Endoscopic management of cranial screw migration to cerebral aqueduct causing hydrocephalus

Intracranial migration of cranial fixation hardware is a rare complication of neurosurgical procedures, and migration into the ventricular system is exceedingly uncommon. When such migration leads to obstruction of cerebrospinal fluid (CSF) pathways, it can result in acute hydrocephalus requiring urgent intervention.

A 10-year-old girl with a history of left frontotemporal ganglioglioma underwent synthetic Medpor cranioplasty for radiation necrosis-associated calvarial erosion. Intraoperatively, a fixation screw inadvertently plunged through a bone defect into an area of encephalomalacia. Postoperative imaging revealed the screw within the antrum of the left lateral ventricle. The patient remained asymptomatic and was discharged with close monitoring. At 3-week follow-up, she developed progressive headaches and fatigue. Neuroimaging demonstrated migration of the screw into the cerebral aqueduct, with resulting obstructive hydrocephalus. She underwent endoscopic third ventriculostomy and successful endoscopic removal of the screw, with full clinical recovery.

This case illustrates a rare but serious complication of cranioplasty: delayed migration of a cranial screw into the ventricular system causing aqueduct obstruction. Endoscopic management allowed for both CSF diversion and removal of the foreign body and was associated with an excellent clinical outcome.