Levodopa-resistant parkinsonism developing after ventriculoperitoneal shunting for obstructive hydrocephalus and improving after endoscopic third ventriculostomy, with specific consideration of brainstem morphology: illustrative case.

BACKGROUND: Parkinsonism has been reported in patients with obstructive hydrocephalus (OH) following ventriculoperitoneal shunting (VPS). While levodopa works well, some cases are drug resistant. A few case series have reported that endoscopic third ventriculostomy (ETV) is beneficial, though its mechanism remains unclear. The use of a pathophysiology-reflected marker can aid in the diagnosis and treatment strategy. The authors report a case of parkinsonism due to OH after VPS that improved after ETV in a patient taking levodopa, which was subsequently discontinued. OBSERVATIONS: A 52-year-old man who had undergone VPS for OH caused by aqueductal stenosis with a tectal tumor presented with severe consciousness disturbance due to acute hydrocephalus and levodopa-refractory parkinsonism after multiple episodes of shunt malfunction. Magnetic resonance imaging showed an elevation of the floor of the third ventricle. ETV was performed to stabilize the pressure imbalance across the stenosis, and his parkinsonism symptoms improved after long-term rehabilitation, resulting in levodopa discontinuation. His pontomesencephalic angle, the angle between the anterior surface of the midbrain and upper surface of the pons in the midline of the sagittal plane, was significantly decreased. LESSONS: The focus in such cases should be on the essence of the pathophysiology for improving the symptoms rather than on easy-to-understand indicators such as ventricle size. https://thejns.org/doi/10.3171/CASE2429.

Neurosurgical intervention for giant arachnoid cyst-induced hydrocephalus in a teenager: Delving into Pandora's box.

Early recognition and prompt surgical intervention are crucial in managing giant arachnoid cysts causing obstructive hydrocephalus, as illustrated in this case of a 17-year-old male. Timely treatment can alleviate symptoms and prevent neurologic complications, ensuring favorable outcomes in affected patients.

Acute Cerebellitis and Obstructive Hydrocephalus: An Unseen Neurological Complication After Surgical Repair for Tetralogy of Fallot.

Acute cerebellitis with obstructive hydrocephalus post-Tetralogy of Fallot surgery is extremely rare but can present aggressively in pediatric cases. Early diagnosis is critical for prompt medical and surgical intervention. We report a fatal case in a 7-year-old boy post-surgery, where neurological symptoms rapidly progressed, leading to drowsiness and intermittent response to commands. Despite initial computed tomography scans showing no abnormality, subsequent scans revealed cerebellitis and hydrocephalus. Treatment with steroids, antibiotics, and cerebrospinal fluid drainage was unsuccessful, and the condition's etiology remained unclear despite negative serological tests and cultures. This highlights the challenge of diagnosing and treating acute cerebellitis, especially when no specific cause is found and when deterioration is swift. The role of opioids in pediatric patients and their potential association with neurosurgical complications is also discussed, prompting further inquiry into postoperative symptoms and opioid-related risks in susceptible individuals.

Management of entrapped temporal horn: Literature review and operative technique for endoscopic fenestration.

CONTEXT: Entrapment of the temporal horn (TH) is rare condition that can lead to increased intracranial pressure, but there is no consensus on a standard treatment. The aim of this study was to conduct a systematic literature review of the reported cases of TH entrapment and describe our operative technique for endoscopic fenestrations of the lateral ventricle into the basal cisterns. METHODS: We searched the databases Pubmed and Google scholar to find all studies reporting cases of entrapped TH and the subsequent treatment. Additionally, we report two illustrative cases of endoscopic fenestration with a step-by-step description of our surgical technique. RESULTS: Twenty-nine studies with a total of 67 patients were included in the analysis. The mean age was 36.5 years (SD± 21.9), and the female-to-male ratio was 1.5. The most frequent cause of TH entrapment was post-surgical scarring after tumor surgery (n= 30), and the most commonly reported treatment modality was endoscopic fenestration of the TH (n = 14). We observed an increasing use of endoscopic fenestration over time. CONCLUSION: Entrapped TH is a rare condition often requiring surgical treatment. Neuronavigation-guided endoscopic fenestration of the ventricle into the basal cisterns appears to be a safe, efficient, and device-free technique that has gained importance over the past years.

Case Presentation of a Neuroglial Cyst Causing Acute Hydrocephalus.

Neuroglial cysts are rare congenital cysts that seldom require surgical treatment. This case highlights a rare instance when a neurolglial cyst caused acute hydrocephalus in a 10-year old boy. Originally diagnosed and managed as pediatric-onset migraines, the patient presented to the emergency department with nausea, vomiting, and ataxia without clear pathology on neuroradiology. The neurosurgical team took him to the operating room based on his clinical picture and history and the cyst was discovered there. The pathology was benign, and he has had a complete resolution of symptoms.

Endoscopic Third Ventriculostomy for the Management of Obstructive Hydrocephalus in Pregnancy: A Case Report and Review of the Literature.

Introduction Hydrocephalus is a condition characterized by the abnormal accumulation of cerebrospinal fluid within the brain's ventricular system. It can stem from obstructive and nonobstructive causes. Pregnancy introduces physiopathological changes that may heighten the risk of developing or worsening symptomatic hydrocephalus. Nevertheless, comprehensive reports on this aspect, especially regarding surgical interventions, remain scarce. Case Report A young woman with a history of recurrent headaches experienced a worsening of her symptoms at the onset of her pregnancy. A magnetic resonance imaging (MRI) in the first trimester revealed increased ventricular dilation, indicating an obstructive cause due to aqueduct stenosis. During a neurosurgical board meeting, treatment options were discussed, considering the identifiable obstruction, the heightened intra-abdominal pressure associated with pregnancy, and the risk of ventricular shunt dysfunction. The patient underwent an endoscopic third ventriculostomy (ETV) without complications, leading to both symptom relief and a successful conclusion to the pregnancy. Discussion Neurosurgical procedures in pregnant women are uncommon due to the increased risks to both the mother and the fetus. However, when performed by a qualified multidisciplinary team, they can lead to positive outcomes. In cases of hydrocephalus during pregnancy, ETV appears to be a viable alternative for surgical intervention, particularly when hydrocephalus becomes symptomatic and an obstructive cause is identified, whether in patients with existing shunts or those with newly developed hydrocephalus.

Case Report on Mycobacterium tuberculosis Presenting As Lemierre's Syndrome: A Reemerging Catastrophe.

Lemierre's syndrome is characterized by internal jugular vein thrombophlebitis and bacteremia, primarily from anaerobic organisms. The condition usually arises after a recent oropharyngeal infection. Young, healthy people with prolonged pharyngitis that progresses into septicemia, pneumonia, or lateral neck stiffness should be suspected of having Lemierre's syndrome. Identifying internal jugular vein thrombophlebitis and developing anaerobic bacterial growth on blood culture are frequently used to confirm the diagnosis. Treatment consists of long-term antibiotic treatment, sometimes in conjunction with anticoagulant medication. In this case report, we describe the unique case of a 29-year-old male with Mycobacterium tuberculosis with pulmonary tuberculosis, tubercular meningitis, tuberculosis-related acute ischemic stroke with septic thrombophlebitis. The patient presented with sudden onset altered sensorium for 4 hours. Magnetic resonance imaging of the brain was done, which suggested obstructive hydrocephalus with periventricular ooze. The patient was started on antibacillary treatment, antibiotics, anticoagulants, and systemic steroids. The patient was vitally stable when he was discharged. Therefore, it is crucial to consider the likelihood of such atypical tuberculosis presentations while providing a prompt and relevant diagnosis and recommending the right course of therapy.

Epileptic Seizures in a Pediatric Patient With Vein of Galen Aneurysmal Malformation and Obstructive Hydrocephalus: A Rare Case Report.

The vein of Galen aneurysmal malformation (VGAM) is a rare congenital arteriovenous fistula of the embryonic median prosencephalic vein of Markowski, resulting in its pathological dilation. If left untreated, it can lead to multiple severe complications in the neonatal period, among which obstructive hydrocephalus. We present a case report of a six-year-old male patient with severe status epilepticus and a clinical history of VGAM and obstructive hydrocephalus, diagnosed via an MRI and an MR-angiography. The hydrocephalus was treated via a ventriculostomy at the age of six months, while the VGAM underwent a partial transarterial endovascular embolization when the patient was four years old. The procedures were successful, and there were no significant post-operative complications observed. The epileptic seizures began at a later point and were successfully medicated with valproate. However, they resumed due to a lowering of the medication dosage by the patient's parents. The patient was given a new valproic acid regimen with an appropriate dosage, and his parents reported no further seizures. This case report emphasizes the use of appropriate prenatal and neonatal diagnostic methods for VGAM and explores the nature of the multi-procedural therapy approach towards the pathology and its complications in relation to a possibly idiopathic co-pathology, namely epilepsy.

Immunocompetent isolated cerebral mucormycosis presenting with obstructive hydrocephalus: illustrative case.

BACKGROUND: Isolated cerebral mucormycosis is rare in immunocompetent adults and is only sparsely reported to be associated with obstructive hydrocephalus. OBSERVATIONS: Here, the authors report a case of obstructive hydrocephalus secondary to central nervous system mucormycosis without other systems or rhino-orbital involvement and its technical surgical management. A 23-year-old, incarcerated, immunocompetent patient with history of intravenous (IV) drug use presented with syncope. Although clinical and radiographic findings failed to elucidate an infectious pathology, endoscopy revealed an obstructive mass lesion at the level of the third ventricle, which, on microbiological testing, was confirmed to be Rhizopus fungal ventriculitis. Perioperative cerebrospinal fluid diversion, endoscopic third ventriculostomy, endoscopic biopsy technique, patient outcomes, and the literature are reviewed here. The patient received intrathecal and IV amphotericin B followed by a course of oral antifungal treatment and currently remains in remission. LESSONS: The patient's unique presentation and diagnosis of isolated cerebral mucormycosis reveal this pathogen as a cause of ventriculitis and obstructive hydrocephalus in immunocompetent adult patients, even in the absence of infectious sequelae on neuroimaging.

Aqueductal developmental venous anomaly causing obstructive hydrocephalus: A case report and review of the literature.

A developmental venous anomaly (DVA) is a venous drainage of the associated parenchyma that is normally asymptomatic. However, a DVA located adjacent to the aqueduct can cause obstructive hydrocephalus by blocking the flow of cerebrospinal fluid. We describe a rare case of obstructive hydrocephalus due to aqueductal stenosis secondary to a DVA. A 43-year-old man presented with sudden bilateral temporal pain during weight training. Using a 3-Tesla scanner, cranial magnetic resonance imaging (MRI) was performed, and hydrocephalus was found with mild enlargement of the lateral and third ventricles. Susceptibility-weighted imaging and postcontrast MRI revealed that the DVA from the bilateral thalami narrowed the orifice of the aqueduct on its drainage route towards the vein of Galen. We assumed that force exerted during weight training may have caused dilation of the anomalous veins, leading to his symptom. A review of the relevant English-language literature yielded only 19 cases of aqueductal stenosis due to DVA. In comparison to these cases, the duration of symptom in our case was extremely short because the patient had a history of ventriculomegaly detected on plain computed tomography and was diagnosed quickly based on the characteristic finding of DVA: the caput medusae appearance.

Corticosteroid treatment for acute hydrocephalus in neurosarcoidosis: a case report.

BACKGROUND: Neurosarcoidosis occurs symptomatically in 5-10% of patients with sarcoidosis, and hydrocephalus is a rare complication of neurosarcoidosis, with either acute or subacute onset and presenting symptoms related to increased intracranial pressure. It represents a potentially fatal manifestation with a mortality rate of 22% (increased to 75% in case of coexistence of seizures) that requires a prompt initiation of treatment. High-dose intravenous corticosteroid treatment and neurosurgical treatment must be considered in all cases of neurosarcoidosis hydrocephalus. CASE PRESENTATION: Here we present a case of hydrocephalus in neurosarcoidosis, complicated by generalized seizures, in a 29-year-old Caucasian male patient treated with medical treatment only, with optimal response. CONCLUSION: Since neurosurgery treatment can lead to severe complications, this case report underlines the possibility to undergo only medical treatment in selected cases. Further studies are needed to stratify patients and better identify those eligible for only medical approach.

Enlarged tumefactive perivascular, or Virchow-Robin, spaces and hydrocephalus: do we need to treat? Illustrative cases.

BACKGROUND: Perivascular spaces (PVSs) are spaces in brain parenchyma filled with interstitial fluid surrounding small cerebral vessels. Massive enlargements of PVSs are referred to as "giant tumefactive perivascular spaces" (GTPVSs), which can be classified into three types depending on their localization. These lesions are rare, predominantly asymptomatic, and often initially misinterpreted as cystic tumor formations. However, there are several reported cases in which GTPVSs have induced neurological symptoms because of their size, mass effect, and location, ultimately leading to obstructive hydrocephalus necessitating neurosurgical intervention. Presented here are three diverse clinical presentations of GTPVS. OBSERVATIONS: Here, the authors observed an asymptomatic case of type 1 GTPVS and two symptomatic cases of type 3 GTPVS, one causing local mass effect and the other hydrocephalus. LESSONS: GTPVSs are mostly asymptomatic lesions. Patients without symptoms should be closely monitored, and biopsy is discouraged. Hydrocephalus resulting from GTPVS necessitates surgical intervention. In these cases, third ventriculostomy, shunt implantation, or direct cyst fenestration are surgical options. For patients presenting with symptoms from localized mass effect, a thorough evaluation for potential neurosurgical intervention is imperative. Follow-up in type 3 GTPVS is recommended, particularly in untreated cases. Given the infrequency of GTPVS, definitive guidelines for neurosurgical treatment and subsequent follow-up remain elusive.

Intraventricular Subependymoma With Obstructive Hydrocephalus: A Case Report and Literature Review.

Subependymomas are benign tumors of the ventricles that grow from the ventricular wall into the cerebrospinal fluid spaces within the brain, obstructing the flow of the cerebrospinal fluid and causing obstructive hydrocephalus. It is estimated that ependymomas represent between 0.2% and 0.7% of all intracranial tumors. They arise most frequently in the fourth ventricle (50-60%) and the lateral ventricles (30-40%). We present the case of a 50-year-old patient, previously diagnosed with an intraventricular process, admitted in our clinic. At neurological examination, the patient was cooperative, bradylalic, and bradypsychic, with right hemiparesis, postural and balance disorders, and occasionally sphincteric incontinence. MRI with contrast described a left intraventricular tumor, in the frontal horn of the left lateral ventricle with homogeneous appearance, with a maximum diameter of 50 mm and base of insertion at the adjacent ependyma of the foramen of Monro, which determined obstructive hydrocephalus. Total resection of the left intraventricular cerebral tumor was achieved. Histopathological analysis revealed a subependymoma. Postoperative recovery was slowly favorable, with significant neurological improvement. At neurological examination at three-month follow-up, the patient's right hemiparesis and unsystematized balance disorders improved. A contrast-enhanced CT scan was performed, highlighting left frontal sequelae hypodensity corresponding to the operated tumor, enlarged left lateral ventricle without active hydrocephalus, and no sign of tumor recurrence. At six-month follow-up, clinico-radiologic findings coincide with those from three-month follow-up. Subependymomas are slow-growing (grade 1) tumors and generally have a favorable prognosis. Unfortunately, due to their anatomical level, multiple complications can arise, caused from obstructive hydrocephalus complications, such as cognitive dysfunction and incontinence. Tumor resection should be complete, a successful operation being a challenge for every neurosurgeon.

Acute Obstructive Hydrocephalus: An Unexpected Cause of Cardiac Arrest.

BACKGROUND: Emergency physicians are well-versed in managing cardiac arrests, including the diagnostic and therapeutic steps after return of spontaneous circulation. Neurologic emergencies are a common cause of out-of-hospital cardiac arrest and must remain high in the differential diagnosis, as such cases often require specific interventions that may deviate from more common care pathways. Performing a noncontrast head computed tomography (NCHCT) scan after cardiac arrest has been found to change management, although the optimal timing of this imaging is unclear. CASE REPORT: This is the case of a young, pregnant woman who presented to the emergency department after cardiac arrest with return of spontaneous circulation in the prehospital setting. She was found to have acute obstructive hydrocephalus on NCHCT, which was later confirmed to be due to a previously undiagnosed colloid cyst of the third ventricle. This acute obstruction resulted in myocardial stunning and, ultimately, cardiac arrest. Although outcomes are often dismal when the cause of arrest is secondary to neurologic catastrophe, this patient survived with completely intact neurologic function. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Although acute obstructive hydrocephalus due to a colloid cyst adjacent to the third ventricle is a rare condition, it is a potentially reversible neurologic cause of out-of-hospital cardiac arrest. However, positive outcomes depend on obtaining the diagnosis rapidly with neurologic imaging and advocating for neurosurgical intervention. This case supports the recommendation that emergency physicians should strongly consider post-cardiac arrest neurologic imaging when another cause is not immediately obvious.

Septostomy and Monroplasty in Isolated Lateral Ventricle After Removal of a Third Ventricle Colloid Cyst: 2-Dimensional Operative Video.

Isolated unilateral hydrocephalus (IUH) is a condition caused by unilateral obstruction of the foramen of Monro.1 Etiopathogenic causes include tumors, congenital lesions, infective ventriculitis, intraventricular haemorrhage, and iatrogenic causes such as the presence of contralateral shunts.2,3 Neuroendoscopic management is considered the "gold-standard" treatment in IUH.4 Even if endoscopic septostomy and foraminoplasty in IUH are well-known procedures,5,6 IUH after an interhemispheric transcallosal transchoroidal approach for removal of a III ventricle colloid cyst is a complication barely described in literature. Video 1 describes this rare complication and the neuroendoscopic treatment adopted, including the operative room setup, patient's positioning, instrumentation needed, and a series of intraoperative tips for the performance of septostomy and Monroplasty via a single, precoronal burr hole. The scalp entry point and endoscope trajectory, homolateral to the dilated ventricle, were planned on the neuronavigation system. The avascular septal zone away from the septal veins and body of the fornix was reached, and the ostomy was performed. At the end of the procedure, Monroplasty was performed, too. The procedure was effective in solving the hydrocephalus and patient's clinical picture. No surgical complications occurred. Imaging demonstrated an evident and progressive reduction of enlarged lateral ventricle. In authors' opinion, the single burr-hole approach, ipsilateral to the enlarged ventricle, provides an optimal identification the intraventricular anatomy and allows Monroplasty to be performed, if deemed feasible during surgery. The patient consented to the procedure. The participants and any identifiable individuals consented to publication of their images.

A case report of hemorrhagic presentation of diffuse neonatal hemangiomatosis (DNH) associated to obstructive hydrocephalus: Medical and neurosurgical considerations.

BACKGROUND: Diffuse neonatal hemangiomatosis (DNH) is a rare disorder typically recognized at birth or during the neonatal period. DNH involves three or more organ systems, including the central nervous system (CNS). In these cases, serious complications such as hemorrhages and obstructive hydrocephalus can develop. CASE REPORT: We present a case of DNH with intracranial hypertension and CNS hemorrhagic lesions on the mesencephalic aqueduct, resulting in triventricular hydrocephalus, treated with endoscopic ventriculocisternostomy (ETV) and medical therapy. DISCUSSION: DNH is a rare condition that can involve the CNS with serious complications. From a review of the literature, we highlighted only two cases of DNH with brain involvement treated surgically. We report the successful outcome of ETV, along with surgical considerations, imaging findings, and the complete resolution of cerebral and skin lesions following medical therapy. CONCLUSIONS: Medical therapy is not standardized and must be individualized. In patients who develop severe neurological symptoms such as obstructive hydrocephalus, surgery may be considered to avoid neurological sequelae.

Prenatal dispositions and genetic analysis of monozygotic female twins with suprasellar cysts and hydrocephalus: A case report.

INTRODUCTION: We present a unique case of monozygotic female twins with virtually identical clinical and radiological presentations of supratentorial hydrocephalus and cystic formations from the suprasellar cistern. DISCUSSION: Evaluating genetic predispositions and prenatal exposures is crucial for hydrocephalus in twins. Familial cases imply a genetic contribution to the development of these anomalies, including chromosomal abnormalities and specific variants linked to arachnoid cyst formation in various syndromes. Extensive genetic analyses found no pathogenic variants in the twins. Prenatal exposure to anti-epileptic medication was known during pregnancy and may be associated with fetal abnormalities, but not central nervous system (CNS) malformations, and was therefore not considered the cause of the condition in the twins. The twins presenting simultaneously with hydrocephalus caused by suprasellar cysts (SAC) underwent a two-step surgical management: initial ventriculoperitoneal shunt (VPS) placement followed by fenestration. Postoperative imaging showed cyst reduction, but a secondary VPS was necessary in both cases. CONCLUSION: Genetic analysis is less likely to identify a monogenic etiology in non-syndromic cases of SACs, which are assumed to be multifactorial. There is no established evidence linking a teratogenic effect of anti-epileptic drugs to CNS malformations. Moreover, the surgical treatment of this complex condition constitutes a point of discussion.

Chronic Ventriculitis Caused by Cryptococcus neoformans: A Rare Presentation.

Cryptococcus neoformans is a fungus notorious for invading the central nervous system. while Cryptococcus is known to cause meningitis, encephalitis, and meningoencephalitis in immunocompromised patients, especially those with AIDS (CD4 <100), and found to be rapidly fatal, instances of ventricular involvement with chronic sequelae are exceedingly rare. Typical presentations of cryptococcal meningitis involve headache, altered mental status, nuchal rigidity, and vomiting. We report a case of a 58-year-old HIV-positive male who presented with intermittent headaches and changes in gait. The MRI revealed ventriculomegaly and advanced chronic sequela of prior ventriculitis with serum and CSF cryptococcal antigen being positive. The treatment of cryptococcal chronic ventriculitis requires a multidisciplinary approach involving internal medicine, neurosurgery, neurology, and infectious diseases. However, this patient's CSF had no pleocytosis and had very high protein, which is a poor prognostic indicator for this disease and could have been prevented with the prompt recognition of the condition before it had progressed to the chronic stage. We recommend that clinicians maintain a high index of suspicion for opportunistic infections, such as cryptococcal meningitis, in any patient with HIV regardless of typical clinical findings.

Colloid Cyst Presenting With Severe Headache and Bilateral Leg Weakness: Case Report and Review.

Colloid cysts are benign growths commonly found in the third ventricle at the foramen of Monro. They can be asymptomatic or present with a variety of symptoms, including headaches, diplopia, memory problems, psychosis, urinary incontinence, and ataxia. Obstructive hydrocephalus from a colloid cyst is caused by a blockage of cerebral spinal fluid (CSF) from the lateral ventricles at the foramen of Monro. Colloid cysts have rarely been reported to cause sudden death. Here we present the case of a 32-year-old female with a known history of a colloid cyst who presented with a headache and transient weakness in her lower extremities noted while climbing stairs.