Barami Kaveh, Chakrabarti Indro, Silverthorn James, Ciporen Jeremy, Akins Paul T
Department of Neurosurgery, Kaiser Permanente, Sacramento, California, USA.
Department of Neurosurgery, Kaiser Permanente, Sacramento, California, USA.
World Neurosurg. 2018 Aug;116:e709-e722. doi: 10.1016/j.wneu.2018.05.073. Epub 2018 May 17.
An enlarged fourth ventricle, otherwise known as fourth ventriculomegaly (4th VM), has been reported previously in the pediatric population, yet literature on adults is scant. We report our experience with 4th VM in adults over an 11-year period and review the literature.
This was a retrospective chart review of adult patients with the diagnosis of 4th VM admitted to the intensive care unit in a tertiary care center.
Nine patients were identified with 4th VM. Most presented with symptoms in the posterior fossa. Five cases were related to previous shunting and the underlying neurosurgical diseases, and average time interval to develop symptoms was 5.3 years. We divided our cases into primary, acquired, and degenerative based on the pathophysiology involved. Treatments included extended subzero cerebrospinal fluid diversion using a frontal external ventricular drain followed by low-pressure shunt revision, endoscopic third ventriculostomy, suboccipital decompression, and fourth ventricular catheter placement. Literature review identified additional published cases, and there were no reports of a formal classification scheme or treatment algorithm.
This case series illustrates a narrow spectrum of etiologies associated with 4th VM in adults. We propose a simple classification scheme dividing 4th VM into 3 categories: primary, acquired, and degenerative. We recommend a stepwise treatment approach starting with extended subzero cerebrospinal fluid diversion followed by shunting for symptomatic primary and acquired 4th VM. Lower success rates and greater morbidity are associated with rescue procedures such as fourth ventricle drainage catheters, endoscopic third ventriculostomies, and skull base decompression.
既往曾有报道称小儿群体中存在第四脑室扩大，即第四脑室积水（4th VM），但关于成人的文献却很少。我们报告了11年间成人4th VM的诊治经验并对相关文献进行了综述。
这是一项对入住三级医疗中心重症监护病房、诊断为4th VM的成年患者进行的回顾性病历审查。
共确定9例4th VM患者。大多数患者表现为后颅窝症状。5例与既往分流及潜在神经外科疾病有关，出现症状的平均时间间隔为5.3年。我们根据所涉及的病理生理学将病例分为原发性、后天性和退行性。治疗方法包括使用额部脑室外引流进行延长的零下脑脊液分流，随后进行低压分流修复、内镜下第三脑室造瘘术、枕下减压术以及第四脑室置管。文献综述发现了其他已发表的病例，且尚无正式分类方案或治疗算法的报道。
该病例系列显示成人4th VM相关病因范围较窄。我们提出一种简单的分类方案，将4th VM分为3类：原发性、后天性和退行性。我们建议采用逐步治疗方法，首先进行延长的零下脑脊液分流，随后对有症状的原发性和后天性4th VM进行分流。诸如第四脑室引流管、内镜下第三脑室造瘘术和颅底减压等挽救性手术的成功率较低且发病率较高。
