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Updated: May 12, 2026
Neuronavigation and Laparoscopy Guided Ventriculoperitoneal Shunt Insertion for the Treatment of Hydrocephalus
Published on: October 14, 2022
Comparing fourth ventricle shunt survival after placement via stereotactic transtentorial and suboccipital approaches
Sarah T Garber1, Jay Riva-Cambrin, Frank S Bishop
1Department of Neurosurgery, Primary Children's Medical Center, University of Utah, Salt Lake City, UT 84132, USA.
Insights
The stereotactic parietal transtentorial (SPT) approach for fourth ventricle hydrocephalus shunts showed significantly longer survival times compared to the suboccipital method. SPT shunts lasted an average of 901 days versus 122 days for suboccipital shunts.
Area of Science:
- Pediatric Neurosurgery
- Hydrocephalus Management
- Surgical Techniques
Background:
- Fourth ventricle hydrocephalus, or "trapped" fourth ventricle, poses a significant challenge in pediatric neurosurgery.
- Common causes include congenital anomalies, intraventricular hemorrhage, and infection.
- Standard treatment involves suboccipital shunt placement, but alternative methods are being explored.
Purpose of the Study:
- To compare shunt survival rates between the traditional suboccipital approach and the stereotactic-guided transtentorial (SPT) approach for fourth ventricle hydrocephalus.
- To evaluate the efficacy and revision rates of each surgical technique.
Main Methods:
- A retrospective chart review identified patients who underwent fourth ventricle shunt placement between 1998 and 2011.
- Time to shunt failure, patient demographics, hydrocephalus origin, comorbidities, and prior shunt revisions were analyzed.
- Crossover rates between techniques following shunt failure were also investigated.
Main Results:
- The SPT approach (11 shunts) demonstrated significantly longer shunt survival (901 days) compared to the suboccipital approach (18 shunts, 122 days) (p=0.04).
- Crossover rates were higher from suboccipital to SPT (45.5%) than from SPT to suboccipital (5.6%).
Conclusions:
- Stereotactic parietal transtentorial (SPT) shunt placement offers superior shunt survival and lower revision rates for fourth ventricle hydrocephalus compared to the suboccipital approach.
- SPT may be a viable primary option or an alternative for revision in cases of failed suboccipital shunts.
Object:
Fourth ventricle hydrocephalus, or a "trapped" fourth ventricle, presents a treatment challenge in pediatric neurosurgery. Fourth ventricle hydrocephalus develops most commonly as a result of congenital anomalies, intraventricular hemorrhage, or infection. Standard management of loculated fourth ventricle hydrocephalus consists of fourth ventricle shunt placement via a suboccipital approach. An alternative approach is stereotactic-guided transtentorial fourth ventricle shunt placement via the nondominant superior parietal lobule. In this report, the authors compare shunt survival after placement via the suboccipital and stereotactic parietal transtentorial (SPT) approaches.
Methods:
A retrospective chart review was performed to find all patients with a fourth ventricle shunt placed between January 1, 1998, and December 31, 2011. Time to shunt failure was quantified as the number of days from shunt placement to first shunt revision or removal. Other variables studied included patient age and sex, origin of hydrocephalus, comorbidities, number of existing supratentorial catheters at the time of fourth ventricle shunt placement (as a proxy for complexity), operating surgeon, and number of previous shunt revisions. The crossover rate from one technique to the other after shunt failure from the original approach was also investigated.
Results:
In the 29 fourth ventricle shunts placed during the study period, 18 were placed via the suboccipital approach (62.1%) and 11 via the SPT approach (37.9%). There was a statistically significant difference in time to shunt failure, with the SPT shunts lasting an average of 901 days and suboccipital shunts lasting 122 days (p = 0.04). In addition, there was a significant difference in the rate of crossover from one technique to another, with 1 SPT shunt changed to a suboccipital shunt (5.6%) and 5 suboccipital shunts changed to SPT shunts (45.5%).
Conclusions:
Fourth ventricle shunt placement using an SPT approach resulted in significantly longer shunt survival times and lower rates of revision than the traditional suboccipital approach, despite a higher rate of crossover from previously failed shunting procedures. Stereotactic parietal transtentorial shunt placement may be considered for patients with loculated fourth ventricle hydrocephalus, especially when shunt placement via the standard suboccipital approach fails. It is therefore reasonable to offer this procedure either as a first option for the treatment of fourth ventricle hydrocephalus or when the need for fourth ventricle shunt revision arises.
