Transventricular, transaqueductal scope-in-scope endoscopic excision of fourth ventricular neurocysticercosis: a series of 13 cases and a review

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Neurocysticercosis (NCC) is the most common parasitic infestation of the central nervous system worldwide. In patients presenting with acute hydrocephalus due to intraventricular NCC, surgery is the only option. Still, there is no consensus regarding the optimal surgical strategy, although neuroendoscopic excision is a promising method. However, the literature regarding the use of this modality in fourth ventricular NCC is scarce. The authors describe a series of patients with fourth ventricular NCC treated endoscopically.


The clinical records of 13 patients with fourth ventricular NCC who had presented with hydrocephalus were retrospectively analyzed. A fourth ventricular cyst was completely excised in all patients by using a transventricular, transaqueductal “scope-in-scope” endoscopic technique. Twelve endoscopic third ventriculostomies and 1 septostomy had been performed.


Shunt placement was avoided in all patients. There were minimal peri- and postoperative complications. The mean duration of follow-up was 22.3 months (range 3–41 months). All patients had an improved clinical outcome. Follow-up neuroimaging revealed no residual lesion and a decreased ventricle size in all patients.


The present series of patients with fourth ventricular NCC is the largest in the existing English-language medical literature. Endoscopic fourth ventricular cysticercal cyst excision along with internal cerebrospinal fluid diversion via endoscopic third ventriculostomy is an effective alternative to open microneurosurgical procedures and avoids shunt placement and its related complications.

Abbreviations used in this paper: CSF = cerebrospinal fluid; ETV = endoscopic third ventriculostomy; MR = magnetic resonance; NCC = neurocysticercosis.

Article Information

Address correspondence to: Ashish Suri, M.Ch., Department of Neurosurgery, Neurosciences Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India. email:

© AANS, except where prohibited by US copyright law.



  • View in gallery

    Intraoperative photographs showing the foramen of Monro with the choroid plexus (A), a flexible scope within a rigid neuroendoscope (B), and biopsy forceps grasping the fourth ventricle cyst (C). Postoperative photograph (D) demonstrating the excised cyst in toto.

  • View in gallery

    Preoperative sagittal (A) and coronal (B) Gd-enhanced MR images showing a cysticercal cyst in the fourth ventricle causing obstructive hydrocephalus. Continuous arrow (A) shows the pathway of the rigid scope in reaching the sylvian aqueduct; broken arrow depicts the transaqueductal route followed by the flexible scope. Postoperative sagittal (C) and coronal (D) MR images demonstrating resolution of hydrocephalus after cyst removal.



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