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LETTER TO THE EDITOR
Dementia and Neurocognitive Disorders 2023: 22: 1: 46-48

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Combined Endoscopic Third Ventriculostomy and Lumboperitoneal Shunt Surgery in an Elderly Patient With Complex Hydrocephalus: Mixture of Late-onset Obstructive and Communicating Hydrocephaluses
Sang-Youl Yoon ,1 Kyunghun Kang ,2 Chaejin Lee ,1 Jeong-Hyun Hwang ,1 Myoung Hun Hahm ,3 Eunhee Park ,4 Ki-Su Park 1
1 Department of Neurosurgery, School of Medicine, Kyungpook National University, Daegu, Korea 2 Department of Neurology, School of Medicine, Kyungpook National University, Daegu, Korea 3 Department of Radiology, School of Medicine, Kyungpook National University, Daegu, Korea 4 Department of Rehabilitation Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
Combined Endoscopic Third Ventriculostomy and Lumboperitoneal Shunt Surgery in an Elderly Patient With Complex Hydrocephalus: Mixture of Late-onset Obstructive and Communicating Hydrocephaluses
Sang-Youl Yoon ,1 Kyunghun Kang ,2 Chaejin Lee ,1 Jeong-Hyun Hwang ,1 Myoung Hun Hahm ,3 Eunhee Park ,4 Ki-Su Park 1
1 Department of Neurosurgery, School of Medicine, Kyungpook National University, Daegu, Korea 2 Department of Neurology, School of Medicine, Kyungpook National University, Daegu, Korea 3 Department of Radiology, School of Medicine, Kyungpook National University, Daegu, Korea 4 Department of Rehabilitation Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
Dear Editor,
Obstructive hydrocephalus due to aqueductal stenosis (AS) is a disease that mainly occurs in
children. Late-onset obstructive hydrocephalus due to AS can rarely occur in elderly patients.1
The treatment of obstructive hydrocephalus due to AS by endoscopic third ventriculostomy
(ETV) shows good results.2
However, ETV alone cannot be used for treating elderly
patients with complex hydrocephalus. This complex hydrocephalus may be accompanied
by obstructive and communicating hydrocephaluses due to different causes.3
We present
the case of an elderly patient with rare complex hydrocephalus, a combination of lateonset obstructive and communicating hydrocephaluses, treated using combined ETV and
lumboperitoneal shunt (LPS) surgeries.
A 75-year-old man presented to our hospital for progressive impairments in gait and
cognition. The initial examination showed a cognitive decline (Supplementary Table 1).
Brain magnetic resonance imaging (MRI) showed ventriculomegaly and obstruction of
the aqueduct of Sylvius (Fig. 1A). Cerebrospinal fluid (CSF) flow dynamic MRI showed no
CSF flow through the aqueduct of Sylvius (Fig. 1B). He was diagnosed with obstructive
hydrocephalus due to late-onset AS. We performed ETV surgery first (Fig. 1C). After surgery,
his symptoms improved for ten months. However, the symptoms worsened again, and he
was re-hospitalized. CSF flow dynamic MRI showed patent CSF flow through the previously
penetrated hole (Fig. 1D), and his symptoms improved again after a CSF tap test. These
findings suggested complex hydrocephalus with a mixture of late-onset obstructive and
communicating hydrocephaluses. Even though the CSF bypass was well maintained, the
communicating hydrocephalus was considered unresolved. Therefore, LPS surgery was
performed (Fig. 1E). After LPS surgery, the patient’s symptoms improved for ten months
(Supplementary Table 1).
Obstructive hydrocephalus is classified according to its pathology into the congenital type
due to aqueductal webs, diaphragms, and gliosis, and acquired pathology, which includes
tumors, vascular malformations, hemorrhage, and infection.4
Congenital pathology is rarely
seen in obstructive hydrocephalus in elderly patients. In most elderly patients, obstructive
hydrocephalus has the same clinical features as normal-pressure hydrocephalus (NPH), and
the late-onset of symptoms is presumed to be due to enlarged ventricles and a compensatory
mechanism by intra-parenchymal CSF transportation.5
The first treatment of obstructive hydrocephalus is generally ETV. However, in some cases,
when symptoms did not improve with ETV, a ventriculoperitoneal shunt (VPS) was used
as a secondary adaptation.5
In this case, there is a possibility that the communicating
hydrocephalus is present in addition to obstructive hydrocephalus. In particular, since
obstructive hydrocephalus in elderly patients is likely to be accompanied by communicating
hydrocephalus with poor CSF absorption, like NPH, it may not be resolved by ETV alone
in elderly patients, as in our case. Of course, it may be good to perform VPS as the first
treatment for obstructive hydrocephalus in elderly patients, but good effects of ETV
treatment for obstructive hydrocephalus have been reported.2
In addition, due to the concern
for destroying the already adapted CSF homeostasis, poor brain expansion, and sequelae,
such as subdural fluid collection or chronic subdural hematoma, may occur, the use of direct
VPS for the obstructive hydrocephalus in the elderly patient may be limited.6
Therefore, as
in our case, LPS surgery after ETV in elderly patients with obstructive hydrocephalus can
be a new alternative treatment. Moreover, after ETV failure, LPS through local or regional
anesthesia is possible instead of VPS surgery under general anesthesia, so it is considered to
be a sufficient alternative treatment.
Key Words:
대한치매학회지 (Dementia and Neurocognitive Disorders)

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