case_images: PMC10629316_01
case_images: (a and b) Initial brain magnetic resonance imaging in case one; multiloculated hydrocephalus is evident. (c) Second septostomy surgery to allow communication in the entire left ventricular system connecting the superior lateral ventricle with the inferior lateral ventricle (inferior temporal horn). Due to the greater thickness and fibrosis of this septum, it was not possible to perform the septostomy only with the take apart bipolar coagulator and Fogarty catheter (as in the other surgeries); however, we had to use sharp dissection with the help of microscissors. (d) Intraoperative neuronavigation images of the second septostomy surgery.
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case_images: PMC10629316_01_SNI-14-354-g001.jpg
case_images: F1
case_images: Brain computed tomography and magnetic resonance imaging revealed multiloculated hydrocephalus [Figures 1a and b]. For the septostomy surgeries, Karl Storz endonasal and skull base endoscopy equipment was used: a 2-mm and 0  endoscope, Fogarty French 3 catheter, Take Apart bipolar, and microscissors to cut adhesions and septa [Figures 1c and d]. In the second surgery, the superior lateral ventricle was connected to the inferior lateral ventricle (left temporal horn) [Figures 1a-d].
case_images: (a) Third endoscopic septostomy surgery on the right side to connect the right ventricular temporal horn with the basal cisterns and left ventricular system through a transchoroidal fissure approach. (b) Intraoperative neuronavigation images. (c and d) Postsurgical magnetic resonance imaging before the patient was discharged. The entire communicating network of the ventricular system is evident, although not easily visible in a few images we can see the cerebral cortex without any tension and in fact a little separated from the skull, the most important thing is that with a single ventriculoperitoneal shunt system the clinical hydrocephalus resolved.
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case_images: PMC10629316_01_SNI-14-354-g002.jpg
case_images: F2
case_images: When the right ventricular septum was incised, the right temporal horn was connected with the cisterns of the base using the transchoroidal fissure approach [Figures 2a and b]. This allowed the communication of the entire ventricular system, which left only one ventriculoperitoneal shunt system [Figures 2c and d] after the resolution of the ventriculitis on day 6 of the intraventricular antibiotic treatment.
case_images: (a) Initial magnetic resonance imaging in case two, where ventricular empyema is evident in the fluid-attenuated inversion recovery sequence (the initial stage of neuroinfection). (b-d) magnetic resonance imaging in case two, where multiloculated hydrocephalus is evident (advanced stage of neuroinfection).
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case_images: PMC10629316_01_SNI-14-354-g003.jpg
case_images: F3
case_images: The surgery was complicated by hydrocephalus and ventriculitis with ventricular empyema, which required endoscopic evacuation of the intraventricular empyema and placement of an external ventricular drain [Figure 3a]. Over the following 3 weeks, the patient presented with multiple intraventricular septations [Figures 3b-d], complicating the management of the hydrocephalus and leading to simultaneous use of two external ventricular drains.
case_images: (a and b) Intraventricular endoscopic septostomy in case two, with the aid of a Fogarty catheter. (c and d) Postsurgical magnetic resonance imaging in case two after intraventricular septostomy 2 months after discharge.
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case_images: PMC10629316_01_SNI-14-354-g004.jpg
case_images: F4
case_images: After performing three intraventricular endoscopic septostomies, we connected two cavities of the ventricular system [Figures 4a and b]. The patient was discharged with two ventriculoperitoneal shunts [Figures 4c and d].