An MRI of a 3-year-old with progressive macrocephaly and papilledema shows dilated lateral ventricles and a normal-sized fourth ventricle with a funnel-shaped cerebral aqueduct. Intracranial pressure is elevated. Assuming no contraindication, which intervention offers definitive treatment with the lowest long-term shunt dependence?

• A Ventriculoperitoneal shunt insertion
• B Serial lumbar punctures
• C Endoscopic third ventriculostomy ✓
• D Acetazolamide therapy

Explanation

Triventricular dilatation with an aqueductal funnel indicates aqueductal stenosis, a non-communicating hydrocephalus in which CSF obstruction lies proximal to the fourth ventricle. Endoscopic third ventriculostomy creates a fenestration in the third ventricular floor, bypassing the stenosed aqueduct and avoiding lifelong shunt hardware and its failure and infection risks. Serial lumbar punctures are ineffective above the obstruction, and acetazolamide only transiently reduces production.

Reference: Nelson Textbook of Pediatrics, 21st ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.