title: Delayed stoma failure in adult communicating hydrocephalus after initial successful treatment by endoscopic third ventriculostomy: case report.
abstract: OBJECTIVE
  To describe 2 cases of delayed endoscopic third ventriculostomy (ETV) failure in 2 adult patients initially successfully treated for normal pressure hydrocephalus by ETV. The cause of ETV failure was stoma closure, and this was documented in both instances by direct endoscopic inspection.
  
  
  METHODS
  In the first case, a 67-year-old woman presented with progressive gait disturbance, incontinence, and memory problems. Brain magnetic resonance imaging exhibited ventricular dilation, including the fourth ventricle, disproportionate to cortical atrophy. In the second case, a 55-year-old man presented with progressive gait disturbance, urinary incontinence, memory problems, and headaches. Brain magnetic resonance imaging exhibited communicating hydrocephalus.
  
  
  METHODS
  The first patient underwent an ETV with subsequent improvement in all symptom areas. Three years and 2 months later, she experienced a return of original symptoms and ventricular dilation on brain computed tomography, compared with previous postoperative scans. Direct endoscopic inspection of the third ventricular floor revealed stoma closure secondary to fibrotic scar. The patient subsequently underwent ventriculoperitoneal shunt placement that resulted in symptom improvement. The patient in the second case underwent an ETV that resulted in marked symptom improvement in all areas. Four years and 3 months later, he experienced a return of gait difficulties and headaches. Direct endoscopic inspection showed a lack of cerebrospinal fluid pulsations through the third ventricular stoma and dense arachnoid adhesions around the basilar artery. A repeat ETV was unsuccessful. Subsequent ventriculoperitoneal shunt placement resulted in symptom improvement.
  
  
  CONCLUSIONS
  ETV may provide an effective treatment for patients with normal pressure hydrocephalus, a form of communicating hydrocephalus. Stoma closure can be a mechanism of delayed ETV failure in normal pressure hydrocephalus, consistent with reports of ETV failure in pediatric obstructive hydrocephalus.
authors.affiliation: Department of Neurosurgery, Millard Fillmore Gates Hospital-Kaleida Health, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York 14209, USA.
authors.forename: Andrew J
authors.initials: AJ
authors.lastname: Fabiano
authors.forename: Kristina
authors.initials: K
authors.lastname: Doyle
authors.forename: Walter
authors.initials: W
authors.lastname: Grand
mesh_terms: D000368:Aged; D004724:Endoscopy / Q000009:adverse effects* / Q000379:methods; D005260:Female; D006801:Humans; D006849:Hydrocephalus / Q000601:surgery*; D006850:Hydrocephalus, Normal Pressure / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000209:etiology / Q000503:physiopathology*; D054047:Surgical Stomas / Q000009:adverse effects*; D014696:Ventriculostomy / Q000009:adverse effects* / Q000379:methods