Endoscopic Third Ventriculostomy for Obstructive Hydrocephalus Caused by a Large Upper Basilar Artery Aneurysm After Coil Embolization

Abstract

A 76-year-old female presented with a large upper basilar artery (BA) aneurysm causing obstructive hydrocephalus after coil embolization manifesting as diplopia. Magnetic resonance (MR) imaging and MR angiography showed a large BA top aneurysm. Coil embolization was performed. More than 6 months after the first coil embolization, the aneurysm had re-grown and we performed a second coil embolization. Soon after that, obstructive hydrocephalus at the aqueduct of the midbrain occurred. MR imaging was performed to evaluate whether there was enough space at the prepontine cistern for a third ventriculostomy and also to verify the posterior direction of the aneurysm growth because of the risk of rupturing the aneurysm during the operative procedure. Then, we performed an endoscopic third ventriculostomy (ETV) via a left-sided approach. We could easily identify the infundibular recess, mamillary bodies, and tuber cinereum in the third ventricular floor. We detected a pulsating upper BA aneurysm that appeared to have caused a reddish color change in the right mammillary body and the right side of the thalamus and midbrain. If there is sufficient space in the prepontine cistern for the surgical procedure, ETV is a good choice for the treatment of obstructive hydrocephalus associated with cerebral aneurysms.

Large Aneurysm of Basilar Artery Tip Mimicking Midbrain Tumor and Causing Unilateral Obstructive Hydrocephalus: a Case Report and Technical Note

“…The selection of various treatment strategies was mainly aimed at aneurysm obliteration and CSF derivation to decrease ICP and to relieve the mass effect. These different strategies, including external temporary ventriculostomy, ventriculo-peritoneal (V-P) shunting, or endoscopic third ventriculostomy (ETV), together with aneurysm clipping or coiling [17][18][19][20] , have brought diverse outcomes that were not always favorable. Considering this, it seems that EVT is a safe and effective alternative to V-P shunting in selected patients [17][18][19] , particularly in cases where a sufficient space for the surgical procedure is present in the prepontine cistern 19 .…”

Presentation of the Success Rate of ETV in Distinct Indication Cases of Hydrocephalus

“…An obstructive hydrocephalus through giant aneurysm is rare, but it has been already reported in some cases [49][50][51][52]. Commonly, these cases are treated via shunt placement, although an aneurysm growing after shunt implantation has been already reported.…”

“…In certain cases, an endoscopic ventriculostomy might be performed [49,50]. Even though the anatomy is commonly changed as a consequence of the aneurysm (e.g., the third ventricle or aqueduct may be compressed and the anatomical structures as the floor of ventricle and mammillary bodies may be displaced), the landmarks can be identified and the surgery can be performed in the usual way [49].…”

“…Successful endoscopic ventriculostomy was reported in some giant aneurysm-related obstruction [49,50]. The most feared complications are related to vascular injury leading to infarction, hemorrhage, or pseudoaneurysm development [49].…”

Improvement of Long-term Results with Neoadjuvant Chemotherapy and Radiotherapy for Central Nervous System Germinoma

“…The histological diagnosis was established from specimens obtained by endoscopic biopsy procedures or resection via craniotomy or the transsphenoidal approach, according to the World Health Organization classification of tumors of the nervous system. A flexible fiberscope Neu-4L (Machida, Japan) and videoscope (VEF type V; Olympus, Tokyo) were used for neuroendoscopic biopsy and third ventriculostomy (14,15). We explained the treatment strategies about the disease to all patients involved in this study and treated them.…”