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CT stereotaxy guided lateral trans-cerebellar programmable fourth ventriculo-peritoneal shunting for symptomatic
R R Sharma1, S J Pawar, R V Devadas
1The National Neurosurgical Centre, Khoula Hospital, PO Box 397, Al-Harthy Complex, 118, Muscat, Oman. rrsharma@omantel.net.com
Insights
A trapped fourth ventricle, a rare complication of shunting, can cause severe symptoms. A novel lateral trans-cerebellar stereotactic approach successfully treated a pediatric patient, relieving intracranial pressure and neurological deficits.
Area of Science:
- Neurosurgery
- Pediatric Neurology
- Radiological Imaging
Background:
- A trapped fourth ventricle is a rare condition mimicking posterior fossa masses, often a late complication of shunting in children with hydrocephalus.
- Conventional midline shunting for trapped fourth ventricle carries significant complication risks (approx. 40%).
Observation:
- A 14-year-old girl presented with symptoms of a trapped fourth ventricle, a sequela of infantile ventriculoperitoneal shunting.
- Preoperative symptoms included increased intracranial pressure, bobble-head doll syndrome, and bilateral abducens palsies.
Findings:
- Successful CT Stereotaxy-guided high-pressure programmable ventriculo-peritoneal shunting was performed via a lateral trans-cerebellar approach.
- The patient experienced complete resolution of preoperative neurological deficits following the procedure.
Implications:
- This lateral trans-cerebellar stereotactic technique offers a potentially safer and effective alternative for managing trapped fourth ventricle.
- Utilizing high-pressure, low-flow programmable shunts may mitigate over-drainage complications in this patient population.
Abstract:
A trapped fourth ventricle is a rare clinico-radiological entity producing symptoms suggestive of a progressive posterior fossa mass lesion. It is mainly reported in children as a late complication of lateral ventricular shunting to relieve infantile post-meningitic or post-hemorrhagic hydrocephalus. Optional treatment of the trapped fourth ventricle remains controversial. Placement of fourth ventricular shunting via a conventional midline approach can be fraught with complications in about 40% of the patients. Authors report a successful CT Stereotaxy guided high pressure (80 mm H(2)O) programmable fourth ventriculo-peritoneal shunting via a lateral trans-cerebellar approach in a 14-year-old girl with a trapped fourth ventricle, which occurred as a late complication of ventriculo-peritoneal shunting in her infancy. Her preoperative symptoms of raised intracranial pressure, bobble-head doll syndrome and bilateral abducens palsies completely improved following the surgery. Lateral trans-cerebellar stereotactic placement of the fourth ventricular catheter and the use of high-pressure (low flow) programmable shunt (to avoid complications associated with over drainage) are beneficial in some patients with trapped fourth ventricle.