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Neuronavigated foraminoplasty, shunt removal, and endoscopic third ventriculostomy in a 54-year-old patient with third shunt malfunction episode: how I do it

  • How I Do it
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Abstract

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.

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Abbreviations

ETV :

Endoscopic third ventriculostomy

VPS :

Ventriculoperitoneal shunt

VAS :

Ventriculoatrial shunt

MRI :

Magnetic resonance imaging

EVD :

External ventricular drain

CSF :

Cerebrospinal fluid

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Authors and Affiliations

  1. Department of Neurosurgery, Torrecárdenas University Hospital, Almeria, Spain

    José Javier Guil-Ibáñez, Leandro Saucedo & José Masegosa-González

  2. Department of Health Science, University of Almería, Almeria, Spain

    José Javier Guil-Ibáñez & Tesifón Parrón-Carreño

  3. Department of Neurosurgery, Hospital Universitario Torrecárdenas, Calle Hermandad Donantes de Sangre s/n, 04009, Almeria, Spain

    José Javier Guil-Ibáñez

Authors
  1. José Javier Guil-Ibáñez
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  2. Tesifón Parrón-Carreño
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  3. Leandro Saucedo
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  4. José Masegosa-González
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Corresponding author

Correspondence to José Javier Guil-Ibáñez.

Ethics declarations

Ethics approval

All procedures performed in the studies involving human participants were in accordance with ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standard.

Consent to participate and consent for publication

Informed consent to participate and consent for publication were obtained from the patient included in this report.

Competing interests

The authors declare no competing interests.

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Key points

In complex anatomies, consider the use of neuronavigation.

Knowledge of ventricular anatomy and experience in intraventricular endoscopy are crucial to obtain good outcomes.

Study preoperative images and develop a surgical plan by identifying limiting structures and the best surgical route.

Periodic follow-up with MRI is recommended for patients. We have protocolized the performance of a control magnetic resonance imaging before discharge, another one three after the procedure, at 6 months, and then annually.

In cases with a high risk of complications during the removal of previous shunt systems, they can be left in situ and ligated to prevent ostomy failure.

It is imperative to recognize that ETV may not be universally applicable in all instances of shunt malfunction. Factors such as patient age, hydrocephalus etiology, anatomical considerations, and concurrent comorbidities necessitate thorough evaluation prior to considering ETV as a viable treatment option.

The use of an EVD for intracranial pressure monitoring and as a therapeutic safety measure during the immediate postoperative period is crucial in mitigating the risk of ostomy closure and the development of acute hydrocephalus.

Controlled dilation of the Monro foramen using low-volume devices to prevent damage to the structure.

A proper technique for closing the cortical-subcortical tract is ideal to avoid the risk of cerebrospinal fluid leak.

To explain to the patient and their family the possibility of technique failure and associated complications.

The authors declare that this manuscript has not been previously published in whole or in part or submitted elsewhere for review.

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Guil-Ibáñez, J.J., Parrón-Carreño, T., Saucedo, L. et al. Neuronavigated foraminoplasty, shunt removal, and endoscopic third ventriculostomy in a 54-year-old patient with third shunt malfunction episode: how I do it. Acta Neurochir 165, 3289–3296 (2023). https://doi.org/10.1007/s00701-023-05777-2

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