Tetraventricular Hydrocephalus Due to Idiopathic Fourth Ventricle Outlet Obstruction: A Case Report and Literature Review

Abstract

Introduction

Tetraventricular hydrocephalus happens due to the fourth ventricle outlet obstruction. Idiopathic fourth ventricle outlet obstruction (IFVOO) is a condition where no clear-cut etiology for fourth ventricle outlet obstruction can be found. The etiopathogenesis of IFVOO is unclear. There is no clear-cut consensus regarding the treatment practices for its management. These cases present a diagnostic dilemma to the treating neurosurgeon and are thus often managed inappropriately. This study aims to review the existing literature regarding this condition, illustrating with a case from our hospital.

Case Details

We present a case of a 50-year-old female who presented to us with the chief complaints of headache, difficulty in walking, with an inability to balance while standing and walking, diplopia, and three episodes of loss of consciousness for 6 months. A brain MRI was done, which was suggestive of dilatation of all ventricles with obstruction at the foramina of Luschka and Magendie. She underwent a right-sided, medium-pressure ventriculoperitoneal shunt at our hospital. Postsurgery, there was immediate improvement in her symptoms.

Conclusion

IFVOO is a rare cause of tetraventricular hydrocephalus with an unknown cause. Endoscopic third ventriculostomy (ETV) appears to have a higher risk of failure in such cases. Fenestration procedures after craniotomy and shunt procedures are still effective in their management. ETV is still an alternative to the above-mentioned procedures. To confirm these conclusions, larger studies involving multiple hospitals and institutes are required.

Keywords

idiopathic - fourth ventricle outlet obstruction - hydrocephalus - Luschka - Magendie - endoscopic third ventriculostomy - foramina

Publikationsverlauf

Eingereicht: 01. Mai 2025

Angenommen: 21. September 2025

Artikel online veröffentlicht:
13. Oktober 2025

• References

• 1 Mohanty A, Biswas A, Satish S, Vollmer DG. Efficacy of endoscopic third ventriculostomy in fourth ventricular outlet obstruction. Neurosurgery 2008; 63 (05) 905-913 , discussion 913–914
• 2 Coleman CC, Troland CE. Congenital atresia of the foramina of Luschka and Magendie with report of two cases of surgical cure. J Neurosurg 1948; 5 (01) 84-88
• 3 Inamura T, Morioka T, Nishio S, Ikezaki K, Nonaka H, Yoshiura T. Diverticular enlargement of the foramina of Luschka and congenital hydrocephalus. Childs Nerv Syst 2002; 18 (11) 652-655
• 4 Longatti P, Fiorindi A, Martinuzzi A, Feletti A. Primary obstruction of the fourth ventricle outlets: Neuroendoscopic approach and anatomic description. Neurosurgery 2009; 65 (06) 1078-1085 , discussion 1085–1086
• 5 Barr ML. Observations on the foramen of Magendie in a series of human brains. Brain 1948; 71 (Pt. 3): 281-289
• 6 Torres-Corzo J, Sánchez-Rodríguez J, Cervantes D. et al. Endoscopic transventricular transaqueductal Magendie and Luschka foraminoplasty for hydrocephalus. Neurosurgery 2014; 74 (04) 426-435 , discussion 436
• 7 Krejčí O, Krejčí T, Mrůzek M, Večeřa Z, Šalounová D, Lipina R. Hydrocephalus caused by primary fourth ventricle outlet obstruction: Our experience and literature review. World Neurosurg 2021; 148: e425-e435
• 8 Warf BC, Kulkarni AV. Intraoperative assessment of cerebral aqueduct patency and cisternal scarring: impact on success of endoscopic third ventriculostomy in 403 African children. J Neurosurg Pediatr 2010; 5 (02) 204-209
• 9 Siomin V, Cinalli G, Grotenhuis A. et al. Endoscopic third ventriculostomy in patients with cerebrospinal fluid infection and/or hemorrhage. J Neurosurg 2002; 97 (03) 519-524
• 10 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 (05) 517-521 , discussion 521–522
• 11 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; 98 (04) 897-902
• 12 Dlouhy BJ, Capuano AW, Madhavan K, Torner JC, Greenlee JDW. Preoperative third ventricular bowing as a predictor of endoscopic third ventriculostomy success. J Neurosurg Pediatr 2012; 9 (02) 182-190
• 13 Krejčí T, Krejčí O, Večeřa Z, Chlachula M, Šalounová D, Lipina R. The role of third ventricle bowing in the success of endoscopic third ventriculostomy in pediatric and adult patients. Clin Neurol Neurosurg 2019; 187: 105554
• 14 Rosa MRF, Cruz TZ, Magalhães Junior EV, Nigri F. Tetraventricular noncommunicating hydrocephalus: Case report and literature review. Surg Neurol Int 2021; 12: 519
• 15 Ishi Y, Asaoka K, Kobayashi H. et al. Idiopathic fourth ventricle outlet obstruction successfully treated by endoscopic third ventriculostomy: A case report. Springerplus 2015; 4: 565
• 16 Aesch B, Goldenberg N, Maheut-Lourmiere J, Jan M. [Hydrocephalus caused by obstruction of the foramina of Luschka and Magendie in adults. Report of a case. Etiopathogenic discussion]. Neurochirurgie 1991; 37 (04) 269-272
• 17 Holland HC, Graham WL. Congenital atresia of the foramina of Luschka and Magendie with hydrocephalus; report of a case in an adult. J Neurosurg 1958; 15 (06) 688-694
• 18 Rifkinson-Mann S, Sachdev VP, Huang YP. Congenital fourth ventricular midline outlet obstruction. Report of two cases. J Neurosurg 1987; 67 (04) 595-599
• 19 Osaka Y, Shin H, Sugawa N. et al. [“Disproportionately large, communicating fourth ventricle” due to membranous obstruction of Magendie's foramen]. No Shinkei Geka 1995; 23 (05) 429-433
• 20 Huang YC, Chang CN, Chuang HL, Scott RM. Membranous obstruction of the fourth ventricle outlet. A case report. Pediatr Neurosurg 2001; 35 (01) 43-47
• 21 Kasapas K, Varthalitis D, Georgakoulias N, Orphanidis G. Hydrocephalus due to membranous obstruction of Magendie's foramen. J Korean Neurosurg Soc 2015; 57 (01) 68-71
• 22 Duran D, Hadzipasic M, Kahle KT. Mystery case: Acute hydrocephalus caused by radiographically occult fourth ventricular outlet obstruction. Neurology 2017; 88 (05) e36-e37
• 23 Bai J, Yu Q, Sun X. et al. Hydrocephalus due to idiopathic fourth ventricle outflow obstruction. J Craniofac Surg 2019; 30 (05) e397-e400
• 24 Amacher AL, Page LK. Hydrocephalus due to membranous obstruction of the fourth ventricle. J Neurosurg 1971; 35 (06) 672-676
• 25 Yoshioka S, Matsukado Y, Uemura S, Nagahiro S, Ootsuka T, Yadomi C. [Hydrocephalus due to membranous obstruction of the fourth ventricle aperture]. No Shinkei Geka 1985; 13 (10) 1135-1139
• 26 Hashish H, Guenot M, Mertens P, Sindou M. [Chronic hydrocephalus in an adult due to congenital membranous occlusion of the apertura mediana ventriculi quartii (foramen of Magendie). Report of two cases and review of the literature]. Neurochirurgie 1999; 45 (03) 232-236
• 27 Chai WX. Long-term results of fourth ventriculo-cisternostomy in complex versus simplex atresias of the fourth ventricle outlets. Acta Neurochir (Wien) 1995; 134 (1-2): 27-34
• 28 Torkildsen A. A follow-up study 14 to 20 years after ventriculocisternostomy. Acta Psychiatr Scand 1960; 35 (01) 113-121
• 29 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; 93 (02) 326-329
• 30 Sacko O, Boetto S, Lauwers-Cances V, Dupuy M, Roux FE. Endoscopic third ventriculostomy: Outcome analysis in 368 procedures. J Neurosurg Pediatr 2010; 5 (01) 68-74
• 31 Giannetti AV, Malheiros JA, da Silva MC. Fourth ventriculostomy: An alternative treatment for hydrocephalus due to atresia of the Magendie and Luschka foramina. J Neurosurg Pediatr 2011; 7 (02) 152-156