Garber Sarah T, Riva-Cambrin Jay, Bishop Frank S, Brockmeyer Douglas L
Department of Neurosurgery, Primary Children's Medical Center, University of Utah, Salt Lake City, UT 84132, USA.
J Neurosurg Pediatr. 2013 Jun;11(6):623-9. doi: 10.3171/2013.3.PEDS12442. Epub 2013 Apr 19.
Fourth ventricle hydrocephalus, or a "trapped" fourth ventricle, presents a treatment challenge in pediatric neurosurgery. Fourth ventricle hydrocephalus develops most commonly as a result of congenital anomalies, intraventricular hemorrhage, or infection. Standard management of loculated fourth ventricle hydrocephalus consists of fourth ventricle shunt placement via a suboccipital approach. An alternative approach is stereotactic-guided transtentorial fourth ventricle shunt placement via the nondominant superior parietal lobule. In this report, the authors compare shunt survival after placement via the suboccipital and stereotactic parietal transtentorial (SPT) approaches.
A retrospective chart review was performed to find all patients with a fourth ventricle shunt placed between January 1, 1998, and December 31, 2011. Time to shunt failure was quantified as the number of days from shunt placement to first shunt revision or removal. Other variables studied included patient age and sex, origin of hydrocephalus, comorbidities, number of existing supratentorial catheters at the time of fourth ventricle shunt placement (as a proxy for complexity), operating surgeon, and number of previous shunt revisions. The crossover rate from one technique to the other after shunt failure from the original approach was also investigated.
In the 29 fourth ventricle shunts placed during the study period, 18 were placed via the suboccipital approach (62.1%) and 11 via the SPT approach (37.9%). There was a statistically significant difference in time to shunt failure, with the SPT shunts lasting an average of 901 days and suboccipital shunts lasting 122 days (p = 0.04). In addition, there was a significant difference in the rate of crossover from one technique to another, with 1 SPT shunt changed to a suboccipital shunt (5.6%) and 5 suboccipital shunts changed to SPT shunts (45.5%).
Fourth ventricle shunt placement using an SPT approach resulted in significantly longer shunt survival times and lower rates of revision than the traditional suboccipital approach, despite a higher rate of crossover from previously failed shunting procedures. Stereotactic parietal transtentorial shunt placement may be considered for patients with loculated fourth ventricle hydrocephalus, especially when shunt placement via the standard suboccipital approach fails. It is therefore reasonable to offer this procedure either as a first option for the treatment of fourth ventricle hydrocephalus or when the need for fourth ventricle shunt revision arises.
第四脑室脑积水，即“被困”第四脑室，是小儿神经外科治疗中的一项挑战。第四脑室脑积水最常见的病因是先天性异常、脑室内出血或感染。局限性第四脑室脑积水的标准治疗方法是通过枕下入路放置第四脑室分流管。另一种方法是通过非优势顶上小叶进行立体定向引导经小脑幕第四脑室分流管置入术。在本报告中，作者比较了通过枕下和立体定向顶叶经小脑幕（SPT）入路放置分流管后的分流管存活情况。
进行回顾性病历审查，以找出1998年1月1日至2011年12月31日期间所有放置第四脑室分流管的患者。分流管失效时间量化为从分流管置入到首次分流管翻修或移除的天数。研究的其他变量包括患者年龄和性别、脑积水的病因、合并症、第四脑室分流管置入时现有的幕上导管数量（作为复杂性的指标）、手术医生以及先前分流管翻修的次数。还研究了原方法分流管失效后从一种技术转换到另一种技术的交叉率。
在研究期间放置的29根第四脑室分流管中，18根通过枕下入路放置（62.1%），11根通过SPT入路放置（37.9%）。分流管失效时间存在统计学显著差异，SPT分流管平均持续901天，枕下分流管持续122天（p = 0.04）。此外，从一种技术转换到另一种技术的比率也存在显著差异，1根SPT分流管转换为枕下分流管（5.6%），5根枕下分流管转换为SPT分流管（45.5%）。
尽管先前失败的分流手术转换率较高，但使用SPT入路放置第四脑室分流管的分流管存活时间明显更长，翻修率更低。对于局限性第四脑室脑积水患者，尤其是当通过标准枕下入路放置分流管失败时，可考虑立体定向顶叶经小脑幕分流管置入术。因此，将此手术作为治疗第四脑室脑积水的首选方法或在需要翻修第四脑室分流管时提供该手术是合理的。
