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Updated: Dec 14, 2025
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Published on: October 14, 2022
Progressive Hydrocephalus after Endoscopic Third Ventriculostomy in Pediatric Patients with Blake's Pouch Cyst
Youhei Takeuchi1, Tomomi Kimiwada1, Reizo Shirane1
1Department of Neurosurgery, Miyagi Children's Hospital, Sendai, Miyagi, Japan.
Insights
Endoscopic third ventriculostomy may fail for hydrocephalus with Blake's pouch cyst (BPC). Ventriculoperitoneal shunts offer an alternative treatment for persistent BPC-associated hydrocephalus.
Area of Science:
- Pediatric Neurosurgery
- Neuroimaging
- Cerebrospinal Fluid Dynamics
Background:
- Hydrocephalus associated with Blake's pouch cyst (BPC) presents complex management challenges.
- The pathophysiology and optimal treatment strategies for BPC-associated hydrocephalus remain debated.
- Endoscopic third ventriculostomy (ETV) is a potential treatment, but its efficacy in BPC cases is not fully established.
Observation:
- Two pediatric cases of BPC-associated hydrocephalus are presented.
- Both patients experienced hydrocephalus progression after ETV, despite evidence of a patent stoma.
- Clinical symptoms included delayed development, headaches, nausea, seizures, and vomiting.
Findings:
- Post-ETV imaging revealed enlarged ventricles in both cases.
- Cerebrospinal fluid (CSF) flow at the third ventricular floor was patent, even hyperdynamic in one case.
- Ventriculoperitoneal shunt (VPS) placement successfully treated the hydrocephalus in both patients.
Implications:
- ETV may not be sufficient for all cases of BPC-associated hydrocephalus.
- Third ventricular floor bulging may play a role in the pathophysiology of BPC-associated hydrocephalus.
- VPS placement is a viable and effective treatment option for refractory BPC-associated hydrocephalus.
Abstract:
The pathophysiology and optimal treatment for hydrocephalus with Blake's pouch cyst (BPC) remain controversial. The authors present two pediatric cases of hydrocephalus associated with BPC, in which the patients' hydrocephalus progressed after endoscopic third ventriculostomy (ETV), despite a patent stoma of the third ventricular floor. Case 1: A 4-year-old girl with delayed gait development was diagnosed with BPC-associated hydrocephalus and received ETV. Postoperatively, the patient presented headaches and nausea. Computed tomography (CT) scans demonstrated larger ventricles than those observed on the preoperative images. Because phase-contrast cine magnetic resonance imaging (MRI) and constructive interference in steady state (CISS) MRI revealed patent cerebrospinal fluid (CSF) flow at the third ventricular floor level, a ventriculoperitoneal shunt (VPS) was placed using a programmable pressure valve to treat the hydrocephalus. Case 2: A 6-year-old girl with newly developed repeated convulsive seizures was diagnosed with BPC-associated hydrocephalus and received ETV. Phase-contrast cine MRI on the 5th postoperative day showed hyperdynamic CSF flow at the third ventricular floor level. She also developed vomiting and headache 6 weeks after ETV. CT scans demonstrated much larger tetraventricular hydrocephalus than that observed on the preoperative images. VPS placement improved her hydrocephalus. Referencing the previous literature, we discuss the CSF dynamics and the mechanism of BPC-associated hydrocephalus, focusing on the third ventricular floor bulging. We hope our experience will help elucidate the pathophysiology and treatment strategies for BPC-associated hydrocephalus.
