Ventriculoperitoneal Shunting and Endoscopic Adhesiolysis of Multiloculated Obstructive Hydrocephalus in an Extreme Preterm: A Case Report

Multiloculated obstructive hydrocephalus is a complication of infection in early life, especially in preterms. In cases of obstructive hydrocephalus with loculated fluid pockets, procedures like Ventriculo-Peritoneal (VP) shunting can target 1-2 loculi, subsequently leading to occlusion of Cerebrospinal Fluid (CSF) even after shunting, resulting in obstruction of the shunt. Incomplete treatment leads to a progressive increase in head circumference and subsequent developmental delay. Obstructive hydrocephalus in infancy poses a significant neurosurgical challenge, particularly in cases with multiloculated compartments or congenital anomalies such as aqueductal stenosis. An extreme preterm infant born at 27 weeks presented with progressive head enlargement and was diagnosed with obstructive hydrocephalus at three months of age. The child underwent right VP shunt placement, followed by a contralateral shunt after 14 months due to further obstruction. Despite this, she presented again with signs of raised intracranial pressure, and imaging revealed multiloculated hydrocephalus with midline shift. Endoscopic adhesiolysis and septostomy with fenestration were subsequently performed, resulting in clinical improvement. This case emphasises the importance of neuroendoscopy as a minimally invasive and effective alternative in selected cases of shunt malfunction, avoiding repeated shunt revisions and associated complications. This case report presents a challenging scenario of recurrent obstructive hydrocephalus in an expreterm infant, initially managed with VP shunt placement but ultimately requiring endoscopic adhesiolysis and septostomy due to multiple intraventricular septations and compartmentalised hydrocephalus.