# Two Cerebrospinal Fluid (CSF) Diversion Procedures for Two Separate CSF Pathologies in a 19-Year-Old Male: A Case Report

## TL;DR

A 19-year-old man required two different CSF diversion procedures to manage two separate CSF-related issues, highlighting the complexity of hydrocephalus treatment.

## Contribution

The case highlights the paradox of post-ETV intracranial hypertension and the need for personalized CSF diversion strategies.

## Key findings

- Endoscopic third ventriculostomy (ETV) initially relieved symptoms but failed in the long term.
- A lumboperitoneal shunt resolved refractory intracranial hypertension despite a patent ETV.
- Patent ETV does not guarantee normal cerebrospinal fluid dynamics.

## Abstract

Hydrocephalus is a dynamic neurosurgical entity, with cerebrospinal fluid (CSF) diversion methods continually evolving to strike a balance between long-term efficacy and the risk of complications. We describe a 19-year-old man who was treated with endoscopic third ventriculostomy (ETV) for congenital aqueductal stenosis, with initial relief of symptoms. Two years later, he experienced recurring headaches and papilledema, but neuroimaging showed stable ventricles and patency of the ETV stoma. Magnetic resonance venography (MRV) ruled out venous sinus thrombosis, while lumbar CSF manometry revealed persistently elevated intracranial pressure (ICP), consistent with CSF absorption dysfunction. Given his refractory symptoms despite medical therapy, a lumboperitoneal (LP) shunt was placed, leading to complete resolution of symptoms and papilledema.

This case underscores the paradox of post-ETV intracranial hypertension, reinforcing that a patent ETV does not equate to normal CSF dynamics. Integrating continuous ICP monitoring, advanced CSF flow imaging, and personalized diversion strategies may enhance long-term outcomes in this complex subset of hydrocephalus patients.