Targeted tumor resection to reestablish cerebrospinal fluid flow in the setting of a pediatric third ventricular glioma with obstructive hydrocephalus

Background: Pediatric third ventricular gliomas may obstruct the flow of cerebrospinal fluid (CSF) requiring surgical intervention, typically involving ventriculoperitoneal shunt placement. We present an alternative surgical strategy involving partial resection of the posterior portion of the glioma to reestablish CSF flow. Case Description: A 3-year-old female presents with obstructive hydrocephalus. Visual acuity and fields were preserved. Initial imaging showed a third ventricular tumor with enlargement of the lateral ventricles. Due to broad differential diagnosis, endoscopic biopsy was performed, which showed pilocytic astrocytoma. A craniotomy for a transcortical transventricular approach through a tubular retractor was performed to resect the posterior portion of the glioma and open the cerebral aqueduct. The patient underwent adjuvant chemotherapy. Postoperatively, she had complete resolution of presenting symptoms and, at 20-month follow-up, she has not required any procedures for CSF diversion. Conclusion: Benefits of the reported surgical strategy of partial posterior tumor resection include lack of permanent hardware and associated complications, as well as additional tissue for molecular studies. The approach can be considered in patients with obstructive hydrocephalus in the setting of a large third ventricular pilocytic astrocytoma in which risks of attempted gross total resection are high and there is a desire to avoid shunt placement.