Fourth Ventricle In Children Research Articles

Endoscopic aqueductoplasty and stenting in the treatment of isolated fourth ventricle in children: 20-year institutional experience.

Endoscopic aqueductoplasty with aqueductal stenting is an effective surgical procedure for the treatment of isolated fourth ventricle (IFV). Due to the rarity of the underlying pathology, it can be considered a rare procedure that can be performed with different surgical techniques and approaches. To assess long-term functioning of permanent aqueductal stents implanted in children affected by hydrocephalus and IFV and to describe some variations of the same procedure. We reviewed retrospectively all the patients presenting at our institution in the years 1999-2019 for symptoms of isolated fourth ventricle who underwent a surgical procedure of endoscopic aqueductoplasty and/or aqueductal stent. Surgical reports, radiological images, and surgical videos were retrospectively analyzed. Thirty-three patients with symptomatic isolated fourth ventricle (IFV) underwent fifty (50) neuroendoscopic procedures in the period observed. The median age of the patients at the time of first surgery was 7 months, with 22 premature babies. In twenty-nine patients (87.8%), a precoronal approach was performed, while four patients received a suboccipital burr hole. Ten patients were never reoperated since. Twenty-three patients underwent further surgeries: a new aqueductoplasty with aqueductal stent was performed in 13 cases. The remaining 10 patients required a combination of other procedures for management of hydrocephalus. Long-term follow-up showed a permanent stent functioning rate of 87% at 2 years and 73% at 4 years, remaining stable afterwards at very long term (20 years). Endoscopic aqueductoplasty and stenting is a reliable procedure in the long-term management of isolated fourth ventricle.

Microsurgical management of pediatric ependymomas of the fourth ventricle via the trans-cerebellomedullary fissure approach: A review of 26 cases.

In the present study, the microsurgical management of 26 ependymomas of the fourth ventricle in children via the trans-cerebellomedullary fissure (CMF) approach was reviewed and evaluated. Clinical data were obtained from 26 ependymomas of the fourth ventricle treated with microsurgery using the trans-CMF approach from March 2006 to September 2010 at the Department of Neurosurgery of The First Affiliated Hospital of China Medical University (Shenyang, China). These data were collected and analyzed. Suboccipital median posterior fossa craniotomy and trans-CMF approach were performed in all cases for the microsurgical removal of the tumors. An additional incision was performed in the inferior medullary velum of 5 patients, in order to obtain adequate exposure of the tumors. As a result, all tumors were well exposed during surgery. Gross total resection (GTR) was achieved in 22 cases, near total resection (NTR) in 3 cases and subtotal resection (STR) in 1 case. All excised tumors were pathologically confirmed. No mortality occurred intraoperatively, and no patient presented with mutism or any other surgery-related complications. One patient suffered from postoperative hydrocephalus and received ventriculoperitoneal shunting, which relieved the symptoms. Over the 3.0-7.5-year follow-up period (mean, 4.8 years), tumor relapse occurred in 1 case with GTR, 2 cases with NTR and 1 case with STR. In total, 3 patients succumbed to tumor relapse and 4 were lost to follow-up. According to the literature and the clinical experience of the present authors, the trans-CMF approach provides safe and sufficient access to the fourth ventricle without the requirement of an incision in the inferior vermis. This approach prevents damage to the normal cerebellum and improves the surgical outcome. Tumor removal, restoration of cerebrospinal fluid circulation and preservation of brainstem function are factors that should be taken into consideration during surgery. For patients with residual tumors, adjuvant radiotherapy and/or chemotherapy may be beneficial.

PTCT-05CHEMOTHERAPY ADMINISTRATION DIRECTLY INTO THE FOURTH VENTRICLE IN CHILDREN WITH MALIGNANT FOURTH VENTRICULAR BRAIN TUMORS: A PILOT CLINICAL TRIAL

BACKGROUND: We hypothesize that chemotherapy can be safely and repeatedly administered directly into the fourth ventricle to treat recurrent malignant brain tumors in children. METHODS: For the first time in humans, methotrexate was infused into the fourth ventricle in children with recurrent, malignant brain tumors. A catheter was surgically placed into the fourth ventricle under direct visualization and attached to a ventricular access device. Cerebrospinal fluid (CSF) flow was confirmed by CINE MRI postoperatively. Each cycle consisted of 4 consecutive daily methotrexate infusions (2 milligrams). Disease response was monitored with serial MRI scans and CSF cytologic analysis. Trough CSF methotrexate levels were sampled. RESULTS: Five patients (3 with medulloblastoma and 2 with ependymoma) received 18, 18, 12, 9, and 3 cycles, respectively. There were no serious adverse events or new neurological deficits attributed to methotrexate. Two additional enrolled patients were withdrawn prior to planned infusions due to rapid disease progression. Median serum methotrexate level four hours after infusion was 0.04 micromoles per liter (µmol/L). Range was 0.02–0.13 µmol/L. Median trough CSF methotrexate level 24 hours after infusion was 3.18 µmol/L (range 0.53 - 212.36 µmol/L). All three patients with medulloblastoma had partial response or stable disease until one patient had progressive disease after cycle 18. Both patients with ependymoma had progressive disease after 9 and 3 cycles, respectively. CONCLUSIONS: These data establish the safety of neurosurgical implantation of a catheter into the fourth ventricle and direct infusion of low-dose methotrexate into the fourth ventricle. Some patients with recurrent medulloblastoma experience a beneficial anti-tumor effect both within the fourth ventricle and at distant sites. These results support future clinical trials of direct infusion of chemotherapy and novel agents into the fourth ventricle for children with malignant posterior fossa tumors.

Posterior fossa tumors in children: developmental anatomy and diagnostic imaging.

Modern understanding of the relation between the mutated cancer stem cell and its site of origin and of its interaction with the tissue environment is enhancing the importance of developmental anatomy in the diagnostic assessment of posterior fossa tumors in children. The aim of this review is to show how MR imaging can improve on the exact identification of the tumors in the brainstem and in the vicinity of the fourth ventricle in children, using both structural imaging data and a precise topographical assessment guided by the developmental anatomy. The development of the hindbrain results from complex processes of brainstem segmentation, ventro-dorsal patterning, multiple germinative zones, and diverse migration pathways of the neural progenitors. Depending on their origin in the brainstem, gliomas may be infiltrative or not, as well as overwhelmingly malignant (pons), or mostly benign (cervicomedullary, medullo-pontine tegmental, gliomas of the cerebellar peduncles). In the vicinity of the fourth ventricles, the prognosis of the medulloblastomas (MB) correlates the molecular subtyping as well as the site of origin: WNT MB develop from the Wnt-expressing lower rhombic lip and have a good prognosis; SHH MB develop from the Shh-modulated cerebellar cortex with an intermediate prognosis (dependent on age); recurrences are local mostly. The poor prognosis group 3 MB is radiologically heterogeneous: some tumors present classic features but are juxtaventricular (rather than intraventricular); others have highly malignant features with a small principal tumor and an early dissemination. Group 4 MB has classic features, but characteristically usually does not enhance; dissemination is common. Although there is as yet no clear molecular subgrouping of the ependymomas, their sites of origin and their development can be clearly categorized, as most develop in an exophytic way from the ventricular surface of the medulla in clearly specific locations: the obex region with expansion in the cistern magna, or the lateral recess region with expansion in the CPA and prepontine cisterns (cerebellar ependymomas, and still more intra-brainstem ependymomas are rare). Finally, almost all cerebellar gliomas are pilocytic astrocytomas. A developmental and anatomic approach to the posterior fossa tumors in children (together with diffusion imaging data) provides a reliable pre-surgical identification of the tumor and of its aggressiveness.

Methotrexate administration directly into the fourth ventricle in children with malignant fourth ventricular brain tumors: a pilot clinical trial.

We hypothesize that chemotherapy can be safely administered directly into the fourth ventricle to treat recurrent malignant brain tumors in children. For the first time in humans, methotrexate was infused into the fourth ventricle in children with recurrent, malignant brain tumors. A catheter was surgically placed into the fourth ventricle and attached to a ventricular access device. Cerebrospinal fluid (CSF) flow was confirmed by CINE MRI postoperatively. Each cycle consisted of 4 consecutive daily methotrexate infusions (2 milligrams). Disease response was monitored with serial MRI scans and CSF cytologic analysis. Trough CSF methotrexate levels were sampled. Five patients (3 with medulloblastoma and 2 with ependymoma) received 18, 18, 12, 9, and 3 cycles, respectively. There were no serious adverse events or new neurological deficits attributed to methotrexate. Two additional enrolled patients were withdrawn prior to planned infusions due to rapid disease progression. Median serum methotrexate level 4 h after infusion was 0.04 µmol/L. Range was 0.02–0.13 µmol/L. Median trough CSF methotrexate level 24 h after infusion was 3.18 µmol/L (range 0.53–212.36 µmol/L). All three patients with medulloblastoma had partial response or stable disease until one patient had progressive disease after cycle 18. Both patients with ependymoma had progressive disease after 9 and 3 cycles, respectively. Low-dose methotrexate can be infused into the fourth ventricle without causing neurological toxicity. Some patients with recurrent medulloblastoma experience a beneficial anti-tumor effect both within the fourth ventricle and at distant sites.

Endoscopic aqueductoplasty and placement of a stent in the cerebral aqueduct in the management of isolated fourth ventricle in children

In this study the authors conducted a retrospective evaluation of the effectiveness of endoscopic aqueductoplasty, performed alone or accompanied by placement of a stent, in the treatment of an isolated fourth ventricle (IFV) in seven patients afflicted with loculated hydrocephalus after a hemorrhage or infection. Seven children with symptomatic IFV and membranous aqueductal stenosis underwent endoscopic aqueductoplasty alone or combined with placement of a stent in the cerebral aqueduct. The mean age of the patients at the time of surgery was 10 months. The mean duration of follow up was 26 months. In all patients a supratentorial shunt had already been implanted, and in five patients neuroendoscopy had already been performed because other isolated compartments had been present inside the ventricular system. Aqueductoplasty alone was performed in three patients and aqueductoplasty and aqueductal stent placement in four. A precoronal approach was performed in five patients and a suboccipital approach in two. Signs and symptoms of intracranial hypertension resolved in all cases. Stent placement was successful in all five cases, resulting in clinical and neuroimaging-confirmed improvements in the IFV. Restenosis of the aqueduct occurred in two patients in whom stents had not been placed. In one of these patients restenosis was managed by an endoscopic procedure, during which the aqueduct was reopened and a stent implanted; in the other patient a shunt was placed in the fourth ventricle. Hydrocephalus was controlled by a single shunt in six cases (86%) and by a double shunt in one case. Endoscopic placement of a stent in the aqueduct is more effective in preventing the repeated occlusion of the aqueduct than aqueductoplasty alone and should be indicated as the initial treatment in each case of compatible anatomy.

The isolated fourth ventricle in children: CT and clinical review of 16 cases: G. Scotti, M. A. Musgrave, C. R. Fitz, and D. C. Harwood-Nash. Am J Roentgenol 15:1233–1238, (December), 1980

The isolated fourth ventricle in children: CT and clinical review of 16 cases: G. Scotti, M. A. Musgrave, C. R. Fitz, and D. C. Harwood-Nash. Am J Roentgenol 15:1233–1238, (December), 1980

The isolated fourth ventricle in children: CT and clinical review of 16 cases

Isolated fourth ventricles were diagnosed by computed tomography (CT) in 16 children in a 3 year period. They all had had shunting of the lateral ventricles for hydrocephalus, and all needed subsequent shunt revisions. Seven patients without signs of raised intracranial pressure clinically had new posterior fossa signs at different intervals after lateral ventricular shunting. The clinical findings in the other nine patients were much less specific and in some cases the isolated fourth ventricle was an incidental finding. CT is essential for the diagnosis. The isolated fourth ventricle needs to be differentiated from posterior fossa cysts and cystic tumors. Shunting of the fourth ventricle improved the clinical condition in six of 14 children.

Pneumographic study of the fourth ventricle in children. Its normal height in different age groups and its relation to the size of the brainstem

On the basis of 167 selected cases of infantile pneumoencephalography (tomographic X-ray films in the midsagittal plane of the posterior fossa) the authors have tried to evaluate the growth tendency of the height and area of the fourth ventricle in age groups between 0 and 14 years.