Child's Nervous System

https://doi.org/10.1007/s00381-023-05881-9

TECHNICAL NOTE

Endoscopic fenestration of the superior medullary velum

for the treatment of a trapped fourth ventricle—technical note
Pasquale Gallo1 · Desiderio Rodrigues1 · Fardad T. Afshari1

Received: 1 July 2022 / Accepted: 11 February 2023

© The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature 2023

Abstract
A trapped fourth ventricle is a clinic-radiological entity characterised by progressive neurological symptoms due to an
enlargement of the fourth ventricle secondary to obstruction to its outflow. This condition is most commonly observed in
ex-preterm patients shunted for a post-haemorrhagic or post-infective hydrocephalus. Until the introduction of endoscopic
aqueductoplasty and stent placement, through a supratentorial or an infratentorial approach, treatment of trapped fourth
ventricle entailed high rates of complications, repeated procedures and consequent morbidity. We describe the first case
of successful treatment of trapped fourth ventricle by fenestration of superior medullary velum through an infratentorial
approach in a 20-month-old child with a functional supratentorial ventriculoperitoneal shunt and an aqueductal anatomy
not favourable for stenting. To the best of our knowledge, this is the first reported case of utilisation of this technique in a
patient with a trapped fourth ventricle, and we wish to highlight this new alternative approach in cases where conventional
aqueductoplasty and stenting may not be feasible.

Keywords  Aqueductoplasty · Endoscopy · Hydrocephalus · Trapped fourth ventricle

Introduction techniques employed before the advent of neuro-endoscopy

Trapped fourth ventricle (TFV) is a challenging surgical entity
most commonly observed in paediatric patients shunted in
infancy for the treatment of post-infective or post-haemorrhagic
hydrocephalus [1, 2]. Endoscopic techniques, including aque-
ductoplasty and stenting, either through a supratentorial or a
suboccipital route, have revolutionised the treatment of this
challenging entity providing a safe, effective and long-term
solution [3] compared to the previous surgical approaches
associated with high morbidity, risk of recurrence and repeated
procedures [4]. Performing an isolated aqueductaplasty is asso-
ciated with the recurrence of stenosis, and therefore stents fol-
lowing aqueductoplasty are commonly utilised [3, 5, 6].
Nonetheless, in cases where the anatomical shape of the
aqueduct precludes performing safe aqueductoplasty and
stenting, the only option remains to resort to the classic
* Pasquale Gallo
pasquale.gallo@nhs.net
1
Department of Neurosurgery, Birmingham Women’s
and Children’s NHS Foundation Trust, Steelhouse Lane,
Birmingham B4 6NH, England
such as shunting of the fourth ventricle or microsurgical pos-
terior fossa arachnoidolysis/fenestration of the fourth ven-
tricle outlets. These procedures are known to be associated
with higher rates of complications and repeated procedures
[4].
We describe here a case of a 20-month-old child presenting
with symptomatic progressive trapped fourth ventricle on the
background of a previous ventriculoperitoneal shunt with slit
ventricles and an unfavourable anatomy of the aqueduct of
Sylvius, which was managed successfully with the endoscopic
fenestration of the superior medullary velum into the quadri-
geminal cistern through a posterior fossa approach.
Case history
We report on a case of a premature baby male born at 27 weeks
and 5 days. The weight at birth was 1034 g, and ultrasound
demonstrated evidence of grade 3 intraventricular haemor-
rhage. He was initially monitored in the neonatal intensive care
unit in the local hospital. Repeat cranial ultrasound over time
demonstrated increasing ventricular indices with clinical evi-
dence of bulging anterior fontanelle, prominent scalp veins and

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intermittent episodes of desaturation. In light of deterioration,
he was transferred to our neurosurgical unit for further man-
agement and treatment. He underwent a right-sided ventricu-
loperitoneal shunt insertion (Delta 1.5 valve, Medtronic) at the
corrected age of 34 weeks and 2 days. He was subsequently
followed up in the outpatient clinic every 3 months.
The patient was represented acutely at 20 months of age
with a week’s history of progressive ataxia, regression in
his motor milestones, vomiting, drowsiness and a left VI
nerve palsy. An urgent MRI brain demonstrated evidence of
supratentorial slit ventricles and a trapped 4th ventricle with
compression of the brainstem and the cerebellar structures
(Fig. 1A–D). The aqueductal anatomy was found to be non-
favourable for an aqueductoplasty owing to the length of
obstruction and the curved shape of the aqueduct; the scan
showed instead a remarkable bowing conformation of the
superior medullary velum (SMV).
Possible treatment options included a microscopic approach
with an opening of the IV ventricular outlets or direct shunting
of the fourth ventricle versus an attempt of endoscopic fen-
estration of the superior medullary velum. On the balance of
risks versus benefits and following discussion in a multidis-
ciplinary meeting, the decision was made for an endoscopic
approach and fenestration of the superior medullary velum.
Surgical technique
The patient was placed in a prone position with the head in
Concorde position in a 3-point fixation using a paediatric
Mayfield clamp. Following minimal hair shave, the skin was
prep and draped. Following a straight (3 cm) skin incision over
the cranio-cervical junction, muscles were dissected laterally.
Minimal bony decompression of Foramen magnum along with
partial C1 laminectomy was performed using Kerrison ron-
geurs to improve the working angle. Under endoscope-assisted
visualisation, a 1 cm dura incision was made. Arachnoid adhe-
sions at the level of the foramen of Magendie were fenestrated
and a 30 degrees rigid endoscope (B-braun Miniop) was

Fig. 1  Post-shunting coronal
MRI brain T2 sequence dem-
onstrating large fourth ventricle
with ballooned SMV (A). Post-
shunting MRI brain axial view,
T2 sequence demonstrating slit
ventricles (B). Sagittal (C) and
axial (D) MRI T2 brain demon-
strating trapped fourth ventricle
at age of 20 months following
the symptomatic presentation

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Child's Nervous System

Fig. 2  Endoscopic view of superior medullary velum pre-fenestration grasper forceps (B). Dilatation of stoma using neuro balloon (C). Created
(A). Asterix points to the location of the abnormal aqueduct. Endoscopic stoma following deflation of balloon (D). Magnified view of the stoma at
view following perforation of the superior medullary velum using blunt the end of the procedure (E)

advanced into the fourth ventricle. A safe area in the superior
medullary velum was carefully identified (Fig. 2A), a stoma
was created by perforating the velum and then neuro-balloon
was utilised to enlarge the fenestration (Fig. 2B–C). Once sat-
isfactory communication with the quadrigeminal cistern was
established (Fig. 2D–E), the dura was closed in a watertight
fashion with 5/0 Prolene.
Closure of muscle and fascia was done in a layered fash-
ion (muscle closure with 2/0 Vicryl; fascia and subcuticular
layers with 3/0 Vicryl). The skin was closed with running
4/0 Monocryl. Postoperatively, the patient made an une-
ventful recovery with rapid resolution of the preoperative
symptoms. Post-operative MRI at 4 months (Fig. 3A–B) and
12 months (Fig. 3C–D) demonstrated decompression of the

Fig. 3  Coronal (A) and axial

(B) MRI T2 brain demonstrat-
ing reduction in the size of the
trapped fourth ventricle and
deflated SMV at 4 months follow-
ing fenestration. Sagittal (C) and
axial (D) MRI brain T2 sequence
demonstrating a further reduction
in the size and decompression
of trapped fourth ventricle at
12 months post fenestration

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fourth ventricle and stoma patency. The last follow-up clinic
assessment at 24 months post-surgery has confirmed full
resolution of preoperative signs and symptoms.
Discussion
Management of TFV is challenging and dictated by the size
of the supratentorial ventricles, the anatomy of the aque-
duct and whether there is already an associated functional
supratentorial shunt in place [1, 3, 7].
In cases with viable lateral ventricles, endoscopic aqueduc-
toplasty can be performed from a supratentorial approach with
additional stent placement fixed to an Ommaya/Rickham res-
ervoir. Alternatively, in cases with slit ventricles and short seg-
ment obstruction of the aqueduct, aqueductoplasty and stenting
through an infratentorial approach are the favoured option [8].
In cases where aqueductal anatomy is non-favourable for
aqueductoplasty or there is long segment obstruction, fourth
ventricular shunting or open posterior fossa approaches for
microscopic fenestration of fourth ventricular outlets can
be attempted [4, 7, 9, 10]. Nonetheless, these techniques are
associated with a higher risk of failure, the need for other
procedures and consequent morbidity [4, 7].
Endoscopic approach and fenestration of the superior med-
ullar velum through a right supratentorial burr hole has been
previously described in 10 adult cadavers [11]; however, it has
not been reported in adults nor in paediatric patients. Our case
represents the first such case in a patient with TFV.
This technique has the added benefit of being less invasive
compared to open microscopic approaches or shunting of the
fourth ventricle. The main limitations include a steep learning
curve and familiarity for IV ventricular endoscopic approach.
Long-term follow-ups and a larger cohort of patients are required
to further validate long-term patency of the stoma and outcomes.
Conclusions
Endoscopic fenestration of the superior medullary represents a
viable and effective surgical option in cases where aqueductal
anatomy prevents the use of other endoscopic approaches.
Abbreviations  CSF: Cerebrospinal fluid; MRI: Magnetic resonance
imaging; TFV: Trapped fourth ventricle
Author contribution  PG has conceived and performed the procedure;
PG and FA have prepared the article with further input from DR.
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Child's Nervous System
Availability of data and Material  Not applicable.
Declarations 
Ethics approval and consent to participate  Appropriate consent has
been obtained.
Consent to participate  Appropriate consent has been obtained.
Conflict of interest  The authors declare no competing interests.
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