Fourth ventricular meningioma

Fourth ventricular meningioma

Epidemiology

Of the intraventricular meningiomas, only 6% are primarily in the fourth ventricle1).

The most common age of onset was from the third decade to sixth decade of life. The female/male ratio was about 1.16:1. The most frequent subtype of meningioma was fibrous meningioma 2).

Diagnosis

The FVMs had specific imaging features, such as calcification (20%), peritumoral edema (30.3%), heterogeneous enhancement (22.5%), cystic formation (4.3%) and hydrocephalus (52.8%) 3).


The computed tomography (CT; n=5), magnetic resonance imaging (MRI; n=9) features and clinical presentations of 10 patients with pathologically documented fourth-ventricular meningiomas were retrospectively analysed.

All tumours appeared as well-demarcated masses in the fourth ventricle at CT and MRI. The tumour shape was round in eight cases (80%) and irregular in two cases (20%). The CT images of five cases showed predominantly isoattenuation in three cases and high attenuation in two cases, with a mean attenuation value of 52 HU. In addition, calcifications were seen in three cases. At MRI, nine masses were isointense (n=6) or hypointense (n=3) to grey matter on T1-weighted images and mildly hyperintense (n=4), isointense (n=3), hypointense (n=1), and of mixed signal intensity (n=1) on T2-weighted and fluid-attenuated inversion recovery (FLAIR) images. Signal voids were visible in two cases. Enhancement after injection of contrast material was marked homogeneous (n=5) or heterogeneous (n=5) on CT or T1-weighted images. Three tumours had mild peritumoural oedema. Three tumours were associated with obstructive hydrocephalus. The pathological subtype of the 10 meningiomas was fibromatous (n=5), atypical (n=2), and one each of transitional, psammomatous, and clear-cell type.

The relatively typical radiological appearance, combined the age and sex of patients, can suggest the diagnosis of fourth-ventricular meningioma 4).

Treatment

The recommended treatment is surgical treatment via the telovelar approach with suboccipital craniotomy/craniectomyAdjuvant therapy is needed in some of the high grade meningiomas and in cases underwent partial resection 5).

Outcome

The prognosis is relatively good, with less postoperative complications and higher rate of total resection 6).

In the series of Luo et al., the proportion of total tumor resection was about 94.9%, with 15.3% of postoperative complications. During follow-up, the recurrent rate of FVMs was about 6.8%. There was no significant difference in the analysis of correlation between hydrocephalus and the maximum diameter of tumors, correlation between hydrocephalus and the volume of tumor, correlation between peritumoral edema and the volume of tumor, as well as correlation between heterogeneous enhancement and the grade of meningiomas 7).

Case series

Luo et al., published a series of eleven Fourth ventricular meningioma at one single institution. A comprehensive literature analysis was conducted.

The information of eleven cases were extracted from the patient data. And English cases were obtained from the literature. Including the 11 cases, 71 cases were analyzed in this study. 8).


Sadashiva et al., published two cases harboring a primary fourth ventricular meningioma Grade II, which was surgically excised successfully. Total excision was achieved in both cases and as the tumor was firm to soft and vermian splitting was not required. Understanding the clinical features and a careful preoperative radiological examination is required to differentiate this tumor from more commonly occurring lesions at this location 9).


Zhang et al., presented the neuroradiological and clinical findings of fourth-ventricular meningiomas to increase awareness of this entity.

The computed tomography (CT; n=5), magnetic resonance imaging (MRI; n=9) features and clinical presentations of 10 patients with pathologically documented fourth-ventricular meningiomas were retrospectively analysed.

All tumours appeared as well-demarcated masses in the fourth ventricle at CT and MRI. The tumour shape was round in eight cases (80%) and irregular in two cases (20%). The CT images of five cases showed predominantly isoattenuation in three cases and high attenuation in two cases, with a mean attenuation value of 52 HU. In addition, calcifications were seen in three cases. At MRI, nine masses were isointense (n=6) or hypointense (n=3) to grey matter on T1-weighted images and mildly hyperintense (n=4), isointense (n=3), hypointense (n=1), and of mixed signal intensity (n=1) on T2-weighted and fluid-attenuated inversion recovery (FLAIR) images. Signal voids were visible in two cases. Enhancement after injection of contrast material was marked homogeneous (n=5) or heterogeneous (n=5) on CT or T1-weighted images. Three tumours had mild peritumoural oedema. Three tumours were associated with obstructive hydrocephalus. The pathological subtype of the 10 meningiomas was fibromatous (n=5), atypical (n=2), and one each of transitional, psammomatous, and clear-cell type.

Although fourth-ventricular meningioma is quite rare, it should be considered in differential diagnosis of neoplasms within the fourth ventricle. The relatively typical radiological appearance, combined the age and sex of patients, can suggest the diagnosis of fourth-ventricular meningioma 10).


A adult patient with a rare chordoid meningioma located within the fourth ventricle. This lesion was treated with gross total resection. Chordoid meningioma must be considered within the differential diagnosis of intraventricular tumors. This histological subtype of meningioma warrants close follow-up. The patient must also be evaluated for systemic manifestations of Castleman’s disease 11).


Case reports

A 14-year-old man with seizure and headache. The magnetic resonance imaging reported bilateral acoustic neuroma and fourth ventricle meningioma. The patient was scheduled for total tumor resection and the histopathology revealed psammomatous type of meningioma. The patient discharged with good general status 12).


A 60-year-old man was admitted with slowly progressive dizziness. Cranial nerve evaluation found no abnormalities. Magnetic resonance imaging revealed a well-circumscribed mass with homogeneous enhancement located in the fourth ventricle. The patient underwent surgery for the removal of the tumor via the bilateral suboccipital approach. Subtotal removal of the tumor was achieved in a piecemeal fashion. Histological diagnosis was meningothelial meningioma 13).


A 25-year-old man with fourth ventricular meningioma. Qin et al., refer to the usefulness of diffusion-weighted imaging and apparent diffusion coefficient measurements for the differential diagnosis of fourth ventricular tumors 14).


A fourth ventricular clear cell meningioma without dural attachment in a 14-year-old boy with an unusual presentation of failure to thrive 15).


Lyngdoh et al., published in 2007 two cases 16).


Liu et al., published one case in a series of intraventricular meningiomas 17).


A 76 year old male patient presenting with a 2-week history of headache and cognitive disorders with agitation and restlessness particularly exacerbated at night or when lying down. CT scan and MR imaging showed a contrast-enhancing lesion located purely within the whole fourth ventricle, with slight ventricular enlargement. At surgery, we totally removed a well-vascularised, greyish encapsulated mass attached to the choroid plexus. Pathological examination revealed a WHO grade I fibroblastic meningioma 18).


A 72-year-old female presented with an intra-fourth ventricular meningioma manifesting as truncal ataxia. Computed tomography (CT) showed a slightly high-density, well-demarcated, and homogeneously enhanced mass located in the fourth ventricle and extending to the right lateral recess. T2-weighted magnetic resonance (MR) imaging revealed a peritumoral high-intensity band without dural tail sign. Bilateral vertebral angiography revealed faint tumor staining supplied from the choroidal branches of the posterior inferior cerebellar arteries. The mass was totally resected via a suboccipital approach. CT, T2-weighted MR imaging, and vertebral angiography are informative for the preoperative diagnosis of fourth ventricular meningioma 19).


A 72-year-old man operated upon for such a tumor. The pre-operative magnetic resonance images revealed a well circumscribed mass in the fourth ventricle that exhibited a low signal on T1-weighted magnetic resonance images and homogenously enhanced with gadolinium. By light microscopy the tumor was composed of tightly packed spindle cells separated by collagen. Immunohistochemistry showed the tumor cells to be positive for vimentin and epithelial membrane antigen, and negative for glial fibrillary acidic protein. Electron microscopy revealed typical findings of meningioma, including interdigitating cell processes, desmosomes, and intermediate filaments. Although rare, fibroblastic meningioma must be included in the differential diagnosis of a fourth ventricular spindle cell tumor in elderly patients 20).


In 1992 a rare case of fourth ventricle meningioma with a combined intraventricular-intracerebellar localization, successfully removed by surgical treatment, is reported 21).


Perry et al., reported two cases, one with typical CT, angiographic, and magnetic resonance (MR) appearances and one with atypical features of central cyst formation on CT and MR. The utility of MR in demonstrating intraventricular location in three imaging planes is illustrated. Given the rarity of these tumors, atypical features may preclude accurate preoperative diagnosis, even with MR 22)


Rodriguez-Carbajal and Palacios published in 1974 2 cases 23).

References

1)

Alver I, Abuzayed B, Kafadar AM, Muhammedrezai S, Sanus GZ, Akar Z. Primary fourth ventricular meningioma: Case report and review of the literature. Turk Neurosurg. 2011;21:249–53.
2) , 3) , 5) , 6) , 7) , 8)

Luo W, Xu Y, Yang J, Liu Z, Liu H. Fourth ventricular meningiomas. World Neurosurg. 2019 Apr 17. pii: S1878-8750(19)31089-7. doi: 10.1016/j.wneu.2019.04.097. [Epub ahead of print] PubMed PMID: 31004862.
4) , 10)

Zhang BY, Yin B, Li YX, Wu JS, Chen H, Wang XQ, Geng DY. Neuroradiological findings and clinical features of fourth-ventricular meningioma: a study of 10 cases. Clin Radiol. 2012 May;67(5):455-60. doi: 10.1016/j.crad.2011.10.017. Epub 2011 Dec 6. PubMed PMID: 22153230.
9)

Sadashiva N, Rao S, Srinivas D, Shukla D. Primary intra-fourth ventricular meningioma: Report two cases. J Neurosci Rural Pract. 2016 Apr-Jun;7(2):276-8. doi: 10.4103/0976-3147.178665. PubMed PMID: 27114661; PubMed Central PMCID: PMC4821938.
11)

Wind JJ, Jones RV, Roberti F. Fourth ventricular chordoid meningioma. J Clin Neurosci. 2010 Oct;17(10):1301-3. doi: 10.1016/j.jocn.2010.03.013. Epub 2010 Jul 31. PubMed PMID: 20673720.
12)

Salehpour F, Aghazadeh J, Bazzazi AM, Mirzaei F, Eftekhar Saadat AT, Alavi SAN. Meningioma in Fourth Ventricle of Brain: A Case Report and Literature Review. Asian J Neurosurg. 2018 Apr-Jun;13(2):428-430. doi: 10.4103/1793-5482.228551. PubMed PMID: 29682051; PubMed Central PMCID: PMC5898122.
13)

Takeuchi S, Sugawara T, Masaoka H, Takasato Y. Fourth ventricular meningioma: a case report and literature review. Acta Neurol Belg. 2012 Mar;112(1):97-100. doi: 10.1007/s13760-012-0040-2. Epub 2012 Feb 3. Review. PubMed PMID: 22427300.
14)

Qin Y, Kanasaki Y, Takasugi M, Shinohara Y, Kaminou T, Kurosaki M, Ogawa T. Primary fourth ventricular meningioma: a case report of an adult male. Clin Imaging. 2012 Jul-Aug;36(4):379-82. doi: 10.1016/j.clinimag.2011.11.034. Epub 2012 Jun 8. PubMed PMID: 22726979.
15)

Burgan OT, Bahl A, Critcher V, Zaki HS, McMullan PJ, Sinha S. Clear cell meningioma of the fourth ventricle in a child: a case report and literature review. Pediatr Neurosurg. 2010;46(6):462-5. doi: 10.1159/000325072. Epub 2011 May 3. Review. PubMed PMID: 21540624.
16)

Lyngdoh BT, Giri PJ, Behari S, Banerji D, Chhabra DK, Jain VK. Intraventricular meningiomas: a surgical challenge. J Clin Neurosci. 2007 May;14(5):442-8. Epub 2007 Mar 12. PubMed PMID: 17350844.
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Liu M, Wei Y, Liu Y, Zhu S, Li X. Intraventricular meninigiomas: a report of 25 cases. Neurosurg Rev. 2006 Jan;29(1):36-40. Epub 2005 Oct 12. PubMed PMID: 16220350.
18)

Chaskis C, Buisseret T, Michotte A, D’Haens J. Meningioma of the fourth ventricle presenting with intermittent behaviour disorders: a case report and review of the literature. J Clin Neurosci. 2001 May;8 Suppl 1:59-62. Review. PubMed PMID: 11386828.
19)

Akimoto J, Sato Y, Tsutsumi M, Haraoka J. Fourth ventricular meningioma in an adult–case report. Neurol Med Chir (Tokyo). 2001 Aug;41(8):402-5. PubMed PMID: 11561352.
20)

Cummings TJ, Bentley RC, Gray L, Check WE, Lanier TE, McLendon RE. Meningioma of the fourth ventricle. Clin Neuropathol. 1999 Sep-Oct;18(5):265-9. PubMed PMID: 10505436.
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Delfini R, Capone R, Ciappetta P, Domenicucci M. Meningioma of the fourth ventricle: a case report. Neurosurg Rev. 1992;15(2):147-9. PubMed PMID: 1635630.
22)

Perry RD, Parker GD, Hallinan JM. CT and MR imaging of fourth ventricular meningiomas. J Comput Assist Tomogr. 1990 Mar-Apr;14(2):276-80. PubMed PMID: 2312858.
23)

Rodriguez-Carbajal J, Palacios E. Intraventricular meningiomas of the fourth ventricle. Am J Roentgenol Radium Ther Nucl Med. 1974 Jan;120(1):27-31. PubMed PMID: 4543954.

Fourth ventricle outlet obstruction

Fourth ventricle outlet obstruction

The fourth ventricle outlet obstruction (FVOO) is a rare but well-established cause of obstructive tetra-ventricular hydrocephalus, characterizing with dilatation or large cerebrospinal fluid collection of the foramen of Magendie and foramen of Luschka.

Hydrocephalus is classified as noncommunicating and communicating based on whether all ventricular and subarachnoid spaces are communicating. Although the diagnosis between the two different states is crucial, it is difficult in certain conditions. In particular, communicating hydrocephalus and noncommunicating hydrocephalus owing to fourth ventricle outlet obstruction are highly misdiagnosed.

In FVOO, cerebrospinal fluid (CSF) is blocked at the fourth ventricle outlets by a membranous structure in the absence of any additional obstructive organic pathologies. Various terms for referring to FVOO have been used in previous reports, such as fourth ventricle/ventricular outlet obstruction 1) 2) 3) 4), fourth ventricular outflow obstruction 5), membranous obstruction of the fourth ventricle outlet 6) , obstruction of Magendie’s and Luschka’s foramina 7) , obstruction of fourth ventricular exit8) and primary obstruction of the fourth ventricle outlets 9). Far distal obstructive hydrocephalus is a term that includes Dandy Walker or Arnold Chiari malformation, membranous obstruction or fourth ventricle and intercisternal external obstruction of the CSF 10).

Etiology

The etiology and pathogenesis of FVOO are unclear, although some cases present with a history of meningitis or intraventricular hemorrhage.


In children, it is usually the consequence of posterior cerebral fossa malformations; while in adult, the occlusion is rather acquired than congenital, mostly linked to an inflammatory process, intraventricular hemorrhagehead traumabrain tumors or Arnold-Chiari malformation. However, idiopathic FVOO is extremely rare, and only 6 such cases have been reported in the English literature.

Bai et al., described an extraordinarily rare case of idiopathic FVOO in a 15-year-old patient successfully treated with direct microsurgical excision of the obstruction membrane. Furthermore, the clinical characteristics and treatment for this rare disease were investigated and reviewed 11).

Diagnosis

CT ventriculography in infants, and CT cisternography in elder children, may assist to differentiate between FVOO and communicating hydrocephalus. The importance of these tests is for children with MRI suggestive of FVOO related hydrocephalus, but with no clear demonstration of the obstruction site. The implication of this differentiation may be for deciding between treatment of hydrocephalus with a ventriculoperitoneal shunt or with an endoscopic third ventriculostomy 12).

Treatment

Third ventricle-fourth ventriculostomy is by far the most frequently used technique for cannulation of the aqueduct in a trapped fourth ventricle. In reported cases of , they have introduced a silicone tube stent from below after accessing the fourth ventricle through a small suboccipital craniectomy, ascending it on the aqueduct in order to reach the third ventricle. Management of this infrequently isolated fourth ventricle, but communicated with the rest of ventricular system, remains a challenge for neurosurgeons. Lack of knowledge of the pathophysiology makes it difficult to treat a problem that we do not understand 13).


ETV is a viable option for treatment of patients with FVOO. The high failure rate in infants younger than 6 months of age suggests that ventriculoperitoneal shunting is a favorable option in this age group, rather than ETV. Isolated fourth ventricle is uncommon after ETV in hydrocephalus attributable to FVOO 14).


Suehiro et al., reported the use of neuroendoscopic third ventriculostomy to treat successfully both hydrocephalus and syringomyelia associated with fourth ventricle outlet obstruction. A 27-year-old woman presented with dizziness, headache, and nausea. Magnetic resonance (MR) imaging demonstrated dilation of all ventricles, downward displacement of the third ventricular floor, obliteration of the retrocerebellar cerebrospinal fluid (CSF) space, funnellike enlargement of the entrance of the central canal in the fourth ventricle, and syringomyelia involving mainly the cervical spinal cord. Cine-MR imaging indicated patency of the aqueduct and an absent CSF flow signal in the area of the cistema magna, which indicated obstruction of the outlets of the fourth ventricle. Although results of radioisotope cisternography indicated failure of CSF absorption, neuroendoscopic third ventriculostomy completely resolved all symptoms as well as the ventricular and spinal cord abnormalities evident on MR images. Neuroendoscopic third ventriculostomy is an important option for treating hydrocephalus in patients with fourth ventricle outlet obstruction15).

Case series

Three patients who were 21, 53, and 68 years of age presented with either headaches (isolated or associated with raised intracranial pressure) or vertigo, or a combination of gait disorders, sphincter disorders, and disorders of higher functions. In each case, magnetic resonance (MR) imaging demonstrated hydrocephalus involving the four ventricles (mean transverse diameter of third ventricle 14.15 mm; mean sagittal diameter of fourth ventricle 23.13 mm; and mean ventricular volume 123.92 ml) with no signs of a Chiari Type I malformation (normal posterior fossa dimensions, no herniation of cerebellar tonsils). The diagnosis of obstruction was confirmed using ventriculography (in two patients) and/or MR flow images (in two patients). All patients presented with marked dilation of the foramen of Luschka that herniated into the cisterna pontis. All patients were treated using ETV. No complications were observed. All three patients became asymptomatic during the weeks following the surgical procedure and remained stable at a mean follow-up interval of 36 months. Postoperative MR images demonstrated regression of the hydrocephalus (mean transverse diameter of third ventricle 7.01 mm; mean sagittal diameter of fourth ventricle 16.6 mm; and mean ventricular volume 79.95 ml), resolution of dilation of the foramen of Luschka, and good patency of the ventriculostomy (flow sequences). These results confirm the existence of hydrocephalus caused by idiopathic fourth ventricle outflow obstruction without an associated Chiari Type I malformation, and the efficacy of ETV for this rare indication 16).

Case reports

Duran D, Hadzipasic M, Kahle KT. Mystery Case: Acute hydrocephalus caused by radiographically occult fourth ventricular outlet obstruction. Neurology. 2017 Jan 31;88(5):e36-e37. doi: 10.1212/WNL.0000000000003555. PubMed PMID: 28138085 17).


A 66-year-old woman with gait disturbance and incontinence caused by hydrocephalus underwent ventriculoperitoneal shunt surgery. After 9 months, her fourth ventricle became enlarged and could not be controlled by lowering the shunt pressure. Magnetic resonance imaging (MRI) demonstrated obstruction at the foramen of Magendie, foramina of Luschka, and the cerebral aqueduct. Endoscopic surgery for aqueduct plasty with third ventriculostomy was planned. Because the aqueduct was observed to open spontaneously, only the standard third ventriculostomy was performed. When MRI findings were reviewed retrospectively, an unnatural space was observed between the lower cranial nerves and cerebellar hemisphere that grew along with the fourth ventricular enlargement. This space was determined by MRI cisternography to be the cystic membrane ballooning out from the foramen of Luschka. The primary hydrocephalus likely resulted from fourth ventricle outlet obstruction.

Enlargement of the whole ventricular system with an expanded space between the lower cranial nerves and cerebellar hemisphere can be caused by fourth ventricle outlet obstruction. In such cases, preoperative evaluation of anatomic architecture and cerebrospinal fluid obstruction using MRI cisternography is essential and leads to a successful endoscopic strategy 18).


A 3-year old boy without any remarkable medical history presented with a headache and vomiting. Computed tomography (CT) images, which had incidentally been taken 2 years previously due to a minor head injury, showed no abnormality. Magnetic resonance imaging on admission showed tetra-ventricular hydrocephalus associated with the dilatation of the fourth ventricle outlets, without any obstructive lesions. However, CT ventriculography, involving contrast medium injection through a ventricular catheter, suggested mechanical obstruction of the cerebrospinal fluid (CSF) at the fourth ventricle outlets. Thus, the patient was diagnosed with FVOO and ETV was performed; the hydrocephalus was subsequently resolved. Although hydrocephalus recurred 1 year postoperatively, re-ETV for the highly stenosed fenestration successfully resolved this condition.

ETV should be considered for FVOO treatment, particularly in idiopathic cases without CSF malabsorption 19).


A 15-year-old girl with amenorrhea and a several-week history of headache. After the diagnosis of membranous obstruction of the foramen of Magendie suggested by MRI, suboccipital craniotomy for removal of the membrane was carried out. The patient made an excellent postoperative recovery, and postoperative phase-contrast MRI demonstrated patent cerebrospinal fluid (CSF) pathways at the level of the foramina of Magendie and Luschka. We believe that this case is of interest because of the unequivocal evidence on MRI studies of the occlusion of the foramen of Magendie preoperatively, and because of the dramatic postoperative MRI findings demonstrating the effectiveness of the surgical procedure both in terms of ventricular size and CSF flow characterization 20).

References

1) , 13)

Ferrer E, de Notaris M. Third ventriculostomy and fourth ventricle outlets obstruction. World Neurosurg. 2013 Feb;79(2 Suppl):S20.e9-13. doi: 10.1016/j.wneu.2012.02.017. Epub 2012 Feb 10. Review. PubMed PMID: 22381846.
2) , 14)

Mohanty A, Biswas A, Satish S, Vollmer DG. Efficacy of endoscopic third ventriculostomy in fourth ventricular outlet obstruction. Neurosurgery. 2008 Nov;63(5):905-13; discussion 913-4. doi: 10.1227/01.NEU.0000333262.38548.E1. PubMed PMID: 19005381.
3) , 12)

Roth J, Ben-Sira L, Udayakumaran S, Constantini S. Contrast ventriculo-cisternography: an auxiliary test for suspected fourth ventricular outlet obstruction. Childs Nerv Syst. 2012 Mar;28(3):453-9. doi: 10.1007/s00381-011-1639-y. Epub 2011 Nov 29. PubMed PMID: 22124573.
4) , 15)

Suehiro T, Inamura T, Natori Y, Sasaki M, Fukui M. Successful neuroendoscopic third ventriculostomy for hydrocephalus and syringomyelia associated with fourth ventricle outlet obstruction. Case report. J Neurosurg. 2000 Aug;93(2):326-9. PubMed PMID: 10930021.
5) , 16)

Karachi C, Le Guérinel C, Brugières P, Melon E, Decq P. Hydrocephalus due to idiopathic stenosis of the foramina of Magendie and Luschka. Report of three cases. J Neurosurg. 2003 Apr;98(4):897-902. PubMed PMID: 12691419.
6) , 20)

Huang YC, Chang CN, Chuang HL, Scott RM. Membranous obstruction of the fourth ventricle outlet. A case report. Pediatr Neurosurg. 2001 Jul;35(1):43-7. Review. PubMed PMID: 11490191.
7)

Carpentier A, Brunelle F, Philippon J, Clemenceau S. Obstruction of Magendie’s and Luschka’s foramina. Cine-MRI, aetiology and pathogenesis. Acta Neurochir (Wien). 2001;143(5):517-21; discussion 521-2. PubMed PMID: 11482704.
8)

Choi JU, Kim DS, Kim SH. Endoscopic surgery for obstructive hydrocephalus. Yonsei Med J. 1999 Dec;40(6):600-7. PubMed PMID: 10661039.
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Longatti P, Fiorindi A, Martinuzzi A, Feletti A. Primary obstruction of the fourth ventricle outlets: neuroendoscopic approach and anatomic description. Neurosurgery. 2009 Dec;65(6):1078-85; discussion 1085-6. doi: 10.1227/01.NEU.0000360133.29217.44. PubMed PMID: 19934967.
10)

Oertel JM, Mondorf Y, Schroeder HW, Gaab MR. Endoscopic diagnosis and treatment of far distal obstructive hydrocephalus. Acta Neurochir (Wien). 2010 Feb;152(2):229-40. doi: 10.1007/s00701-009-0494-z. Epub 2009 Aug 26. PubMed PMID: 19707715.
11)

Bai J, Yu Q, Sun X, Xiao H, Wang K, Sun F, Sui Q. Hydrocephalus Due to Idiopathic Fourth Ventricle Outflow Obstruction. J Craniofac Surg. 2019 Mar 6. doi: 10.1097/SCS.0000000000005314. [Epub ahead of print] PubMed PMID: 30865115.
17)

Duran D, Hadzipasic M, Kahle KT. Mystery Case: Acute hydrocephalus caused by radiographically occult fourth ventricular outlet obstruction. Neurology. 2017 Jan 31;88(5):e36-e37. doi: 10.1212/WNL.0000000000003555. PubMed PMID: 28138085.
18)

Shimoda Y, Murakami K, Narita N, Tominaga T. Fourth Ventricle Outlet Obstruction with Expanding Space on the Surface of Cerebellum. World Neurosurg. 2017 Apr;100:711.e1-711.e5. doi: 10.1016/j.wneu.2017.01.088. Epub 2017 Jan 31. PubMed PMID: 28153613.
19)

Ishi Y, Asaoka K, Kobayashi H, Motegi H, Sugiyama T, Yokoyama Y, Echizenya S, Itamoto K. Idiopathic fourth ventricle outlet obstruction successfully treated by endoscopic third ventriculostomy: a case report. Springerplus. 2015 Sep 30;4:565. doi: 10.1186/s40064-015-1368-x. eCollection 2015. PubMed PMID: 26543700; PubMed Central PMCID: PMC4627988.

Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition

The scope and purpose of the Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition. is 2-fold: to synthesize the available evidence and to translate it into recommendations. This document provides recommendations only when there is evidence to support them. As such, they do not constitute a complete protocol for clinical use.
The intention is that these recommendations be used by others to develop treatment protocols, which necessarily need to incorporate consensus and clinical judgment in areas where current evidence is lacking or insufficient.
Carney et al. think it is important to have evidence-based recommendations to clarify what aspects of practice currently can and cannot be supported by evidence, to encourage use of evidence-based treatments that exist, and to encourage creativity in treatment and research in areas where evidence does not exist. The communities of neurosurgery and neurointensive care have been early pioneers and supporters of evidence based medicine and plan to continue in this endeavor. The complete guideline document, which summarizes and evaluates the literature for each topic, and supplemental appendices (A-I) are available online at https://www.braintrauma.org/coma/guidelines 1).
4th edition
Free article of Neurosurgery

1) Carney N, Totten AM, OʼReilly C, Ullman JS, Hawryluk GW, Bell MJ, Bratton SL, Chesnut R, Harris OA, Kissoon N, Rubiano AM, Shutter L, Tasker RC, Vavilala MS, Wilberger J, Wright DW, Ghajar J. Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition. Neurosurgery. 2016 Sep 20. [Epub ahead of print] PubMed PMID: 27654000.
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