PMC4627988_01
a Computed tomography images obtained to evaluate a head injury 2 years prior to admission, which did not indicate any apparent intracranial abnormality. b-d Contrast-enhanced T1-weighted image (WI) on admission indicating the dilatation of bilateral, third and fourth ventricles. e-f Contrast-enhanced T1-WI (E axial, F sagittal) indicating no obstructive lesions such as a brain tumor or cerebellar anomaly
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Fig1
Computed tomography (CT) images, which had incidentally been taken 2 years before at a local neurosurgical clinic for the assessment of a minor head injury, were available and showed no significant abnormality (Fig. 1a). Magnetic resonance imaging (MRI) showed enlargement of all ventricular systems associated with the dilatation of the foramina of Magendie and Luschka, with no obstructive organic lesions (such as brain tumors) on contrast enhanced MRI (Fig. 1b-f).
Computed tomography images after the injection of contrast medium through the ventricular catheter (a 1 h after injection, b 3 h after injection). Both images show delayed diffusion of contrast medium to the pre-pontine cistern
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Fig2
We thus conducted CT ventriculo-cisternography on the fifth day post-surgery by injecting contrast medium (Isovist ) via a ventricular catheter (Fig. 2).
Intraoperative view of the foramina of Magendie (a) and Luschka (b) via neuroendoscopy. Membranous lesions (arrow) covering both foramina suggested the blockage of CSF flow in the fourth ventricle outlets
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Fig3
Tokyo, Japan). The endoscope was inserted into the fourth ventricle through the dilated cerebral aqueduct and encountered the suspected cause of obstructive hydrocephalus:a thickened, arachnoid, membranous structure that enveloped the foramina of Magendie and Luschka (Fig. 3).
a Magnetic resonance imaging (MRI; fast imaging employing steady state acquisition, FIESTA), performed 1 month after the surgery, shows significant shrinkage of each ventricle. b MRI (T1-weighted image), performed 1 year after the initial endoscopic third ventriculostomy (ETV), indicating recurrent hydrocephalus. c MRI (FIESTA), performed 6 months after the second ETV, indicating improvement of the hydrocephalus
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Fig4
MR images obtained 1 month post-surgery revealed significant resolution of the hydrocephalus (Fig. 4a). However, after 1 year, the patient again presented with vomiting, and it was noted that the hydrocephalus had recurred (Fig. 4b). Postoperative MRI confirmed that the hydrocephalus was resolved (Fig. 4c).