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].