over most of its length. Occasionally there may be a simple membrane, division of which will restore communication between the third and the fourth ventricles. Again, MR with CISS is invaluable in defining the anatomy.
Neuroendoscopy can also be useful for liberating ventricular shunt catheters, either to make their removal safer, or as a definitive procedure if secondary NTV is not feasible . It can be used to retrieve loose shunt components. This is also a situation in which cutting/coagulating diathermy is most useful to cut down on the ventricular catheter, just as would be done in dissecting out the extracranial portion of a shunt.
Slit-ventricle syndrome is another most unpleasant shunt complication in which neu-roendoscopy may play a useful role. An initial subtemporal decompression may be effective in promoting sufficient ventricular enlargement to permit secondary NTV. Alternatively, patients may undergo shunt externalization, followed by a period of invasive intracranial pressure monitoring without CSF drainage, with those showing elevated or symptomatic intracranial hypertension then proceeding to NTV. The risk of acute deterioration mandates very careful observation.
The small ventricular size and relatively non-compliant ventricles do bring a risk of life-threatening cardiac dysrhythmias during NTV, so great care needs to be taken when irrigating.
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