【See Figure for Surgery】 Neuroendoscopic triple ventricular floor fistula–surgical treatment of obstructive hydrocephalus July 27, 2015 15:54 Read 195 Zhou Yan, Department of Neurosurgery, Air Force General Hospital Obstructive hydrocephalus is one of the common clinical neurosurgical diseases, which refers to various factors causing cerebrospinal fluid circulation pathways in the fourth It is a pathological phenomenon caused by the obstruction of cerebrospinal fluid circulation above the fourth ventricle and the subsequent flow of cerebrospinal fluid into the subarachnoid space or the medulla oblongata pool of the cerebellum. Obstructive hydrocephalus can lead to excessive accumulation of cerebrospinal fluid in the skull, which further leads to enlargement of the ventricles, increased intracranial pressure, atrophy of the brain parenchyma, and a variety of clinical symptoms and signs in patients. Surgery is the main treatment method for obstructive hydrocephalus, but there are many clinical procedures for treating obstructive hydrocephalus, and each procedure has its own characteristics. Regardless of the method, the main treatment principles include reducing cerebrospinal fluid secretion, increasing body water drainage, relieving the cause of ventricular obstruction and cerebrospinal fluid shunt. Based on these treatment principles, ventriculoperitoneal shunts are often used to treat patients with obstructive hydrocephalus. It is worth noting that there are some shortcomings of ventriculoperitoneal shunts, such as a high incidence of postoperative complications, including poor shunt position requiring multiple surgical transfers; shunt implantation in the body increasing the risk of infection and affecting the patient’s activities; shunt blockage leading to shunt failure; cerebrospinal fluid pressure and shunt pressure discordance leading to insufficient or excessive shunts, which have caused many problems in clinical treatment. In recent years, with the increasing maturity of neuroendoscopic technology and the continuous improvement of neuroendoscopic instruments, neuroendoscopic third ventriculostomy has been gradually applied to the treatment of obstructive hydrocephalus. During neuroendoscopic third ventriculostomy, no shunt tube is needed, which can avoid the complications related to shunt tube in ventriculoperitoneal shunts, and can also avoid the pain of multiple tube changes in younger patients due to body growth. What does hydrocephalus look like under neuroendoscopy? How is the triple ventriculostomy procedure done? How are the benefits of this procedure demonstrated? Let me tell you more. The procedure must be performed under general anesthesia. The head is elevated and flexed forward to avoid excessive loss of cerebrospinal fluid. The surgical incision is approximately 3 cm and the bone hole is approximately 1 cm in diameter. The dura is cut crosswise and the endoscopic sheath is introduced into the lateral ventricle. The lateral ventricle is first entered with a 0° endoscope, and the interventricular foramen structure is observed, allowing visualization of the fornix, vein of septum pellucidum, choroid plexus, and thalamostriate vein. The endoscope is then switched to a 30° endoscope to look forward at the structures in the lateral ventricle. The white one is the corpus callosum and the gray one is the head of the caudate nucleus. The endoscope is then switched back to 0° and the interventricular foramen is used to enter the triventricular ventricle, i.e., the end plate (terminal lamina), optic chiasm (optic cross), and funnel crypt (infundibular recess) are visible. The endplate, optic chiasm, and anterior cerebral artery are then visualized posteriorly in the midbrain aqueduct. The fornix and anterior commissure were visualized. On further forward exploration, the anterior cerebral artery complex was seen. On posterior examination, the entrance to the aqueduct, posterior commissure, pineal recess and habenular commissure, and choroid plexus were seen. After all intraventricular structures were explored, a 0° endoscopy was performed to start a triple ventricular floor fistula. The fistula is located between the infundibular recess and the mammillary bodies. A micro clamp is used to create the fistula at the base of the triple ventricle and then a balloon is used to dilate the fistula. The figure below shows the shape of the fistula. The endoscope is passed through the fistula into the basal pool and the basilar artery and its surrounding arachnoid structures are seen. After confirming that the base of the tricuspid ventricle is completely free of obstruction to the basal pool, the ventriculoscope is withdrawn and the morphology of the fistula and the presence of active hemorrhage are again observed.