Minim Invasive Neurosurg 2010; 53(1): 29-33
DOI: 10.1055/s-0030-1247555
Case Report

© Georg Thieme Verlag KG Stuttgart · New York

Minimally Invasive Computer-Assisted Stereotactic Fenestration of an Aqueductal Cyst: Case Report

E. T. Fonoff1 , A. F. Gentil2 , P. M. Padilha1 , M. J. Teixeira1
  • 1Division of Functional Neurosurgery, Department and Institute of Psychiatry, University of Sao Paulo Medical School, Brazil
  • 2Protoc, Department and Institute of Psychiatry, University of Sao Paulo Medical School, Brazil
Further Information

Publication History

Publication Date:
07 April 2010 (online)


Introduction: Current advances in frame modeling and computer software allow stereotactic procedures to be performed with great accuracy and minimal risk of neural tissue or vascular injury.

Case Report: In this report we associate a previously described minimally invasive stereotactic technique with state-of-the-art 3D computer guidance technology to successfully treat a 55-year-old patient with an arachnoidal cyst obstructing the aqueduct of Sylvius. We provide detailed technical information and discuss how this technique deals with previous limitations for stereotactic manipulation of the aqueductal region. We further discuss current advances in neuroendoscopy for treating obstructive hydrocephalus and make comparisons with our proposed technique.

Conclusion: We advocate that this technique is not only capable of treating this pathology but it also has the advantages to enable reestablishment of physiological CSF flow thus preventing future brainstem compression by cyst enlargement.


  • 1 Hydrocephalus Fact Sheet, National Institute of Health Publication No. 05-385, Aug 2005
  • 2 Shin M, Nishihara T, Iai S. et al . Benign aqueductal cyst causing bilateral internuclear ophthalmoplegia after external ventricular drainage. Case report.  J Neurosurg. 2000;  92 490-492
  • 3 Norlén G. Contribution to the surgical treatment of inoperable tumours causing obstruction of the sylvian aqueduct.  Acta Psychiatr Neurol Scand. 1949;  24 629-637
  • 4 Elvidge AR. Treatment of obstructive lesions of the aqueduct of Sylvius and the fourth ventricle by interventriculostomy.  J Neurosurg. 1966;  24 11-23
  • 5 Avman N, Dincer C. Venous malformation of the aqueduct of Sylvius treated by interventriculostomy: 15 years follow-up.  Acta Neurochir (Wien). 1980;  52 219-224
  • 6 Lapras C, Bret P, Patet JD. et al . Hydrocephalus and aqueduct stenosis. Direct surgical treatment by interventriculostomy (aqueduct cannulation).  J Neurosurg Sci. 1986;  30 47-53
  • 7 Miki T, Nakajima N, Wada J. et al . Indications for neuroendoscopic aqueductoplasty without stenting for obstructive hydrocephalus due to aqueductal stenosis.  Minim Invas Neurosurg. 2005;  48 136-141
  • 8 Fritsch MJ, Kienke S, Manwaring KH. et al . Endoscopic aqueductoplasty and interventriculostomy for the treatment of isolated fourth ventricle in children.  Neurosurgery. 2004;  55 372-377 ; discussion 377–379
  • 9 Dalrymple SJ, Kelly PJ. Computer-assisted stereotactic third ventriculostomy in the management of noncommunicating hydrocephalus.  Stereotact Funct Neurosurg. 1992;  59 105-110
  • 10 Kelly PJ. Stereotactic third ventriculostomy in patients with nontumoral adolescent/adult onset aqueductal stenosis and symptomatic hydrocephalus.  J Neurosurg. 1991;  75 865-873
  • 11 Blacklund EO, Grepe A, Lunsford D. Stereotaxic reconstruction of the aqueduct of Sylvius.  J Neurosurg. 1981;  55 800-810
  • 12 Stern JD, Ross DA. Stereotactic management of benign pineal region cysts: report of two cases.  Neurosurgery. 1993;  32 310-314 ; discussion 314
  • 13 Gokalp HZ, Erdogan A. Hydatid cyst of the aqueduct of Sylvius. Case report.  Clin Neurol Neurosurg. 1988;  90 83-85
  • 14 Vlaho S, Gebhardt B, Gerlach R. et al . Cyst of the third ventricle as an unusual cause of acquired hydrocephalus.  Pediatr Neurol. 2003;  28 225-227
  • 15 Murphy MJ, Lyon LW, Carlstrom TA. et al . Normal pressure hydrocephalus due to membranous obstruction of the sylvian aqueduct.  Neurology. 1978;  28 835-837
  • 16 Hirsch JF, Hirsch E, Sainte Rose C. et al . Stenosis of the aqueduct of Sylvius. Etiology and treatment.  J Neurosurg Sci. 1986;  30 29-39
  • 17 Drake JM, Kestle JR, Tuli S. CSF shunts 50 years on – past, present and future.  Childs Nerv Syst. 2000;  16 800-804
  • 18 Shah SS, Smith MJ, Zaoutis TE. Device-related infections in children.  Pediatr Clin North Am. 2005;  52 1189-1208
  • 19 Schroeder HW, Oertel J, Gaab MR. Endoscopic aqueductoplasty in the treatment of aqueductal stenosis.  Childs Nerv Syst. 2004;  20 821-827
  • 20 O’Brien DF, Javadpour M, Collins DR. et al . Endoscopic third ventriculostomy: an outcome analysis of primary cases and procedures performed after ventriculoperitoneal shunt malfunction.  J Neurosurg. 2005;  103 ((5 Suppl)) 393-400
  • 21 Abdullah J, Ariff AR, Ghazaime G. et al . Stereotactic neuroendoscopic management of hydrocephalus: a three-year follow-up and analysis of Malaysian children with aqueduct stenosis.  Stereotact Funct Neurosurg. 2001;  76 175-180
  • 22 Kadrian D, van Gelder J, Florida D. et al . Long-term reliability of endoscopic third ventriculostomy.  Neurosurgery. 2005;  56 1271-1278 ; discussion 1278
  • 23 Handler MH, Abbott R, Lee M. A near-fatal complication of endoscopic thrid ventriculostomy: case report.  Neurosurgery. 1994;  35 525-527
  • 24 McLaughlin MR, Wahlig JB, Kaufmann AM. et al . Traumatic basilar aneurysm after endoscopic third ventriculostomy.  Neurosurgery. 1997;  41 1400-1404
  • 25 Schroeder HWS, Warzok RW, Assaf JA. et al . Fatal subarachnoid hemorrhage after endoscopic third ventriculostomy – case report.  J Neurosurg. 1999;  90 153-155
  • 26 Dandy WE. The diagnosis and treatment of hydrocephalus resulting from strictures of the aqueduct of Sylvius.  Surg Gynecol Obstet. 1920;  31 340-358
  • 27 Greenwood Jr J, Hickey WC. Cerebral aqueduct stenosis – treatment by aqueduct-cisternal shunt.  Dis Nerv Syst. 1956;  17 277-279
  • 28 Crosby RMN, Henderson CM, Paul RL. Catheterization of the cerebral aqueduct for obstructive hydrocephalus in infants.  J Neurosurg. 1973;  38 596-601
  • 29 Sansone JM, Iskandar BJ. Endoscopic cerebral aqueductoplasty: a trans-fourth ventricle approach.  J Neurosurg. 2005;  103 ((5 Suppl)) 388-392
  • 30 Toyota S, Taki T, Oshino S. et al . A neuroendoscopic approach to the aqueduct via the fourth ventricle combined with suboccipital craniectomy.  Minim Invas Neurosurg. 2004;  47 312-315
  • 31 Oka K, Yamamoto M, Ikeda K. et al . Flexible endoneurosurgical therapy for aqueductal stenosis.  Neurosurgery. 1993;  33 236-242
  • 32 Manwaring KH, Fritsch MJ. Endoscopic aqueductal stenting as an option for obstructive hydrocephalus.  Neurosurgery. 1998;  43 712-713
  • 33 Fritsch MJ, Kienke S, Mehdorn HM. Endoscopic aqueductoplasty: stent or not to stent?.  Childs Nerv Syst. 2004;  20 137-142
  • 34 Miki T, Nakajima N, Wada J. et al . Indications for neuroendoscopic aqueductoplasty without stenting for obstructive hydrocephalus due to aqueductal stenosis.  Minim Invas Neurosurg. 2005;  48 136-141
  • 35 Cinalli G, Spennato P, Savarese L. et al . Endoscopic aqueductoplasty and placement of a stent in the cerebral aqueduct in the management of isolated fourth ventricle in children.  J Neurosurg. 2006;  104 ((1 Suppl)) 21-27
  • 36 Teo C. Third ventriculostomy in the treatment of hydrocephalus: experience with more than 120 cases.. Springer, Berlin Heidelberg; 1998. pp 73-76


E. T. FonoffMD, PhD 

Division of Functional Neurosurgery

Department & Institute of Psychiatry

University of Sao Paulo Medical School

R. Dr. Ovídio

Pires de Campos 785

01060-970 Sao Paulo – SP


Phone: +55/11/3237 2031

Fax: +55/11/3214 1557