Introduction:
Hydrocephalus is a pathological condition where cerebrospinal fluid (CSF) accumulates due to increased production, obstructed flow or reduced absorption, causing ventricles to expand and potentially damaging brain tissue. It can be congenital or acquired and is classified into non-communicating (CSF cannot flow through ventricles (e.g., cerebral aqueduct stenosis) and communicating hydrocephalus (flow of CSF is obstructed outside the ventricles, such as in the sub-arachnoid space). Common causes include genetic defects, infections, trauma, and central nervous system (CNS) tumours. Symptoms include headache, nausea, blurred vision, and cognitive decline, and diagnosis is confirmed by imaging methods such as CT or MRI [4].
In children, hydrocephalus is a major cause of morbidity, with rates of (30-423) cases per 100,000 children, higher in developing countries. Primary aqueduct stenosis, Dandy-Walker malformation, and Chiari malformations are some disorders that might result in congenital hydrocephalus, while acquired hydrocephalus has been reported in the literature to arise from intracranial infections, haemorrhages, or tumours [1, 2]. CSF is synthesised by the choroid plexus, and it circulates through the ventricles, with obstacles resulting in elevated ICP or hydrocephalus. The Monro-Kellie principle prposes surged ICP is secondary to elevated levels of CSF, resulting in damage to brain tissue through trans-ependymal flow and atrophy [3].Ventriculoperitoneal (VP) shunts are nowadays in practice to cure hydrocephalus by shifting extra CSF to the peritoneum, though they can also drain to the pleura or heart. Congenital hydrocephalus, tumours, infections, myelomeningocele, craniosynostosis, and normal-pressure hydrocephalus are reported to be the main indications for VP shunts [5]. However, VP shunts carry a complication rate of 2-20%, with potential issues like infection, haemorrhage, shunt malposition and obstruction [5].
A rare consequence of VP shunts is TFV, where CSF builds up in the ventricle due to blockage of the aqueduct and exit foramina. One rare, late result of shunting the lateral ventricles for hydrocephalus, is the ’encysted’ or solitary enlargement of the fourth ventricle [12]. Patients who have had several shunt procedures are most likely to experience this disease, which can cause cerebellar and brainstem compression, worsen hydrocephalus, and perhaps lead to neurological impairments. Patients with a history of multiple shunt procedures should be closely monitored for TFV [6, 9].
Surgery is typically advised when patients show symptoms of brainstem compression or a trapped fourth ventricle gets markedly worse [13].
Patients with VP shunts require regular monitoring for complications like headaches, vomiting, or neurological changes, which may indicate shunt failure. Early identification through imaging and clinical assessment is essential for preventing further damage. An interprofessional team—including paediatricians, surgeons, and radiologists—plays a critical role in managing shunt-related complications [7, 8, 10]. Endoscopic approaches for hydrocephalus include supratentorial techniques using ventriculomegaly for safe navigation. Aqueductoplasty is followed by stent insertion to connect the third and fourth ventricles [11]. Given its minimally invasive nature, higher efficacy, durability, and comparable safety to shunt installation, endoscopy ought to be the first-line treatment for TFV [14].