Delayed Fourth Ventricle Outlet Obstruction after Fourth Ventricle Tumor Removal Successfully Treated with Endoscopic Third Ventriculostomy in a Pediatric Patient

José M González-Darder,Félix Pastor-Escartín,Fernando Talamantes Esbriba,Vicent Quilis-Quesada,Pau Capilla-Guasch,Esteban Vega Torres

doi:10.31487/j.gscr.2020.01.06

Abstract

Introduction: Fourth ventricle outlet obstruction (FVOO) at the level of Magendie’s and Luschka’s foramina is a rare cause of non-communicating hydrocephalus. Case Report: We present a case of a 15-year-old woman successfully operated on a fourth ventricle WHO grade 1 pilocytic astrocytoma developing a delayed FVOO five months after surgery, when the patient experienced progressive headache, nausea and gate disturbances. Magnetic resonance imaging (MRI) study showed a tetra-ventricular hydrocephalus, with enlargement and bulging of both lateral recesses and Luschka’s foramina. An endoscopic third ventriculostomy (ETV) was successfully performed. Postoperative computed tomography (CT) and MRI studies showed a significant improvement of the hydrocephalus. Conclusion: FVOO is a rare cause of hydrocephalus. Posterior fossa and fourth ventricle microsurgical procedures can produce a delayed FVOO leading to an unexpected deterioration of the clinical status of the patient. The ETV is an effective and safe procedure to treat this unusual condition.

Highlights

Fourth ventricle outlet obstruction (FVOO) at the level of Magendie’s and Luschka’s foramina is a rare cause of non-communicating hydrocephalus
Case Report: We present a case of a 15-year-old woman successfully operated on a fourth ventricle WHO grade 1 pilocytic astrocytoma developing a delayed FVOO five months after surgery, when the patient experienced progressive headache, nausea and gate disturbances
To explain the usually late onset of FVOO symptoms in adults, the authors hypothesize that in Luschka’s dysgenesis there is a valve-like obstruction leading to an intermittent cerebrospinal fluid (CSF) flow

Summary

Introduction

Fourth ventricle outlet obstruction (FVOO) due to the obstruction of the Magendie’s and Luschka’s foramina, is a rare cause of noncommunicating hydrocephalus. Very few cases have been reported on the literature, most of them in adult population [1,2,3,4,5,6,7,8,9] This condition produces a disproportionate dilatation of the fourth ventricle and subsequently a forward displacement of the forebrain that can displace the basilar artery cranially. Postoperative CT scan showed no postoperative complications, nor ventricular dilatation (Figure 1). The patient was discharged without neurological deficit and routine surveillance MRI was scheduled six months later. MRI showed hydrocephalus, more eminent at the fourth ventricle and its lateral recesses (Figure 2). Six-month postoperative MRI showed improvement of hydrocephalus and complete remission of tonsillar herniation and hydromyelia.

Discussion

Conclusion