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.
METHODS: 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.
CONCLUSIONS: 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.

UNASSIGNED: This study was designed to assess the effectiveness and safety of using a modified Kocher\'s point for ventriculostomy using endoscopic third ventriculostomy (ETV) and external ventricular drainage (EVD) in 200 patients at PAR Private Hospital in Erbil, Iraqi Kurdistan.
UNASSIGNED: In this retrospective analysis, a total of 200 patients who were diagnosed with obstructive hydrocephalus and underwent ETV and EVD utilizing a modified entry site were included. The revised Kocher point was located 11.5 cm posterior and superior to the nasion, 3 cm laterally, and 0-1 cm before the coronal suture.
UNASSIGNED: The use of this modified Kocher\'s point has brought much improvement in surgical precision and safety. This would minimize incidences of bleeding and misplacement of the catheters. The anatomical structure was well organized, and nothing was challenging in the process of traversing through the foramen of Monro into the third ventricle. It was easily introduced through the modified Kocher point with increasing efficacy and near zero possibility of sustaining injury to the limiting cerebral region.
UNASSIGNED: Using the modified point of Kocher provides added reliability and accuracy to ventriculostomy, thereby reducing complications and increasing the overall outcome of surgeries. It overcomes all the drawbacks of classical entry sites and, further, helps in increasing the productivity of ETV and EVD. More research must be done to support the benefits of this modification in other clinical settings.

UNASSIGNED: Human herpesvirus 6 (HHV-6) is a double-stranded DNA virus well established in the clinical literature to cause the near-universal childhood infection roseola infantum (exanthema subitum/sixth disease). Primary HHV-6 infection has been reported to cause meningoencephalitis in pediatric patients, although generally in the immunocompromised.
UNASSIGNED: The authors treated an immunocompetent 18-month-old female who transferred to our institution for a higher level of care given concerns for meningitis in the setting of decreased level of arousal (Glasgow Coma Scale 12), and bradycardia 9 days after the onset of nasal congestion, fatigue, and repeated bouts of emesis. Outside hospital cerebrospinal fluid (CSF) studies were notable for hypoglycorrhachia, elevated protein, elevated nucleated cells with a mononuclear predominance, and a meningitis polymerase chain reaction panel that was positive only for HHV-6. Brain magnetic resonance imaging with and without contrast revealed a basal cistern predominant leptomeningeal enhancement pattern as well as moderate ventriculomegaly with associated periventricular edema concerning acute communicating hydrocephalus. Considering the CSF studies, neuroimaging, and recent travel history to Mexico, central nervous system (CNS) tuberculosis (TB) was the leading suspicion, and antimicrobial therapy was initiated for this presumptive diagnosis with culture data only proving the TB suspicion correct after nearly 2 months in culture. Anti-viral therapy was initially not felt to be necessary as the HHV-6 was interpreted as incidental and not a cause of symptomatic meningitis in our immunocompetent host. The patient\'s hydrocephalus was treated with temporary CSF diversion followed by performance of an endoscopic third ventriculostomy. Despite appropriate hydrocephalus management, clinical improvement ultimately seemed to correlate with the initiation of antiviral therapy.
UNASSIGNED: The authors present this case and review the literature on HHV-6-associated CNS infections with the goal of informing the neurosurgeon about this often clinically underestimated pathogen.

OBJECTIVE: Determining the long-term success of endoscopic third ventriculostomy (ETV) remains challenging. This study aimed to investigate the impact of clinical and radiological factors on ETV success in pediatric patients with hydrocephalus.
METHODS: The study included patients < 18 years old with hydrocephalus who underwent ETV between March 2014 and May 2021. Data including patient age, gender, history of previous shunt surgery, previous external ventricular drain placement, intraventricular hemorrhage history, and postoperative meningitis were extracted from medical records. Imaging features such as aqueductal stenosis, third ventricle floor bowing, displaced lamina terminalis, pulsatility index (PI), and maximum diameter of the cortical subarachnoid space (CSAS) were recorded for each patient using preoperative CT scans. Two independent neurosurgeons measured the CSAS maximum diameter and the PI. CSAS measurements were obtained on axial slices of the preoperative CT scans, whereas the PI was based on intraoperative third ventricle pulsatility. Patients were followed up for 1 year after surgery, with failure defined as the need for ventriculoperitoneal shunt (VPS) placement or death attributable to hydrocephalus.
RESULTS: Ninety-eight children with a mean age of 16.39 ± 19.07 months underwent ETV for hydrocephalus. No deaths were recorded, but over 6 months and 1 year of follow-up, 12.2% and 22.4% of patients, respectively, experienced documented ETV failure requiring VPS placement. At the 6-month follow-up, a smaller maximum diameter of the CSAS was significantly associated with ETV failure; multivariate analysis revealed that CSAS maximum diameter was a predictor of 6-month ETV failure. At the 1-year follow-up, a lower PI was significantly associated with ETV failure, and multivariate analysis confirmed the PI as a significant predictor of ETV failure within 1 year after surgery. CSAS and PI measurements were repeated to assess interrater reliability: the intraclass correlation coefficients were 0.897 and 0.669 for CSAS and PI, respectively.
CONCLUSIONS: This study found that the CSAS maximum diameter and the PI are predictors of ETV failure at 6 months and 1 year, respectively. These findings highlight the importance of considering specific factors such as the CSAS and PI when assessing the likelihood of ETV success in pediatric patients with hydrocephalus. Further research and consideration of these factors may help optimize patient selection and improve outcomes for those undergoing ETV as a treatment for hydrocephalus.

Pediatric neurosurgery faces a major difficulty in the treatment of hydrocephalus, a condition marked by an abnormal build-up of cerebrospinal fluid (CSF) in the brain. Its prevalence varies between 0.5 and 0.8 per 1,000 live births worldwide, with different etiologies, including congenital abnormalities and acquired diseases. With benefits including a lower risk of infection and avoiding issues due to the shunt, endoscopic third ventriculostomy (ETV) has become a beneficial surgical technique in certain instances. Bypassing clogged ventricular channels, ETV creates a new channel for CSF drainage. Despite its effectiveness, a thorough examination of underlying disease and anatomical variables is necessary for positive outcomes in patient selection. To give patients, the best possible care, this article attempts to summarize the prevalence of hydrocephalus and the part that ETV plays in managing it. It also emphasizes the significance of customized surgical techniques. It is critical to comprehend the incidence of hydrocephalus and available treatment choices to enhance the infant\'s quality of life and long-term outcomes.

Endoscopic third ventriculostomy (ETV) is a safe treatment option for chronic obstructive hydrocephalus. However, we encountered a case of chronic subdural hematoma (CSDH) with bilateral large hematoma volumes after ETV for chronic obstructive hydrocephalus. We herein report a rare complication of ETV. The patient was a 53-year-old woman who had been diagnosed with asymptomatic ventricular enlargement with aqueductal stenosis 5 years previously. However, over the course of 5 years, her gait and cognitive function gradually declined. ETV was administered to relieve symptoms. Head Magnetic resonance imaging performed 1 week after ETV indicated bilateral subdural hygroma. Three weeks after ETV, she presented with headache and left incomplete paralysis, and head Computed tomography (CT) demonstrated bilateral CSDH with a large volume hematoma. Burr-hole evacuation and drainage of the bilateral CSDH were performed, after which the symptoms resolved. However, 7 weeks after ETV, she again presented with headache and incomplete right paralysis, and CT revealed bilateral CSDH re-enlargement. After the second burr-hole evacuation and drainage of bilateral CSDH, her symptoms resolved. The bilateral CSDH continued to shrink following the second hematoma evacuation surgery and completely disappeared on CT scan performed 3 months after ETV. Ventricular enlargement due to chronic obstructive hydrocephalus stretches the brain mantle for several years. This long-term stretching may have diminished the brain compliance and led to the development, growth, and recurrence of CSDH. In ETV for chronic obstructive hydrocephalus, surgeons should consider the risk of postoperative CSDH with a high hematoma volume and tendency to recur.

OBJECTIVE: Hydrocephalus is a lifelong condition punctuated in most cases by unpredictable hospital admissions for surgical maintenance. It occupies more of the attention of the pediatric neurosurgeon than any other condition. Benchmarks for the measurement of outcomes are of interest to patients, their families, and the healthcare system. Compared to other metrics, 30-day outcomes require modest resources to collect, are conceptually transparent, and are responsive to process improvement.
METHODS: The National Surgical Quality Improvement Program-Pediatric of the American College of Surgeons was queried for operations for hydrocephalus in the years 2013 through 2020. Demographic data and data regarding comorbidities were collected. Thirty-day rates of return to the operating room, of shunt infection, and of readmission to hospital were analyzed on a univariate basis and in multivariate models.
RESULTS: There were 29,098 surgical procedures in the sample, including 10,135 shunt insertions, 16,420 shunt revisions, and 2543 endoscopic third ventriculostomies. The overall 30-day reoperation rate was 10.3%. The most powerful associations were with the nature of the index procedure and with a history of extreme prematurity. The 30-day shunt infection rate was 1.80%. The major associations were with young age, major cardiac risk factors, nutritional support, and ventilator dependence. The 30-day readmission rate was 17.2%. The nature of the index procedure, current malignancy, nutritional support, and recent steroid administration were major associations. Comorbidities negatively associated with these outcomes were highly prevalent.
CONCLUSIONS: Precise benchmarks for important 30-day outcomes have been calculated from a very large sample of operations for hydrocephalus in childhood.

OBJECTIVE: Endoscopic third ventriculostomy (ETV) is an effective treatment for obstructive hydrocephalus. Secondary stoma closure may be life threatening and is the most common reason for late ETV failure, mostly secondary to local scarring. Local stents intended to maintain patency are rarely used. In this study, we summarize our experience using stented ETV (sETV), efficacy, and safety.
METHODS: Data was retrospectively collected from all consecutive patients who underwent ETV with stenting at four centers. Collected data included indications for using sETV, hydrocephalic history, surgical technique, outcomes, and complications.
RESULTS: Sixty-seven cases were included. Forty had a primary sETV, and 27 had a secondary sETV (following a prior shunt, ETV, or both). The average age during surgery was 22 years. Main indications for sETV included an adjacent tumor (n = 15), thick or redundant tuber cinereum (n = 24), and prior ETV failure (n = 16). Fifty-nine patients (88%) had a successful sETV. Eight patients failed 11 ± 8 months following surgery. Reasons for failure included obstruction of the stent, reabsorption insufficiency, and CSF leak (n = 2 each), and massive hygroma and tumor spread (n = 1 each). Complications included subdural hygroma (n = 4), CSF leak (n = 2), and stent malposition (n = 1). There were no complications associated with two stent removals.
CONCLUSIONS: Stented ETV appears to be feasible and safe. It may be indicated in selected cases such as patients with prior ETV failure, or as a primary treatment in cases with anatomical alterations caused by tumors or thickened tuber cinereum. Future investigations are needed to further elucidate its role in non-communicating hydrocephalus.

OBJECTIVE: The prevalence, management, and outcomes of hydrocephalus remain underexplored in Africa. This study aimed to analyze demographic and clinical features, evaluate treatment strategies, and assess neurological outcomes of pediatric hydrocephalus in Africa.
METHODS: A systematic review of the literature using the PubMed, Google Scholar, and Web of Science electronic databases was completed according to the PRISMA guidelines to identify articles describing pediatric patients in Africa with hydrocephalus.
RESULTS: Seventy-four retrospective and prospective studies and 33 case reports involving 12,355 patients were included. In 54 retrospective articles reporting patient demographics, 53.8% (3926/7297) were male with a mean age of 12.3 months. Nineteen studies reported macrocephaly (80.2%, 1639/2043) as the most common presentation. The etiology of hydrocephalus was reported as postinfectious (41.0%, 2303/5614) across 27 articles and congenital (48.6%, 1246/2563) in 10 articles. Eleven articles reported 46.7% (609/1305) of patients had communicating hydrocephalus while 53.3% (696/1305) had obstructive hydrocephalus. Diagnostic imaging included CT (76.1%, 2435/3202; n = 29 articles), ultrasonography (72.9%, 2043/2801; n = 15 articles), and MRI (44.8%, 549/1225; n = 11 articles). In 51 articles, 83.1% (7365/8865) of patients had ventriculoperitoneal shunting (VPS) while 33 articles described 54.1% (2795/5169) receiving endoscopic third ventriculostomy (ETV) for hydrocephalus surgical management. Postoperative complications included sepsis (6.9%, 29/421; n = 4 articles), surgical site infections (5.1%, 11/218; n = 4 articles), and CSF leaks (2.0%, 15/748; n = 8 articles). Shunt-related complications included infections (4.3%, 117/2717; n = 21 articles) and blockages (4.1%, 34/829; n = 6 studies). In 15 articles, 9.0% (301/3358) of patients with shunts had revisions. The mean follow-up duration was 18.9 ± 16.7 months with an overall mortality rate of 7.4% (397/5383; n = 29 articles). In the analysis of comparative studies, the 160 patients undergoing ETV demonstrated significantly higher odds of a successful operation (OR 1.54, 95% CI 0.51-4.69; p = 0.03) and neurological improvement at last follow-up (OR 3.36, 95% CI 0.46-24.79; p < 0.01) compared with the 158 who received VPS, but no significant differences were observed for complications and mortality between the two groups (p > 0.05).
CONCLUSIONS: This review offers a comprehensive summary of pediatric hydrocephalus in Africa, highlighting shunting as the primary treatment. However, the observed variations across studies highlight the need to establish standardized guidelines for reporting patient characteristics, management strategies, and outcomes to ensure consistency and comparability in articles.

OBJECTIVE: The objective of this study was to report the results of a bibliometric analysis on the modern corpus of literature pertaining to endoscopic third ventriculostomy (ETV). Prior bibliometrics studies on ETV have focused on highly cited articles, but an advanced bibliometric analysis has not yet been conducted.
METHODS: The authors queried the Web of Science (WoS) for (ALL = (endoscopic third ventriculostomy)) OR (ALL = (ETV) AND ALL = (neurosurgery)). Articles or reviews published in English were included. Articles, along with their metadata, were exported. Statistical, bibliometric, and network analyses were performed using the Bibliometrix R package and various Python packages. Reference publication year spectroscopy (RPYS), a method that analyzes the frequency with which references are cited in terms of these references\' publication years, was employed to explore the historical roots of the field.
RESULTS: Between 1994 and 2023, 1663 documents were identified (1382 articles) from 5457 authors. The mean annual growth rate of publications was 4.9%. International coauthorship increased 4-fold over this time period and was noted for 18.95% of published studies from 2011 to 2023. We observed that Child\'s Nervous System published the most articles, Journal of Neurosurgery (JNS) articles were cited most frequently, and JNS: Pediatrics articles had the highest impact. Female coauthorship increased from < 1% of published studies before 2000 to 19% by 2022, with an increase in female first authorship from 2% in 2005 to 22% in 2022 and at least 1 female coauthor rising from 3% in 2000 to 68% in 2022. Likewise, minority authorship has increased, as in the early ETV literature > 75% of authors were White while currently only 43% are White. The authors of this study also identified the most prolific authors on the subject. Early in the publication record, etiological and technical terms such as \"aqueductal stenosis\" and \"technical note\" predominated. More recently, \"complications,\" \"failure,\" \"success,\" \"neuroendoscopy,\" and \"choroid plexus cauterization\" were prominent. Utilizing RPYS, the authors identified 32 articles that comprise the foundational articles on ETV, published between 1966 and 2010.
CONCLUSIONS: Interest in ETV increased in the 1990s with the advent of advanced endoscopic technologies-particularly digital video. The focus of research has shifted from etiology to outcomes, complication management, and technical mastery.