Endoscopic approach to noncommunicating fluid spaces in the shunted patient

It is well known that shunted hydrocephalic patients can, over time, develop entrapped ventricles or cystic spaces not in communication with the remaining ventricles. This situation has traditionally been treated with placement of an additional catheter or shunt system in the noncommunicating fluid space. With the advent of minimally invasive endoscopic techniques, it has become possible to fenestrate trapped fluid spaces into the shunted ventricular system, thus preventing the need for additional catheters.

Fifteen shunted patients presented with noncommunicating fluid spaces over a 4-year period at our two institutions. We attempted fenestration procedures in 14 of those patients. The various procedures included: septum pellucidum fenestration, cyst fenestration, third ventriculocisternostomy and a combination of the above.

Thirteen of 16 (81%) endoscopic fenestrations successfully prevented the need for a complicated shunting system. There were 3 technical failures (3/16, 19%) in which an additional catheter was added to the existing shunt system at the time of the endoscopic procedure. There were no adverse neurologic effects from the endoscopic procedures; however, in 4 of the 14 patients (29%) a shunt revision was performed between 2 and 30 days following the fenestration.

These results show that the endoscopic approach to establishing communication between noncommunicating CSF spaces in the shunted patient is safe and efficacious in preventing the need for additional CSF catheters. Though we encountered failures, the majority of cases are technically feasible. In these patients early shunt malfunction may occur, most likely due to intraoperative bleeding and will require shunt revision.