Department of Neurosurgery, Faculty of Medicine, Alexandria University, Champillion st, Elazaritta, Alexandria, Egypt.
Acta Neurochir (Wien). 2013 Oct;155(10):1957-63. doi: 10.1007/s00701-013-1843-5. Epub 2013 Aug 18.
Entrapped fourth ventricle is the result of both inlet aqueduct and outlet fourth ventricular midline and lateral foraminae obstruction. It occurs as a sequalae of intracranial hemorrhagic or inflammatory disease condition. Usually it presents after previous shunting for communicating hydrocephalus with a period of improvement, after which manifestations of posterior fossa expanding process appear. The diagnosis of this rare condition is easy considering the patient past history and the recent clinical state, together with the midline CSF density of the dilated fourth ventricle in either the CT or MR images. The treatment options for this condition include open and endoscopic approaches together with the traditional ventricular to extracranial CSF diversionary procedures.
The aim of the study was to adopt a procedure for treatment of entrapped fourth ventricle that carries the advantage of the minimally invasive technique thus avoiding the complications of the traditional opened and shunt surgeries as well as decreasing multiple procedures due to aqueduct restenosis or stent fall.
Thirteen patients with symptomatic entrapped fourth ventricle underwent suboccipital endoscopic trans-fourth ventricular aqueductoplasty from May 2007 till November 2011. The Gabb endoscopic system was used and aqueductoplasty was performed using 3F Fogarty balloon followed by stent placement. Nine patients were females. The mean age was 3.6 years and the mean follow up period was 23 months. All cases had a previous one or two supratentorial VP shunt placement.
Short stent was used in eight patients. During the follow up, stent migration occurred in five of them. Three of these five patients developed posterior fossa compression manifestations due to aqueduct restenosis. Long stent from the aqueduct till the bur hole site for these three patients and the following five patients was used. All cases showed both clinical and radiologic improvement. Apart from the stent migration, no procedure-related complications were encountered.
Endoscopic suboccipital paramedian aqueductoplasty with the use of a stent is a safe and effective surgical option that-in our opinion-should stand as the first line treatment for the entrapped fourth ventricle. Long stent is better used after aqueductoplasty to avoid the restenosis if no stent is used or stent fall after short stents. However, good case selection, familiarity with this fairly common endoscopic approach and longer follow-up is needed for obtaining an optimal result.
第四脑室受压是由于中脑导水管和第四脑室中线及外侧孔阻塞引起的。它是颅内出血或炎症性疾病的后遗症。通常在先前分流交通性脑积水后出现，在分流后一段时间内病情改善，随后出现后颅窝扩张过程的表现。考虑到患者的既往病史和近期临床状况，以及 CT 或 MRI 图像中扩张第四脑室的中线 CSF 密度，这种罕见情况的诊断很容易。这种情况的治疗选择包括开放和内镜方法，以及传统的脑室到颅外 CSF 分流术。
本研究旨在采用一种治疗第四脑室受压的方法，该方法具有微创技术的优势，可避免传统的开放性和分流手术的并发症，并减少因中脑导水管再狭窄或支架脱落而导致的多次手术。
2007 年 5 月至 2011 年 11 月，13 例症状性第四脑室受压患者接受了枕下入路内镜第四脑室正中孔成形术。使用 Gabb 内镜系统，用 3F Fogarty 球囊进行中脑导水管成形术，然后放置支架。9 例为女性，平均年龄 3.6 岁，平均随访时间为 23 个月。所有患者均有 1 次或 2 次前颅窝脑室-腹腔分流术。
8 例患者使用短支架，随访中支架移位 5 例。其中 3 例因中脑导水管再狭窄出现后颅窝压迫表现。对这 3 例患者和随后的 5 例患者，使用从中脑导水管到颅骨钻孔部位的长支架。所有患者均表现出临床和影像学改善。除支架移位外，无与手术相关的并发症。
内镜下枕下正中旁中脑导水管成形术联合支架置入是一种安全有效的手术选择，我们认为应作为第四脑室受压的一线治疗方法。如果不使用支架或短支架后支架脱落，中脑导水管成形术后应使用长支架，以避免再狭窄。然而，为了获得最佳效果，需要进行良好的病例选择、熟悉这种相当常见的内镜方法和更长时间的随访。
