Endoscopic Third Ventriculostomy for Hydrocephalus with Interhypothalamic Adhesion: A Case Report and Literature Review

Summary

Endoscopic third ventriculostomy (ETV) treats obstructive hydrocephalus by creating a new cerebrospinal fluid pathway. Interhypothalamic adhesion (IHA), a rare congenital anomaly, can complicate surgery by obscuring reference points. While it is crucial to avoid damaging the IHA, ETV can be performed with careful planning and imaging guidance.

Abstract

Endoscopic third ventriculostomy (ETV) is a well-established treatment for obstructive hydrocephalus; however, anatomical variations, such as the interhypothalamic adhesion (IHA), may obscure critical third ventricular landmarks and complicate intraoperative orientation. IHA is a rare congenital band of neural tissue connecting the medial hypothalamic walls and may pose a technical challenge during ventricular endoscopy. A case of obstructive hydrocephalus in which IHA was encountered during ETV is presented, and a structured surgical approach to safely perform ventriculostomy without disrupting the adhesion is described. Preoperative magnetic resonance imaging was used to assess ventricular anatomy and to plan the trajectory. Intraoperative ultrasound guidance facilitated accurate ventricular access. After identification of the infundibular recess and mammillary bodies, the third ventricular floor was perforated anterior to the mammillary bodies using a blunt instrument. A balloon catheter was employed to dilate the fenestration while minimizing traction on the IHA. Adequate cerebrospinal fluid flow was confirmed endoscopically. Postoperative imaging demonstrated stoma patency, and the patient showed clinical improvement during follow-up. This case illustrates that the presence of IHA does not preclude successful ETV when critical landmarks are clearly visualized, and a methodical intraoperative strategy is followed. Preservation of the adhesion may enhance procedural safety, and ventriculoperitoneal shunting should remain a secondary option when anatomical constraints prevent safe fenestration.

Introduction

Hydrocephalus is a life-threatening condition characterized by abnormal ventricular enlargement due to abnormal cerebrospinal fluid (CSF) dynamics. It is one of the most common neurosurgical conditions in pediatric patients and usually presents as progressive head enlargement in infants or increased intracranial pressure in older children¹. The etiology of hydrocephalus is multifactorial, encompassing both congenital forms associated with genetic abnormalities and acquired conditions that disrupt cerebrospinal fluid dynamics. These may include mechanisms involving impaired ventricular outflow, dysfunction of the subarachnoid space, altered cere....

Protocol

This study describes a single patient case and does not constitute human subject research according to institutional policies. Formal Institutional Review Board approval was therefore not required. Written informed consent for the surgical procedure and publication of clinical and radiological data was obtained from the patient’s legal guardians. All procedures were conducted in accordance with institutional guidelines and the principles of the Declaration of Helsinki.

1. Preoperative preparation

1. The patient was transferred to the operating room for emergency surgical intervention.
2. Positioned in ....

Results

Postoperatively, the patient received analgesics (acetaminophen or ibuprofen) for pain control. A non-contrast cranial CT scan was obtained within 24 h to exclude hemorrhage (Figure 2). Neurological examinations were performed hourly during the first 24 h and every four hours thereafter until discharge. The patient was discharged on postoperative day two with instructions for wound care and outpatient follow-up. Because the patient was pediatric and required.......

Discussion

Hydrocephalus remains a significant global health challenge. Walter Dandy, in 1913, classified hydrocephalus into two primary categories: communicating (non-obstructive) and non-communicating (obstructive). This classification forms the foundation of the understanding of this condition and has guided subsequent research into its pathophysiology and management¹⁵. Since Dandy’s pioneering work, advances in technology and surgical techniques have significantly improved outcomes for patients wit.......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Adson periosteal elevator	Ruggles-Redmond	RO263	Semi-sharp, 5 mm, curved 6-3/8, length 164 mm
Automatic skin retractors	Integra	3,72,245	Heiss Automatic Skin Retractor Length - Overall (mm): 102 Length 1 - Tip/Jaw (mm): 8
Balloon catheter	Edwards Fogarty	120804FP	Length (cm): 80, Catheter size (F):4,  Inflated balloon diameter (mm):9
Bisture	Beybi	24,02,502	Beybi Bisture Tip. No:20 and No:11
High-speed drill	Medtronic Midas Rex MR8	MR8 Electric Plus EM850	Perforator tip used
Kerrison Rongeur	Aesculap	FK950B	Length (cm): 7 in, Jaw Size widht: 3.0 mm, Jaw opening: 10.0 mm
Operating sheath	Karl Storz LOTTA	28164 LSB	Graduated, rotating, outer diameter 6.8 mm, working length 13 cm
Trocar	Karl Storz LOTTA	28164 LLO	Use with Operating Sheaths for ventricular puncture
Ultrasound	BK	bk5000	Use via N11C5s Transducer (9063) for ventricular puncture
Ventriculoscope	Karl Storz LOTTA Ventriculoscope with HOPKINS	28164 LAB	Wide angle telescope 30°, angled eyepiece, outer diameter 6.1 mm, length 18 cm, working channel diameter 2.9 mm, irrigation/suction channel diameter 1.6 mm