• Alberto Feletti, Alessandro Fiorindi, Vincenzo Lavecchia, Rafael Boscolo-Berto, Elisabetta Marton, Veronica Macchi, Raffaele De Caro, Pierluigi Longatti, Andrea Porzionato, and Giacomo Pavesi.
• 1Department of Neurosciences, Biomedicine, and Movement Sciences, Institute of Neurosurgery, University of Verona.
• J. Neurosurg. 2021 Jul 1; 135 (1): 309317309-317.

ObjectiveDespite the technological advancements of neurosurgery, the posterior part of the third ventricle has always been the "dark side" of the ventricle. However, flexible endoscopy offers the opportunity for a direct, in vivo inspection and detailed description of the posterior third ventricle in physiological and pathological conditions. The purposes of this study were to describe the posterior wall of the third ventricle, detailing its normal anatomy and surgical landmarks, and to assess the effect of chronic hydrocephalus on the anatomy of this hidden region.MethodsThe authors reviewed the video recordings of 59 in vivo endoscopic explorations of the posterior third ventricle to describe every identifiable anatomical landmark. Patients were divided into 2 groups based on the absence or presence of a chronic dilation of the third ventricle. The first group provided the basis for the description of normal anatomy.ResultsThe following anatomical structures were identified in all cases: adytum of the cerebral aqueduct, posterior commissure, pineal recess, habenular commissure, and suprapineal recess. Comparing the 2 groups of patients, the authors were able to detect significant variations in the shape of the adytum of the cerebral aqueduct and in the thickness of the habenular and posterior commissures. Exploration with sodium fluorescein excluded the presence of any fluorescent area in the posterior third ventricle, other than the subependymal vascular network.ConclusionsThe use of a flexible scope allows the complete inspection of the posterior third ventricle. The anatomical variations caused by chronic hydrocephalus might be clinically relevant, in light of the commissure functions.

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