MANAGEMENT OF ACUTE HYDROCEPHALUS 29-9-2012 Dewan Auditorium, HTAA EMERGENCIES IN NEUROSURGERY Symposium 7: Hydrocephalus
MANAGEMENT OF ACUTE
HYDROCEPHALUS
MANAGEMENT OF ACUTE
HYDROCEPHALUS29-9-2012
Dewan Auditorium, HTAA29-9-2012
Dewan Auditorium, HTAA
EMERGENCIES IN NEUROSURGERY
Symposium 7: Hydrocephalus
Medical Management of Hydrocephalus
• Diuretics (frusemide and acetazolamide) and steroids are known to decrease CSF production.
• Maintaining PaCO2
• Surgical drainage of CSF appears to date from the time of Hippocrates, but it was not until the 18th century that ventricular drainage was seriously attempted.
• By the 19th century, it had become clear that prevention of infection would require internal CSF drainage.
• Virtually every cavity has been tried, including the subdural space, the subarachnoid space, the subcutaneous tissues of the scalp, the paranasal sinuses, the thoracic duct, the pleura, the peritoneum, the gall bladder, the ureters, and the bloodstream.
Surgical Management of
Hydrocephalus
• The atrium was initially the preferred site for placement of the distal catheter in children, but atrial shunts have a unique set of complications including endocarditis and glomerulonephritis.
• They also migrate from the atrium with linear growth of the child, needing surgical revision of the distal catheter.
• The peritoneum is now the “favoured” site for the distal catheter unless there are problems with absorption or abdominal sepsis.
• Lumbar peritoneal shunts are rarely used for the treatment of hydrocephalus in children and have been associated with the development of scoliosis and cerebellar tonsillar herniation.
Surgical Management of
Hydrocephalus
Shunts
• Although results for treating hydrocephalus were far superior, it soon became apparent that shunts had their limitations.
• Three ways in which shunts can malfunction: – (a) they can become infected; – (b) they can fail mechanically; – (c) they can overdrain or underdrain
(termed a “functional” failure)
Surgical Management of
Hydrocephalus
Third ventriculostomy• Open third ventriculostomy (TV)—literally making a hole to connect the third ventricle with the subarachnoid space—was first reported in the 1920s by Dandy, but it had significant mortality.
• It was not until the last two decades that endoscopic TV has grown in popularity as an alternative to shunt placement for patients with triventricular (obstructive) hydrocephalus
Surgical Management of
Hydrocephalus
• Endoscopic TV entails entering the lateral ventricle, passage through the Foramen of Monro, identification of the mamillary bodies, and then perforation of the floor of the third ventricle just anterior to the bifurcation of the basilar artery
Endoscopic Third ventriculostomy
Neuroendoscopy
Creating alternative CSF pathways (third ventriculostomy),
reducing the CSF production (choroid plexus coagulation), or
restoring the physiological ones (aqueductoplasty, septostomy, foraminal plasty
of foramen of Monro, and foraminal plasty of foramens of Magendie and/or
Luschka)Neuroendoscopy provides a magnified view of the ventricular system
viewed from inside and allows a better resolution of the surgical field.
It avoids the implant of foreign bodies and reduces the need for
re-intervention commonly observed in shunted patients, with
the potential to avoid shunt dependency
Complications of Endoscopic Third Ventriculostomy
Hemorrhage
(the most severe being due to basilar rupture)
Injury of neural structures
. In the immediate
postoperative period
Hematomas, infections,
and
cerebrospinal fluid leaks
Utility of point of obstruction model
CT and MRI
2 samples of lumbar CSF analysis from 2 different lumbar punctures.
The CSF was sent for routine cytological and biochemical evaluation,
bacterial and fungal cultures, antituberculosis and anticysticercosis antibodies, and
India ink preparation for cryptococcosis.Gram stains, cultures, serology and cytology
were negative
Neuroendoscopic Exploration of the
Subarachnoid Basal Cisterns
septum pellucidum fenestration,
ETV, aqueductoplasty, Liliequist fenestration, and basal
cisternal dissection
Basal Meningitis and Hydrocephalus
Transventricular Neuroendoscopic Exploration and Biopsy of the Basal
Cisterns
At 15 months of follow-up, 70% of the
patients with hydrocephalus did not require a ventriculoperitoneal shunt.
Basal Meningitis and Hydrocephalus
Hydrocephalus in TB Meningitis
MEDICAL MANAGEMENTThe appropriateness of this therapeutic approach depends on three key factors:
1) Demonstration of communication between the ventricles and the subarachnoid space;
2) Prevention of ongoing increased ICP during the treatment phase;
3) Adherence to a strict protocol for treatment and monitoring of ICP.Treatment
with furosemide and acetazolamide,
with weekly lumbar puncture pressure
measurements,
Has been reported to be successful
in approximately 75% to 80% of patients
Repeat the cranial CT
after three weeks of treatment, or earlier if
there is a clinical indication.
Hydrocephalus in TB Meningitis
SURGICAL MANAGEMENT
Repeat the cranial CT
after three weeks of treatment, or earlier if
there is a clinical indication.If there is progression
of the hydrocephalus on head CT,
or if ICP control is still not achieved
by three weeks
Receives a VPS.
depressed level of consciousness,
temporary external
ventricular drainage
Endoscopy TV
who do not respond to medical therapy or who have
NCHC.
VPS insertion is not benign.
Complications requiring reoperation
in the first 6 to 12 months occur
in 30% to 43% of
TBM cases
Hydrocephalus in TB Meningitis
SURGICAL MANAGEMENT
Endoscopy TVfirst described in 2003 as an alternative to VPS
insertion in patients with NCHCThe clinical outcome of the hydrocephalus
in a nonselective approach to ETV was reported
as “satisfactory” in 50% and “acceptable” in
18%Perform lumbar punctures
for a few days after the ETV
To encourage flow across the stoma
To monitor the ICP
If the ETV cannot be completed technically,
VPS.
Shunt Malfunction
presence of an obstructive
hydrocephalus at the time of shunt
malfunction
Frequently located at the level of the aqueduct,
with a radiological appearance of triventricular
hydrocephalus.Preoperative evaluation
by magnetic resonance imaging
(MRI) is mandatory to assess anatomical
suitability and the patency of the aqueduct
and fourth ventricle outlets.
Absolute anatomical considerations are that Lateral ventricle, foramen of Monro, and the third
ventricle should be large enough to admit the endoscope;
there should be no major anatomical abnormality of the third ventricle;
there should be some space between the dorsum sellae and the basilar
Endoscopy TV
Ideally there should not be any
marked degree of arachnoid membranes in
the prepontine cistern.
Shunt Malfunction
Endoscopy TV
Posthemorrhagic hydrocephalus.
(A) CT scan at first presentation, showing
tetraventricular
hydrocephalus. The patient was managed
with insertion of a VP shunt. (B) CT scan at
shunt
malfunction.
(C) Mid-sagittal T2 MRI showing stenosis of
the aqueduct and bulging of the floor of the
third ventricle in the interpeduncular cistern.
(D) Post-ETV mid-sagittal T2 MRI. CT,
computed tomography;
Results of ETV in Shunt Infection
shunt infection should not
be considered a contraindication to ETV,
even though the success rate may be lower.Third ventriculostomy
offers a welcome alternative to the
management of this group of patients
Avoiding the reimplantation of foreign material
in the long term
TREATMENT OF HEMATOCEPHALUS
Massive intraventricular hemorrhage is a
life-threatening condition that requires aggressive
management to decrease intracranial
hypertension.The control of intracranial
pressure by external ventricular drainage is
a rescue surgical action
tetraventricular
blood flooding should be often
managed with bilateral ventricular
catheter
TREATMENT OF HEMATOCEPHALUS
In these cases to treat patients surgically
for hematoma removal if deemed, and
to place an external ventricular
drainage immediately.
serial computed tomographic
(CT) scans;if a good clinical response
is obtained in the early days after
surgery
Reconsider endoscopic removal
of clots in cases with massive
ventricular
hemorrhage and tetraventricular
extension
Oral anticoagulant
therapy should be considered a contraindication
for early endoscopic treatment
TREATMENT OF HEMATOCEPHALUS
If ventricular clots are secondary to aneurysm
rupture or arteriovenous malformations
Perform early surgery or coiling to
secure the aneurysm or malformation
Fisher 4 subarachnoid
hemorrhage with massive tetraventricular
clots
Early endoscopic
aspiration in patients
in patients who are
intubated and have a Glasgow Coma Scale
score 6 (motor response 4–5)
decrease intracranial hypertension by
endoscopically cleansing clots
NORMAL PRESSURE HYDROCEPHALUS
NPH who improve clearly after one
or several CSF lumbar punctures.
proceed with shunting
disease should progress
Patients at an early clinical stage
with mild gait disturbance
may be monitored initially,
repeated CSF removal via lumbar puncture
proceed with shuntingExtensive counselling with the patients’
relatives should be performed to
weigh the expected benefits from
shunting and the possibilities of long-term
shunt dysfunction
More marked symptoms and a longer history earlier
Acute Obstructive Hydrocephalus
Caused by Cerebellar Infarction
Toward the end of the first week the need for
conversion to a shunt (if clamping or elevation
of the emptying pressure of the
ventriculostomy tube is followed by clinical
regression. ) can be determined.
Repeat CT scan in 48-72 hours will
perhaps confirm a decrease in mass
effect and stabilization or reduction of
ventriculomegalyVentriculostomy and external ventricular
drainage
Immediate intubation to control ventilation and
prevent buildup of Paco2.
Intravenous administration of
dexamethasone and mannitol.
prompt improvement in the state of consciousness is not
detected
If external ventricular drainage is effective and
consciousness is restored,
Prompt suboccipital craniectomy with resection of necrotic
cerebellar tissue if there is no amelioration in the level of
consciousness within a few hours after
ventricular decompression.
Correction of Congenital Hydrocephalus in
Utero
In utero decompression
of obstructive hydrocephalus improves
overall survivalImproves gross ventriculomegaly,
Associated with significant complications .
Does not improve histopathologic brain damage
Thank You