extending into the third ventricle as well as obstructive hydrocephalus. The patient was operated on using an endoscopic endonasal approach and histopathology revealed a diagnosis of CM. Transient diabetes insipidus and adrenal insufficiency were reported postoperatively., Conclusion:  This report demonstrates safe resection of a third ventricle CM via the endonasal route., Competing Interests: None declared., (Thieme. All rights reserved.)

Purpose: Endoscopic third ventriculostomy (ETV) is a surgical procedure that can lead to complications and requires detailed preoperative planning. This study aimed to provide a more accurate understanding of the anatomy of the third ventricle and the location of important structures to improve the safety and success of ETV., Methods: We measured the stereotactic coordinates of six points of interest relative to a predefined stereotactic reference point in 23 cadaver brain hemi-sections, 200 normal brain magnetic resonance imaging (MRI) scans, and 24 hydrocephalic brain MRI scans. The measurements were statistically analyzed, and comparisons were made., Results: We found some statistically significant differences between genders in MRIs from healthy subjects. We also found statistically significant differences between MRIs from healthy subjects and both cadaver brains and MRIs with hydrocephalus, though their magnitude is very small and not clinically relevant. Some stereotactic points were more posteriorly and inferiorly located in cadaver brains, particularly the infundibular recess and the basilar artery. It was found that all stereotactic points studied were more posteriorly located in brains with hydrocephalus., Conclusion: The study describes periventricular structures in cadaver brains and MRI scans from healthy and hydrocephalic subjects, which can guide neurosurgeons in planning surgical approaches to the third ventricle. Overall, the study contributes to understanding ETV and provides insights for improving its safety and efficacy. The findings also support that practicing on cadaveric brains can still provide valuable information and is valid for study and training of neurosurgeons unfamiliar with the ETV technique., (© 2024. The Author(s).)

Objective: The Hydrocephalus Clinical Research Network (HCRN) conducted a prospective study 1) to determine if a new, better-performing version of the Endoscopic Third Ventriculostomy Success Score (ETVSS) could be developed, 2) to explore the performance characteristics of the original ETVSS in a modern endoscopic third ventriculostomy (ETV) cohort, and 3) to determine if the addition of radiological variables to the ETVSS improved its predictive abilities., Methods: From April 2008 to August 2019, children (corrected age ≤ 17.5 years) who underwent a first-time ETV for hydrocephalus were included in a prospective multicenter HCRN study. All children had at least 6 months of clinical follow-up and were followed since the index ETV in the HCRN Core Data Registry. Children who underwent choroid plexus cauterization were excluded. Outcome (ETV success) was defined as the lack of ETV failure within 6 months of the index procedure. Kaplan-Meier curves were constructed to evaluate time-dependent variables. Multivariable binary logistic models were built to evaluate predictors of ETV success. Model performance was evaluated with Hosmer-Lemeshow and Harrell's C statistics., Results: Seven hundred sixty-one children underwent a first-time ETV. The rate of 6-month ETV success was 76%. The Hosmer-Lemeshow and Harrell's C statistics of the logistic model containing more granular age and etiology categorizations did not differ significantly from a model containing the ETVSS categories. In children ≥ 12 months of age with ETVSSs of 50 or 60, the original ETVSS underestimated success, but this analysis was limited by a small sample size. Fronto-occipital horn ratio (p = 0.37), maximum width of the third ventricle (p = 0.39), and downward concavity of the floor of the third ventricle (p = 0.63) did not predict ETV success. A possible association between the degree of prepontine adhesions on preoperative MRI and ETV success was detected, but this did not reach statistical significance., Conclusions: This modern, multicenter study of ETV success shows that the original ETVSS continues to demonstrate good predictive ability, which was not substantially improved with a new success score. There might be an association between preoperative prepontine adhesions and ETV success, and this needs to be evaluated in a future large prospective study.

Background: One-fourth of Parkinson's disease (PD) patients suffer from cognitive impairment. However, few neuroimaging markers have been identified regarding cognitive impairment in PD., Objective: This study aimed to explore the association between third ventricular width by transcranial sonography (TCS) and cognitive decline in PD., Method: Participants with PD were recruited from one medical center in China. Third ventricular width was assessed by TCS, and cognitive function was analyzed by the Mini-Mental State Examination (MMSE). Receiver operating characteristic (ROC) analysis and Cox model analysis were utilized to determine the diagnostic and predictive accuracy of third ventricular width by TCS for cognitive decline in PD patients., Result: A total of 174 PD patients were recruited. Third ventricular width was negatively correlated with MMSE scores. ROC analysis suggested that the optimal cutoff point for third ventricular width in screening for cognitive impairment in PD was 4.75 mm (sensitivity 62.7%; specificity 75.6%). After 21.5 (18.0, 26.0) months of follow-up in PD patients without cognitive impairment, it was found that those with a third ventricular width greater than 4.75 mm exhibited a 7.975 times higher risk of developing cognitive impairment [hazard ratio = 7.975, 95% CI 1.609, 39.532, p = 0.011] compared with patients with a third ventricular width less than 4.75 mm., Conclusion: Third ventricular width based on TCS emerged as an independent predictor of developing cognitive impairment in PD patients., (© 2023 The Authors. CNS Neuroscience & Therapeutics Published by John Wiley & Sons Ltd.)

Objective: We sought to reclassify the "anatomic risk zones of colloid cysts" as proposed by Beaumont et al, by proposing newer landmarks, and to assess predictive value for the risk of occurrence of hydrocephalus with the new classification compared with the old., Methods: A retrospective cohort of 122 cases of colloid cyst of third ventricle were categorized into zones 1, 2, or 3 based on Beaumont's classification (old zone) and our classification (new zone) based on radiologic images. We attempted to recategorize these zones by assigning new anatomic landmarks. The difference in zonal distribution of colloid cyst and association with hydrocephalus was studied using the 2 methods of zonal classification., Results: Per the old zone classification, 3/122 patients were in zone 2, whereas 21/122 were in zone 2 per the new zone classification. The new zone method had a higher specificity (36.21% vs. 5.263 %) and positive predictive value (63.37% vs. 54.23%) for occurrence of hydrocephalus in patients with colloid cyst. The Spearman correlation showed better correlation with the new method for occurrence of hydrocephalus (rho = 0.4 [P < 0.00000] vs. 0.2 [P = 0.011])., Conclusions: Symptomatic colloid cysts are more likely to develop hydrocephalus and sudden acute deterioration. The colloid cyst risk score is a step towards objective decision making, with scope for modification such as the one that we have attempted with new zone classification to achieve superior prognostic ability., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background and Objectives: One of the key aspects in the surgical technique of endoscopic third ventriculostomy (ETV) is the perforation of the floor of the third ventricle because of the high risk of injuring vital structures located in that region. According to the standard technique, this perforation should be performed in the midline halfway between mammillary bodies and the infundibular recess to avoid damage to the structures. This can be performed without excessive complications when the diameter of the prepontine cistern is wide. However, in situations where the diameter is reduced (defined in the literature as having a prepontine interval [PPI] ≤1 mm), the probability of complications increases exponentially.In this article, we propose using dorsum sellae as a key point to safely perform ETV in patients with a decreased PPI, guiding the trajectory and its marking using neuronavigation., Methods: A review was conducted on the latest 100 ETV procedures performed by our team in the past 5 years. The measurement of the PPI was conducted using archived preoperative MRI imaging studies, specifically between the dorsum sellae and the basilar artery. In cases where the PPI was ≤1 mm and, therefore, the use of the dorsum sellae was applied as a reference point, the technical results and procedural functions were documented., Results: In the cohort, 7 patients with a PPI ≤1 mm were identified. In all 7 cases, fenestration of the tuber cinereum was successfully performed without causing vascular damage or associated complications. ETV was successful in 6 patients, with only one experiencing ETV failure necessitating the placement of a ventriculoperitoneal shunt., Conclusion: The utilization of the dorsum sellae as a reference point to perform ETV in reduced PPI constitutes a safe alternative to the classical technique., (Copyright © Congress of Neurological Surgeons 2023. All rights reserved.)

Background: Currently, endoscopic third ventriculostomy and simultaneous biopsy of deep midline brain tumors are a generally accepted option in neurooncology. Nevertheless, effectiveness of this surgery and diagnostic accuracy of biopsy are not without drawbacks. An alternative to endoscopic surgery may be simultaneous microsurgical third ventriculostomy and biopsy of deep midline tumors., Objective: To evaluate effectiveness and safety of burr hole microsurgical third ventriculostomy in the treatment of deep midline brain tumors., Material and Methods: We used transcortical (25 cases) and transcallosal (8 cases) approaches for microsurgical third ventriculostomy., Results: Initially scheduled biopsy was performed in 19 cases, partial resection in 6 cases, subtotal resection in 4 cases and total resection in 4 cases. All patients underwent microsurgical third ventriculostomy. In 12 cases, stenting of stoma was performed in addition to ventriculostomy. Biopsy was informative in all cases. Postoperative follow-up period ranged from 3 to 44 months (mean 29 months). There was no postoperative hydrocephalus and need for shunting procedure., Conclusion: Burr hole microsurgery may be an alternative to endoscopic surgery for the treatment of pineal, periaqueductal and third ventricular tumors.

Management of lateral and third ventricular tumors has been a challenge for neurosurgeons. Advances in imaging and pathology have helped in a better understanding of the treatment options. Technical refinement of microsurgical technique and addition of endoscopy has enabled more radical excision of tumors, when indicated, and added more safety.A proper understanding of the pathology at various ages and treatment options is continuously evolving. Many pediatric tumors are amenable to conservative surgical methods with effective complementary treatments. However, radical surgery is required in many adults as the main treatment and for many benign tumors. Various intraventricular lesions encountered and their surgical management is reviewed here for their efficacy, safety, and outcome, encompassing changes in our practice over the last 20 years., (© 2024. The Author(s), under exclusive license to Springer Nature Switzerland AG.)

Purpose: Hydrocephalus after craniovertebral decompression (CVD) for Chiari I malformation (CM-1) is a well-recognised complication. The mainstay of management involves medical management with high-dose steroids and/or acetazolamide, repeated lumbar punctures, external ventricular drainage (EVD) or insertion of a ventriculoperitoneal shunt (VPS). Endoscopic third ventriculostomy (ETV) has only been used a handful of times to treat this type of hydrocephalus with controversial outcomes. Not much is known about this or the technical nuances of this procedure. We report our experience., Methods: All children who underwent ETV to treat hydrocephalus post CVD done for CM-1 were identified from a prospectively kept database., Results: Three children were identified (13F, 11F, 13F). The average time to presentation of hydrocephalus was 8 days after craniovertebral decompression. Two were successfully treated with ETV with brain imaging showing a reduction in the size of the ventricles post-operatively and not requiring any further cerebrospinal fluid drainage. In one patient, the procedure had to be abandoned after the peel away catheter was introduced into the right ventricle because CSF egressed under high pressure with ventricle walls collapse resulting in an obstructed view. This child ultimately required a VPS., Conclusion: ETV can be used to successfully treat post CVD hydrocephalus in CM-1 patients depending on the aetiology of the hydrocephalus. There are technical and anatomical commonalities between these cases which make it more challenging than an ETV performed in "typical" obstructive hydrocephalus. We describe our experience and review the cases previously reported in the literature., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Colloid cysts of the third ventricle are benign intracranial lesions that account for 0.5 to 2% of all brain tumors and are even rarer in pediatric population. Dandy was the first to successfully excise a colloid cyst of the third ventricle via a transcortical transventricular approach in 1921. For several decades to follow, the transcortical transventricular and transcallosal microsurgical approaches remained the cornerstone of surgical management of these lesions. With time and refinements in endoscopic equipment and techniques, endoscopic resection of colloid cysts evolved into a currently well-established and appealing minimally invasive alternative to microsurgery. Endoscopic endochannel techniques for colloid cysts of the third ventricle may either be transforaminal or trans-septal interforniceal, depending on the pathoanatomical features of the colloid cyst and its relation to the juxtaposed anatomical structures. The endoscopic trans-septal interforniceal approach is required to access the rare subset of colloid cysts that extend superior to the roof of the third ventricle between the two fornices insinuating themselves between the leaflets of the septum pellucidum. In this article, the surgical technique of the endochannel endoscopic trans-septal interforniceal approach is elaborated upon. A representative case is presented along with an operative video., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: Pediatric intraventricular tumors of the third ventricle are among the most difficult-to-treat brain tumors. Recently, endonasal endoscopic surgery for suprasellar, third ventricle, and median clivus lesions has become the common procedure, and its indications are expanding to pediatric cases. We describe our strategy for endonasal endoscopic surgery for pediatric third ventricle tumors., Method: We report on surgical anatomies and our surgical procedures in detail, including case presentations., Result: Endoscopic endonasal surgery has the advantage of providing a wider view of the tumor site, hypothalamus, optic chiasm, and other critical structures. Good indications for the endoscopic endonasal approach for intra-third ventricular tumors are those arising from the floor of the third ventricle. In particular, craniopharyngioma, a typical pediatric suprasellar tumor, sometimes extends into the third ventricle, causing great operative difficulty. However, aggressive removal for long-term control while preserving memory and visual function is important. We perform surgery with a strategy of radically removing tumors without causing damage to visual or brain function, and we adopt the "4-hands technique by two neurosurgeons" in full endoscopic surgery to remove tumors safely and aggressively., Conclusion: We describe our strategy for endonasal endoscopic surgery for pediatric third ventricle tumors, especially those extending from the suprasellar region into the third ventricle, and present a representative case., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objective: To demonstrate the feasibility and preliminary results of percutaneous fetal endoscopic third ventriculostomy (ETV) in human fetuses (pfETV) with isolated progressive and/or severe bilateral cerebral ventriculomegaly (IPSBV)., Methods: The initial results of pfETV for IPSBV were described. Perioperative, perinatal and postnatal variables were described. The Ages and Stages Questionnaire (ASQ-3), 3rd edition (ASQ-3) was used for follow-up of all infants., Results: Successful pfETV was performed in 10/11 (91%) fetuses, at a median gestational age (GA) of 28.7 weeks (25.3-30.7). There were no perioperative complications. After pfETV, 70% (7/10) of the fetuses had a decreased or stabilized lateral ventricle atria|lateral ventricle's atria. The median GA at delivery was 38.2 weeks (35.9-39.3). There were no perinatal complications. The postnatal ventriculoperitoneal shunt rate was 80% (8/10). Among neonates/infants who had prenatal stabilization or a decrease in the LVAs, 4 (4/7: 57.1%) had abnormal scores on the ASQ-3. Among neonates/infants that experienced prenatal increases in the LVAs, all of them (3/3: 100%) had abnormal scores on the ASQ-3., Conclusion: Percutaneous ETV is feasible in human fetuses with progressive and/or severe cerebral ventriculomegaly and seems to be a safe procedure for both the mother and the fetus., (© 2023 John Wiley & Sons Ltd.)

Background: Reaching a tumor within the third ventricle is challenging, and planning an accessible trajectory is crucial without injuring the surrounding structures. We report a 5-year-old boy presented with headache and a seizure where sequential MRI brain studies in a short time period revealed a rapid growing immature teratoma within the third ventricle with hydrocephalic changes. Several management procedures were performed for CSF diversion and medical treatment of the tumor with chemotherapy and stem cell therapy. The tumor was rapidly growing, and surgical excision was decided. Total resection was achieved via endoscope-assisted microsurgical transcallosal approach. Seven years after surgery, the patient experienced no recurrence of the tumor with a favorable clinical condition., Conclusion: We report a rare case of posterior third ventricular immature teratoma where the endoscope-assisted microsurgical technique was implemented with favorable long-term postoperative outcome., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Colloid cysts are benign tumors usually located on the roof of the third ventricle. Cyst removal is the treatment of choice. It can be accomplished microsurgically through a transcortical- or transcallosal approach, or endoscopically. There is a lack of consensus regarding the best strategy for cyst removal. One of the challenges of the traditional endoscopic technique is dealing with the cyst content density. Hyperdensity on computed tomography scan and low signal on T2-weighted magnetic resonance imaging (MRI) cyst are correlated with high viscosity cystic content., Case Reports: We present a case of a colloid cyst of the third ventricle in a 15-year-old boy removed through a pure endoscopic transventricular approach. The cyst presented a low signal on T2 MRI; nevertheless, it was easily removed with the help of an endoscopic ultrasonic aspirator., Discussion and Conclusion: The colloid cyst of the third ventricle can be safely treated by a purely endoscopic approach. The rationale of the use of the ultrasonic aspirator relies on the facilitation of aspiration of the content even when the consistency is extremely firm., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Tumors of the choroid plexus of the third ventricle are uncommon. Surgical excision is technically challenging because of the rich vascularisation, central location, and high incidence in young children. Open microsurgical resection is considered the standard treatment. However, attempts at purely endoscopic removal of choroid plexus tumors of the third ventricle have also been made in the past, with encouraging results., Case Reports: We report our experience with endoscopic ultrasonic removal of two cases of tumors of the third ventricular choroid plexus. The first case was a large atypical choroid plexus papilloma (WHO grade 2) in the anterior third ventricle associated with hydrocephalus; the second case was a smaller choroid plexus papilloma (WHO grade 1) in the middle/posterior third ventricle without overt hydrocephalus requiring a more anterior neuronavigation guided approach., Discussion and Conclusion: Choroid plexus papillomas of the third ventricle can be safely treated by a purely endoscopic approach because they are usually smaller than their counterparts in the lateral ventricle and often have a recognizable vascular pedicle. Early detection and control of the vascular pedicle at the choroidal border is key to success. The use of ultrasonic aspirator facilitates and expedites endoscopic access. By alternating surface coagulation with fragmentation and aspiration with the ultrasonic aspirator, the tumor can be removed without difficult dissection maneuvers., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Patients with pulvinar area lesions may develop hydrocephalus at any stage. The role of endoscopic third ventriculostomy (ETV) in this setting remains unclear., Method: We retrospectively enrolled 15 patients with a mean age of 43 years who underwent endoscopic resection of pulvinar area lesions using the supracerebellar infratentorial approach (SCITA). We compared the different modalities of hydrocephalus management and their outcomes., Results: Nine of 15 patients (60.0%) had preoperative obstructive hydrocephalus. Five patients underwent ETV before tumor resection, and none developed postoperative hydrocephalus. Four patients underwent one-stage surgery for tumor removal, and one patient with a polymorphous low-grade neuroepithelial tumor of the young required postoperative ETV. Another patient with diffuse astrocytoma and hydrocephalus underwent concurrent lamina terminalis fenestration and endoscopic resection via the SCITA, which resulted in the resolution of hydrocephalus. The preoperative ETV group had no major postoperative complications, while the non-ETV group had three (0/5 vs. 3/4, P = 0.048). The ETV group also had a shorter intensive care unit stay; however, the difference was not significant (1.2 vs. 2.8; P = 0.188). ETV was effective in alleviating symptoms of postoperative hydrocephalus in patients with midbrain-invading tumors., Conclusion: Endoscopic surgery via the SCITA can address both tumor and hydrocephalus issues in some cases but has a higher surgical risk and postoperative hydrocephalus rate. Preoperative ETV can prevent these complications and improve postoperative outcomes., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Background: The application of endoscopic third ventriculostomy (ETV) for the treatment of obstructive hydrocephalus in shunt malfunction represents a paradigm shift, as it allows hydrocephalus to be transformed from a chronic condition treated with an artificial device to a curable disease., Methods: We present a 54-year-old male with a diagnosis of idiopathic Sylvian aqueduct stenosis treated with shunt. The patient presented to our institution with symptoms of shunt malfunction and an increase in ventricular size on imaging, which was his third episode throughout his life. Through a right precoronal approach, with prior informed consent from the patient, we performed foraminoplasty, endoscopic third ventriculostomy, and finally removal of the shunt system., Conclusion: ETV shows promise as a viable treatment option for shunt malfunction in noncommunicating obstructive hydrocephalic patients. Its potential to avoid VPS-related complications, preserve physiological CSF circulation, and provide an alternative drainage pathway warrants further investigation., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Austria, part of Springer Nature.)

We present a unique case of a man presenting with progressive short-term memory deficits over 10+ years who was found to have a large intraventricular cavernoma in the anterior wall of the third ventricle with invasion of medial limbic structures. Identifying intraventricular cavernomas early is crucial to prevent substantial growth and to increase the chance of successful patient outcomes., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: The outcome of endoscopic third ventriculostomy (ETV) in children who had previously received shunts and who were experiencing shunt dysfunction is still discussed in terms of efficacy (success rate from 40% to 80%) and safety (0%-32.5% of complications). Reported predictive factors of secondary ETV failure are age, early onset of hydrocephalus, and prematurity. The best surgical strategy in the different subgroups of patients with shunt dysfunction is still debated. Therefore, the authors aimed to identify subgroups of patients in whom shunt treatment was associated with favorable outcome of ETV, to define the role of ETV in patients with global rostral midbrain dysfunction syndrome., Methods: This study was a monocentric retrospective case series and a meta-analysis of children who had previously received shunts and who underwent secondary ETV for shunt dysfunction between 2012 and 2022. Clinical and MRI features were examined, along with surgical outcome, etiology of hydrocephalus, and preoperative ETV Success Score. Univariate and multivariate analyses were performed to find predictors of outcome of secondary ETV. Youden's J index was calculated on age distribution to find an optimal age cutoff. Systematic review of the literature and a meta-analysis were performed according to the PRISMA statement., Results: Seventy consecutive patients were included. The overall success rate of secondary ETV was 63%. Primary obstructive hydrocephalus, age ≥ 36 months, and the presence of aqueductal obstruction were predictors of ETV success. Multivariate analysis found that age < 36 months, primary inflammatory hydrocephalus, and presence of fourth ventricular obstruction were associated with ETV failure. All patients with global rostral midbrain dysfunction syndrome experienced clinical and radiological improvement after ETV. The meta-analysis showed that postinflammatory etiology and age < 36 months were predictors of ETV failure., Conclusions: ETV is safe and effective for children with obstructive hydrocephalus experiencing shunt dysfunction, notably in cases of primary obstructive hydrocephalus with aqueductal stenosis, and among children whose age was ≥ 36 months who had postinflammatory hydrocephalus.

Objective: The objective of this study was to describe the incidence and management of hydrocephalus in patients with achondroplasia over a 60-year period at four skeletal dysplasia centers., Methods: The Achondroplasia Natural History Study (CLARITY) is a registry for clinical data from achondroplasia patients receiving treatment at four skeletal dysplasia centers in the US from 1957 to 2017. Data were entered and stored in a REDCap database and included surgeries with indications and complications, medical diagnoses, and radiographic information., Results: A total of 1374 patients with achondroplasia were included in this study. Of these, 123 (9%) patients underwent treatment of hydrocephalus at a median age of 14.4 months. There was considerable variation in the percentage of patients treated for hydrocephalus by center and decade of birth, ranging from 0% to 28%, although in the most recent decade, all centers treated less than 6% of their patients, with an average of 2.9% across all centers. Undergoing a cervicomedullary decompression (CMD) was a strong predictor for treatment of hydrocephalus (OR 5.8, 95% CI 3.9-8.4), although that association has disappeared in those born since 2010 (OR 1.1, 95% CI 0.2-5.7). In patients born since 1990, treatment of hydrocephalus with endoscopic third ventriculostomy (ETV) has become more common; it was used as the first line of treatment in 38% of patients in the most recent decade. Kaplan-Meier analysis suggests that a single ETV will treat hydrocephalus in roughly half of these patients., Conclusions: While many children with achondroplasia have features of hydrocephalus with enlarged intracranial CSF spaces and relative macrocephaly, treatment of hydrocephalus in achondroplasia patients has become relatively uncommon in the last 20 years. Historically, there was a significant association between symptomatic foramen magnum stenosis and treatment of hydrocephalus, although concurrent treatment of both has fallen out of favor with the recognition that CMD alone will treat hydrocephalus in some patients. Despite good experimental data demonstrating that hydrocephalus in achondroplasia is best understood as communicating in nature, ETV appears to be reasonably successful in certain patients and should be considered an option in selected patients.