Subdural Hematoma as a Complication of Endoscopic Third Ventriculostomy in a Pediatric Patient: A Case Report & Literature Review

Subdural Hematoma as a Complication of Endoscopic Third Ventriculostomy in a Pediatric Patient: A Case Report & Literature Review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Subdural Hematoma as a Complication of Endoscopic Third Ventriculostomy in a Pediatric Patient: A Case Report & Literature Review Rafael Tiza Fernandes, Rui Sobrinho, Miguel Azevedo, Mário Matos, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5346121/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 04 Jan, 2025 Read the published version in Child's Nervous System → Version 1 posted 7 You are reading this latest preprint version Abstract Background : Subdural hematoma (SDH) typically occurs due to traumatic brain injury but can arise as a rare complication of procedures like endoscopic third ventriculostomy (ETV). Case Presentation : We report an unusual case in a 9-year-old male with previous resection of a fourth-ventricle ependymoma at 2 years of age. Seven years post-surgery, he presented with worsening hydrocephalus and underwent ETV. One month later, he developed severe headaches and motor difficulties. Imaging revealed a significant right SDH, necessitating urgent drainage. Postoperative recovery was uneventful, and follow-up imaging showed resolution of the hematoma. Literature Review & Discussion : ETV is generally preferred for obstructive hydrocephalus due to lower complication rates compared to shunt procedures. However, cases of SDH post-ETV remain reported, albeit rarely. Potential mechanisms include altered cerebrospinal fluid dynamics and intraoperative vessel injury. This case aligns with literature findings and reinforces the importance of postoperative monitoring and prompt intervention in symptomatic cases to prevent complications. Conclusion : Clinicians should consider SDH in pediatric patients with new symptoms post-ETV. Further research should focus on understanding the risk factors and mechanisms for SDH development. Subdural Hematoma Pediatric ETV Complication Hydrocephalus Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Introduction Subdural hematoma (SDH) in pediatric patients is typically linked to traumatic brain injury (TBI) [ 1 , 2 ]. It can also result from procedures involving the ventricular system, such as ventriculoperitoneal shunt (VPS). The mechanisms are still unclear, as some patients develop only asymptomatic subdural effusions, not SDH. Endoscopic third ventriculostomy (ETV) is considered an effective treatment option for certain cases of obstructive hydrocephalus. It has also been associated, albeit at a much lower rate than VPS, with SDH development. This report aims to describe a rare case of SDH following ETV in a 9-year-old male with a history of ependymoma of the fourth ventricle. Case Presentation We report a case of a nine-year-old male with a relevant past medical history of an ependymoma (WHO grade II) located in the fourth ventricle which was diagnosed at 21 months of age (Fig. 1 ). The patient underwent subtotal surgical resection and adjuvant radiotherapy. Yearly magnetic resonance imaging (MRI) showed controlled disease and chronic ventricular dilation. Seven years post-diagnosis, the patient presented with intermittent evening headaches. On MRI, worsening obstructive hydrocephalus was detected, with no signs of tumor recurrence (Fig. 2 ). An ETV was subsequently performed through a right frontal burr hole. The procedure had no immediate complications (Fig. 3 ). The patient was discharged on postoperative day two with no additional symptoms or neurological deficits. One month after the ETV, he developed progressively worsening headaches, refractory to medication, along with generalized weakness and difficulty walking. He had no history of recent trauma. Initial evaluation revealed a Glasgow Coma Scale score of 15, and generalized weakness without focal deficits. CT scan showed a right subdural collection, measuring up to 35 mm in thickness, and causing midline shift to the left (Fig. 4 ). Its imaging characterization suggested SDH. The patient underwent urgent drainage of the SDH through 2 burr holes on the right side (frontal and parietal). The drained blood was in the subacute phase and a subdural drain was placed. The postoperative period was uneventful, with favorable clinical progress. The drain was removed on the 2nd postoperative day and almost complete reabsorption of the hematoma was documented in serial CT scans (Fig. 5 ). Due to the SDH’s unknown etiology, the patient was referred to Hematology. No laboratory abnormalities suggestive of an increased risk of hemorrhage were identified. He had no family history of hematologic disorders, signs of bleeding diathesis, or history of bleeding in previous surgeries. No history of spontaneous or disproportionate bleeding relative to trauma. He scored 3 points on the Bleeding Assessment Tool (only for CNS hemorrhage). The patient had no further complications and was discharged in a stable condition (GCS 15, no focal deficits) on postoperative day 12. At one-month follow-up, the patient maintained his condition and went back to school. He underwent an MRI 3 months post-op which showed no signs of hydrocephalus and confirmed stoma patency (Fig. 6 ). Discussion ETV is considered an effective treatment option for obstructive hydrocephalus, as it may eliminate the need for a definitive shunt. However, its success rate can vary [3]. This case report highlights a SDH in a 9-year-old male that developed one month after ETV. The occurrence of SDH post-ETV is not frequent, and to date, only a limited number of cases have been reported in the literature. We identified 4 case reports of SDH following ETV in pediatric patients, as shown in Table 1 [4,5,6,7]. The timing between the surgery and the first symptoms varied from a few days to 1 month. Table 1 denotes the cases reported in the literature regarding subdural collections after ETV. The case reported in this article appears as the last one in this table for comparison. Year Authors Age Sex Time from ETV to diagnosis Symptoms/Signs Side Blood Surgery Reason for management Procedure Follow-up Imaging 1997 Mohanty et al. 3 m NR Immediately post-op Cardiorespiratory arrestment Left convexity Acute Yes Immediate post-op deterioration Percutaneous aspiration 8 months post-op, no recurrence 2000 Maeda et al. 2 y M 5 days post-op Mild consciousness disturbance, decreased activity Bilateral Effusion No Gradual improvement N/A Still seen on MRI 9 months post-op 2006 Kamel et al. 16 y M 1 month Headache, Gait disturbance Right convexity Subacute Yes Symptoms Minicraniotomy 2 years post-op, no recurrence 2018 Coulibaly et al. 4 m M 6 months Lethargy, Sunset eyes Bilateral Chronic Yes Symptoms Burr hole evacuation 2 months post-op, no recurrence 2024 Present Case 9 y M 1 month Headache, Gait disturbance Right convexity Subacute Yes Symptoms Burr hole evacuation 3 months post-op, no recurrence NR - non reported; N/A - non applicable The exact mechanisms leading to SDH post-ETV remain unclear, as noted in prior reviews on this subject [7,8,9]. The abrupt change in CSF dynamics post-ETV is reported as one of the possible mechanisms. Another hypothesis is damage to a vessel during the procedure, whether cortical or from the scalp, that might lead to blood accumulation in the subdural space. A thin cerebral mantle and reduced brain elasticity might be predisposing factors. Schroeder et al [10] reviewed complications associated with ETV and reported three subdural collections following the procedure. However, the specific type of subdural collection, whether hematoma or effusion, was not clarified. All patients remained asymptomatic. El-Ghandour et al [11] compared ETV and VPS for the treatment of obstructive hydrocephalus caused by posterior fossa tumors in children, reporting no subdural collections in the ETV group. In contrast, subdural collections were observed in 2 out of 21 patients from the VPS group. On the other hand, Schroeder et al reported three cases of subdural collections following ETV, though they did not specify their exact nature. This highlights the importance of further research to better understand the nature of subdural collections, as they can vary in severity and clinical impact. Xiao et al [12] reported 3 cases of subdural collections out of 12 children who underwent ETV combined with Ommaya reservoir insertion. All cases required drainage, and the reservoirs were subsequently removed. Based on these findings, they concluded that the combination of ETV and Ommaya reservoir may carry a higher risk of developing extra-axial fluid collections. It remains unclear if a previous shunt is a risk factor for developing SDH after ETV. Kurschel et al [13] proposed a technique to prevent subdural collections using fibrin glue. However, their conclusions were limited by the small sample size and lack of comparison to a control group. While SDH is more commonly reported following VPS procedures, the present case demonstrates that ETV, though less frequently implicated, can also lead to SDH, requiring careful postoperative monitoring. Risk factors and prevention strategies are yet to be clarified. Burr hole drainage is likely an effective treatment for these cases. Conclusion This case highlights the need to monitor patients after ETV for the delayed development of SDH. Clinicians should be aware of this potential complication, especially in pediatric patients presenting with new or worsening neurological symptoms postoperatively. Further research is necessary to elucidate the pathophysiological mechanisms driving SDH post-ETV and to identify potential risk factors for this rare but serious complication. Declarations Statement of Ethics Ethical approval was not required for this study following national guidelines. Written informed consent was obtained from the patient's legal guardian to publish this case report. Conflict of Interest Statement The authors have no conflicts of interest to declare. Funding Sources There were no funding sources for the manuscript under consideration. Author Contributions Rafael Tiza Fernandes and Dalila Forte: conceptual design, manuscript authoring and manuscript review. Rui Sobrinho, Miguel Azevedo, Mário Matos and Amets Sagarribay: manuscript review. Data Availability Statement Data are not available due to ethical reasons. Further inquiries can be directed to the corresponding author. References Binder H, Tiefenboeck TM, Majdan M, et al. Management and outcome of traumatic subdural hematoma in 47 infants and children from a single center. Wien Klin Wochenschr. 2020;132(17-18):499-505. doi:10.1007/s00508-020-01648-3 Matschke J, Voss J, Obi N, et al. Nonaccidental head injury is the most common cause of subdural bleeding in infants <1 year of age. Pediatrics. 2009;124(6):1587-1594. doi:10.1542/peds.2008-3734 Kulkarni AV, Drake JM, Mallucci CL, Sgouros S, Roth J, Constantini S; Canadian Pediatric Neurosurgery Study Group. Endoscopic third ventriculostomy in the treatment of childhood hydrocephalus. J Pediatr. 2009 Aug;155(2):254-9.e1. doi: 10.1016/j.jpeds.2009.02.048. Epub 2009 May 15. PMID: 19446842. Mohanty A, Anandh B, Reddy MS, Sastry KV. Contralateral massive acute subdural collection after endoscopic third ventriculostomy - a case report. Minim Invasive Neurosurg. 1997 Jun;40(2):59-61. doi: 10.1055/s-2008-1053417. PMID: 9228339. Maeda Y, Inamura T, Morioka T, Muratani H, Fukui M. Hemorrhagic subdural effusion complicating an endoscopic III ventriculostomy. Childs Nerv Syst. 2000 May;16(5):312-4. doi: 10.1007/s003810050521. PMID: 10883376. Kamel MH, Murphy M, Aquilina K, Marks C. Subdural haemorrhage following endoscopic third ventriculostomy. A rare complication. Acta Neurochir (Wien). 2006 May;148(5):591-3. doi: 10.1007/s00701-005-0715-z. PMID: 16475020. Coulibaly O, Diallo O, Dama M, Kané B, Zhou F, Sogoba Y et al. Bilateral chronic subdural hematoma after endoscopic third ventriculostomy in a child: a case report and review of the literature. World Journal of Neuroscience. 2018, 8(1). doi:10.4236/wjns.2018.81005 Tekin T, Colak A, Kutlay M, Demircan MN. Chronic subdural hematoma after endoscopic third ventriculostomy: a case report and literature review. Turk Neurosurg. 2012;22(1):119-22. doi: 10.5137/1019-5149.JTN.3336-10.0. PMID: 22274985. Gondar R, Rogers A, Momjian S. Subdural hematoma after endoscopic third ventriculostomy: Struggling against the Laplace law. Neurochirurgie. 2015 Oct;61(5):347-51. doi: 10.1016/j.neuchi.2015.06.003. Epub 2015 Aug 5. PMID: 26255033. Schroeder HW, Niendorf WR, Gaab MR. Complications of endoscopic third ventriculostomy. J Neurosurg. 2002 Jun;96(6):1032-40. doi: 10.3171/jns.2002.96.6.1032. PMID: 12066903. El-Ghandour NM. Endoscopic third ventriculostomy versus ventriculoperitoneal shunt in the treatment of obstructive hydrocephalus due to posterior fossa tumors in children. Childs Nerv Syst. 2011 Jan;27(1):117-26. doi: 10.1007/s00381-010-1263-2. Epub 2010 Aug 25. PMID: 20737274. Xiao B, Roth J, Udayakumaran S, Beni-Adani L, Constantini S. Placement of Ommaya reservoir following endoscopic third ventriculostomy in pediatric hydrocephalic patients: a critical reappraisal. Childs Nerv Syst. 2011 May;27(5):749-55. doi: 10.1007/s00381-010-1371-z. Epub 2010 Dec 23. PMID: 21181175. Kurschel S, Ono S, Oi S. Risk reduction of subdural collections following endoscopic third ventriculostomy. Childs Nerv Syst. 2007 May;23(5):521-6. doi: 10.1007/s00381-006-0278-1. Epub 2007 Jan 13. PMID: 17221272. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 04 Jan, 2025 Read the published version in Child's Nervous System → Version 1 posted Editorial decision: Revision requested 03 Dec, 2024 Reviews received at journal 02 Dec, 2024 Reviewers agreed at journal 22 Nov, 2024 Reviewers invited by journal 22 Nov, 2024 Editor assigned by journal 30 Oct, 2024 Submission checks completed at journal 30 Oct, 2024 First submitted to journal 28 Oct, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5346121","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":372023720,"identity":"8bcb7e5c-9a52-4ef3-8850-9c6b712ebd08","order_by":0,"name":"Rafael Tiza Fernandes","email":"","orcid":"","institution":"Hospital de São José","correspondingAuthor":false,"prefix":"","firstName":"Rafael","middleName":"Tiza","lastName":"Fernandes","suffix":""},{"id":372023724,"identity":"f62799e3-a2d1-420c-9d3f-eee85fda82e9","order_by":1,"name":"Rui Sobrinho","email":"","orcid":"","institution":"Hospital de São José","correspondingAuthor":false,"prefix":"","firstName":"Rui","middleName":"","lastName":"Sobrinho","suffix":""},{"id":372023725,"identity":"11ef4183-ab3c-4bce-8500-fcc0797ab840","order_by":2,"name":"Miguel Azevedo","email":"","orcid":"","institution":"Hospital Garcia de Orta","correspondingAuthor":false,"prefix":"","firstName":"Miguel","middleName":"","lastName":"Azevedo","suffix":""},{"id":372023726,"identity":"a167fd27-70ed-4ff8-aa3b-45df473fe95b","order_by":3,"name":"Mário Matos","email":"","orcid":"","institution":"Hospital de Dona Estefânia","correspondingAuthor":false,"prefix":"","firstName":"Mário","middleName":"","lastName":"Matos","suffix":""},{"id":372023727,"identity":"26025894-f7ff-4980-b20f-5ce5e39a9201","order_by":4,"name":"Amets Sagarribay","email":"","orcid":"","institution":"Hospital de São José","correspondingAuthor":false,"prefix":"","firstName":"Amets","middleName":"","lastName":"Sagarribay","suffix":""},{"id":372023728,"identity":"c97963fd-77cd-4d56-84d8-ec73c79eb563","order_by":5,"name":"Dalila Forte","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA90lEQVRIiWNgGAWjYDCCA8wNBx4wMPCDOR+AmI2doBbGhgMJDAySDQzMDIwzQFqYidDCANPCzAMSIaSF7/jBxgMJNQwS/NLnDz62+bVNng9o24ePObi1SJ5JBDrsGIOEZF8ys3Fu323DNqBtkjO34dZicACkhY2hzuAMM5t0bs9tRqAWNmZefFrOPwRq+ccgAdTC/tuy57Y9YS03gLYktoG1AMPqx+1EglokbwBtSeyTkJDsYTaW7G24ndzGzNiM1y9855MPf/jwzUaCn4fx4Ycff27bzm9vPvjhIx4tUCABoRjbwGQDQfVI4A8pikfBKBgFo2CkAABdlFKa25ZOQgAAAABJRU5ErkJggg==","orcid":"","institution":"Hospital de São José","correspondingAuthor":true,"prefix":"","firstName":"Dalila","middleName":"","lastName":"Forte","suffix":""}],"badges":[],"createdAt":"2024-10-28 10:08:24","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5346121/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5346121/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00381-024-06726-9","type":"published","date":"2025-01-04T15:57:16+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":70035500,"identity":"e85aabc5-87fc-4e08-98db-55689a15c3ee","added_by":"auto","created_at":"2024-11-27 17:13:22","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":77125,"visible":true,"origin":"","legend":"\u003cp\u003ePreoperative MRI scans of the fourth ventricle mass. (a) Axial T1-weighted image; (b) Coronal T2-weighted image.\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5346121/v1/c477c4aca91a85dc3eedab04.jpg"},{"id":70035503,"identity":"4c7d5f8b-95d7-41c2-a0c5-a35cf0d5148c","added_by":"auto","created_at":"2024-11-27 17:13:22","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":176782,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of follow-up MRI scans over time. Left column (a, c, e): images taken at age 8 (6-year follow-up). Right column (b, d, f): images taken at age 9 (7-year follow-up), highlighting progression of ventricular dilation suggestive of worsening hydrocephalus, without tumor recurrence.\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5346121/v1/1b8520899a7cb1fcd160fec6.jpg"},{"id":70036211,"identity":"bb661c8b-b7b4-4d47-a872-2cc1553dbf78","added_by":"auto","created_at":"2024-11-27 17:21:22","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":59834,"visible":true,"origin":"","legend":"\u003cp\u003epostoperative CT scan following ETV. Sagittal (a) and axial (b) views show stable postoperative changes with no signs of acute complications, such as hemorrhage.\u003c/p\u003e","description":"","filename":"Figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5346121/v1/bffd34d1334364d6487614ce.jpg"},{"id":70036212,"identity":"13ae9471-b17b-4a0d-8e6e-8ed10f91068a","added_by":"auto","created_at":"2024-11-27 17:21:22","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":106867,"visible":true,"origin":"","legend":"\u003cp\u003eCT scan showing a large new right hemispheric subdural hematoma, approximately 35 mm at its thickest point, mostly isodense with the cortex but with acute hyperdense blood components deposited on its medial and inferior aspects. Images (a-d) display progressive sections demonstrating the extent of the hematoma and the resulting mass effect on surrounding structures. A marked leftward shift of midline structures, quantified at approximately 17 mm at the level of the septum pellucidum, was noted.\u003c/p\u003e","description":"","filename":"Figure4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5346121/v1/d6aae57a72e33df18872ba65.jpg"},{"id":70035502,"identity":"b79260fa-b71e-42d5-bf35-9c684e5b39f7","added_by":"auto","created_at":"2024-11-27 17:13:22","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":98010,"visible":true,"origin":"","legend":"\u003cp\u003eCT scans demonstrating postoperative evolution following burr hole drainage of the right subdural hematoma (SDH). (a) Day 1 post-drainage, showing partial evacuation of the hematoma with residual collection and midline shift improvement. (b) Day 12 post-drainage, displaying further reabsorption of the SDH with normalization of midline structures and significant reduction in mass effect.\u003c/p\u003e","description":"","filename":"Figure5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5346121/v1/2a2b695bfcdd273cee40855f.jpg"},{"id":70035504,"identity":"f4352161-a693-4b0d-80a7-127205906f68","added_by":"auto","created_at":"2024-11-27 17:13:22","extension":"jpg","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":99702,"visible":true,"origin":"","legend":"\u003cp\u003eMRI scan one-month post-burr hole drainage demonstrating no residual tumor and confirming stoma patency. There is near-total reabsorption of the previously large subdural hematoma, without mass effect. No evidence of tumor recurrence.\u003c/p\u003e","description":"","filename":"Figure6.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5346121/v1/987fbd70d69bbe4af3b26001.jpg"},{"id":73094813,"identity":"e3617e8c-2b82-444a-b2e3-753021f4abdf","added_by":"auto","created_at":"2025-01-06 16:24:27","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":957764,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5346121/v1/3fffda71-8d53-4650-b301-b5e00a204fae.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Subdural Hematoma as a Complication of Endoscopic Third Ventriculostomy in a Pediatric Patient: A Case Report \u0026 Literature Review","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSubdural hematoma (SDH) in pediatric patients is typically linked to traumatic brain injury (TBI) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. It can also result from procedures involving the ventricular system, such as ventriculoperitoneal shunt (VPS). The mechanisms are still unclear, as some patients develop only asymptomatic subdural effusions, not SDH.\u003c/p\u003e \u003cp\u003eEndoscopic third ventriculostomy (ETV) is considered an effective treatment option for certain cases of obstructive hydrocephalus. It has also been associated, albeit at a much lower rate than VPS, with SDH development.\u003c/p\u003e \u003cp\u003eThis report aims to describe a rare case of SDH following ETV in a 9-year-old male with a history of ependymoma of the fourth ventricle.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eWe report a case of a nine-year-old male with a relevant past medical history of an ependymoma (WHO grade II) located in the fourth ventricle which was diagnosed at 21 months of age (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The patient underwent subtotal surgical resection and adjuvant radiotherapy. Yearly magnetic resonance imaging (MRI) showed controlled disease and chronic ventricular dilation.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eSeven years post-diagnosis, the patient presented with intermittent evening headaches. On MRI, worsening obstructive hydrocephalus was detected, with no signs of tumor recurrence (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). An ETV was subsequently performed through a right frontal burr hole. The procedure had no immediate complications (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The patient was discharged on postoperative day two with no additional symptoms or neurological deficits.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eOne month after the ETV, he developed progressively worsening headaches, refractory to medication, along with generalized weakness and difficulty walking. He had no history of recent trauma. Initial evaluation revealed a Glasgow Coma Scale score of 15, and generalized weakness without focal deficits. CT scan showed a right subdural collection, measuring up to 35 mm in thickness, and causing midline shift to the left (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Its imaging characterization suggested SDH.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe patient underwent urgent drainage of the SDH through 2 burr holes on the right side (frontal and parietal). The drained blood was in the subacute phase and a subdural drain was placed. The postoperative period was uneventful, with favorable clinical progress. The drain was removed on the 2nd postoperative day and almost complete reabsorption of the hematoma was documented in serial CT scans (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eDue to the SDH\u0026rsquo;s unknown etiology, the patient was referred to Hematology. No laboratory abnormalities suggestive of an increased risk of hemorrhage were identified. He had no family history of hematologic disorders, signs of bleeding diathesis, or history of bleeding in previous surgeries. No history of spontaneous or disproportionate bleeding relative to trauma. He scored 3 points on the Bleeding Assessment Tool (only for CNS hemorrhage).\u003c/p\u003e \u003cp\u003eThe patient had no further complications and was discharged in a stable condition (GCS 15, no focal deficits) on postoperative day 12. At one-month follow-up, the patient maintained his condition and went back to school. He underwent an MRI 3 months post-op which showed no signs of hydrocephalus and confirmed stoma patency (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eETV is considered an effective treatment option for obstructive hydrocephalus, as it may eliminate the need for a definitive shunt. However, its success rate can vary [3]. This case report highlights a SDH in a 9-year-old male that developed one month after ETV. The occurrence of SDH post-ETV is not frequent, and to date, only a limited number of cases have been reported in the literature. We identified 4 case reports of SDH following ETV in pediatric patients, as shown in Table 1 [4,5,6,7]. The timing between the surgery and the first symptoms varied from a few days to 1 month.\u003c/p\u003e\n\u003cp\u003eTable 1 denotes the cases reported in the literature regarding subdural collections after ETV. The case reported in this article appears as the last one in this table for comparison.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"921\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 4.11701%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eYear\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.77573%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAuthors\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4.55038%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4.11701%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.5926%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime from ETV to diagnosis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.1181%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSymptoms/Signs\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.17551%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSide\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.17551%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBlood\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.50054%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSurgery\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.2925%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eReason for management\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.31744%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eProcedure\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.2676%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFollow-up Imaging\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 4.11701%;\"\u003e\n \u003cp\u003e1997\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.77573%;\"\u003e\n \u003cp\u003eMohanty et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4.55038%;\"\u003e\n \u003cp\u003e3 m\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4.11701%;\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.5926%;\"\u003e\n \u003cp\u003eImmediately post-op\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.1181%;\"\u003e\n \u003cp\u003eCardiorespiratory arrestment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.17551%;\"\u003e\n \u003cp\u003eLeft convexity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.17551%;\"\u003e\n \u003cp\u003eAcute\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.50054%;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.2925%;\"\u003e\n \u003cp\u003eImmediate post-op deterioration\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.31744%;\"\u003e\n \u003cp\u003ePercutaneous aspiration\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.2676%;\"\u003e\n \u003cp\u003e8 months post-op, no recurrence\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 4.11701%;\"\u003e\n \u003cp\u003e2000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.77573%;\"\u003e\n \u003cp\u003eMaeda et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4.55038%;\"\u003e\n \u003cp\u003e2 y\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4.11701%;\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.5926%;\"\u003e\n \u003cp\u003e5 days post-op\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.1181%;\"\u003e\n \u003cp\u003eMild consciousness disturbance, decreased activity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.17551%;\"\u003e\n \u003cp\u003eBilateral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.17551%;\"\u003e\n \u003cp\u003eEffusion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.50054%;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.2925%;\"\u003e\n \u003cp\u003eGradual improvement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.31744%;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.2676%;\"\u003e\n \u003cp\u003eStill seen on MRI 9 months post-op\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 4.11701%;\"\u003e\n \u003cp\u003e2006\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.77573%;\"\u003e\n \u003cp\u003eKamel et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4.55038%;\"\u003e\n \u003cp\u003e16 y\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4.11701%;\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.5926%;\"\u003e\n \u003cp\u003e1 month\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.1181%;\"\u003e\n \u003cp\u003eHeadache, Gait disturbance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.17551%;\"\u003e\n \u003cp\u003eRight convexity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.17551%;\"\u003e\n \u003cp\u003eSubacute\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.50054%;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.2925%;\"\u003e\n \u003cp\u003eSymptoms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.31744%;\"\u003e\n \u003cp\u003eMinicraniotomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.2676%;\"\u003e\n \u003cp\u003e2 years post-op, no recurrence\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 4.11701%;\"\u003e\n \u003cp\u003e2018\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.77573%;\"\u003e\n \u003cp\u003eCoulibaly et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4.55038%;\"\u003e\n \u003cp\u003e4 m\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4.11701%;\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.5926%;\"\u003e\n \u003cp\u003e6 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.1181%;\"\u003e\n \u003cp\u003eLethargy, Sunset eyes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.17551%;\"\u003e\n \u003cp\u003eBilateral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.17551%;\"\u003e\n \u003cp\u003eChronic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.50054%;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.2925%;\"\u003e\n \u003cp\u003eSymptoms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.31744%;\"\u003e\n \u003cp\u003eBurr hole evacuation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.2676%;\"\u003e\n \u003cp\u003e2 months post-op, no recurrence\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 4.11701%;\"\u003e\n \u003cp\u003e2024\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.77573%;\"\u003e\n \u003cp\u003e\u003cu\u003ePresent Case\u003c/u\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4.55038%;\"\u003e\n \u003cp\u003e9 y\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4.11701%;\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.5926%;\"\u003e\n \u003cp\u003e1 month\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.1181%;\"\u003e\n \u003cp\u003eHeadache, Gait disturbance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.17551%;\"\u003e\n \u003cp\u003eRight convexity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.17551%;\"\u003e\n \u003cp\u003eSubacute\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.50054%;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.2925%;\"\u003e\n \u003cp\u003eSymptoms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.31744%;\"\u003e\n \u003cp\u003eBurr hole evacuation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.2676%;\"\u003e\n \u003cp\u003e3 months post-op, no recurrence\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNR - non reported; N/A - non applicable\u003c/p\u003e\n\u003cp\u003eThe exact mechanisms leading to SDH post-ETV remain unclear, as noted in prior reviews on this subject [7,8,9]. The abrupt change in CSF dynamics post-ETV is reported as one of the possible mechanisms. Another hypothesis is damage to a vessel during the procedure, whether cortical or from the scalp, that might lead to blood accumulation in the subdural space. A thin cerebral mantle and reduced brain elasticity might be predisposing factors.\u003c/p\u003e\n\u003cp\u003eSchroeder et al [10] reviewed complications associated with ETV and reported three subdural collections following the procedure. However, the specific type of subdural collection, whether hematoma or effusion, was not clarified. All patients remained asymptomatic.\u003c/p\u003e\n\u003cp\u003eEl-Ghandour et al [11] compared ETV and VPS for the treatment of obstructive hydrocephalus caused by posterior fossa tumors in children, reporting no subdural collections in the ETV group. In contrast, subdural collections were observed in 2 out of 21 patients from the VPS group. On the other hand, Schroeder et al reported three cases of subdural collections following ETV, though they did not specify their exact nature. This highlights the importance of further research to better understand the nature of subdural collections, as they can vary in severity and clinical impact.\u003c/p\u003e\n\u003cp\u003eXiao et al [12] reported 3 cases of subdural collections out of 12 children who underwent ETV combined with Ommaya reservoir insertion. All cases required drainage, and the reservoirs were subsequently removed. Based on these findings, they concluded that the combination of ETV and Ommaya reservoir may carry a higher risk of developing extra-axial fluid collections. It remains unclear if a previous shunt is a risk factor for developing SDH after ETV.\u003c/p\u003e\n\u003cp\u003eKurschel et al [13] proposed a technique to prevent subdural collections using fibrin glue. However, their conclusions were limited by the small sample size and lack of comparison to a control group.\u003c/p\u003e\n\u003cp\u003eWhile SDH is more commonly reported following VPS procedures, the present case demonstrates that ETV, though less frequently implicated, can also lead to SDH, requiring careful postoperative monitoring. Risk factors and prevention strategies are yet to be clarified. Burr hole drainage is likely an effective treatment for these cases.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis case highlights the need to monitor patients after ETV for the delayed development of SDH. Clinicians should be aware of this potential complication, especially in pediatric patients presenting with new or worsening neurological symptoms postoperatively. Further research is necessary to elucidate the pathophysiological mechanisms driving SDH post-ETV and to identify potential risk factors for this rare but serious complication.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eStatement of Ethics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was not required for this study following national guidelines.\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient\u0026apos;s legal guardian to publish this case report.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no conflicts of interest to declare.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Sources\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere were no funding sources for the manuscript under consideration.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRafael Tiza Fernandes and Dalila Forte: conceptual design, manuscript authoring and manuscript review. Rui Sobrinho, Miguel Azevedo, M\u0026aacute;rio Matos and Amets Sagarribay: manuscript review. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData are not available due to ethical reasons. Further inquiries can be directed to the corresponding author.\u003c/p\u003e"},{"header":"References","content":"\u003col start=\"1\" type=\"1\"\u003e\n \u003cli\u003eBinder H, Tiefenboeck TM, Majdan M, et al. Management and outcome of traumatic subdural hematoma in 47 infants and children from a single center. Wien Klin Wochenschr. 2020;132(17-18):499-505. doi:10.1007/s00508-020-01648-3\u003c/li\u003e\n \u003cli\u003eMatschke J, Voss J, Obi N, et al. Nonaccidental head injury is the most common cause of subdural bleeding in infants \u0026lt;1 year of age. Pediatrics. 2009;124(6):1587-1594. doi:10.1542/peds.2008-3734\u003c/li\u003e\n \u003cli\u003eKulkarni AV, Drake JM, Mallucci CL, Sgouros S, Roth J, Constantini S; Canadian Pediatric Neurosurgery Study Group. Endoscopic third ventriculostomy in the treatment of childhood hydrocephalus. J Pediatr. 2009 Aug;155(2):254-9.e1. doi: 10.1016/j.jpeds.2009.02.048. Epub 2009 May 15. PMID: 19446842.\u003c/li\u003e\n \u003cli\u003eMohanty A, Anandh B, Reddy MS, Sastry KV. Contralateral massive acute subdural collection after endoscopic third ventriculostomy - a case report. Minim Invasive Neurosurg. 1997 Jun;40(2):59-61. doi: 10.1055/s-2008-1053417. PMID: 9228339.\u003c/li\u003e\n \u003cli\u003eMaeda Y, Inamura T, Morioka T, Muratani H, Fukui M. Hemorrhagic subdural effusion complicating an endoscopic III ventriculostomy. Childs Nerv Syst. 2000 May;16(5):312-4. doi: 10.1007/s003810050521. PMID: 10883376.\u003c/li\u003e\n \u003cli\u003eKamel MH, Murphy M, Aquilina K, Marks C. Subdural haemorrhage following endoscopic third ventriculostomy. A rare complication. Acta Neurochir (Wien). 2006 May;148(5):591-3. doi: 10.1007/s00701-005-0715-z. PMID: 16475020.\u003c/li\u003e\n \u003cli\u003eCoulibaly O, Diallo O, Dama M, Kan\u0026eacute; B, Zhou F, Sogoba Y et al. Bilateral chronic subdural hematoma after endoscopic third ventriculostomy in a child: a case report and review of the literature. World Journal of Neuroscience. 2018, 8(1). doi:10.4236/wjns.2018.81005\u003c/li\u003e\n \u003cli\u003eTekin T, Colak A, Kutlay M, Demircan MN. Chronic subdural hematoma after endoscopic third ventriculostomy: a case report and literature review. Turk Neurosurg. 2012;22(1):119-22. doi: 10.5137/1019-5149.JTN.3336-10.0. PMID: 22274985.\u003c/li\u003e\n \u003cli\u003eGondar R, Rogers A, Momjian S. Subdural hematoma after endoscopic third ventriculostomy: Struggling against the Laplace law. Neurochirurgie. 2015 Oct;61(5):347-51. doi: 10.1016/j.neuchi.2015.06.003. Epub 2015 Aug 5. PMID: 26255033.\u003c/li\u003e\n \u003cli\u003eSchroeder HW, Niendorf WR, Gaab MR. Complications of endoscopic third ventriculostomy. J Neurosurg. 2002 Jun;96(6):1032-40. doi: 10.3171/jns.2002.96.6.1032. PMID: 12066903.\u003c/li\u003e\n \u003cli\u003eEl-Ghandour NM. Endoscopic third ventriculostomy versus ventriculoperitoneal shunt in the treatment of obstructive hydrocephalus due to posterior fossa tumors in children. Childs Nerv Syst. 2011 Jan;27(1):117-26. doi: 10.1007/s00381-010-1263-2. Epub 2010 Aug 25. PMID: 20737274.\u003c/li\u003e\n \u003cli\u003eXiao B, Roth J, Udayakumaran S, Beni-Adani L, Constantini S. Placement of Ommaya reservoir following endoscopic third ventriculostomy in pediatric hydrocephalic patients: a critical reappraisal. Childs Nerv Syst. 2011 May;27(5):749-55. doi: 10.1007/s00381-010-1371-z. Epub 2010 Dec 23. PMID: 21181175.\u003c/li\u003e\n \u003cli\u003eKurschel S, Ono S, Oi S. Risk reduction of subdural collections following endoscopic third ventriculostomy. Childs Nerv Syst. 2007 May;23(5):521-6. doi: 10.1007/s00381-006-0278-1. Epub 2007 Jan 13. PMID: 17221272.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"childs-nervous-system","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"cnsy","sideBox":"Learn more about [Child's Nervous System](http://link.springer.com/journal/381)","snPcode":"381","submissionUrl":"https://submission.nature.com/new-submission/381/3","title":"Child's Nervous System","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Subdural Hematoma, Pediatric, ETV, Complication, Hydrocephalus","lastPublishedDoi":"10.21203/rs.3.rs-5346121/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5346121/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e: Subdural hematoma (SDH) typically occurs due to traumatic brain injury but can arise as a rare complication of procedures like endoscopic third ventriculostomy (ETV).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase Presentation\u003c/strong\u003e: We report an unusual case in a 9-year-old male with previous resection of a fourth-ventricle ependymoma at 2 years of age. Seven years post-surgery, he presented with worsening hydrocephalus and underwent ETV. One month later, he developed severe headaches and motor difficulties. Imaging revealed a significant right SDH, necessitating urgent drainage. Postoperative recovery was uneventful, and follow-up imaging showed resolution of the hematoma.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLiterature Review \u0026amp; Discussion\u003c/strong\u003e: ETV is generally preferred for obstructive hydrocephalus due to lower complication rates compared to shunt procedures. However, cases of SDH post-ETV remain reported, albeit rarely. Potential mechanisms include altered cerebrospinal fluid dynamics and intraoperative vessel injury. This case aligns with literature findings and reinforces the importance of postoperative monitoring and prompt intervention in symptomatic cases to prevent complications.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e: Clinicians should consider SDH in pediatric patients with new symptoms post-ETV. Further research should focus on understanding the risk factors and mechanisms for SDH development.\u003c/p\u003e","manuscriptTitle":"Subdural Hematoma as a Complication of Endoscopic Third Ventriculostomy in a Pediatric Patient: A Case Report \u0026amp; Literature Review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-27 17:13:17","doi":"10.21203/rs.3.rs-5346121/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-12-03T10:41:19+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-12-02T06:33:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"146849214292554407275077775597151653616","date":"2024-11-22T21:21:28+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-11-22T15:15:29+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-10-30T04:33:50+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-10-30T04:32:48+00:00","index":"","fulltext":""},{"type":"submitted","content":"Child's Nervous System","date":"2024-10-28T10:04:41+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"childs-nervous-system","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"cnsy","sideBox":"Learn more about [Child's Nervous System](http://link.springer.com/journal/381)","snPcode":"381","submissionUrl":"https://submission.nature.com/new-submission/381/3","title":"Child's Nervous System","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"87008fb0-0e2c-4569-9e51-e49346a1a1f0","owner":[],"postedDate":"November 27th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-01-06T16:22:07+00:00","versionOfRecord":{"articleIdentity":"rs-5346121","link":"https://doi.org/10.1007/s00381-024-06726-9","journal":{"identity":"childs-nervous-system","isVorOnly":false,"title":"Child's Nervous System"},"publishedOn":"2025-01-04 15:57:16","publishedOnDateReadable":"January 4th, 2025"},"versionCreatedAt":"2024-11-27 17:13:17","video":"","vorDoi":"10.1007/s00381-024-06726-9","vorDoiUrl":"https://doi.org/10.1007/s00381-024-06726-9","workflowStages":[]},"version":"v1","identity":"rs-5346121","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5346121","identity":"rs-5346121","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}