Racemose Fourth Ventricle Neurocysticercosis Excision Through Telovelar Approach and Hydrodissection

Intraventricular neurocysticercosis is associated with more severe complications and a worse overall outcome.^1,2 Fourth ventricle neurocysticercosis (FVNCC) often presents with cerebrospinal fluid obstruction and hydrocephalus by means of direct mechanical occlusion of ventricular outlets by the cysts or due to an ependymal inflammatory response. Unfortunately, there is little consensus on the optimal management for FVNCC. If possible, surgical removal of cysticerci rather than medical therapy and/or shunt surgery is recommended.³ Endoscopic removal of cysts is described to be an effective treatment modality.⁴ However, endoscopic removal of inflamed or adherent ventricular cysticerci is associated with increased risk of complications.⁵ Although microdissection through a posterior fossa telovelar approach is a valid method for FVNCC,^6,7 scarce reports describe the therapeutic decision making and provide a surgical video of adherent FVNCC cyst resection. Video 1 shows a 40-year-old female born in Honduras who presented with progressive headache. Computed tomography revealed ventriculomegaly and transependymal flow. Magnetic resonance imaging demonstrated obstructive hydrocephalus secondary to a multiloculated cystic mass within the fourth ventricle. According to the diagnostic criteria, probable racemose FVNCC was suspected.⁸ Magnetic resonance imaging raised suspicion that the cysts could be densely adherent to surrounding structures,⁹ precluding endoscopic removal. We performed a combined microscopic and endoscopic approach, which permitted removal of the cysts through a telovelar approach and hydrodissection technique without damaging nearby structures and treatment of the associated hydrocephalus through an endoscopic third ventriculostomy, allowing complete resolution of symptoms and avoidance of cerebrospinal fluid shunting.