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TO THE EDITOR: We read with interest the article by Guida et al.1 related to stent placement for aqueductal stenosis (Guida L, Beccaria K, Benichi S, et al. Endoscopic aqueductal stenting in the management of pediatric hydrocephalus. J Neurosurg Pediatr. 2020;26:346–352). It is interesting that, in 71 years, this procedure remains relatively rare and its overall efficacy remains difficult to discern on a long-term basis. We reviewed the work of Erik-Olof Backlund at the Karolinska Hospital (Stockholm) in 19812 and noted that the patient selection criteria were critical for stent placement, whether done from a posterior fossa, third ventricular, endoscopic, or other minimally invasive approach. Backlund’s unique work was based on the 1949 publication of his mentor, Lars Leksell,3 who in the early era of hydrocephalus management proposed a stent placement inserted through the fourth ventricle (Fig. 1). This was a tightly wound metal spiral threaded onto the end of a catheter. The catheter was inserted into the aqueduct by means of a bent silver tube used as a guide. The tube was removed once the catheter had been withdrawn, leaving the flexible spiral in place in the aqueduct. In that era, 13 patients underwent reconstruction of the aqueduct.
It is interesting that innovation in neurosurgery is often forgotten, only to be rediscovered and republished in successive eras. It is important to research the literature more thoroughly in order to give credit to the true pioneers, as well as to recognize the problems that such innovation may repeatedly present. In reviewing the present article, it seems that there are select cases in which this approach may have benefit, but there seems to be little additional insight gained relative to the best method to select patients and to manage the problems presented by this cause of hydrocephalus.
Dr. Lunsford has direct stock ownership in Elekta AB and is a consultant for Insightec, DSMB.