{"id":"0109a035-668a-41e3-8a4a-6ddc66195a3d","slug":"third-ventriculostomy-and-endoscopic-aqueductoplasty-in-a-child-with-isolated-fourth-ventricle-after-intraventricular-hemorrhage-of-prematurity","title":"Third ventriculostomy and endoscopic aqueductoplasty in a child with isolated fourth ventricle after intraventricular hemorrhage of prematurity","authors":["Franklin Bernardes Faraj de Lima","Vitor Ribeiro Gonçalves","André Guimarães Soares","Gabriel Godoi Torres"],"abstract":"Background: Isolated fourth ventricle represents a challenging complication of posthemorrhagic hydrocephalus in premature newborns. Traditional therapeutic strategies include direct shunting of the fourth ventricle or microsurgical approaches. With the advancement of neuroendoscopic techniques, endoscopic aqueductoplasty has emerged as a minimally invasive alternative aimed at restoring fluid circulation between the fourth and third ventricles, with or without the use of aqueductal stents. This video illustrates tunneling aqueductoplasty with an intraventricular catheter under direct vision as an effective option in the treatment of isolated fourth ventricle of posthemorrhagic etiology. Case Description: We present a case of a 2-year-old pediatric patient with a history of hydrocephalus secondary to intraventricular hemorrhage of prematurity (Papile grade III). At 2 months of age, due to extreme prematurity (27 weeks) and low birth weight, an Ommaya device for repeated ventricular punctures was implanted. At 4 months of age, a ventriculoperitoneal shunt was implanted in the left frontal horn. He remained neurologically stable with adequately treated hydrocephalus until the age of 2, when he began experiencing progressive symptoms of valvular dysfunction (irritability, vomiting, and changes in respiratory pattern). He was readmitted, where a cranial computed tomography (CT) scan revealed ventriculomegaly, especially in the fourth ventricle (isolated ventricle) with signs of brainstem compression. The patient then underwent cerebral endoscopy for endoscopic third ventriculostomy and aqueductoplasty through tunneling of the intraventricular catheter through the cerebral aqueduct, restoring cerebrospinal fluid (CSF) circulation and peritoneal shunt. A follow-up CT scan of the head showed adequate shunt from the fourth and third ventricles to the peritoneum, with significant decompression of the brainstem. The patient was discharged on the 5th postoperative day. At present, he has been under outpatient follow-up for approximately 6 months, showing no signs of intracranial hypertension or brainstem dysfunction and with adequate neuropsychomotor development. Conclusion: This case highlights a practical strategy for managing hydrocephalus associated with an isolated fourth ventricle. Under direct endoscopic visualization, tunneling with an intraventricular catheter allowed restoration of CSF diversion through a ventriculoperitoneal shunt, illustrating a feasible technical solution in this challenging scenario. 00:11 - Case presentation 00:46 - Surgical planning 01:05 - Endoscopic anatomy of the foramen of Monro 01:24 - Endoscopic anatomy of the floor of the third ventricle 01:33 - Opening of the tuber cinereum 01:46 - Endoscopic third ventriculostomy 02:44 - Posterior view of the third ventricle 02:59 - Ventricular puncture with a shunt catheter 03:05 - Direct visualization of the intraventricular catheter 04:26 - Unsuccessful catheter tunneling through the cerebral aqueduct 04:49 - Opening of the cerebral aqueduct 05:38 - Successful aqueductoplasty 05:50 - Clinical outcome 00:00 – 00:11 In this article video [ Video 1 ], we present a case of endoscopic third ventriculostomy and aqueductoplasty for the treatment of an isolated fourth ventricle in a child with hydrocephalus following hemorrhage of prematurity (Papile grade III).[ 1 , 3 , 8 ] 00:11 – 00:24 At 2 months of age, due to extreme prematurity (27 weeks) and low birth weight, an Ommaya device was implanted for repeated ventricular punctures, followed by implantation of a ventriculoperitoneal shunt in the left frontal horn at 4 months of age. 00:24 – 00:35 The patient remained neurologically stable, with adequately controlled hydrocephalus, until 2 years of age, when he began to present progressive symptoms of valvular dysfunction (irritability, vomiting, and changes in respiratory pattern). 00:35 – 00:45 He was readmitted, and a cranial computed tomography scan revealed ventriculomegaly, especially in the fourth ventricle, indicating that it was an isolated ventricle, with signs of brainstem compression. 00:45 – 00:59 The surgical plan consisted of removing the Ommaya device, proceeding with a third ventriculostomy and aqueductoplasty with a peritoneal shunt. A right frontal preexisting trephine was used, located at the level of Kocher’s point, with slight anterior extension to allow for a greater working angle.[ 2 , 4 , 10 ] 00:59 – 01:14 Immediately after puncture of the right lateral ventricle, the anatomical structures and landmarks that define the foramen of Monro are visualized – the body and column of the fornix, the thalamostriate and anterior septal veins, and the choroid plexus of the right lateral ventricle. 01:14 – 01:32 By advancing through the foramen of Monro, one enters the third ventricle. A more anterior angulation allows visualization of the structures of the third ventricle floor: mammillary bodies, tuber cinereum, infundibular recess, optic chiasm, and optic recess. The basilar artery can be observed through the tuber cinereum. 01:32 – 01:38 With the aid of a monopolar cautery, coagulation and a small incision are made in the tuber cinereum. 01:45 – 02:00 To properly perform the ventriculostomy, we enlarged the opening with a 3F Fogarty catheter. At this stage, care and attention must be taken not to pull or manipulate the Fogarty catheter with the balloon inflated, due to the risk of laceration of the structures. 02:13 – 02:20 After the ventriculostomy was performed, a shunt from the third ventricle to the cisterns anterior to the brainstem was observed. 02:43 – 02:50 Next, using an anteroposterior angle, we successfully visualized the cerebral aqueduct without damaging the fornix.[ 6 ] 02:58 – 03:07 With access to the cerebral aqueduct, we proceeded with the ventricular puncture in the right frontal horn, using the proximal catheter of the shunt to be performed. 03:07 – 03:15 Under direct endoscopic visualization of the intraventricular catheter tip, we were able to guide it to the third ventricle using a punch-type clamp. 03:40 – 04:07 Retracting the catheter, suspended by the clamp, is necessary for greater endoscope mobility without damaging adjacent structures. In this way, by angling it anteroposteriorly, we gain access to the cerebral aqueduct – previously visualized – allowing us to direct the catheter to the region closest to our target. At this stage, we also use the endoscope itself to push the catheter back and bring it into close contact with the aqueduct opening. 04:26 – 04:35 Next, under traction of the ventricular catheter, we attempted to tunnel it through the cerebral aqueduct, but without success due to stenosis of this passage.[ 5 , 7 ] 04:52 – 05:02 Therefore, to dilate and open it, we tunneled the 3F Fogarty catheter, followed by inflation of the balloon under low pressure, due to the risk of brainstem compression.[ 5 , 7 ] 05:19 – 05:28 With the aqueduct slightly dilated, now with the aid of the punch forceps, we pulled and tunneled the intraventricular catheter through the cerebral aqueduct, performing an aqueductoplasty.[ 6 , 8 ] 05:32 – 05:45 Care is taken to ensure that the catheter fenestrations are patent in both the third and fourth ventricles. Next, we connect the ventricular catheter to the ventriculoperitoneal shunt valve system, which has been previously tunneled to the peritoneum. 05:49 – 06:03 A follow-up computed tomography scan showed adequate shunting of the fourth and third ventricles to the peritoneum, with significant decompression of the brainstem. The patient remained under observation in the ICU for 2 days and was discharged home on the 5th postoperative day. 06:03 – 06:13 This case illustrates an effective and safe alternative to aqueductoplasty for the treatment of hydrocephalus with an isolated fourth ventricle.[ 1 , 8 , 10 ] Institutional Review Board approval is not required. The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given consent for their images and other clinical information to be reported in the journal. The patient understands that the patient’s names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. There are no conflicts of interest. The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI. https://doi.org/10.25259/SNI_3_2026 The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Journal or its management. The information contained in this article should not be considered to be medical advice; patients should consult their own physicians for advice as to their specific medical needs.","thumbnailUrl":"https://sni-digital-videos.s3.amazonaws.com/placeholders/specialty/neuroendoscopy.png","publishDate":"2026-05-01T00:00:00.000Z","doi":"10.25259/SNI_3_2026","categories":["Neuroendoscopy","Video Abstract"],"fullTextUrl":"https://surgicalneurologyint.com/api/articles/0109a035-668a-41e3-8a4a-6ddc66195a3d/pdf"}