Trapped fourth ventricle: a rare complication in children after supratentorial CSF shunting

Abstract

Purpose Trapped fourth ventricle (TFV) is a well-identified problem in hydrocephalic children. Patients with post-hemorrhagic hydrocephalus (PHH) are mostly affected. We tried to find out predisposing factors and describe clinical findings to early diagnose TFV and manage it. Methods We reviewed our database from 1991 to 2018 and included all patients with TFV who required surgery. We analyzed prematurity, cause of hydrocephalus, type of valve implanted, revision surgeries, modality of treatment of TFV, and their clinical examination and MRI imaging. Results We found 21 patients. Most of patients suffered from PHH (16/21), tumor (2/21), post-meningitis hydrocephalus (2/21), and congenital hydrocephalus (1/21). Seventeen patients were preterm. Seven patients suffered from a chronic overdrainage with slit ventricles in MRI. Thirteen patients showed symptoms denoting brain stem dysfunction; in 3 patients, TFV was asymptomatic and in 5 patients, we did not have available information regarding presenting symptoms due to missing documentation. An extra fourth ventricular catheter was the treatment of choice in 18/21 patients. One patient was treated by cranio-cervical decompression. Endoscopic aqueductoplasty with stenting was done in last 2 cases. Conclusion Diagnosis of clinically symptomatic TFV and its treatment is a challenge in our practice of pediatric neurosurgery. PHH and prematurity are risk factors for the development of such complication. Both fourth ventricular shunting and endoscopic aqueductoplasty with stenting are effective in managing TFV. Microsurgical fourth ventriculostomy is not recommended due to its high failure rate. Early detection and intervention may help in avoiding fatal complication and improving the neurological function.

Evaluation of Connecting a Fourth Ventricular Catheter with Y Connector to a Previous Ventriculoperitoneal Shunt, as a Treatment Option for Patients with Symptomatic Trapped Fourth Ventricle

“…Prematurity seems to be a risk factor due to the high incidence of cerebral hemorrhage. The same observation has been reported by El Damaty et al (13) . Prematurity was found to be a significant risk of the development of trapped 4 th ventricle in their study.…”

“…This finding supports the theory of inflammatory response with the subsequent closure of the aqueduct together with the 4 th ventricular outlets. Another study found posthemorrhagic hydrocephalus is the main etiology that predisposes to trapped 4 th ventricle in up to 76% of their cases (13) . Dandy-Walker malformation: Dandy-Walker malformation represents a separate dilemma, options for treatment include either shunting the lateral ventricle only or 4 th ventricular shunting only, or shunting both ventricles.…”

“…Choosing the type of connector depended only on the availability in our hospital. Y connectors have been advocated by many authors when a fourth ventricular catheter is a plan (13) . They claimed that this may also prevent any pressure difference between supra and infratentorial ventricular systems, being connected to the same valve, thus decreasing the possibility of headache that may occur by changes in the position of the body (18) .…”

“…In their long-term study, El Damaty et al (13) reported 21 patients with trapped 4 th ventricles managed surgically. 18 out of 21 patients had a 4 th ventricular catheter connected to the previously implanted lateral ventricular catheter.…”

Trapped fourth ventricle: to stent, shunt, or fenestrate—a systematic review and individual patient data meta-analysis

“…Therefore, initial stent placement is recommended by this study. As for shunt placement, a study by El Damaty et al [ 10 ] mentioned a decline in the occurrence of TFV over the last years of the follow-up, after the introduction of the anti-siphon device in ventriculoperitoneal shunt systems due to the marked decrease in overdrainage. As for the surgical approaches for the shunt placement, no conclusions can be drawn about their effect on the clinical outcomes of TFV patients because of a lack of data reported by the included studies.…”