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INTRODUCTION: Fetal aqueductal stenosis (AS) affects approximately 1:1,000 pregnancies. Obstruction of cerebral spinal fluid circulation occurs at the aqueduct of Sylvius, leading to progressive hydrocephalus and macrocephaly, which often necessitates cesarean section (CS). The purpose of this study was to describe maternal outcomes associated with fetal AS. METHODS: This study is conducted through the North American Fetal Therapy Network (NAFTNet). Subjects with a prenatal diagnosis of severe fetal central nervous system ventriculomegaly were recruited and followed longitudinally. Maternal events around the delivery of fetuses with AS were recorded and analyzed. RESULTS: Thirty-seven subjects with fetal AS confirmed by neonatal neuroimaging were analyzed. The average gestational age at delivery was 36.7 weeks. Overall, 86% were delivered by CS, and 62% of these were elective. Ninety-one percent of CSs were performed through a Pfannenstiel abdominal incision. A classical uterine incision was required in 13% of cesarean deliveries. The peripartum complication rate was 27%. CONCLUSION: Women carrying a fetus with AS were at risk for preterm birth, cesarean delivery, a classical uterine incision, and peripartum complications. These data highlight the maternal morbidity associated with fetal AS and the potential benefit of in utero therapy not only for neonatal outcomes but also for maternal outcomes.

This in vitro study aims at clarifying the relation between the oscillatory flow of cerebrospinal fluid (CSF) in the cerebral aqueduct, a narrow conduit connecting the third and fourth ventricles, and the corresponding interventricular pressure difference. Dimensional analysis is used in designing an anatomically correct scaled model of the aqueduct flow, with physical similarity maintained by adjusting the flow frequency and the properties of the working fluid. The time-varying pressure difference across the aqueduct corresponding to a given oscillatory flow rate is measured in parametric ranges covering the range of flow conditions commonly encountered in healthy subjects. Parametric dependences are delineated for the time-averaged pressure fluctuations and for the phase lag between the transaqueductal pressure difference and the flow rate, both having clinical relevance. The results are validated through comparisons with predictions obtained with a previously derived computational model. The parametric quantification in this study enables the derivation of a simple formula for the relation between the transaqueductal pressure and the stroke volume. This relationship can be useful in the quantification of transmantle pressure differences based on non-invasive magnetic-resonance-velocimetry measurements of aqueduct flow for investigation of CSF-related disorders. [Display omitted] • In vitro experiments are used to quantify flow and pressure in the cerebral aqueduct. • The transaqueductal pressure is quantified as a function of the stroke volume. • The results are useful for non-invasive clinical evaluation of transmantle pressure. [ABSTRACT FROM AUTHOR]

Rationale: Intracranial ependymal cysts are relatively rare. The current case report focuses on a patient who was diagnosed with an ependymal cyst and underwent surgical treatment. Postoperative pathological examination confirmed the presence of this lesion in the cerebellum. Chief complaint: A 32-year-old female patient presented with a chief complaint of dizziness and headache with no triggers for the past 1 year. She also reported an increase in the frequency and intensity of symptoms in the past 2 weeks. Diagnosis: Cranial magnetic resonance imaging (MRI) showed a rounded long T1 and T2 abnormal signal foci in the left posterior part of the brainstem under the cerebellar pallidum. The lesion had a clear boundary, was approximately 4.0 x 3.1 x 3.2 cm in size, and did not exhibit any definitive enhancement. Interventions: Total resection of the lesion was carried out after completion of the preoperative examination. Treatment outcomes. The patient was discharged from the hospital on postoperative day 11 once their symptoms had disappeared. The sensory and motor functions of the limbs remained unaffected by treatment. Experiences: Cerebellum ependymal cysts are rare, and most patients only experience discomfort due to cerebral edema. These lesions are also often difficult to differentiate from other intracranial cysts using imaging alone. The aim of this study was to report a rare case of ependymal cyst so that it may serve as a reference for diagnosis and treatment in the future. [ABSTRACT FROM AUTHOR]

Dorsal human midbrain contains two nuclei with clear laminar organization, the superior and inferior colliculi. These nuclei extend in depth between the superficial dorsal surface of midbrain and a deep midbrain nucleus, the periaqueductal gray matter (PAG). The PAG, in turn, surrounds the cerebral aqueduct (CA). This study examined the use of two depth metrics to characterize depth and thickness relationships within dorsal midbrain using the superficial surface of midbrain and CA as references. The first utilized nearest-neighbor Euclidean distance from one reference surface, while the second used a level-set approach that combines signed distances from both reference surfaces. Both depth methods provided similar functional depth profiles generated by saccadic eye movements in a functional MRI task, confirming their efficacy for delineating depth for superficial functional activity. Next, the boundaries of the PAG were estimated using Euclidean distance together with elliptical fitting, indicating that the PAG can be readily characterized by a smooth surface surrounding PAG. Finally, we used the level-set approach to measure tissue depth between the superficial surface and the PAG, thus characterizing the variable thickness of the colliculi. Overall, this study demonstrates depth-mapping schemes for human midbrain that enables accurate segmentation of the PAG and consistent depth and thickness estimates of the superior and inferior colliculi.

Stenosis of the cerebral aqueduct (CA) is featured in many studies relating to elevated intracranial cerebral pressures. It also presents a challenging situation to clinicians. Compressive forces play a lead role in pathological situations such as the presence of tumors and hence can cause obstruction to the flow of cerebrospinal fluid (CSF). Because of this barrier, excessive retention of CSF in the ventricles can occur. This, in turn, can contribute to increased pressure gradients inside the cranium. Most of the numerical models in the literature are restricted to modeling the CSF flow by considering the ventricle walls as rigid material, although in reality they are deformable. This paper, therefore, addresses the same from a holistic perspective by taking into consideration the dynamics of the flexible characteristics of the ventricular wall. It adds novelty to this field by reconstructing anatomically realistic ventricular wall behavior. To do this, the authors aim to develop a computational model of stenosis of the CA due to a brain tumor by invoking a fluid–structure interaction (FSI) method. The proposed three-dimensional FSI model is simulated under two cases: first, simulation of the pre-stenosis case with no interaction of tumor forces and, secondly, a stenosis condition with dynamic interaction of tumor forces. Comparison of the forces with and without a tumor reveals a marked obstruction of CSF outflow after the third ventricle and CA. In addition, a drastic rise in CSF velocity from 21.2 mm/s in the pre-stenosis case to 54.1 mm/s in the stenosis case is observed, along with a net increase in deformation of 0.144 mm on the walls of the ventricle. This paper makes a significant contribution to brain simulation studies for pressure calculations, in which the presence of tumors is a major concern.

Introduction Cerebral aqueduct (of Sylvius) connects the third and fourth ventricles of the brain, and the shape of the aqueduct varies. The aim of the study is to assess the morphometry of the cerebral aqueduct in normal south Indian adult population and to look for pattern by shape, if any. Materials and Methods One hundred and fifty normal brain MR images (75 males and 75 females) using 3D heavily T2-weighted sequence were analyzed for various normal parameters of cerebral aqueduct. Mean and standard deviation were calculated. Based on the shape of the aqueduct, an attempt was made to classify them. Unpaired t-test was used to assess any significant difference between age groups and gender. The intraclass coefficient correlation was used to analyze the interobserver variability. Results The mean value of the length of the cranial and caudal part of aqueduct in males were 0.69 cm and 0.86 cm and in females 0.65 cm and 0.80 cm, respectively. The length was more in males, and it was statistically significant (p = 0.006 and 0.02). There are four types of cerebral aqueduct based on shape. Conclusion MRI is considered as the investigation of choice for preoperative planning of brain operative procedures. The MR morphometric evaluation of cerebral aqueduct provides precise knowledge about the anatomy and may be of help in the diagnosis and treatment by endoscopic neurosurgery.

Background: The etiology of enlarged subarachnoid spaces of infancy is unknown; however, there is radiologic similarity with normal pressure hydrocephalus. Adults with normal pressure hydrocephalus have been shown to have altered cerebrospinal (CSF) flow through the cerebral aqueduct. Objective: To explore potential similarity between enlarged subarachnoid spaces of infancy and normal pressure hydrocephalus, we compared MRI-measured CSF flow through the cerebral aqueduct in infants with enlarged subarachnoid spaces of infancy to infants with normal brain MRIs. Materials and methods: This was an IRB approved retrospective study. Clinical brain MRI examinations including axial T2 imaging and phase contrast through the aqueduct were reviewed for infants with enlarged subarachnoid spaces of infancy and for infants with a qualitatively normal brain MRI. The brain and CSF volumes were segmented using a semi-automatic technique (Analyze 12.0) and CSF flow parameters were measured (cvi42, 5.14). All data was assessed for significant differences while controlling for age and sex using analysis of covariance (ANCOVA). Results: Twenty-two patients with enlarged subarachnoid spaces (mean age 9.0 months, 19 males) and 15 patients with normal brain MRI (mean age 18.9 months, 8 females) were included. Volumes of the subarachnoid space (P < 0.001), lateral (P < 0.001), and third ventricles (P < 0.001) were significantly larger in infants with enlarged subarachnoid spaces of infancy. Aqueductal stroke volume significantly increased with age (P = 0.005), regardless of group. Conclusion: CSF volumes were significantly larger in infants with enlarged subarachnoid spaces of infancy versus infants with a normal MRI; however, there was no significant difference in CSF flow parameters between the two groups. [ABSTRACT FROM AUTHOR]

Xenopus tadpoles serve as an exceptional model organism for studying post‐embryonic development in vertebrates. During post‐embryonic development, large‐scale changes in tissue morphology, including organ regeneration and metamorphosis, occur at the organ level. However, understanding these processes in a three‐dimensional manner remains challenging. In this study, the use of X‐ray micro‐computed tomography (microCT) for the three‐dimensional observation of the soft tissues of Xenopus tadpoles was explored. The findings revealed that major organs, such as the brain, heart, and kidneys, could be visualized with high contrast by phosphotungstic acid staining following fixation with Bouin's solution. Then, the changes in brain shape during telencephalon regeneration were analyzed as the first example of utilizing microCT to study organ regeneration in Xenopus tadpoles, and it was found that the size of the amputated telencephalon recovered to >80% of its original length within approximately 1 week. It was also observed that the ventricles tended to shrink after amputation and maintained this state for at least 3 days. This shrinkage was transient, as the ventricles expanded to exceed their original size within the following week. Temporary shrinkage and expansion of the ventricles, which were also observed in transgenic or fluorescent dye‐injected tadpoles with telencephalon amputation, may be significant in tissue homeostasis in response to massive brain injury and subsequent repair and regeneration. This established method will improve experimental analyses in developmental biology and medical science using Xenopus tadpoles. [ABSTRACT FROM AUTHOR]

BACKGROUND: This study investigated cerebrospinal fluid (CSF) hydrodynamics using cine phase-contrast MRI in the cerebral aqueduct and the prepontine cistern between three distinct groups: pre-shunt normal pressure hydrocephalus (NPH) patients, post-shunt NPH patients, and controls. We hypothesized that the hyperdynamic flow of CSF through the cerebral aqueduct seen in NPH patients was due to a reduction in cisternal CSF volume buffering. Both hydrodynamic (velocity, flow, stroke volume) and peak flow latency (PFL) parameters were investigated. METHODS: Scans were conducted on 30 pre-treatment patients ranging in age from 58 to 88 years along with an additional 12 controls. Twelve patients also received scans following either ventriculoatrial (VA) or ventriculoperitoneal (VP) shunt treatment (9 VP, 3 VA), ranging in age from 74 to 89 years with a mean follow up time of 6 months. RESULTS: Significant differences in area, velocity, flow, and stroke volume for the cerebral aqueduct were found between the pre-treatment NPH group and the healthy controls. Shunting caused a significant decrease in both caudal and cranial mean flow and stroke volume in the cerebral aqueduct. No significant changes were found in the prepontine cistern between the pre-treatment group and healthy controls. For the PFL, no significant differences were seen in the cerebral aqueduct between any of the three groups; however, the prepontine cistern PFL was significantly decreased in the pre-treatment NPH group when compared to the control group. CONCLUSIONS: Although several studies have quantified the changes in aqueductal flow between hydrocephalic groups and controls, few studies have investigated prepontine cistern flow. Our study was the first to investigate both regions in the same patients for NPH pre- and post- treatment. Following shunt treatment, the aqueductal CSF metrics decreased toward control values, while the prepontine cistern metrics trended up (not significantly) from the normal values established in this study. The opposing trend of the two locations suggests a redistribution of CSF pulsatility in NPH patients. Furthermore, the significantly decreased latency of the prepontine cisternal CSF flow suggests additional evidence for CSF pulsatility dysfunction.

Abstract Background Recent studies have suggested alternative cerebrospinal fluid (CSF) clearance pathways for brain parenchymal metabolic waste products. One fundamental but relatively under-explored component of these pathways is the anatomic region surrounding the superior sagittal sinus, which has been shown to have relevance to trans-arachnoid molecular passage. This so-called parasagittal dural (PSD) space may play a physiologically significant role as a distal intracranial component of the human glymphatic circuit, yet fundamental gaps persist in our knowledge of how this space changes with normal aging and intracranial bulk fluid transport. Methods We re-parameterized MRI methods to assess CSF circulation in humans using high resolution imaging of the PSD space and phase contrast measures of flow through the cerebral aqueduct to test the hypotheses that volumetric measures of PSD space (1) are directly related to CSF flow (mL/s) through the cerebral aqueduct, and (2) increase with age. Multi-modal 3-Tesla MRI was applied in healthy participants (n = 62; age range = 20–83 years) across the adult lifespan whereby phase contrast assessments of CSF flow through the aqueduct were paired with non-contrasted T 1-weighted and T 2-weighted MRI for PSD volumetry. PSD volume was extracted using a recently validated neural networks algorithm. Non-parametric regression models were applied to evaluate how PSD volume related to tissue volume and age cross-sectionally, and separately how PSD volume related to CSF flow (significance criteria: two-sided p

Stenosis of the cerebral aqueduct (CA) is featured in many studies relating to elevated intracranial cerebral pressures. It also presents a challenging situation to clinicians. Compressive forces play a lead role in pathological situations such as the presence of tumors and hence can cause obstruction to the flow of cerebrospinal fluid (CSF). Because of this barrier, excessive retention of CSF in the ventricles can occur. This, in turn, can contribute to increased pressure gradients inside the cranium. Most of the numerical models in the literature are restricted to modeling the CSF flow by considering the ventricle walls as rigid material, although in reality they are deformable. This paper, therefore, addresses the same from a holistic perspective by taking into consideration the dynamics of the flexible characteristics of the ventricular wall. It adds novelty to this field by reconstructing anatomically realistic ventricular wall behavior. To do this, the authors aim to develop a computational model of stenosis of the CA due to a brain tumor by invoking a fluid–structure interaction (FSI) method. The proposed three-dimensional FSI model is simulated under two cases: first, simulation of the pre-stenosis case with no interaction of tumor forces and, secondly, a stenosis condition with dynamic interaction of tumor forces. Comparison of the forces with and without a tumor reveals a marked obstruction of CSF outflow after the third ventricle and CA. In addition, a drastic rise in CSF velocity from 21.2 mm/s in the pre-stenosis case to 54.1 mm/s in the stenosis case is observed, along with a net increase in deformation of 0.144 mm on the walls of the ventricle. This paper makes a significant contribution to brain simulation studies for pressure calculations, in which the presence of tumors is a major concern. [ABSTRACT FROM AUTHOR]

Introduction Cerebral aqueduct (of Sylvius) connects the third and fourth ventricles of the brain, and the shape of the aqueduct varies. The aim of the study is to assess the morphometry of the cerebral aqueduct in normal south Indian adult population and to look for pattern by shape, if any. Materials and Methods One hundred and fifty normal brain MR images (75 males and 75 females) using 3D heavily T2-weighted sequence were analyzed for various normal parameters of cerebral aqueduct. Mean and standard deviation were calculated. Based on the shape of the aqueduct, an attempt was made to classify them. Unpaired t-test was used to assess any significant difference between age groups and gender. The intraclass coefficient correlation was used to analyze the interobserver variability. Results The mean value of the length of the cranial and caudal part of aqueduct in males were 0.69 cm and 0.86 cm and in females 0.65 cm and 0.80 cm, respectively. The length was more in males, and it was statistically significant (p = 0.006 and 0.02). There are four types of cerebral aqueduct based on shape. Conclusion MRI is considered as the investigation of choice for preoperative planning of brain operative procedures. The MR morphometric evaluation of cerebral aqueduct provides precise knowledge about the anatomy and may be of help in the diagnosis and treatment by endoscopic neurosurgery. [ABSTRACT FROM AUTHOR]

This paper suggests a chemical mechanism for the earliest stages of Alzheimer's disease (AD). Cerebrospinal fluid (CSF) flow stresses provide the energy needed to induce molecular conformation changes leading to AD by initiating amyloid-β (Aβ) and tau aggregation. Shear and extensional flow stresses initiate aggregation in the laboratory and in natural biophysical processes. Energy-rich CSF flow regions are mainly found in lower brain regions. MRI studies reveal flow stress "hot spots" in basal cisterns and brain ventricles that have chaotic flow properties that can distort molecules such as Aβ and tau trapped in these regions into unusual conformations. Such fluid disturbance is surrounded by tissue deformation. There is strong mapping overlap between the locations of these hot spots and of early-stage AD pathology. Our mechanism creates pure and mixed protein dimers, followed by tissue surface adsorption, and long-term tissue agitation ultimately inducing chemical reactions forming more stable, toxic oligomer seeds that initiate AD. It is proposed that different flow stress energies and flow types in different basal brain regions produce different neurotoxic aggregates. Proliferating artery hardening is responsible for enhanced heart systolic pulses that drive energetic CSF pulses, whose critical maximum systolic pulse energy location migrates further from the heart with increasing vascular disease. Two glymphatic systems, carotid and basilar, are suggested to contain the earliest Aβ and tau AD disease pathologies. A key to the proposed AD mechanism is a comparison of early chronic traumatic encephalopathy and AD pathologies. Experiments that test the proposed mechanism are needed. [ABSTRACT FROM AUTHOR]

• Aqueductal CSF flow can differentiate iNPH from other neurological conditions. • Stroke volumes have generally stronger correlation than velocity parameters. • Peak flow velocity has high specificity and may aid in exclusion of iNPH. • Net caudocranial flow through the aqueduct was not predictive of iNPH status. Idiopathic normal pressure hydrocephalus (iNPH) is a potentially reversible cause of dementia-like symptoms among the elderly. Current diagnostic guidelines for iNPH rely on clinical manifestations and ventricular morphology, which often lack accuracy. While magnetic resonance imaging (MRI) CSF flowmetry of the cerebral aqueduct provides a noninvasive aid to differential diagnosis, previous studies suffered from small sample sizes. This study compares the accuracy of different CSF flow parameters for iNPH diagnosis in a general patient population. From 2016 to 2018, a total of 216 subjects over 60 years of age were retrospectively enrolled, including 38 patients with iNPH and 178 patients with non-iNPH neurological conditions. All participants received phase-contrast MRI (PC-MRI) CSF flowmetry, with measurements performed independently by two radiologists. Flow parameters of iNPH and non-iNPH groups were compared along with their diagnostic accuracy. Absolute stroke volume (ABSV), forward flow, backward flow, mean flux and peak velocity were significantly higher in iNPH patients (P < 0.001, P < 0.001, P < 0.001, P = 0.008, P = 0.038, respectively). Backward flow had the highest diagnostic accuracy, followed by ABSV and forward flow. Net caudocranial aqueductal flow was observed in both groups, but with greater volume in the iNPH group. PC-MRI provides a non-invasive method of CSF flowmetry across the cerebral aqueduct and may aid in iNPH diagnosis. ABSV and its component flow values may provide better accuracy in identifying iNPH than other parameters. [ABSTRACT FROM AUTHOR]

Objective: To evaluate cerebrospinal fluid dynamics, using cine phase-contrast magnetic resonance imaging (cine-PC MRI), in healthy pediatric subjects, determining the normal flow values in this population, as well as identifying differences related to age, sex, and body surface area. Materials and Methods: This was a descriptive cross-sectional study involving 32 healthy children and adolescents, in whom the flow of cerebrospinal fluid through the cerebral aqueduct was evaluated quantitatively with cine-PC MRI. We used specialized software to analyze the images obtained with cine-PC MRI, drawing a region of interest on the aqueduct. A flow-time curve was obtained, as were automated measurements of the various parameters. Results: The following normal (mean) values were obtained: net flow, 1.10 ± 0.99 mL/m; stroke volume, 12.2 ± 10.1 µL/cycle; mean velocity, 0.72 ± 1.00 cm/s; peak systolic velocity, 5.28 ± 2.30 cm/s; peak diastolic velocity, 4.51 ± 1.77 cm/s. These values were not affected by age or sex. In addition, body surface area was not found to correlate significantly with mean velocity or stroke volume. Conclusion: In children and adolescents, the basic cerebrospinal fluid flow parameters, as determined by cine-PC MRI, appear to be independent of age and sex. [ABSTRACT FROM AUTHOR]

Abstract Background Several central nervous system diseases are associated with disturbed cerebrospinal fluid (CSF) flow patterns and have typically been characterized in vivo by phase-contrast magnetic resonance imaging (MRI). This technique is, however, limited by its applicability in space and time. Phase-contrast MRI has yet to be compared directly with CSF tracer enhanced imaging, which can be considered gold standard for assessing long-term CSF flow dynamics within the intracranial compartment. Methods Here, we studied patients with various CSF disorders and compared MRI biomarkers of CSF space anatomy and phase-contrast MRI at level of the aqueduct and cranio-cervical junction with dynamic intrathecal contrast-enhanced MRI using the contrast agent gadobutrol as CSF tracer. Tracer enrichment of cerebral ventricles was graded 0–4 by visual assessment. An intracranial pressure (ICP) score was used as surrogate marker of intracranial compliance. Results The study included 94 patients and disclosed marked variation of CSF flow measures across disease categories. The grade of supra-aqueductal reflux of tracer varied, with strong reflux (grades 3–4) in half of patients. Ventricular tracer reflux correlated with stroke volume and aqueductal CSF pressure gradient. CSF flow in the cerebral aqueduct was retrograde (from 4th to 3rd ventricle) in one third of patients, with estimated CSF net flow volume about 1.0 L/24 h. In the cranio-cervical junction, net flow was cranially directed in 78% patients, with estimated CSF net flow volume about 4.7 L/24 h. Conclusions The present observations provide in vivo quantitative evidence for substantial variation in direction and magnitude of CSF flow, with re-direction of aqueductal flow in communicating hydrocephalus, and significant extra-cranial CSF production. The grading of ventricular reflux of tracer shows promise as a clinical useful method to assess CSF flow pattern disturbances in patients. Graphic abstract

Purpose: Phase‐contrast MRI (PC‐MRI) of cerebrospinal fluid (CSF) velocity is used to evaluate the characteristics of intracranial diseases, such as normal‐pressure hydrocephalus (NPH). Nevertheless, PC‐MRI has several potential error sources, with eddy‐current‐based phase offset error being non‐negligible in CSF measurement. In this study, we assess the measurement error of CSF velocity maps obtained using 4D flow MRI and evaluate correction methods. Methods: CSF velocity maps of 10 patients with NPH were acquired using 4D flow MRI (velocity‐encoding = 5 cm/s). Distributed phase offset error was estimated for a whole 3D background field by polynomial fitting using robust regression analysis. This estimated phase offset error was then used to correct the CSF velocity maps. The estimated error profiles were compared with those obtained using an existing 2D correction approach involving local background information near the region of interest. Results: The residual standard error of the polynomial fitting against the phase offset error extracted from the measured velocities was within 0.2 cm/s. The spatial dependencies of the phase offset errors showed similar tendencies in all cases, but sufficient differences in these values were found to indicate requirement of velocity correction. Differences of the estimated errors among other correction approaches were in the order of 10−2 cm/s, and the estimated errors were in good agreement with those obtained using existing approaches. Conclusion: Our method is capable of estimating the measurement error of CSF velocity maps obtained from 4D flow MRI and provides quantitatively reasonable characteristics for the main CSF profile in the cerebral aqueduct in patients with NPH. [ABSTRACT FROM AUTHOR]

Background: Recent studies have suggested alternative cerebrospinal fluid (CSF) clearance pathways for brain parenchymal metabolic waste products. One fundamental but relatively under-explored component of these pathways is the anatomic region surrounding the superior sagittal sinus, which has been shown to have relevance to trans-arachnoid molecular passage. This so-called parasagittal dural (PSD) space may play a physiologically significant role as a distal intracranial component of the human glymphatic circuit, yet fundamental gaps persist in our knowledge of how this space changes with normal aging and intracranial bulk fluid transport. Methods: We re-parameterized MRI methods to assess CSF circulation in humans using high resolution imaging of the PSD space and phase contrast measures of flow through the cerebral aqueduct to test the hypotheses that volumetric measures of PSD space (1) are directly related to CSF flow (mL/s) through the cerebral aqueduct, and (2) increase with age. Multi-modal 3-Tesla MRI was applied in healthy participants (n = 62; age range = 20–83 years) across the adult lifespan whereby phase contrast assessments of CSF flow through the aqueduct were paired with non-contrasted T1-weighted and T2-weighted MRI for PSD volumetry. PSD volume was extracted using a recently validated neural networks algorithm. Non-parametric regression models were applied to evaluate how PSD volume related to tissue volume and age cross-sectionally, and separately how PSD volume related to CSF flow (significance criteria: two-sided p < 0.05). Results: A significant PSD volume enlargement in relation to normal aging (p < 0.001, Spearman's- ρ = 0.6), CSF volume (p < 0.001, Spearman's- ρ = 0.6) and maximum CSF flow through the aqueduct of Sylvius (anterograde and retrograde, p < 0.001) were observed. The elevation in PSD volume was not significantly related to gray or white matter tissue volumes. Findings are consistent with PSD volume increasing with age and bulk CSF flow. Conclusions: Findings highlight the feasibility of quantifying PSD volume non-invasively in vivo in humans using machine learning and non-contrast MRI. Additionally, findings demonstrate that PSD volume increases with age and relates to CSF volume and bi-directional flow. Values reported should provide useful normative ranges for how PSD volume adjusts with age, which will serve as a necessary pre-requisite for comparisons to persons with neurodegenerative disorders. [ABSTRACT FROM AUTHOR]

Quadrigeminal arachnoid cyst are one of the rarest form of intracranial arachnoid cyst, this unique congenital malformation posses an special risk for hydrocephalus and neurological symptoms due to its proximity to the aqueduct and the brain stem. The treatment for this cyst tends to be surgical in cases when intracranial hypertension presents by hydrocephalus. Few cases of non surgical treatment of quadrigeminal arachnoid cyst with clinical follow up has been studied in global literature . Here it’s a case of a young patient with quadrigeminal arachnoid cyst with clinical monitoring for three years without any change in symptoms and without any neurological deterioration over the time

Purpose: An extensive literature has postulated multiple etiologies for aqueductal stenosis. No publications were found, discussing that evolutionary modifications might explain aqueductal anomalies. This study's objectives were to review the evolutionary modifications of vertebrates' tectum structures that might explain human aqueduct anomalies. Undertaking vertebrate comparative study is currently not feasible in view of limitations in obtaining vertebrate material. Thus, vertebrate material collected, injected, dissected, and radiographed in the early 1970s was analyzed, focusing on the aqueduct and components of the midbrain tectum. Methods: Photographs of brain dissections and radiographs of the cerebral ventricles and arteries of adult shark, frog, iguana, rabbit, cat, dog, and primate specimens, containing a barium-gelatin radiopaque compound, were analyzed focusing on the aqueduct, the optic ventricles, the quadrigeminal plate, and collicular ventricles. The anatomic information provided by the dissections and radiographs is not reproducible by any other radiopaque contrast currently available. Results: Dissected and radiographed cerebral ventricular and arterial systems of the vertebrates demonstrated midbrain tectum changes, including relative size modifications of the mammalian components of the tectum, simultaneously with the enlargement of the occipital lobe. There is a transformation of pre-mammalian optic ventricles to what appear to be collicular ventricles in mammals, as the aqueduct and collicular ventricle form a continuous cavity. Conclusions: The mammalian tectum undergoes an evolutionary cephalization process consisting of relative size changes of the midbrain tectum structures. This is associated with enlargement of the occipital lobe, as part of overall neocortical expansion. Potentially, aqueductal anomalies could be explained by evolutionary modifications. [ABSTRACT FROM AUTHOR]

Purely aqueductal tumors represent a rare but distinct entity of neoplasms with characteristic morphology and clinical presentation. This study aims to describe the extreme anterior interhemispheric transcallosal approach as a surgical option for purely aqueductal tumors in the upper part of the cerebral aqueduct and present the surgical results. Prospectively collected data of 4 patients undergoing the extreme anterior interhemispheric transcallosal approach for purely aqueductal tumors in the upper cerebral aqueduct was analyzed. The technique is a variation of the anterior interhemispheric transcallosal approach. The callosotomy is placed at the transition between the body and genu of the corpus callosum, allowing an approach steep enough to reach through the foramen of Monro to the upper cerebral aqueduct without opening the choroidal fissure. All patients had preoperative, and intraoperative or immediate postoperative 3-T magnetic resonance imaging, and underwent examination at admission, after surgery, at discharge, and 3 months postoperatively. Patient data are reported according to common descriptive statistics. All patients harbored low-grade gliomas causing hydrocephalus. Complete resection was achieved without mortality or morbidity. All patients recovered and presented neurologically intact at the 3-month postoperative follow-up. None had recurrence or needed adjuvant therapy. The extreme anterior interhemispheric transcallosal approach proved to be effective and safe. This approach does not require manipulation of the choroidal fissure or disrupt healthy brain parenchyma (except for a small callosotomy). We propose it as an option for removing a purely aqueductal tumor in the upper cerebral aqueduct with associated hydrocephalus. [ABSTRACT FROM AUTHOR]

Abstract Background Communicating hydrocephalus is a disease where the cerebral ventricles are enlarged. It is characterized by the absence of detectable cerebrospinal fluid (CSF) outflow obstructions and often with increased CSF pulsatility measured in the cerebral aqueduct (CA). We hypothesize that the cardiac-related pulsatile flow over the CA, with fast systolic outflow and slow diastolic inflow, can generate net pressure effects that could source the ventriculomegaly in these patients. This would require a non-zero cardiac cycle averaged net pressure difference (ΔP net ) over the CA, with higher average pressure in the lateral and third ventricles. Methods We tested the hypothesis by calculating ΔP net across the CA using computational fluid dynamics based on prospectively collected high-resolution structural (FIESTA-C, resolution 0.39 × 0.39 × 0.3 mm3) and velocimetric (2D-PCMRI, in-plane resolution 0.35 × 0.35 mm2) MRI-data from 30 patients investigated for communicating hydrocephalus. Results The ΔP net due to CSF pulsations was non-zero for the study group (p = 0.03) with a magnitude of 0.2 ± 0.4 Pa (0.001 ± 0.003 mmHg), with higher pressure in the third ventricle. The maximum pressure difference over the cardiac cycle ΔP max was 20.3 ± 11.8 Pa and occurred during systole. A generalized linear model verified an association between ΔP net and CA cross-sectional area (p = 0.01) and flow asymmetry, described by the ratio of maximum inflow/outflow (p = 0.04), but not for aqueductal stroke volume (p = 0.35). Conclusions The results supported the hypothesis with respect to the direction of ΔP net , although the magnitude was low. Thus, although the pulsations may generate a pressure difference across the CA it is likely too small to explain the ventriculomegaly in communicating hydrocephalus.

• Convolutional neural networks can automatically measure aqueduct CSF flow accurately. • MultiResUNet had better performance than UNet for cerebral aqueduct segmentation. • Failed cases had very low aqueduct CSF flow or blood vessels close to the aqueduct. Since the development of phase-contrast magnetic resonance imaging (PC-MRI), quantification of cerebrospinal fluid (CSF) flow across the cerebral aqueduct has been utilized for diagnosis of conditions such as normal pressure hydrocephalus (NPH). This study aims to develop an automated method of aqueduct CSF flow analysis using convolution neural networks (CNNs), which can replace the current standard involving manual segmentation of aqueduct region of interest (ROI). Retrospective analysis was performed on 333 patients who underwent PC-MRI, totaling 353 imaging studies. Aqueduct flow measurements using manual ROI placement was performed independently by two radiologists. Two types of CNNs, MultiResUNet and UNet, were trained using ROI data from the senior radiologist, with PC-MRI studies being randomly divided into training (80%) and validation (20%) datasets. Segmentation performance was assessed using Dice similarity coefficient (DSC), and CSF flow parameters were calculated from both manual and CNN-derived ROIs. MultiResUNet, UNet and second radiologist (Rater 2) had DSCs of 0.933, 0.928, and 0.867, respectively, with p < 0.001 between CNNs and Rater 2. Comparison of CSF flow parameters showed excellent intraclass correlation coefficients (ICCs) for MultiResUNet, with lowest correlation being 0.67. For UNet, lower ICCs of −0.01 to 0.56 were observed. Only 3/353 (0.8%) studies failed to have appropriate ROIs placed by MultiResUNet, compared to 12/353 (3.4%) failed cases for UNet. In conclusion, CNNs were able to measure aqueductal CSF flow with similar performance to a senior neuroradiologist. MultiResUNet demonstrated fewer cases of segmentation failure and more consistent flow measurements compared to the widely adopted UNet. [ABSTRACT FROM AUTHOR]

Background: Several central nervous system diseases are associated with disturbed cerebrospinal fluid (CSF) flow patterns and have typically been characterized in vivo by phase-contrast magnetic resonance imaging (MRI). This technique is, however, limited by its applicability in space and time. Phase-contrast MRI has yet to be compared directly with CSF tracer enhanced imaging, which can be considered gold standard for assessing long-term CSF flow dynamics within the intracranial compartment. Methods: Here, we studied patients with various CSF disorders and compared MRI biomarkers of CSF space anatomy and phase-contrast MRI at level of the aqueduct and cranio-cervical junction with dynamic intrathecal contrast-enhanced MRI using the contrast agent gadobutrol as CSF tracer. Tracer enrichment of cerebral ventricles was graded 0–4 by visual assessment. An intracranial pressure (ICP) score was used as surrogate marker of intracranial compliance. Results: The study included 94 patients and disclosed marked variation of CSF flow measures across disease categories. The grade of supra-aqueductal reflux of tracer varied, with strong reflux (grades 3–4) in half of patients. Ventricular tracer reflux correlated with stroke volume and aqueductal CSF pressure gradient. CSF flow in the cerebral aqueduct was retrograde (from 4th to 3rd ventricle) in one third of patients, with estimated CSF net flow volume about 1.0 L/24 h. In the cranio-cervical junction, net flow was cranially directed in 78% patients, with estimated CSF net flow volume about 4.7 L/24 h. Conclusions: The present observations provide in vivo quantitative evidence for substantial variation in direction and magnitude of CSF flow, with re-direction of aqueductal flow in communicating hydrocephalus, and significant extra-cranial CSF production. The grading of ventricular reflux of tracer shows promise as a clinical useful method to assess CSF flow pattern disturbances in patients. [ABSTRACT FROM AUTHOR]

• Resection of variety of fourth ventricular lesions via median aperture approach. • Utility of angled endoscope in suboccipital resection of fourth ventricular lesions. • Confirmation of aqueductal patency with endoscope avoids future complications. Adequate exposure to fourth ventricular (4V) lesions located adjacent to the cerebral aqueduct and superior medullary velum often mandates extensive telovelar dissection. We assessed the utility of endoscopic assistance via a median aperture approach during suboccipital resection of 4V lesions. We retrospectively reviewed a series of nine patients who underwent suboccipital resection of a 4V lesion via an endoscopic-assisted median aperture approach from 2011 to 2018. Our series included the following pathology: ependymoma (2), rosette-forming glioneuronal tumors (2), pilocytic astrocytoma (1), metastatic melanoma (1), epidermoid cyst (1), organized hematoma (1), and neurocysticercosis (1). Preoperative symptoms included headache (n = 8, 88.9%), nausea (n = 5, 55.6%), vomiting, dizziness, and gait disturbance (n = 4 each, 44.5%). In four cases, the endoscope was used for the majority of the resection or to resect additional tumor located rostrally in the 4V following maximal microscopic resection. In five patients, it was used to confirm extent of resection and patency of the cerebral aqueduct. Gross total resection was achieved in five patients (55.6%). No postoperative complications were attributed to use of the endoscope for additional resection. No patients required immediate CSF diversion, and one patient underwent ventriculoperitoneal (VP) shunt insertion over one year after initial biopsy/fenestration due to tumor progression. Our series is the first to demonstrate the utility of angled endoscopic assistance via a median aperture approach during microsurgical approaches for a variety of 4V lesions. Confirmation of patency of the cerebral aqueduct may help avoid requirements for CSF diversion. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate complex CSF movements and shear stress in patients with idiopathic normal pressure hydrocephalus (iNPH) on four-dimensional (4D) flow MRI.Methods: Three-dimensional velocities and volumes of the reciprocating CSF movements through 12 ROIs from the foramen of Monro to the upper cervical spine were measured in 41 patients with iNPH, 23 patients with co-occurrence of iNPH and Alzheimer's disease (AD), and 9 age-matched controls, using 4D flow imaging and application. Stroke volume, reversed-flow rate, and shear stress were automatically calculated. Relationships between flow-related parameters and morphological measurements were also assessed.Results: Stroke volumes, reversed-flow rates, and shear stress at the cerebral aqueduct were significantly higher in patients with iNPH than in controls. Patients with pure iNPH had significantly higher shear stress at the ventral aspect of the cerebral aqueduct than those with co-occurrence of iNPH and AD. The stroke volume at the upper end of the cerebral aqueduct had the strongest association with the anteroposterior diameter of the lower end of the cerebral aqueduct (r = 0.52). The stroke volume at the foramen of Monro had significant associations with the indices specific to iNPH. The shear stress at the dorsal aspect of the cerebral aqueduct had the strongest association with the diameter of the foramen of Magendie (r = 0.52).Conclusions: Stroke volumes, reversed-flow rates, and shear stress through the cerebral aqueduct on 4D flow MRI are useful parameters for iNPH diagnosis. These findings can aid in elucidating the mechanism of ventricular enlargement in iNPH.Key Points: • The CSF stroke volume and bimodal shear stress at the cerebral aqueduct were considerably higher in patients with iNPH. • The patients with pure iNPH had significantly higher shear stress at the ventral aspect of the cerebral aqueduct than those with co-occurrence of iNPH and AD. • The shear stress at the cerebral aqueduct was significantly associated with the diameter of the foramen of Magendie. [ABSTRACT FROM AUTHOR]

Purpose: In vivo measurements of CSF and venous flow using real-time phase-contrast (RT-PC) MRI facilitate new insights into the dynamics and physiology of both fluid systems. In clinical practice, however, use of RT-PC MRI is still limited. Because many forms of hydrocephalus manifest in infancy and childhood, it is a prerequisite to investigate normal flow parameters during this period to assess pathologies of CSF circulation. This study aims to establish reference values of CSF and venous flow in healthy subjects using RT-PC MRI and to determine their age dependency., Methods: RT-PC MRI was performed in 44 healthy volunteers (20 females, age 5-40 years). CSF flow was quantified at the aqueduct (Aqd), cervical (C3) and lumbar (L3) spinal levels. Venous flow measurements comprised epidural veins, internal jugular veins and inferior vena cava. Parameters analyzed were peak velocity, net flow, pulsatility, and area of region of interest (ROI)., Statistical Tests: linear regression, student's t-test and analysis of variance (ANOVA)., Results: In adults volunteers, no significant changes in flow parameters were observed. In contrast, pediatric subjects exhibited a significant age-dependent decrease of CSF net flow and pulsatility in Aqd, C3 and L3. Several venous flow parameters decreased significantly over age at C3 and changed more variably at L3., Conclusion: Flow parameters varies depending on anatomical location and age. We established changes of brain and spinal fluid dynamics over an age range from 5-40 years. The application of RT-PC MRI in clinical care may improve our understanding of CSF flow pathology in individual patients., (© 2024. The Author(s).)

Background: Communicating hydrocephalus is a disease where the cerebral ventricles are enlarged. It is characterized by the absence of detectable cerebrospinal fluid (CSF) outflow obstructions and often with increased CSF pulsatility measured in the cerebral aqueduct (CA). We hypothesize that the cardiac-related pulsatile flow over the CA, with fast systolic outflow and slow diastolic inflow, can generate net pressure effects that could source the ventriculomegaly in these patients. This would require a non-zero cardiac cycle averaged net pressure difference (ΔPnet) over the CA, with higher average pressure in the lateral and third ventricles. Methods: We tested the hypothesis by calculating ΔPnet across the CA using computational fluid dynamics based on prospectively collected high-resolution structural (FIESTA-C, resolution 0.39 × 0.39 × 0.3 mm3) and velocimetric (2D-PCMRI, in-plane resolution 0.35 × 0.35 mm2) MRI-data from 30 patients investigated for communicating hydrocephalus. Results: The ΔPnet due to CSF pulsations was non-zero for the study group (p = 0.03) with a magnitude of 0.2 ± 0.4 Pa (0.001 ± 0.003 mmHg), with higher pressure in the third ventricle. The maximum pressure difference over the cardiac cycle ΔPmax was 20.3 ± 11.8 Pa and occurred during systole. A generalized linear model verified an association between ΔPnet and CA cross-sectional area (p = 0.01) and flow asymmetry, described by the ratio of maximum inflow/outflow (p = 0.04), but not for aqueductal stroke volume (p = 0.35). Conclusions: The results supported the hypothesis with respect to the direction of ΔPnet, although the magnitude was low. Thus, although the pulsations may generate a pressure difference across the CA it is likely too small to explain the ventriculomegaly in communicating hydrocephalus. [ABSTRACT FROM AUTHOR]

Tumors protruding into the cerebral aqueduct are rare, and tumors arising from within the cerebral aqueduct are rarer still. In this report, we discuss the presentation and clinical outcome of a 65-year-old man who presented to us with symptoms of hydrocephalus. Prior imaging had revealed a small enhancing nodule within the cerebral aqueduct. In the 6 months between initial imaging and our seeing the patient, the tumor demonstrated substantial interval growth, so the patient was offered resection. The tumor was accessed using a sitting, supracerebellar, intracollicular approach, which allowed for gross total resection of the mass without complication. Histopathology later revealed the lesion to be a hemangioblastoma. Two years after surgery, the patient was doing well with no neurologic deficits. We report the first case of an aqueductal hemangioblastoma and describe our use of a sitting, supracerebellar, intracollicular approach to access tumors occupying this cerebrospinal fluid space. [ABSTRACT FROM AUTHOR]

Background Pineal cysts (PCs) are histologically benign lesions of the pineal gland. Although the majority of PCs are asymptomatic, some cases are ambiguous and accompanied by nonspecific symptoms of variable severity. We suggested that disabling headache in nonhydrocephalic patients with PCs is associated with cerebral aqueduct (CAq) stenosis. Methods A retrospective analysis was conducted in patients with PCs suffering from headache without secondary hydrocephalus who underwent surgical resection at Burdenko Neurosurgery Center between 1995 and 2016. All available medical records and radiographic images were retrospectively assessed in these patients. The comparison groups included 22 patients with nonoperated PCs and 25 healthy individuals. Specific magnetic resonance imaging measures were selected to assess the morphometry of the CAq and degree of the stenosis. Results In 25 patients (82%) we observed clinical improvement after surgery in a follow-up period. Among those with improvement, 10 of them (40%) experienced total relief and 15 of them (60%) had marked headache diminishment. In 5 patients the headache remained persistent. The preoperative rostral CAq diameter appeared to be significantly narrower (P = 0.0011045), and the preoperative rostral/caudal diameter ratio (Rd/Cd) was found to be lower (P = 0.004391) in patients who recovered from headache versus those who did not. Conclusion The results indicate a statistically significant relationship between the changes in the CAq morphometrics and the clinical outcome in postoperative period. Surgical removal of symptomatic pineal cysts in patients without hydrocephalus can be considered as an effective treatment. However, a thorough preoperative examination and patient selection should be conducted in every case. [ABSTRACT FROM AUTHOR]

Background: Net cerebrospinal fluid (CSF) flow within the cerebral aqueduct is usually considered to be antegrade, i.e., from the third to the fourth ventricle with volumes ranging between 500 and 600 ml over 24 h. Knowledge of individual CSF flow dynamics, however, is hitherto scarcely investigated. In order to explore individual CSF flow rate and direction, we assessed net aqueductal CSF flow in individuals with intracranial aneurysms with or without a previous subarachnoid hemorrhage (SAH).Methods: A prospective observational study was performed utilizing phase-contrast magnetic resonance imaging (PC-MRI) to determine the magnitude and direction of aqueductal CSF flow with an in-depth, pixel-by-pixel approach. Estimation of net flow was used to calculate CSF flow volumes over 24 h. PC-MRI provides positive values when flow is retrograde.Results: The study included eight patients with intracranial aneurysms. Four were examined within days after their SAH; three were studied in the chronic stage after SAH while one patient had an unruptured intracranial aneurysm. There was a vast variation in magnitude and direction of aqueductal CSF flow between individuals. Net aqueductal CSF flow was retrograde, i.e., directed towards the third ventricle in 5/8 individuals. For the entire patient cohort, the estimated net aqueductal CSF volumetric flow rate (independent of direction) was median 898 ml/24 h (ranges 69 ml/24 h to 12.9 l/24 h). One of the two individuals who had a very high estimated net aqueductal CSF volumetric flow rate, 8.7 l/24 h retrograde, later needed a permanent CSF shunt.Conclusions: The magnitude and direction of net aqueductal CSF flow vary extensively in patients with intracranial aneurysms. Following SAH, PC-MRI may offer the possibility to perform individualized assessments of the CSF circulation. [ABSTRACT FROM AUTHOR]

Background: Net cerebrospinal fluid (CSF) flow through the cerebral aqueduct may serve as a marker of CSF production in the lateral ventricles, and changes that occur with aging and in disease.Purpose: To investigate the confounding influence of the respiratory cycle on net CSF flow and stroke volume measurements.Study Type: Cross-sectional study.Subjects: Twelve young, healthy subjects (seven male, age range 19-39 years, average age 28.3 years).Field Strength/sequence: Phase contrast MRI (PC-MRI) measurements were performed at 7T, with and without respiratory gating on expiration and on inspiration. All measurements were repeated.Assessment: Net CSF flow and stroke volume in the aqueduct, over the cardiac cycle, was determined.Statistical Tests: Repeatability was determined using the intraclass correlation coefficient (ICC) and linear regression analysis between the repeated measurements. Repeated measures analysis of variance (ANOVA) was performed to compare the measurements during inspiration/expiration/no gating. Linear regression analysis was performed between the net CSF flow difference (inspiration minus expiration) and stroke volume.Results: Net CSF flow (average ± standard deviation) was 0.64 ± 0.32 mL/min (caudal) during expiration, 0.12 ± 0.49 mL/min (cranial) during inspiration, and 0.31 ± 0.18 mL/min (caudal) without respiratory gating. Respiratory gating did not affect stroke volume measurements (41 ± 18, 42 ± 19, 42 ± 19 μL/cycle for expiration, no respiratory gating and inspiration, respectively). Repeatability was best during inspiration (ICC = 0.88/0.56/-0.31 for gating on inspiration/expiration/no gating). A positive association was found between average stroke volume and net flow difference between inspiration and expiration (R = 0.678/0.605, P = 0.015/0.037 for the first/second repeated measurement).Data Conclusion: Measured net CSF flow is confounded by respiration effects. Therefore, net CSF flow measurements with PC-MRI cannot in isolation be directly linked to CSF production.Level Of Evidence: 1 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2019;49:433-444. [ABSTRACT FROM AUTHOR]

Background The cerebral aqueduct is a central conduit for cerebrospinal fluid (CSF), and non-invasive quantification of CSF flow in the aqueduct may be an important tool for diagnosis and follow-up of treatment. Magnetic resonance (MR) methods at clinical field strengths are limited by low spatial resolution. Purpose To investigate the feasibility of high-resolution through-plane MR flow measurements (2D-PC) in the cerebral aqueduct at high field strength (7T). Material and Methods 2D-PC measurements in the aqueduct were performed in nine healthy individuals at 7T. Measurement accuracy was determined using a phantom. Aqueduct area, mean velocity, maximum velocity, minimum velocity, net flow, and mean flow were determined using in-plane resolutions 0.8 × 0.8, 0.5 × 0.5, 0.3 × 0.3, and 0.2 × 0.2 mm2. Feasibility criteria were defined based on scan time and spatial and temporal resolution. Results Phantom validation of 2D-PC MR showed good accuracy. In vivo, stroke volume was -8.2 ± 4.4, -4.7 ± 2.8, -6.0 ± 3.8, and -3.7 ± 2.1 µL for 0.8 × 0.8, 0.5 × 0.5, 0.3 × 0.3, and 0.2 × 0.2 mm2, respectively. The scan with 0.3 × 0.3 mm2 resolution fulfilled the feasibility criteria for a wide range of heart rates and aqueduct diameters. Conclusion 7T MR enables non-invasive quantification of CSF flow and velocity in the cerebral aqueduct with high spatial resolution. [ABSTRACT FROM AUTHOR]

We report a case of a 12-year-old boy with previously shunted congenital hydrocephalus, presenting with a progressive headache, nausea, vomiting, and lethargy. In the brain magnetic resonance imaging, a large cyst was seen in the superior recess of the fourth ventricle extending through the cerebral aqueduct toward the third ventricle. Endoscopic dual fenestration of the cyst was performed successfully using the posterior suboccipital approach through the foramen of Magendie, which resulted in the relief of symptoms without any complications, and the patient was symptom-free in the subsequent follow-up visits for 4 years. [ABSTRACT FROM AUTHOR]