Trapped fourth ventricle: a rare complication in children after supratentorial CSF shunting

Ahmed El Damaty,Heidi Baechli,Andreas Unterberg,Ahmed Eltanahy

doi:10.1007/s00381-020-04656-w

Abstract

PurposeTrapped fourth ventricle (TFV) is a well-identified problem in hydrocephalic children. Patients with post-hemorrhagic hydrocephalus (PHH) are mostly affected. We tried to find out predisposing factors and describe clinical findings to early diagnose TFV and manage it.MethodsWe reviewed our database from 1991 to 2018 and included all patients with TFV who required surgery. We analyzed prematurity, cause of hydrocephalus, type of valve implanted, revision surgeries, modality of treatment of TFV, and their clinical examination and MRI imaging.ResultsWe found 21 patients. Most of patients suffered from PHH (16/21), tumor (2/21), post-meningitis hydrocephalus (2/21), and congenital hydrocephalus (1/21). Seventeen patients were preterm. Seven patients suffered from a chronic overdrainage with slit ventricles in MRI. Thirteen patients showed symptoms denoting brain stem dysfunction; in 3 patients, TFV was asymptomatic and in 5 patients, we did not have available information regarding presenting symptoms due to missing documentation. An extra fourth ventricular catheter was the treatment of choice in 18/21 patients. One patient was treated by cranio-cervical decompression. Endoscopic aqueductoplasty with stenting was done in last 2 cases.ConclusionDiagnosis of clinically symptomatic TFV and its treatment is a challenge in our practice of pediatric neurosurgery. PHH and prematurity are risk factors for the development of such complication. Both fourth ventricular shunting and endoscopic aqueductoplasty with stenting are effective in managing TFV. Microsurgical fourth ventriculostomy is not recommended due to its high failure rate. Early detection and intervention may help in avoiding fatal complication and improving the neurological function.

Highlights

A trapped fourth ventricle (TFV) is a well-identified problem in children with hydrocephalus
Diagnosis of clinically symptomatic TFV and its treatment is a challenge in our practice of pediatric neurosurgery due to the diversity of presenting symptoms
We found that posthemorrhagic hydrocephalus which is usually occurring with prematurity is a risk factor for the development of fourth ventricular entrapment

Summary

Introduction

A trapped fourth ventricle (TFV) is a well-identified problem in children with hydrocephalus. The fourth ventricle can become isolated due to multiple causes, most frequently after hemorrhage, infection, or congenital anomalies [1]. A specific pathophysiological explanation remains unclear, post-hemorrhagic hydrocephalus (PHH) may result from an inflammatory response (e.g., ependymitis, arachnoiditis) with attendant occlusion of the cerebral aqueduct of Sylvius and foramina of Luschka and Magendie or Childs Nerv Syst (2020) 36:2961–2969 scarring and obstruction of the surface absorptive mechanisms [2, 3]. Isolation of the fourth ventricle likely occurs from obstruction of the cerebral aqueduct of Sylvius and the fourth ventricle outflow tracts. It presents delayed after the first shunt procedure. Delayed diagnosis of TFV can lead to severe neurological dysfunction and/or death [3, 6, 7]

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