Comparing fourth ventricle shunt survival after placement via stereotactic transtentorial and suboccipital approaches

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Fourth ventricle hydrocephalus, or a “trapped” fourth ventricle, presents a treatment challenge in pediatric neurosurgery. Fourth ventricle hydrocephalus develops most commonly as a result of congenital anomalies, intraventricular hemorrhage, or infection. Standard management of loculated fourth ventricle hydrocephalus consists of fourth ventricle shunt placement via a suboccipital approach. An alternative approach is stereotactic-guided transtentorial fourth ventricle shunt placement via the nondominant superior parietal lobule. In this report, the authors compare shunt survival after placement via the suboccipital and stereotactic parietal transtentorial (SPT) approaches.


A retrospective chart review was performed to find all patients with a fourth ventricle shunt placed between January 1, 1998, and December 31, 2011. Time to shunt failure was quantified as the number of days from shunt placement to first shunt revision or removal. Other variables studied included patient age and sex, origin of hydrocephalus, comorbidities, number of existing supratentorial catheters at the time of fourth ventricle shunt placement (as a proxy for complexity), operating surgeon, and number of previous shunt revisions. The crossover rate from one technique to the other after shunt failure from the original approach was also investigated.


In the 29 fourth ventricle shunts placed during the study period, 18 were placed via the suboccipital approach (62.1%) and 11 via the SPT approach (37.9%). There was a statistically significant difference in time to shunt failure, with the SPT shunts lasting an average of 901 days and suboccipital shunts lasting 122 days (p = 0.04). In addition, there was a significant difference in the rate of crossover from one technique to another, with 1 SPT shunt changed to a suboccipital shunt (5.6%) and 5 suboccipital shunts changed to SPT shunts (45.5%).


Fourth ventricle shunt placement using an SPT approach resulted in significantly longer shunt survival times and lower rates of revision than the traditional suboccipital approach, despite a higher rate of crossover from previously failed shunting procedures. Stereotactic parietal transtentorial shunt placement may be considered for patients with loculated fourth ventricle hydrocephalus, especially when shunt placement via the standard suboccipital approach fails. It is therefore reasonable to offer this procedure either as a first option for the treatment of fourth ventricle hydrocephalus or when the need for fourth ventricle shunt revision arises.

Abbreviation used in this paper:SPT = stereotactic parietal transtentorial.

Article Information

Address correspondence to: Douglas L. Brockmeyer, M.D., Department of Neurosurgery, University of Utah, 175 North Medical Drive East, Salt Lake City, Utah 84132. email:

Please include this information when citing this paper: published online April 19, 2013; DOI: 10.3171/2013.3.PEDS12442.

© AANS, except where prohibited by US copyright law.



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    Kaplan-Meier graph showing time to fourth ventricle shunt failure based on surgical approach.

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    Kaplan-Meier graph showing fourth ventricle shunt failure based on whether the placement was the original approach or a replacement.

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    Kaplan-Meier graph showing stratified analysis of shunt survival based on whether the placement was the original or a replacement and by surgical approach.

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    Axial noncontrast CT scans demonstrating complications resulting from fourth ventricle shunt placement with the catheter migrating out of the ventricle (left) or into the brainstem (right) with a decrease in fourth ventricle size.



Aoki N: Sequestered fourth ventricle. J Neurosurg 81:9629631994


Cinalli GSpennato PSavarese LRuggiero CAliberti FCuomo L: Endoscopic aqueductoplasty and placement of a stent in the cerebral aqueduct in the management of isolated fourth ventricle in children. J Neurosurg 104:1 Suppl21272006


Colpan MESavas AEgemen NKanpolat Y: Stereotactically-guided fourth ventriculo-peritoneal shunting for the isolated fourth ventricle. Minim Invasive Neurosurg 46:57602003


Drake JMKestle JRMilner RCinalli GBoop FPiatt J Jr: Randomized trial of cerebrospinal fluid shunt valve design in pediatric hydrocephalus. Neurosurgery 43:2943051998


Erşahin Y: Endoscopic aqueductoplasty. Childs Nerv Syst 23:1431502007


Erşahin Y: Endoscopic aqueductoplasty with and without stent. Minim Invasive Neurosurg 49:1241252006


Fritsch MJKienke SManwaring KHMehdorn HM: Endoscopic aqueductoplasty and interventriculostomy for the treatment of isolated fourth ventricle in children. Neurosurgery 55:3723792004


Fritsch MJKienke SMehdorn HM: Endoscopic aqueductoplasty: stent or not to stent?. Childs Nerv Syst 20:1371422004


Gawish IReisch RPerneczky A: Endoscopic aqueductoplasty through a tailored craniocervical approach. J Neurosurg 103:7787822005


Hamada HHayashi NKurimoto MEndo S: Endoscopic aqueductal stenting via the fourth ventricle under navigating system guidance: technical note. Neurosurgery 56:1 SupplE2062005


Lee MLeahu DWeiner HLAbbott RWisoff JHEpstein FJ: Complications of fourth-ventricular shunts. Pediatr Neurosurg 22:3093141995


Mohanty A: Endoscopic options in the management of isolated fourth ventricles. Case report. J Neurosurg 103:1 Suppl73782005


Montes JLClarke DBFarmer JP: Stereotactic transtentorial hiatus ventriculoperitoneal shunting for the sequestered fourth ventricle. Technical note. J Neurosurg 80:7597611994


Sagan LMKojder IPoncyljusz W: Endoscopic aqueductal stent placement for the treatment of a trapped fourth ventricle. J Neurosurg 105:4 Suppl2752802006


Sandberg DISouweidane MM: Endoscopic-guided proximal catheter placement in treatment of posterior fossa cysts. Pediatr Neurosurg 30:1801851999


Sansone JMIskandar BJ: Endoscopic cerebral aqueductoplasty: a trans-fourth ventricle approach. J Neurosurg 103:5 Suppl3883922005


Schroeder HWOertel JGaab MR: Endoscopic treatment of cerebrospinal fluid pathway obstructions. Neurosurgery 60:2 Suppl 1ONS44ONS522007


Scotti GMusgrave MAFitz CRHarwood-Nash DC: The isolated fourth ventricle in children: CT and clinical review of 16 cases. AJR Am J Roentgenol 135:123312381980


Teo CBurson TMisra S: Endoscopic treatment of the trapped fourth ventricle. Neurosurgery 44:125712621999


Upchurch KRaifu MBergsneider M: Endoscope-assisted placement of a multiperforated shunt catheter into the fourth ventricle via a frontal transventricular approach. Neurosurg Focus 22:4E82007




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