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Images in Neurology |

Endoscopic Treatment of Hydrocephalus

Brian P. Walcott, MD; Kristopher T. Kahle, MD, PhD; William E. Butler, MD
Arch Neurol. 2012;69(5):664. doi:10.1001/archneurol.2011.1766.
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A 1-year-old child was transported from Liberia for diagnosis and treatment of severe macrocephaly. Although no medical records accompanied the child with transport, on arrival he was noted to have gross retardation of motor development, inability to maintain the position of his head, and intermittent bouts of lethargy. His head circumference measured 65 cm. Magnetic resonance imaging demonstrated massive hydrocephalus with enlargement of the entire ventricular system (Figure, A). He was brought to the operating room for an endoscopic third ventriculocisternostomy and choroid plexus fulguration in an attempt to reduce his cerebrospinal fluid production and reset it to a new cerebrospinal fluid physiologic steady state, without the implantation of permanent shunting hardware. Postoperatively, he was noted to have improvement in his feeding, alertness, and interactiveness. His head control remained poor. Postoperative magnetic resonance imaging performed 2 days later revealed a markedly decompressed ventricular system and infolding of the cortical mantle (Figure, B). It is yet to be determined whether he will reach the intended degree of cerebrospinal fluid balance; a ventricular shunt or repeated ventriculocisternostomy remain options for him in the future should this procedure fail at a later date. He may also require a cranial bone reduction procedure to increase his head control capacity.

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Figure. Massive communicating hydrocephalus. A, Preoperative magnetic resonance imaging (MRI) demonstrated massive enlargement of the ventricular system, including the fourth ventricle consistent with hydrocephalus. No definite obstructing mass lesion or scarring was identified. The cortical mantle was significantly thinned (arrows). B, Postoperative MRI demonstrated interval decompression of the ventricular system. There was prominent infolding of the cortical mantle. Extra-axial pneumocephalus (stars) and layering hemorrhage existed in the immediate postprocedural state.

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